Aortic Valve Disease

Overview

The human heart has four main valves—two on the left and two on the right. The aortic valve is one of the main valves on the left side of the heart. It is the outflow valve for the left ventricle, which means that it is the valve between the heart and the body. The aortic valve opens when the left ventricle squeezes to pump out blood, and closes in between heart beats to keep blood from going backward into the heart.

Normally, the aortic valve has three flaps (leaflets) that regulate blood flow by opening and closing, allowing blood to flow throughout your body.

Aortic valve disease occurs when the aortic valve doesn’t work properly.

Aorta

The aorta is the main artery that carries blood out of the heart to the rest of the body. Blood flows out of the heart and into the aorta through the aortic valve.

Aortic Valve
Normal Aortic Valvue

The aortic valve is one of the two main valves on the left side of your heart. Normally, the aortic valve has three flaps (leaflets) that regulate blood flow by opening and closing, allowing blood to flow throughout your body.

Left Ventricle

One of the four chambers of the heart; the left ventricle pumps oxygen-rich blood through the aortic valve and the aorta to the rest of your body.

Aortic Valve
Aortic Valvue with Aortic Stenosis

In aortic stenosis, the aortic valve becomes narrowed and does not open fully. This decreases blood flow from your heart to the rest of your body.

Left Ventricle

As the aortic valve narrows, the left ventricle has to work harder to pump blood out through the valve. To do this extra work, the muscles in the ventricle walls become thicker. This can lead to problems over time.

Aortic Valve
Aortic Valvue with Aortic Insufficiency

In aortic insufficiency, the aortic valve does not close tightly. This allows blood to leak back from the aorta into the left ventricle.

Left Ventricle

Because the aortic valve does not close tightly with aortic insufficiency, blood can leak back into the left ventricle from the aorta.

Use the image to the right to learn more about aortic valve disease. Click on the red buttons to read about the aorta, aortic valve, and left ventricle. Use the gray drop-down menu to see how the heart changes shape and the blood flow through the aortic valve changes with aortic stenosis and aortic insufficiency.
Types of Aortic Valve Disease

Types of Aortic Valve Disease

Valve leaflets open wide to let blood through, and close tightly to keep it from going backward.

Normal aortic valve: Valve leaflets open wide to let blood through, and close tightly to keep it from going backward.

 

There are two main types of aortic valve disease: 

  1. Regurgitation (also known as aortic insufficiency) — the valve does not close completely, allowing blood to leak backward into the heart
  2. Stenosis — the valve does not open enough to allow blood to leave the heart and spread to the body 

 

Watch the video below as Dr. Robbin Cohen describes aortic stenosis

Causes and Symptoms

Causes and Symptoms

The aortic valve may be abnormal from birth (congenital), or it could become diseased with age (acquired). 

The most common congenital aortic valve abnormality, called a bicuspid aortic valve, occurs when the valve has only two leaflets (bicuspid) instead of three (tricuspid). This prevents the valve from opening or closing completely. Although the abnormality has been there since birth, symptoms may not be felt until adulthood. Your physician may be able to hear distinctive murmurs (abnormal sounds that the doctor can hear with his/her stethoscope) when listening to your heart.

Copyright: alila/123RF Stock Photo

Acquired aortic valve disease occurs because your valve simply wears out over time, and usually happens as you age. Calcium collects on the valve and can cause the leaflets to stiffen and narrow, which limits their motion.

If the aorta—the main blood vessel coming out of the heart—is diseased, this also can lead to problems with the aortic valve.

A faulty or failing aortic valve may cause symptoms such as shortness of breath, chest pain, and dizziness or loss of consciousness (passing out). These symptoms are due to the heart having to work harder because of the narrowed or leaky valve.

Early on, these symptoms may be noticeable only when exercising, but as the disease progresses, you could experience shortness of breath with minimal or no activity.

Some patients will be unable to sleep flat in bed or may awaken short of breath. Another potential symptom is swollen feet, particularly in the late afternoon or early evening.

Diagnosis and Treatment Options

Diagnosis and Treatment Options

There is no one test that can diagnose aortic valve disease, so your doctor may recommend one or more of the following: electrocardiogram (EKG), echocardiogram (echo), chest x-ray, blood tests, and coronary angiography. For more information on these tests, visit our common diagnostic tests page.

Currently, NO MEDICATION can cure aortic valve disease, so it is most commonly treated with surgery.

Aortic stenosis can only be treated with aortic valve replacement. Sometimes, aortic valves that are leaking (regurgitant) can be repaired. Together with you and your medical team, your cardiothoracic surgeon will determine the best treatment option for you based on your symptoms and test results. You can print these sample questions to use as a basis for discussion with your doctor.

