Understanding Surgical and Transcatheter Replacement for Aortic Valve Disease

By

Marijke Vroomen Durning, RN

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Did you know that your heart beats an average of 100,000 times per day? This life-sustaining pump speeds up and slows down on demand and provides your body with the right flow of blood when it’s needed. But sometimes, especially as we age, the heart’s parts stop working properly, causing problems such as aortic valve disease. If this happens to you, you may need an aortic valve replacement.

As your blood moves through your heart, valves control the flow in and out of the heart’s chambers. The last valve, the aortic valve, pushes the blood out of your heart and into your body. The valve then closes temporarily to keep the blood from moving back and pooling in the heart. When this valve malfunctions, it’s called aortic valve disease. The aortic valve can develop aortic stenosis (narrowing of the valve) or aortic regurgitation (the valve doesn’t seal properly and allows blood to flow back into the heart). Aortic valve disease is the most common type of heart valve problem, affecting over 5 million adults in the United States.

How is aortic valve disease treated?

Aortic valve disease can be treated in a few ways, depending on the approach your doctor believes is the best treatment for you. Not everyone with aortic valve disease needs to have treatment right away. If your symptoms are mild to moderate, your doctor may choose to monitor you to see if your symptoms stay stable or get worse. However, if you have aortic valve stenosis and your aortic valve does need to be replaced, your doctor can replace it either through open-heart surgery, called surgical aortic valve replacement (SAVR) or with a newer procedure called a transcatheter aortic valve replacement (TAVR), sometimes known as a transcatheter aortic valve implantation (TAVI).

How does the doctor choose between SAVR and TAVR?

Open-heart surgery (SAVR) used to be the only way a surgeon could replace an aortic valve. Unfortunately, not everyone is strong enough to undergo such a big surgery and recovery. They may have other health problems that could make the procedure dangerous or the recovery difficult. So in the past, if a doctor felt that a patient wasn’t strong enough to survive open-heart surgery or that there was a risk of significant complications, the replacement would probably not be done.

TAVR has changed how aortic valve replacements are performed, making them available to some people who wouldn’t have been able to have the procedure in the past. Recently, TAVR also became an option for people at intermediate risk of complications from open-heart surgery. However, the technique does have its own risks, though. For example, with TAVR, the old valve is left in the heart and a new valve is placed inside it, pushing the old one out of the way. Unlike when a valve is completely replaced, as with SAVR, a new valve inside the old one may not seal off completely, causing some leaking. But for people who aren’t ideal candidates for open-heart surgery, TAVR may be their best option.

How is open-heart surgery done to replace an aortic valve?

Open-heart surgery is generally the first choice for most people who need an aortic valve replacement. An incision, usually about 6 to 8 inches long, is made down the center of the chest. The breastbone, the bone between the ribs, is separated so the surgeon can reach the heart. The patient is hooked up to a heart-lung machine, or heart-lung bypass machine, which acts as the heart during the surgery. The patient’s blood flows through the machine and back into the body while the surgeon removes the old aortic valve and replaces it with the new one.

The new valve may be a mechanical one, made of man-made materials, or it may be a tissue valve, from an animal or a human organ donation. Once the valve is sewn into place and is secure, the heart is restarted and takes back its role of pumping the blood.   

More minimally invasive surgical techniques are now available, but they can’t be performed on all patients, such as those who are obese, have severe valve damage, have atherosclerosis (clogged or blocked arteries), or need to have more than one valve replaced. This type of surgery is also not available in all facilities.

If a person is having minimally invasive surgery, the surgeon makes a few small incisions in the chest, near the aortic valve, and uses a miniature camera to visualize the heart, and special equipment or robotic arms to replace the valve. The advantages to this type of surgery are that it’s quicker to perform, and there is a shorter recovery period.  

How is TAVR performed?

If a patient is undergoing a TAVR procedure to replace the aortic valve instead of open-heart surgery, the heart is not stopped and there is no need for a heart-lung machine. Instead, the surgeon makes a small incision in the patient’s groin, to access the femoral artery. The surgeon then threads a long narrow catheter (tube) through the artery up to the heart until it gets to the aortic valve.

Using the catheter, the surgeon positions a deflated balloon and the new valve inside the old aortic valve. As the balloon is inflated, it opens the new valve, pushing it into place. Once the new valve is secure, the surgeon deflates the balloon, and removes it along with the catheter. The newly implanted valve begins working immediately.

Although TAVR is performed on patients who aren't ideal candidates for open-heart surgery, some patients have problems with their arteries and shouldn’t have TAVR done through the femoral artery. In these situations, their surgeon may do the same procedure, but with minimally invasive surgery, using small incisions in the chest.

All surgical procedures have risks, but aortic valve replacements have come a long way over the past couple of decades, making it possible for some people to have the procedures when they may not have had a chance just a little while ago.

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Medical Reviewers: William C. Lloyd III, MD, FACS Last Review Date: Mar 24, 2016

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