Determining the need for aortic valve replacement surgery

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Determining the need for aortic valve replacement surgery

The major decision in treating aortic valve regurgitation is whether to have aortic valve replacement surgery and, if so, when to do it.

First, you must determine the severity of your condition. Valve surgery is usually only performed if regurgitation is severe and in danger of doing irreparable damage to your heart. The risk of surgery is justified if the regurgitation is severe enough to threaten the health of your heart or your life.

The percentage of blood that leaves the left ventricle with each pump (ejection fraction) and the size of the left ventricle at rest determine the severity of aortic valve regurgitation. In the past, doctors replaced the aortic valve only when symptoms developed, an indication that regurgitation is severe. However, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines now recommend aortic valve replacement when the ejection fraction drops to 50% or the left ventricle is enlarged (dilated) to 55 mm or more.

These guidelines mean that you may need to replace the valve before you develop any symptoms. However, other risk factors including age, speed of deterioration, and overall health will also be considered in deciding the timing of surgery.

The more advanced your age and the poorer your overall health, the greater the risk that you will not survive surgery. These risk factors may cause you to delay surgery beyond the ACC/AHA guidelines. On the other hand, if your valve is deteriorating rapidly, your doctor may consider surgery sooner or may monitor your condition more frequently.

Assessing the possibility your condition will worsen

Another important question, along with the severity of regurgitation, is how likely it is that your condition will worsen soon. Your doctor will assess the progression of regurgitation by comparing the results of your most recent echocardiogram with your earlier echo results. If you have mild regurgitation, your doctor will probably perform an echo every 3 or 4 years because regurgitation usually progresses slowly. However, if your echo comparisons indicate that your regurgitation is worsening or your heart is enlarging or not pumping enough blood, your doctor may order echocardiograms more frequently. The faster the regurgitation progresses, the sooner you will need a valve replacement.

If your condition has been progressing slowly, you may be able to wait a little longer before having a valve replacement. However, if you have other compounding factors, such as high blood pressure or coronary artery disease (CAD), or both, the regurgitation is more likely to worsen soon, and surgery may be necessary in the near term.

Risks of surgery

The severity of regurgitation and the likelihood it will worsen need to be balanced against the risks involved with having a valve replacement surgery. During the operation, your sternum (breastbone) will be separated, which will require time to heal and may be uncomfortable during recovery. Your heart will be stopped during surgery and cut open so that the valve can be replaced. While your heart is stopped, the blood in your body will be pumped and oxygenated by a heart-lung machine.

Although most people have successful outcomes, the risk of death and serious problems during surgery is real. About 5% or less of people having valve surgery die.¹ Risks of surgery need to be weighed in the decision to replace the valve.

Sometimes other factors play a role in the decision to have surgery. When open chest surgery is already planned—for instance, coronary artery bypass surgery for coronary artery disease—then valve replacement is often done at the same time.

Second, while artificial valves are effective, they will wear out faster than a human valve. Eventually all artificial valves will need to be replaced if given a long enough period of time, and you will need to have valve replacement surgery again. By waiting to replace your valve until regurgitation is severe, you will limit the number of artificial valves and surgeries you will need in your lifetime.

Why not valve reconstruction or repair?

Unfortunately, valve reconstruction and repair are not generally viable treatments for aortic valve regurgitation. This is because of the very high pressure in the left ventricle. The additional pressure makes repair ineffective in the long term and replacement of the valve the only real surgical option.

References

Citations

1. Rahimtoola SH (2004). Aortic valve disease. In V Fuster et al., eds., Hurst's The Heart, 11th ed., vol. 2, pp. 1643–1667. New York: McGraw-Hill.

Credits

Last updated:	February 01, 2006
Author:	Merrill Hayden
Reviewed By:	Caroline S. Rhoads, MD - Internal Medicine, Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
Editors:	Kathleen M. Ariss, MS, Terrina Vail