This leaflet is designed to help you to examine the options you have when your aortic valve needs replacing. Some valves require surgery because they become narrowed, and others require surgery because they leak.
The choice of procedure to a certain extent depends on what is wrong with the valve. Your cardiologist and surgeon will be able to discuss these options with you in more detail.
Balloon Valvuloplasty
This procedure is only suitable for people with tightly narrowed valves of a particular type. It involves passing a balloon through the blood vessels in the groin to the narrowed valve. The balloon is then inflated and stretches the valve open. While the procedure works well in some people, there is a risk that the procedure could tear the valve, leading it to leak significantly. This would require an open heart valve replacement operation to fix it.
Tissue Aortic Valve Replacement
This is an open heart operation which can be used in patients who have both narrowed and/or leaky aortic valves. It involves taking out your own damaged valve and replacing it with a valve engineered from a pig or cow heart valve. You would be in hospital for around a week after the operation. The main drawback with tissue valves is that they last on average 10 years before they need to be replaced. This would most commonly be a further open heart operation.
Their main advantage is that you usually do not need to take warfarin (blood thinning medication) afterwards.
Mechanical/Metal Aortic Valve Replacement
This is an open heart operation which is used in patients who have both narrowed and leaky aortic valves. It involves taking out your own damaged valve and replacing it with a metal valve. You would be in hospital for around a week after the operation. You would need to take warfarin tablets for life to avoid blood clots forming on the valve.
Warfarin must be taken properly to try to ensure that blood clots do not form on the valve. Regular blood tests are required to ensure the correct dose of warfarin is prescribed. It thins the blood and, whilst does not make patients bleed, if you do have an injury, you will likely bleed more. You may also notice a ticking noise when the valve is first implanted. Usually patients become less aware of this with time.
The main advantage to having a mechanical valve replacement is that it should last for many years, possibly even forever, which is balanced against the above disadvantages.
Pregnancy in patients with mechanical heart valves carries risk to both a mother and baby. Warfarin can affect the development of a fetus at the same time the mother is at a higher risk of both blood clot formation and bleeding. This should be kept in mind when making decisions about valve type.
Ross Operation
The Ross operation is an open heart operation which involves removing the patient’s own pulmonary valve, on the right side of the heart and swapping this to the left side of the heart where the diseased aortic valve has been removed. In the pulmonary valve position, a ‘homograft’ is inserted which is a tube with a human donor valve inside of it.
This often works well as the patient’s own pulmonary valve can cope reasonably well with the higher pressure on the left side of the heart and the donor valve works well with the lower pressure on the right side of the heart. You would be in hospital for around a week after the operation. This operation avoids the need for warfarin.
The Ross operation should last for many years. The main problem that we see in patients who have had a Ross operation is stretch of the aorta. As the aorta stretches, the ‘neo-aortic’ valve may also stretch and start to leak. This problem can become severe enough to require a further open heart operation. The valve may also become thickened and narrow.
The pulmonary homograft can become narrow and leaky. If these problems are severe, further procedures or surgery to fix then may be required. We can often address homograft problems via a keyhole procedure.
Not everyone can have a Ross operation so your cardiologist will discuss this with you.
The Ross Operation
Bicuspid Aortic Valve
In this video, we’ll discuss bicuspid aortic valve, a congenital heart condition. You may want to view our video on the normal heart before watching this one.
The aortic valve is located between the left ventricle and the aorta. It allows blood to flow from the heart into the aorta, from where it travels to the rest of the body. A normal aortic valve has three leaflets that open to let blood out and close to prevent blood from flowing back into the heart.
A bicuspid aortic valve has only two leaflets instead of three. It affects about 1 to 2 in 100 people and can sometimes run in families. While many people with a bicuspid aortic valve experience no problems, the valve’s function can deteriorate over time, leading to narrowing, leakage, or both.
Aortic Stenosis
Aortic stenosis is when the valve becomes narrowed, meaning it doesn’t open as fully as it should. This forces the heart to work harder to pump blood. Mild or moderate stenosis is usually manageable with regular monitoring. However, as the condition worsens, the left ventricle may become thicker, and symptoms such as breathlessness, chest discomfort, dizziness, or fainting may occur.
Aortic Regurgitation
In aortic regurgitation (or incompetence), the valve doesn’t close properly, allowing blood to leak back into the left ventricle. If severe, this can cause the left ventricle to enlarge and weaken, impairing its ability to pump blood effectively.
Many patients with a bicuspid aortic valve develop both stenosis and regurgitation, a condition called mixed aortic valve disease.
Aortic Dilatation
It’s also common for the aorta itself to enlarge, a condition known as aortic dilatation. While this doesn’t immediately affect heart function, if the aorta becomes too large, it can tear, which is life-threatening.
Treatment Options
When stenosis or regurgitation becomes severe, treatment may be necessary. In some cases, aortic balloon valvuloplasty (a minimally invasive procedure) can treat stenosis. A balloon is passed through the aorta and inflated at the valve, which opens it up. However, for more severe cases, aortic valve replacement via open-heart surgery is usually required.
There are two main types of valve replacement:
1. Mechanical valves, made of carbon and metal, last a lifetime but require lifelong blood thinning (e.g., warfarin) to prevent clots.
2. Tissue valves, made from animal tissue (typically pig or cow), don’t require long-term blood thinners, but have a limited lifespan and may need to be replaced, especially in younger patients.
The choice of valve type depends on the patient’s age, health, and lifestyle.
In certain cases, the Ross procedure, an alternative surgical approach, may be recommended. For more information on this, see our separate video on the Ross procedure.
TAVI
A TAVI (Transcatheter Aortic Valve Implantation) involves implantation of a new valve by the keyhole technique via the large blood vessels in the groin. It is not currently recommended in patients who would otherwise be fit for an operation and is currently only offered to a small number of patients with congenital heart disease in very specific situations.
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ACHD Specialist Nurses
For clinical queries, please contact the ACHD Specialist Nurses.
Further Support and Advice
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