Aortic Valve Replacement: Open

What is an open aortic valve replacement?

An open, invasive aortic valve replacement is a surgery to replace a poorly working aortic valve with an artificial valve. The heart has 4 valves. These valves help blood flow through the heart and out to the body by promoting forward flow and preventing backflow. The aortic valve lies between the left pumping chamber of the heart (ventricle) and the aorta. The aorta is the blood vessel that carries blood away from the heart to the rest of the body.

Under certain circumstances, your valve can stop working well. Your surgeon may use an artificial valve to replace your poorly working valve. This will ensure that blood can exit the heart and flow out to the body normally. The surgery is called "open" because it uses a traditional type of incision and separation of your breastbone (sternum) to expose your heart. This incision is larger than those in minimally invasive types of aortic valve replacement surgery.

Why might I need an open aortic valve replacement?

When your aortic valve isn't working well, you may need it fixed or replaced. Aortic valve stenosis or aortic valve regurgitation are 2 different types of problems that might need a valve replacement.

• Aortic stenosis. Your valve can't open fully. This means less blood is able to exit your heart.

• Aortic regurgitation. Your valve is leaky. Some blood leaks backward through the valve instead of moving out to the rest of your 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

• Leg swelling

• Dizziness

• Chest pain

• Passing out (fainting)

• An unpleasant awareness of your heartbeat

If these symptoms are present or get worse, surgery may be needed. Your healthcare provider may recommend the surgery based on testing, such as an echocardiogram (ultrasound of the heart) even if you don’t have significant symptoms. Surgery is most effective if symptoms are not too advanced.

Both aortic stenosis and aortic regurgitation can result from general aging of the valve. Other causes of aortic valve disease include:

• Heart birth defects such as a bicuspid aortic valve

• Bacterial infection of the heart valve

• A tear in the aorta

• Weakened, stretched aorta wall (aortic aneurysm)

• Certain genetic conditions such as Marfan syndrome

What are the risks of an open 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. Be sure to talk with your healthcare provider about any concerns that you have.

Most people who have open aortic valve replacement will have a successful outcome. But there are some possible risks. These include:

• Infection

• Bleeding

• Irregular heart rhythms, in some cases requiring a pacemaker

• Blood clots leading to stroke or heart attack

• Complications from anesthesia

• Need for more surgery

• Death

Certain things increase the risk of complications, such as:

• Chronic illness

• Other heart conditions, including disease in the coronary arteries

• Lung problems

• Increased age

• Being overweight

• Being a smoker

• Infections

• Diabetes

• Chronic kidney problems

• Frailty

How do I get ready for an open 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 don’t last as long as mechanical valves but the risk for blood clots is less.

• Mechanical valves are manmade. People with mechanical valves need to take blood-thinning medicines for the rest of their lives because of the risk for blood clots. Mechanical valves also have an increased risk for infection.

Talk with your healthcare provider about how to prepare for your upcoming surgery. Remember the following:

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

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

• You may need to stop taking certain medicines before your surgery. Follow your provider’s instructions if you usually take blood-thinning medicine like warfarin or aspirin.

Follow your provider's instructions about when to come to the hospital before your surgery. Ask them any questions that you have about the procedure.

You may 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

It is common to be nervous before a surgery. If needed, you can ask for medicine to help you relax before your surgery. In most cases your surgery will proceed as planned. But sometimes another emergency might delay your surgery for a short time.

What happens during an open aortic valve replacement?

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

• You will be given anesthesia before the surgery starts. This will cause you to sleep deeply and painlessly during the operation. Afterwards you won’t remember the surgery.

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

• Your surgeon will make an incision down the middle of your chest. To access your heart, your surgeon will separate your breastbone.

• 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 heart valve and replace it with a new valve.

• The surgery team will remove the heart-lung machine.

• The team will connect your breastbone back together.

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

What happens after an open aortic valve replacement?

In the hospital

• You will start your recovery in the 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 who have aortic valve replacement notice immediate symptom relief after their surgery.

• The team will watch your vital signs, such as your heart rate, blood pressure, and breathing. You will be hooked up to a monitors 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 will be removed when you are strong enough to breathe on your own. This is typically within 24 hours.

• You may have a chest tube to drain excess fluid from your chest.

• You may have small temporary pacemaker wires exiting from your chest

• Bandages will cover your incision. These can often off come off in a few days.

• You will feel some soreness. But you shouldn’t feel severe pain. If you have pain, you can ask for pain medicine.

• Soon after surgery, you'll likely be encouraged to get up and sit in a chair. In 1 or 2 a days, you should be able to walk with help.

• You may do breathing therapy. This helps remove fluids that collect in your lungs during and after surgery.

• You'll likely be able to drink liquids once the breathing tube is removed. This is often the day after surgery. You can have regular foods as soon as you can handle them.

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

• You'll likely need to stay in the hospital for a few days.

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.

• You may tire easily after the surgery, but you will slowly start to recover your strength. It may be a few weeks before you fully recover.

• 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). Also tell them if your weight changes.

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

• Don't lift anything heavy for a few weeks. Ask your provider about what is safe for you to lift. Also ask when you can go back to normal activity.

• Follow all the instructions your provider gives you for medicines, exercise, diet, and wound care. Depending on the type of valve your got, you may be given blood thinners to take

• Let all of your dentists and other healthcare providers know about your health history. You may need to take antibiotics before certain medical and dental procedures. This is to prevent getting an infection on your replacement valve.

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

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 are the possible side effects or complications are

• When and where you are to have the test or procedure

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

• What would  happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

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

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