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Surgical treatment of aortic valve disease

Nature Reviews Cardiology volume 10, pages 375–386 (2013)Cite this article

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Abstract

The development of intraoperative transoesophageal echocardiography together with improved understanding of the functional anatomy of the aortic valve have allowed the design of several new conservative procedures, such as aortic valve-sparing operations, to treat patients with aortic root aneurysms or aortic insufficiency. The long-term results of these procedures have been excellent, and >90% of patients are free from reoperation on the aortic valve 10–15 years after surgery. Incompetent bicuspid aortic valves can also be repaired if the cusps are pliable and without calcification. Nevertheless, most patients with aortic valve disease, particularly those with aortic stenosis, need aortic valve replacement. Matching a patient to the type and size of prosthetic aortic valve is difficult, because of the limited durability of bioprosthetic valves and the need for lifelong anticoagulation with mechanical valves. Prosthesis–patient mismatch might not affect survival in most patients, but is a determinant of prognosis in patients with impaired ventricular function. Young adults with aortic stenosis, particularly women during childbearing years, can be treated with the Ross procedure. Finally, poor candidates for surgery who have aortic stenosis can now be treated with catheter-based aortic valve implantation but, in this article, the current status of aortic valve surgery is reviewed.

Key Points

  • Aortic root aneurysms caused by an inherited condition, and dilatation of the ascending aorta associated with a bicuspid aortic valve, require surgical repair when the aortic diameter nears 50 mm

  • The native aortic valve is often preserved during surgery for aortic root aneurysms caused by an inherited condition

  • Matching a patient to the type and size of a prosthetic heart valve is challenging in aortic valve replacement

  • Bioprosthetic aortic valves provide better clinical outcomes than mechanical valves in older patients (aged ≥65 years)

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Figure 1
Figure 2: Dilatation of the sinotubular junction causes aortic insufficiency.
Figure 3: Dilatation of the aortic root.
Figure 4: Reimplantation of the aortic valve to treat patients with aortic root aneurysm.
Figure 5: Remodelling of the aortic root to treat patients with aortic root aneurysm.
Figure 6: Pulmonary autograft: aortic root replacement technique.
Figure 7: Pulmonary autograft: subcoronary and aortic inclusion techniques.
Figure 8: Replacement of the aortic root.

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  1. Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth Street 4N-453, Toronto, M5G 2C4, ON, Canada

    Tirone E. David

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David, T. Surgical treatment of aortic valve disease. Nat Rev Cardiol 10, 375–386 (2013). https://doi.org/10.1038/nrcardio.2013.72

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