Aortic valve reconstruction is an operation in which the shape and function of a leaky (insufficient) aortic valve is restored without replacing the valve. Compared to valve replacement, aortic valve reconstruction has the lowest probability of valve-associated complications.
The aortic valve is a valve that closes the aorta at the base of the left ventricle. It is suspended from the aortic wall in the initial part of the aorta and consists of three pockets which, when folded out towards each other, fill and close the diameter of the aorta. Oxygen-rich blood leaves the heart here and is pumped through the aorta into the systemic circulation.
The pumping action of the heart presses the blood against the valve, which then opens. If the pressure decreases, the valve closes and prevents the blood from flowing back into the heart.
The four heart valves @ Dee-sign /AdobeStock
Every year, more than 12,000 people in Germany require surgery on the severely diseased aortic valve. Around 20 % of these operations are necessary because the valve has a severe insufficiency, i.e. leaks.
The heart needs the interaction of the heart muscle and heart valves to function properly. The most important heart valves are those of the left heart: the inlet valve (mitral valve) and the outlet valve (aortic valve).
The most common disorders affect the aortic valve. If it does not close completely, there is a leak and this is referred to as aortic valve insufficiency. In this case, blood flows from the aorta back into the heart.
The reverse occurs when the aortic valve does not open wide enough. It is narrowed and thus prevents enough blood from entering the body's circulation. This narrowing is known as aortic valve stenosis.
It is also possible for both disorders to occur in combination.
Aortic valve stenosis is the most common heart valve defect @ rob3000 /AdobeStock
In 50 % of cases, there is an accompanying widening of theascending aorta, which means that the pockets of the aortic valve no longer touch sufficiently and can therefore no longer close tightly. Very often, a deformation of one or more pockets, which disturbs the geometry of the valve, is seen as an accompanying or sole cause of the insufficiency.
Various causes can lead to insufficiency (leakage) of the aortic valve. In people under the age of 50, the most common cause is an abnormality of the aortic valve, in which the valve consists of only 2 pockets rather than 3. This can lead to deformation of the valve, which then becomes leaky over the course of years or decades.
In people over the age of 50, deformation of the pockets as a result of connective tissue wear and tear is the most important cause, often caused or accompanied by an enlargement of the aorta (main artery). Shrinkage of the valve, e.g. as a result of rheumatic fever, is rare today.
The leading symptom of aortic valve insufficiency is shortness of breath, which initially occurs during exertion and later also at rest. As people tend to adapt to slow changes, shortness of breath or the resulting decline in performance is often noticed first by others in the immediate environment.
Increasing fatigueas a result of physical work is occasionally experienced. Less common is the occurrence of chest pain, which is attributed to the heart. There are people who do not experience any symptoms despite considerable strain on the heart and in whom only echocardiography (cardiac echo) clearly shows the extent and significance of the valve damage.
In most patients, aortic valve insufficiency is tolerated over a longer period of time. The left ventricle (heart chamber) becomes more muscular and enlarges to absorb the load of the returning blood.
After years, changes develop which indicate that the heart's reserves are running low. This often means that the person affected or someone close to them notices that their physical performance is slowly declining or that they are increasingly short of breath under the same strain.
In others, in the absence of self-perceived symptoms, echocardiography reveals that the left ventricle is restricted in its contractility or has developed a pronounced enlargement. All these changes mean that the valve defect is no longer harmless, but that there is now a risk of heart failure and that life expectancy is limited.
At this point, it is then necessary to operate on the diseased aortic valve. The operation should be performed by an experienced heart surgeon.
The aim of the operation is to completely or at least largely normalize the shape and function of the aortic valve. This normalizes the heart function, the patient almost always notices that their performance improves and the symptoms are reduced or eliminated.
Compared to aortic valve replacement, these goals should be achieved with less likelihood of long-term side effects.
The information provided includes all significant advantages and disadvantages, including possible risks for the individual patient. Even if a reconstruction is highly likely to be feasible, surprising aspects may arise during the operation that make a new decision necessary.
It is therefore important to discuss not only the planned aortic valve reconstruction but also one of the possible replacement procedures as an alternative plan.
The operation in detail: The aim of the operation is to restore the shape and function of the patient's own aortic valve. This must be done precisely in order to bring the deformed aortic valve as close as possible to its normal shape and function.
For the operation, the chest is opened through the sternum and the patient is connected to the heart-lung machine after blood clotting has been inhibited. The heart is immobilized by introducing a cold solution.
For valve reconstruction, the aorta and aortic valve must first be stretched so that they are as close to normal as possible.
