Aortic Valve Surgery

The most common problems affecting the aortic valves are narrowing of the valve by scarring (stenosis) and leakage (insufficiency). Once the condition achieves severity and the patients develop symptoms then surgical treatment is indicated. Valve replacement or repair are indicated to treat these conditions.

Aortic valves with stenosis are commonly replaced with either a mechanical (artificial) valve or a biological valve made porcine or bovine tissue. Human tissue valves are also used in patients with severe infections and human valve transposition (Ross procedure) is used in younger patients to avoid blood thinners.

Leaking aortic valves (insufficiency) are usually treated with replacement but in patients with aneurysms and bicuspid valves are often repaired, avoiding prosthetic replacement.

Valve procedures are performed with open surgery, minimally invasive surgery or percutaneous procedures through the groin in many patients.

The type of procedure indicated is based on the patient’s specific clinical condition, age, other cardiac problems requiring surgery, associated medical problems and overall surgical risk.

Our surgeons perform all the different approaches, at high volumes and with excellent outcomes, the best in the region as ranked by the Society of Thoracic Surgeons.

Percutaneous valve replacements (TAVR) are the placement of stent-valves through the groin inside valves with stenosis. It has a lower procedural risk when compared to open surgery but is used frequently in patients with more advanced age (> 75 years) and many other clinical problems. Our TAVR program is one of the busiest in the region.

Our surgeons are regionally known for their expertise and high volume in aortic valve surgery, experience in minimally invasive procedures, valve repair, valve surgery associated with aneurysms, complex valve infections and the use of human valves (cryopreserved homografts) and pulmonary valve transposition (Ross procedures).

Aortic valve endocarditis is a life-threatening condition that occurs when bacteria or fungus infects the valve, commonly with destruction and invasion in the surrounding structures. Most patients require urgent surgery to clear the infections and IV antibiotic use for weeks. Although frequently a simple replacement is performed, oftentimes more advanced procedures require complex reconstruction of the heart with biologic patches, replacement of the valve and aorta with human valves (homografts), and other cardiac simultaneously.

Aortic valve procedures used to avoid blood thinners

Mechanical valves are long lasting and are the main choice in patients younger than 50 years of age. These valves require the use of anticoagulation to avoid clotting and valve malfunction. Although generally safe, anticoagulation is not desirable by young active patients either because the low but certain cumulative risk of bleeding or clot formation or life-style choice. In many patients it is contraindicated due to bleeding issues or specific social situations

Biologic valves are usually implanted in older patients because they have a limited durability, usually around 15 years. Biologic valves are implanted in patients 60 years or older and in younger patients that are accepting the risk of a reoperation, usually ages 50 to 60 years old. With the advent of percutaneous valves and the option of valve in valve, the horizon has expanded to indicate biologic valves as a bridge to a TAVR in many patients younger than 60.

There are many procedures for selected patients younger than 50 years of age that avoid the use of blood thinners or there is a true contra-indication and they represent a treatment dilemma. Fortunately, there are some procedures that can be performed to overcome this issue. These operations are more complex and require training and additional expertise. Our surgeons are known in the region for the performance and excellent outcomes with these procedures.

1. Valve sparing aortic root replacement (David Procedure) is frequently performed in patients with leaking valves and aneurysm in the proximal aorta. The aneurysm is resected and the valve with its annulus is reimplanted in a graft of Dacron material. In expert hands, this operation is long-lasting and patients enjoy a normal lifestyle without restrictions.
2. Aortic valve repair includes different techniques to repair leaflet problems, commonly in bicuspid valves. It allows younger patients to avoid an artificial valve but with a variable durability.
3. Biologic porcine aortic roots are used to replace the aortic valve and the proximal part of the aorta in patients that have a contraindication to use blood thinners. They have a durability up to 15 years or more in some patients.
4. Homograft replacement of the proximal aorta is used in patients with serious aortic valve infection and abscess to avoid the risk of prosthetic valve reinfection. A cadaveric human valve and aortic root is prepared and preserved with low temperature (-132 ˚C) and is transplanted to the patient. The tissue is denaturalized therefore no antirejection drugs are needed.
5. The Ross procedure is an excellent procedure for young patients (<40 years) that have aortic stenosis and wish to return to normal lifestyle. It involves the resection of the patients own pulmonary valve and root and transfer it to the aortic position and then place a pulmonary homograft to replace the donor valve. Durability is excellent and patients commonly enjoy a quick return to normal lifestyle