You also can access the STS Risk Calculator, which can help calculate your risk of death or other complications from certain types of heart surgery. The results can help you and your doctor to determine the best course of treatment.

SURGICAL TREATMENT OPTIONS FOR AORTIC VALVE DISEASE

Surgical Aortic Valve Replacement

Surgical aortic valve replacement (SAVR), performed by a cardiothoracic surgeon, involves making an incision in the chest in order to get to the heart and aortic valve. The heart is stopped, during which time the blood pressure and oxygen levels are maintained with a heart-lung machine (cardiopulmonary bypass). The aorta is opened and the diseased valve removed. It is then replaced with an artificial valve (prosthesis). 

There are two valve options for aortic valve replacement (AVR) – mechanical valves (metal) or biological valves (tissue). 

The principal advantage of mechanical valves is their durability—they do not wear out; however, blood tends to clot on mechanical valves, so patients must take blood thinning medication (anticoagulants) for the rest of their lives. There is also a small risk of stroke due to blood clotting.

Biological valves are most commonly made from animal tissue. Biological valves are less likely to cause blood clots, but they also are less durable than mechanical valves and may need to be replaced in the future.

Your medical team will discuss with you the advantages and disadvantages of both valve types. Regardless of which type of valve you choose, there are two different surgical approaches that can be utilized: traditional AVR or minimally invasive. 

During traditional AVR, the cardiothoracic surgeon makes a 6- to 8-inch incision down the center of your breastbone (sternum) to open the chest, providing direct access to your heart. In minimally invasive surgery, the cardiothoracic surgeon makes a 2- to 4-inch, J-shaped incision that opens part of your chest. This can potentially reduce hospital stay.

Minimally invasive AVR is not appropriate for all patients, but your cardiothoracic surgeon will review the recommended approach to surgery that is safest for you based on your individual symptoms and circumstances. 

  • Trifecta Heart Valve Replacement_St Jude Medical

Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a form of minimally invasive surgery that does not require opening of the breastbone. It is used to treat aortic stenosis, and is also referred to as transcatheter aortic valve implantation (TAVI). 

Surgeons use TAVR when traditional surgery presents too many risks. For example, your surgeon may consider TAVR if you have ever been diagnosed with advanced heart, lung, liver, or kidney disease. It is important to know that not every patient is a candidate for this procedure, so talk with your surgeon to decide what treatment option is safest for you.  

During TAVR, your surgeon usually will access the diseased valve through a blood vessel in your leg (transfemoral) or a small incision in your chest, along the ribcage (transapical). There are other techniques for reaching the aortic valve (transaortic or transcarotid) that your cardiothoracic surgeon may discuss with you, depending on what is right for you. 

A hollow tube (catheter) is inserted into your artery through the access point, and your surgeon will use a special kind of x-ray (fluoroscopy) to guide the catheter through your blood vessels to your heart.

Click here to watch an animated video of TAVR on our YouTube page

Once the catheter reaches the diseased aortic valve, the replacement valve is then passed through the catheter. A balloon is expanded to press the replacement valve into place. When your surgeon is certain the new valve is securely in place, the catheter will be withdrawn from your body through the original access point.

Because not all patients are eligible for TAVR, be sure to speak with your doctor about what form of treatment is best for you. 

Aortic Valve Repair

While the aortic valve is usually replaced, repair may be an option in certain cases, including: 

Bicuspid aortic valve repair — The aortic valve leaflets may be reshaped to allow the valve to open and close more completely. This procedure can be used to treat leaking valves (aortic regurgitation), but it cannot be used to treat aortic stenosis.

Repair of valve tears or holes — Tears or holes on the valve leaflets can be patched with a patient’s own tissue. 

Recovery

Recovery

Most aortic valve surgeries have a very low rate of complications; however, potential complications of all surgical options include bleeding, infection, irregular heart rhythm, stroke, or heart attack. 

Immediately after surgery, you likely will have a tube in your throat so your breathing can be assisted by a ventilator.

The tube will be removed once you are able to breathe completely on your own. This usually happens within a few hours, but your cardiothoracic surgeon will determine when it is safe to do so. You should anticipate spending several days, but likely not more than a week, recovering in the hospital, although the total length of time depends on your overall health, as well as the specific procedure you underwent. 

Once you’re home, it may be several more weeks until you are able to go back to work, depending on your job. Everyday activities such as driving and lifting heavy objects may be restricted for a period of time.

Blood thinning medication may be prescribed for 6 weeks to 3 months after surgery, but your need for this medication will be determined by your doctor. 

After your wounds have healed, you should be able to get back to your normal activities. Always tell a doctor about your valve surgery before any medical procedure. In particular, you may require preventative antibiotics when having dental work.

 

Reviewed by: Robbin G. Cohen, MD, with assistance from John Hallsten and Travis Schwartz
June 2016