Aortic Valve Anatomy
The aortic valve is located between the left ventricle of the heart and the aorta pipe. It is the last heart valve through which blood flows from the heart chambers to the body. The aortic valve opens when the big pumping chamber of the heart called the left ventricle contracts (systole) and closes when the left ventricle relaxes (diastole) to prevent blood flowing back towards the heart. The normal aortic valve anatomy consists of three leaflets which look just like the sign on the front bonnet of a Mercedes car. In some patients, the aortic valve is made up of two leaflets. This is called a bicuspid valve.
Diseases of The Aortic Valve
The aortic valve can be affected by diseases restricting leaflet motion, producing aortic valve stenosis (when the valve is narrowed). In some cases, a weakness in the aortic wall, or in the aortic valve leaflet itself can produce a leaky valve, which is called aortic valve regurgitation (aortic valve leak).
Here are some of the commonest causes of aortic valve disease:
Aged Related Aortic Valve Stenosis
Age related wear and tear is one of the commonest causes of aortic valve stenosis. As we get older the wear and tear on the aortic valve can lead to calcification. This calcification creates progressively rigid aortic valve leaflets which, like jammed doors, fail to open properly. This is called aortic valve stenosis.
Bicuspid Aortic Valve Disease
Bicuspid aortic valve is a congenital abnormality of the aortic valve anatomy where the aortic valve is made up of only two leaflets rather than three leaflets. This anatomy is associated with early damage and calcification of the aortic valve causing aortic valve stenosis. Bicuspid aortic valves are also associated with aneurysm (swelling) of the beginning of the major aorta pipe which may also require surgical replacement when the size exceeds a critical diameter. Bicuspid aortic valves do not always calcify and stenose. Instead, they can become very floppy. This leads to leaking of the aortic valve called aortic valve regurgitation. Aneurysm of the aorta is also seen in this setting. Patients with bicuspid aortic valve disease present much earlier in life with aortic valve disease.
Patients with underlying aortic valve disease can develop infection of the aortic valve. Patients are often extremely unwell with this condition and treatment requires intravenous antibiotics. Aortic valve replacement is often required if the aortic valve becomes damaged by the infection. The common source of infection is grumbling tooth infection. It is therefore very important that if you have heart valve disease, or indeed if you have undergone heart valve replacement, that you visit the dentist regularly, and practice good dental hygiene.
Symptoms of Aortic Valve Stenosis
The symptoms of aortic valve stenosis are progressive over time. Patients can feel short of breath, experience reduced energy levels, lower exercise capacity and suffer from palpitations. Dizziness, chest pain and blackouts are very serious signs that aortic valve stenosis may be severe and require aortic valve replacement surgery. Medication is not helpful in the treatment of severe aortic valve stenosis and urgent surgery is required to improve symptoms and prevent sudden death.
Symptoms of Aortic Valve Regurgitation
Patients with aortic valve regurgitation can tolerate a leaky aortic valve for many years before they become symptomatic. Severe aortic valve regurgitation produces, breathlessness, lethargy, palpitations, and swollen ankles. Patients with aortic valve regurgitation should be monitored by an expert heart valve team to ensure that the timing of surgery is made at the right time. Patients can often have their aortic valve repaired especially in the setting of associated aneurysm of the aorta.
Aortic Valve Replacement Surgery
When certain criteria are met, your heart surgeon will recommend replacement of the aortic valve. These are usually when symptoms develop and certainly when the heart show signs that it is struggling to work properly. In all cases of aortic valve stenosis and some cases of aortic valve regurgitation, aortic valve replacement surgery is required.
Traditionally, aortic valve replacement surgery is performed through a large cut through the breastbone. Pipes are placed into the heart to allow the surgeon to use a sophisticated machine to take over the work of the heart and lungs. The heart is stopped, and the major aorta pipe is opened. Inside the aorta pipe lies the aortic valve. The aortic valve is removed, and a new aortic valve replacement is placed into the aorta to replace the disease aortic valve. The types of aortic valve replacement prostheses include mechanical valves (metal or carbon), or tissue valves (pig or cow). You can learn more about mechanical and tissue aortic valves here.