There are now standard measurement values for various dimensions of the aortic valve. These are measured in order to determine the individual plan for restoring normal function. In many cases, this plan involves correcting the overstretching of a pocket of the aortic valve by means of "suturing". Suitable surgical procedures exist for other problems.
After rewarming the body and restoring blood flow to the heart, the function of the heart and the reconstructed aortic valve is carefully checked with the swallow echo (TEE).
This is followed by weaning from the heart-lung machine. Blood clotting is normalized, wound drains are inserted and the chest is closed.
Echocardiography can be used to objectively determine the presence of aortic valve insufficiency. The most precise information can be obtained using a swallow echo (transesophageal echocardiography). If there is an enlargement of the aorta, this can be precisely documented using computer tomography (CT) or magnetic resonance imaging(MRI).
If there is an increased risk of narrowing of the coronary arteries due to age, family history or particular risk factors, a cardiac catheterization may be necessary.
The insufficiency/leaky aortic valve can currently only be treated by surgery. Large studies have shown that medical treatment does not bring any benefits in cases of severe leakage.
In principle, there are various alternative surgical procedures, all of which have specific advantages and disadvantages, and their use must be carefully considered for each individual patient.
Replacement of the aortic valve is the conventional treatment for advanced aortic insufficiency. Both mechanical and biological prostheses are safe. Mechanical prostheses lead to clot formation on the valve, so that lifelong use of blood clotting inhibitors is necessary. Nevertheless, there remains a small but real possibility of clotting and bleeding complications.
Biological prostheses have only a low tendency to form clots, so that the intake of blood clotting inhibitors is only necessary for 3 months. However, they do wear out over time, and this wear develops more rapidly the younger the patient is.
Mechanical heart valves @ pirke /AdobeStock
Younger people sometimes take advantage of the fact that the pulmonary valve is very similar in shape to the aortic valve. The pulmonary valve is then removed from its original location and implanted in the aorta(Ross operation).
In place of the original pulmonary valve, a biological valve is implanted, which is less stressed than in the aorta. The durability of this operation is good and it is not necessary to take blood clotting inhibitors. However, the operation involves 2 heart valves, although initially only one is diseased.
All procedures carry specific risks, including the possible need for a repeat operation.
In the last 5 years, new procedures have been developed in which a heart valve can be inserted using catheter technology to replace the aortic valve. These procedures are currently only suitable for selected patients.
Overall, the risk of aortic valve reconstruction is low. As with any heart operation, undesirable complications can occur, e.g. in the form of bleeding, cardiac arrhythmia, wound healing disorders, etc. The most important complication is the recurrence of a leak in the aortic valve, which, depending on its severity, may require a repeat operation.
The individual risk of the operation depends largely on age, the presence of other diseases and previous damage to the left ventricle. The surgeon can best explain this in a personal consultation.
The operation is followed by intensive care, where the circulation is carefully monitored, especially in the first few hours after the operation. Once the circulation is stable and oxygen uptake by the lungs is normal, the breathing tube can be removed. It is often possible to transfer the patient to the normal ward within 1 to 2 days. This is followed by gradual recovery.
Patients can speed up their recovery by getting out of bed more often in the first few days after the operation and walking consciously, i.e. exercising the body in doses. Climbing stairs is often possible after 5 or 6 days.
The various medical measures that are carried out include echocardiography, which is used to monitor the function of the aortic valve even after several days in order to objectify the success of the treatment.
The hospital stay of 6 to 10 days is followed by rehabilitation. Complete recovery can be expected after around 8 weeks.
The medication previously taken is usually continued before and after the operation. After the operation, the treating surgeon will consider whether the medication needs to be adjusted to the condition after the operation. Aspirin is often recommended for 2 months after the reconstruction.
The traditional replacement of the aortic valve is in principle a safe procedure, but it does have the aforementioned long-term disadvantages. Reconstruction is not always feasible with a leaky aortic valve. If it is possible and the shape of the aortic valve is correctly restored, fewer problems can be expected in the further course of the procedure.
The tendency to form clots is negligible and it is not normally necessary to take blood-thinning medication. The susceptibility to bacterial infections of the valve (endocarditis) is significantly lower than after mechanical or biological replacement.
In principle, however, the reconstruction of the aortic valve is a procedure for which there is only experience from the last 10 to 15 years, so that it is not yet possible to make any statements about a 20 or 30-year period.
Aortic valve insufficiency is one of several pathological changes in the aortic valve and often manifests itself as shortness of breath on exertion or reduced performance.
Accurate diagnosis and careful evaluation are important for planning the best possible treatment.
Traditionally, the valve is replaced with a mechanical or biological prosthesis. Reconstruction of the aortic valve is an effective treatment for the disease. Compared to valve replacement, it has the lowest likelihood of valve-associated complications.
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