Surgical aortic valve replacement

Reconstruction of the aortic valve with preservation of the patient's own valve

Surgical aortic valve repair is performed in cases of leaky (insufficient) aortic valve. The cause of the insufficiency may lie with the aortic valve itself, but may also affect the leaflets and the annulus, e.g. bicuspid valve, or be caused by changes in the aortic root, e.g. increase in size of the aorta due to aneurysm.

The aim of reconstruction is to restore the anatomical conditions by correcting the valve leaflets and the aortic root.

The most important advantage of valve reconstruction is the preservation of the patient's own natural valve, which is more durable in the long term than a prosthesis. If the rhythm is stable, the use of anticoagulant medication can therefore be dispensed with.

The patient requires general anesthesia and is connected to the heart-lung machine. Over the opened aorta the valve is fixed by means of sutures in such a way that a good closure of the pockets is available again.

In order to perform a successful reconstruction, the anatomy of the aortic valve and the aortic crux must be known, which is described preoperatively by ultrasound.

Surgical aortic valve reconstruction

Criteria for surgical aortic valve replacement

Surgical aortic valve replacement is generally recommended as soon as performance is impaired with low to moderate stress. These patients are usually under 75 years of age and have a low operative risk.

In rare cases, severe concomitant diseases (e.g. pulmonary hypertension, severely impaired liver and/or kidney function) may be a reason against conventional valve surgery. In these cases, TAVI is an alternative.

Pronounced inflammation of the inner lining of the heart (florid endocarditis) should initially be treated with effective antibiotics. If septic temperatures persist after one to two weeks or if the patient's overall condition worsens due to a particularly severe valvular change, septic emboli or similar findings, the decision to perform valve surgery should be made immediately.

Biological or mechanical heart valve replacement

Mechanical and biological valve prostheses are available as valve replacements. The replacement with human donor heart valves (homografts) is rarely used because of the low availability and a more complex surgical technique.

Biological heart valve prostheses

Biological heart valves are made from the pericardium of animals (cattle or pigs). The disadvantage of animal heart valves is that they age and calcify faster than the body's own tissue. After some time (10-20 years) they have to be replaced again.

Two forms of biological prostheses are distinguished: prostheses in which the animal tissue is mounted on a scaffold (stent) and prostheses without a scaffold (stentless), which correspond to the aortic root of the pig. Biological prostheses without a scaffold (stentless prostheses) are only used to replace aortic valves. Both types have advantages and disadvantages, including prosthesis size and durability.

Mechanical prosthetic heart valves

Mechanical heart valves are made of metal. They have a very long lifespan. Therefore, they are well suited for younger patients because repeated operations can be avoided. However, the foreign material of the artificial heart valve affects blood clotting and the risk of thrombosis. Patients have to take anticoagulant medication for the rest of their lives.

Prostheses are manufactured from very well biocompatible carbon compounds. The double wing prosthesis has established itself as a proven mechanical valve prosthesis.

Procedure of the aortic valve operation

Surgical procedures on the aortic valve are open-heart operations and are performed under general anesthesia. In total, a heart valve operation takes 2 to 3 hours. In almost all patients, aortic valve surgery can be performed minimally invasively. Either only the upper third of the sternum or an intercostal space is opened, the skin incision is only 5 - 6 cm.

During the procedure, the patient is connected to the heart-lung machine (HLM) and the heart is stopped with the help of a solution (cardioplegia). The heart-lung machine temporarily takes over the pumping function of the heart and enriches the blood with oxygen.

The aortic valve is reached by opening the aorta. The tissue of the diseased heart valve is completely removed. Numerous sutures are placed at the base of the valve in the heart, which do not dissolve even after years. These sutures are passed through the suture ring of the prosthesis and the prosthesis is thus knotted in the position of the patient's own heart valve.

After completion of the operation, the heart and lungs resume their function and the heart-lung machine is stopped. Still in the operating room, the result of the operation is checked with the help of transesophageal echocardiography (ultrasound of the heart through the esophagus).

Catheter-based valve replacement (TAVI) for narrowed aortic valve

The catheter-based TAVI aortic valve replacement (percutaneous valve replacement) makes it possible to implant a new, biological aortic valve prosthesis on the beating heart. TAVI stands for Transcatheter Aortic Valve Implantation.

Catheter-based TAVI valve replacement