Once the new valve has been inserted, the aorta pipe is closed with nylon stitches, and the heart is restarted. This procedure has been used for many years and is both very safe and very effective. The surgery will resolve symptoms and in nearly all cases will result in a longer healthier life.
One of the drawbacks of this approach is that the breastbone takes 12 weeks to fully heal. There is also a small but important risk of bone infection, increased pain, and a large and unappealing scar.
Keyhole Aortic Valve Replacement Surgery
Ministernotomy Aortic Valve Replacement (Partial Breastbone Cut)
More recently, some surgeons have developed expertise in performing keyhole aortic valve replacement. In this procedure, aortic valve replacement is performed by making a small cut in the breastbone rather than a full cut. This surgery results in less risk of infection, less bleeding and quicker mobilisation. There is also some evidence to suggest better long-term life span than with full breastbone cut. This cut still takes 12 weeks to heal.
Minithoracotomy Aortic Valve Replacement (Between the ribs with no broken bone)
Some, highly skilled surgeons are now even able to perform keyhole aortic valve replacement WITHOUT breaking the breastbone at all. This procedure is performed through a 4cm incision between the ribs over the right chest. The biggest benefit of this incision is that healing occurs in 5-7 days instead of 12 weeks. Patients experience less pain than with the full and partial breastbone cut, and the risk of serious bone infection is reduced to near zero.
Mr Birdi and his team at The Keyhole Heart Clinic recommend minithoracotomy aortic valve replacement in all patients who are suitable for keyhole heart surgery because of the swifter healing process compared to breastbone approaches. Other benefits include:
- Less recovery time necessary – wound healing takes 7 days rather than 3 months
- Less bleeding – the incision is smaller, meaning less bleeding
- Less chance of infection – as the bone is not broken, there’s little chance of bone infection
- Smaller, less noticeable scarring – is more aesthetically pleasing and easier to conceal
Learn more about keyhole aortic valve replacement surgery here.
Transcatheter Aortic Valve Replacement?
Transcatheter Aortic Valve Replacement is also known as TAVI or TAVR. During this procedure, suitable patients have their aortic valve replaced by inserting a collapsed new tissue aortic valve replacement through the groin over a wire. This is a great treatment for patients who are deemed too risky for traditional aortic valve replacement surgery. The evidence is indicating that whenever keyhole aortic valve replacement surgery can be performed, particularly with newer surgical aortic valve replacement technologies, the results are better. Surgery leads to significantly less leaks around the edges of the valve compared to TAVI. We know that these leaks can reduce long term life span. Surgery also leads to a lower risk of pacemaker insertion, and better long-term survival, and better valve durability compared to TAVI. Learn more about surgery versus TAVI here.
Aortic Valve Replacement Cost
Traditional and keyhole aortic valve replacement cost is usually between £35,000 and £40,000. This includes your hospital stay, operation costs including your heart valve replacement, and the clinical fees of your surgeon and anaesthetist. TAVI is often much more expensive mainly because of the cost of the TAVI valve itself. TAVI valves are currently very expensive, not because they are better, but more because of the costs of the research and development. TAVI can cost anywhere upward from £50,000.
How Can Mr Birdi and His Team Help You?
Mr Birdi and his team are highly skilled and experienced in the treatment of aortic valve disease using traditional, minimally invasive and TAVI techniques.
Mr Birdi says:
“The modern heart valve team need to be experienced in all types of treatment for aortic valve disease. It is also essential to remain familiar with clinical evidence and to relate this to each specific patient to optimise their individual outcome from treatment”
If you have any questions about keyhole surgery for Aortic Valve Replacement London, we would love to answer them. Please feel free to get in touch here, and our dedicated team of experts will get back to you as soon as possible!