Patients with aortic valve dysfunction who are experiencing symptoms of shortness of breath, dizzy spells, or chest discomfort (angina) should undergo valve replacement to improve their chances of survival and to alleviate their symptoms.
Patients who require an aortic valve replacement and don’t require any other valve or coronary bypass surgery may be suitable for minimally invasive surgery. Dr Bassin will assess each patient’s suitability depending on the results of the angiogram, CT scan, echocardiogram and various individual patient factors.
There is a group of patients that may not be eligible for surgery at all due to age, frailty or other medical conditions. These patients will be considered for TAVI, a non-surgical method of inserting a new valve through an artery in the leg.
What is involved?
There are two main approaches to minimally invasive aortic valve replacement: 1) partial sternal division (upper hemi-sternotomy) or 2) a right chest incision (right thoracotomy). Both of these are effective and safe techniques and they have some important differences.
The hemi-sternotomy approach still requires division of the breast-bone with a small incision in the midline (7cm) and allows good access to the aortic valve. This approach is suitable for almost all patients.
The right chest approach involves a 5cm incision under the collarbone and the heart is accessed between the second and third ribs. This approach doesn’t require the breast-bone to be touched at all and so has some important benefits. These include decreased pain, reduced blood loss and transfusion, an improved cosmetic result, and most importantly a faster recovery compared with the hemi-sternotomy. It is however not possible in all patients and depends on exactly where the aortic valve is located. A CT scan of the chest is obtained for all patients to assess which approach is best suited to them.
For both approaches the surgery is performed under general anaesthetic. The patient is connected to a heart-lung machine which pumps blood through the body whilst the heart is stopped and the aortic valve is replaced. The operation takes approximately 3-4 hours.
What is the recovery like?
The recovery is more rapid than traditional open heart surgery and this is particularly for the right chest approach. The operation takes 3-4 hours and you will generally wake up in intensive care later that day. There will be small tubes used to drain any residual fluid from around the heart and intravenous lines in your neck to sample blood and administer medications. These tubes and lines will be removed after 1-2 days and then you will be transferred to the ward to continue your recovery.
Once on the ward the focus is on mobilising to get you back on your feet and on breathing exercises to re-expand the lungs. The physiotherapists and nurses will teach you these techniques and will guide you towards recovery. Every patient is different and the assistance is tailored to your needs. Most minimally invasive patients can go home after 4-5 days.
Once at home, patients who have undergone minimally invasive surgery continue to recover a lot faster. Patients who have had a partial sternotomy are still limited in their function whilst waiting for the bone to heal, whereas those who have had a right chest approach have no formal limitations.
What are the benefits and risks of this procedure?
Although the operation is performed minimally invasively, there are still some of the usual risks associated with major heart surgery. The main benefits include a reduced rate of blood transfusion and infection, quicker recovery and a smaller scar. Additionally, patients who have had a right chest approach have no chance of a sternal wound infection. For patients who are otherwise well the risks of surgery include: death (1%), stroke (1%), significant wound infection (1%), kidney injury (2%), requirement for a permanent pacemaker (3%) and blood transfusion (15%). The risk can be higher if patients have other co-morbidities including advanced age, previous heart disease or stroke, lung disease or having undergone cardiac surgery previously.
Dr Bassin will explain these risks to each patient in person and how they pertain to their specific condition.
When can I drive?
You may drive 4 weeks following surgery, according to the national guidelines.