Aortic Valve Replacement: Minimally Invasive

A minimally invasive aortic valve replacement is a surgery to replace a poorly working aortic valve with an artificial valve. The aortic valve is one of the heart’s 4 valves. The valves help blood flow through the heart’s 4 chambers and out to your body normally. The surgery is called “minimally invasive” because it uses a smaller incision than a traditional open repair. This may lead to easier and faster recovery from surgery.

This procedure may be needed  if your aortic valve is working poorly. This may happen if you have aortic valve stenosis or aortic valve regurgitation.

• In aortic stenosis, the valve is unable to open fully. This means less blood is able to exit the heart.
• In aortic regurgitation, the valve is leaky. Some blood leaks back through the valve instead of moving out to the rest of the body.

In both of these cases, you may need to have your aortic valve replaced. A poorly working aortic valve may lead to symptoms such as:

• Shortness of breath
• Fatigue
• Swelling in your legs
• Dizziness
• Chest pain
• Passing out
• An unpleasant awareness of your heartbeat

If these symptoms continue, surgery may be needed. Your healthcare provider may recommend the surgery even if you don’t have significant symptoms. Surgery is most effective before symptoms become severe.

Both aortic stenosis and aortic regurgitation can happen because of general aging of the valve. Other causes of aortic valve disease include:

• Heart birth defects (like a bicuspid aortic valve)
• Bacterial infection of the heart valve
• Tear of the aorta
• Aortic aneurysm (weakened stretched aorta wall)
• Certain genetic conditions (like Marfan syndrome)

There are certain risks with any type of surgery. Your risks will vary based on your medical condition, your age, and other factors. Be sure to talk with your healthcare provider about any concerns that you have.

Most people who have minimally invasive aortic valve replacement will have a successful outcome. However, there are some possible risks. These include:

• Infection
• Bleeding
• Irregular heart rhythms
• Blood clots leading to stroke or heart attack
• Complications from anesthesia

Certain factors increase the risk for complications. Some of these are:

• Chronic illness
• Other heart conditions
• Lung problems
• Increased age
• Being overweight
• Being a smoker
• Infections

As you plan for the surgery, you and your doctor will decide what kind of valve will work best for you. Your surgeon will replace your valve with a biological valve or a mechanical valve.

• Biological valves are made mainly from pig, cow, or human heart tissue. Biological valves may not last as long as mechanical valves, but have less risk for blood clots.
• Mechanical valves are man-made. People with mechanical valves need to take blood-thinning medicine for the rest of their lives because these valves increase the risk for blood clots. Mechanical valves also increase the risk for infection.

Talk with your doctor about how to prepare for your upcoming surgery. Remember the following:

• Avoid eating or drinking anything after midnight before your surgery.
• Try to stop smoking before your operation. Ask your doctor for ways to help.
• You may need to stop taking certain medicines before your surgery. Follow your doctor’s instructions if you usually take blood-thinning medicines like warfarin or aspirin.

You may need to arrive at the hospital the afternoon before your operation. This is a good time to ask any questions you have about the procedure. You may need some routine tests before the procedure to assess your health before surgery. These may include:

• Chest X-ray
• Electrocardiogram (ECG)
• Blood tests
• Echocardiogram (to assess your current valve)
• Coronary angiogram (to assess blood flow in your heart arteries)

The skin over the area where the incision will be made may be shaved. About an hour before the operation, someone will give you medicines to help you relax. In most cases, your surgery will proceed as planned. However, sometimes another emergency might delay your operation.

Check with your healthcare provider about the details of your procedure. In general, during your minimally invasive aortic valve replacement:

• An anesthesiologist will give you anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards you won’t remember it.
• The operation will take several hours. Family and friends should stay in the waiting room, so the surgeon can update them.
• There are several different approaches used in minimally invasive aortic valve replacement. These can include a small incision through your breastbone, to the right of your breastbone, or between the ribs on your side. Sometimes surgeons use special instruments and a camera to do the surgery. With this approach, your surgeon will make several small holes in your chest. Some surgeons use robot-controlled arms to perform the surgery. Your doctor will review all of your options with you along with their associated risks and benefits.    
• The surgery team will connect you to a heart-lung machine. This machine will act as your heart and lungs during the procedure.
• Your surgeon will remove your current aortic heart valve and replace it with a new one.
• The surgery team will remove you from the heart-lung machine.
• The team will wire your breastbone back together (if necessary, depending on your incision position).
• The team will then sew or staple the incision in your skin in back together.

After your minimally invasive aortic valve replacement:

• You will start your recovery in the ICU (intensive care unit) or a recovery room.
• When you wake up, you might feel confused at first. You might wake up a couple of hours after the surgery, or a little later.
• Most people notice relief of their symptoms right after surgery.
• The team will carefully monitor your vital signs, such as your heart rate. They may hook you up to several machines so the nurses can check these more easily.
• You may have a tube in your throat to help you breathe. This may be uncomfortable, and you won’t be able to talk. Your doctor or nurse will usually remove the tube within 24 hours.
• You may have a chest tube to drain excess fluid from your chest.
• You may have small temporary pacemaker wires coming from your chest.
• Bandages will cover your incision. These can usually come off within a couple of days.
• You will feel some soreness, but you shouldn’t feel severe pain. If you need it, you can ask for pain medicine.
• In a day or two, you should be able to sit in a chair and walk with help.
• You may perform breathing therapy to help remove fluids that collect in your lungs during surgery.
• You will probably be able to drink liquids the day after surgery. You can have regular foods as soon as you feel ready to eat.
• You may receive elastic stockings to help blood circulate through your leg veins.
• You will probably need to stay in the hospital for 3 to 5 days.

After you leave the hospital:

• Make sure you have someone to drive you home from the hospital. You will also need some help at home for a while.
• You probably will have your stitches or staples removed in a follow-up appointment in 7 to 10 days. Be sure to keep all follow-up appointments.
• You may tire easily after the surgery, but you will gradually start to recover your strength. Recovery time after minimally invasive valve surgery tends to be less than for an open aortic valve replacement.
• After you go home, take your temperature and your weight every day. Tell your healthcare provider if your temperature is over 100.4°F (38°C), or if your weight changes.
• Ask your doctor when it is safe for you to drive.
• Avoid lifting anything heavy for several weeks.
• Follow all the instructions your healthcare provider gives you for medicine, exercise, diet, and wound care.
• Make sure all your dentists and doctors know about your medical history. You may need to take antibiotics before certain medical and dental procedures to prevent getting an infection on your replacement valve.

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.