Aortic Valve Replacement: Minimally Invasive

What is minimally invasive aortic valve replacement?

A minimally invasive aortic valve replacement is a surgery to replace a poorly working aortic valve with an artificial valve without the need for open heart surgery. The surgery is called minimally invasive because it uses a smaller cut (incision) than a traditional open repair. This may lead to easier and faster recovery from surgery.

The heart has 4 valves. These valves help blood flow through the heart’s 4 chambers and out to your body by promoting forward flow and preventing backflow. The aortic valve lies between the left ventricle (the left pumping chamber of the heart) and the aorta (the blood vessel that carries blood away from the heart to the rest of the body).

Why might I need a minimally invasive aortic valve replacement?

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 can't 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)

What are the risks of minimally invasive aortic valve replacement?

There are certain risks with any type of surgery. Your risks will vary based on your medical condition, your age, and other factors. 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, possibly needing a pacemaker

• Blood clots leading to stroke or heart attack

• Complications from anesthesia

• Pneumonia

• Death

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

• Chronic illness

• Other heart conditions, including disease in the coronary arteries

• Lung problems

• Being older

• Being overweight

• Being a smoker

• Infections

• Diabetes

• Chronic kidney problems

How do I get ready for a minimally invasive aortic valve replacement?

As you plan for the surgery, you and your healthcare provider 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 the risk for blood clots is less. As a result, you would not need to take blood thinning medicine.

• 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 healthcare provider about how to get ready for your upcoming surgery. Remember to:

• Follow any directions you are given for not eating or drinking before surgery.

• Try to stop smoking before your surgery. Ask your provider for ways to help.

• Ask your provider if you need to stop taking certain medicines before your surgery. Tell them if you usually take blood-thinning medicines, such as warfarin or aspirin. Follow your provider's directions about which medicines should be stopped before surgery, and when, as well as which medicines should be continued.

Follow your healthcare provider's instructions about when to come to the hospital before your surgery. Talk with your provider and ask any questions you have about the procedure.

You may also need some routine tests before the procedure to assess your health. 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)

A short time before the surgery, someone may give you medicines to help you relax. In most cases, your surgery will take place as planned. But sometimes another emergency might delay your operation.

What happens during a minimally invasive aortic valve replacement?

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

• A healthcare provider 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 surgery will take several hours. Family and friends should stay in the waiting room, so the surgeon can update them.

• Several different approaches may be 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 do the surgery. Your healthcare provider will review all of your choices with you along with their risks and benefits.    

• During the procedure, 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.

• Your heart will gradually be allowed to take over the work of circulation. The surgery team will remove you from the heart-lung machine.

• The team will then sew or staple the incision in your skin back together.

What happens after a minimally invasive aortic valve replacement?

In the hospital

• 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 check your vital signs, such as your heart rate. You may be hooked 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. The tube is usually removed 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.

• Soon after surgery, you will likely be encouraged to get up and sit in a chair. In a day or 2, you should be able to 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 once the breathing tube is removed, usually the day after surgery. You can have regular foods as soon as you feel ready to eat.

• You may need to wear elastic stockings or compression devices on your legs to help blood circulate through your leg veins.

• You will probably need to stay in the hospital for several days, but this may vary from patient to patient.

At home

• Make sure you have someone to drive you home from the hospital. You will also need some help at home for a while.

• Be sure to keep all follow-up appointments. You'll likely have your stitches or staples removed in a follow-up appointment in 7 to 10 days.

• Be aware that you may tire easily after the surgery, but you will slowly 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 weigh yourself every day. Tell your healthcare provider if your temperature is over 100.4°F (38°C) or as directed, or if your weight changes.

• Call your provider if you have chest pain, shortness of breath, or swelling in your legs.

• Ask your provider when it is safe for you to drive.

• Don't lift anything heavy for several weeks. Ask your provider what is safe for you to lift.

• Follow all the directions your provider gives you for medicine, exercise, diet, and wound care.

• Make sure all your dentists and other healthcare providers 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.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure and who will do it

• Who will do the test or procedure and what that person's qualifications are

• What would happen if you didn't have the test or procedure

• Any alternative tests or procedures to think about

• How long it will take to get the results

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems or an emergency

• How much you will have to pay for the test or procedure