Aortic valve repair/ valve sparing aortic root replacement (David’s procedure)

What type of patients:

  • Patients with leaking aortic valves
  • Patients with swollen (dilated) aorta affecting aortic valve

Who does surgery:

This is done by surgeons who have significant experience in doing this surgery. Your heart surgeon needs special training to be able to do this surgery. He also needs to have an experienced team that includes an anaesthetist who is able to assess your valve before and after your repair to ensure that a good result has been obtained. To maintain the skill and good outcome, your surgeon and his team should be doing this surgery on a regular basis. 

 

Tests before surgery:

Dr Joshi will organise a special preparation CT scan of your entire aorta. You may have had a scan done prior to seeing him but he will need to request a special scan to further assess the feasibility of this operation. The second test that he may organise is known as TOE (Transesophageal echocardiogram). This test is done by a cardiologist which Dr Joshi will organise.  This test is meant to assess the repairability of your valve. With this information Dr Joshi can better plan your surgery and also  inform you prior to surgery about the probability of repairing the valve successfully. 

Apart from above tests, other routine tests prior to heart surgery involve blood tests, x-ray and some other tests which will be done before or after you are admitted to hospital. 

About the Surgery:

This surgery usually takes longer than other usual heart surgeries. The operation can last up to 5 hrs. If your aorta needs to be replaced then Dr Joshi will use one of the commercially available artificial tubes (Figure 1) made from Dacron cloth which is designed to last life long. He may have to use a commercially available ring to reshape your repaired valve. Sometimes to repair a leaflet he may use a patch made from a harvested pig heart to reconstruct one of the leaflets . He removes the unwanted aorta and leaves your valve attached to its skeleton. He then stitches your valve back into the new tube. He checks the valve is geometrically symmetrical and assesses again with intraoperative echo prior to separating you from the heart lung machine. In rare cases, the repaired valve does not function well and in that case Dr Joshi will replace your valve with a pre decided tissue or mechanical valve. 

Complications:

The risk of major complications is low and usually under 1% unless specified by your medical background. This will be discussed in your consultation with Dr Joshi. 

Non major complication, particularly with this surgery is the risk of permanent pacemaker (PPM) which is about 5%. This surgery involves doing some intricate dissection around the electrical system of the heart and there is a risk of accidental injury to it. If your electrical system does not recover within a week then Dr Joshi will ask the cardiologist to insert a PPM under local anaesthetic prior to your discharge from hospital. Insertion of PPM does not hold you long in hospital or affect your recovery adversely.

Younger patients are a risk of developing  fluid build up around the heart. This typically manifests at about 4 weeks. This is reactive fluid and younger patients are more prone. It is not harmful but can make some patients feel short of breath or feverish. If that happens you should present to ED or notify your cardiologist or Dr Joshi. The treatment involves anti-inflammatory medications and in some cases taking the fluid out with a needle or small incision. 

How long will the repaired valve last:

The following factors decides or affects the long term results of valve repair:

  • Your age, and condition that caused your valve to leak
  • Condition of your heart valve
  • How complex the valve repair was at the time of surgery
  • Experience of the operating surgeon
  • The result at the end of surgery

People are usually born with an aortic valve with three leaflets or two leaflets. If you have a three leaflet valve and absence of calcification then you have a 75% chance that your valve can last up to 20 yrs or more and if you have a two leaflet valve then you have a 75% chance that it will last up to 15 yrs. Let’s put that in perspective depending on your age or condition. If you are 60 yrs or more this operation allows you to live your life without being on blood thinners and have the lowest risk of stroke or infection. If you are younger than 60 yrs then you can live the majority of your active life without being on blood thinners  and can have another procedure (chance of that is only 25%) and have tissue valve replacement and still avoid being on blood thinners. 

Why not just have a tissue or mechanical valve instead of a repair?

Our blood circulation system is not designed to have any foreign material in it. Anything in your heart or circulatory system exposes you to a lifetime risk of infection or device related complications. In the case of your heart valve, two major life time complications are risk of stroke and risk of infection. 

Heart valve replacement surgery is replacing a life threatening problem with a relatively benign problem of a new heart valve. Every surgical heart valve has an ongoing risk of stroke or infection. The risks of stroke are even higher if you have a TAVI valve. If you have a mechanical valve then it does require you to take blood thinners on a daily basis lifelong and does expose you to a small but definite risk of major bleeding. The longer you live the more the risk. Therefore, having your own valve repaired and re implanted in your heart eliminates or greatly minimizes the risk of stroke and infection. 

Remember, there is nothing like your own tissue. It is always best to keep it if you can. 

How would I know that my repaired valve is becoming faulty?

After your surgery, Dr Joshi will discharge you back to your cardiologist. The cardiologist will generally organise yearly or two yearly echo to keep an eye on your repaired valve. If your valve starts to leak again then it does not mean that you need surgery straight away. The timing will be decided by your cardiologist and surgeon in collaboration. You may develop symptoms of shortness of breath, lack of energy or being tired. Consult your cardiologist if you develop these symptoms and he can assess you further.  You need to notify Dr Joshi if there is a new problem with your repaired valve. 

When you agree to have surgery with Dr Joshi, you are automatically giving him consent for taking operative photos or videos which may be used for medical records , teaching, presentation or publication  purposes. If you choose not to do so then it is your responsibility to inform him prior to surgery. 

You will be in a room once you arrive on the ward. You will be connected to a monitor so nurses can see any alarming signals from your heart rhythm. You need to be careful that the monitor leads remain attached to your body properly. If they get detached, you should inform your nurse by pressing the call button. The most important thing in the ward is to start getting more mobile. You will be asked to walk 5 times every day and your physio will teach you exercises. Dr Joshi will give instructions for removal of pacing wires. Removal of wires and lines are very tolerable. By day 5-7, you will be asked by the physiotherapist to complete two flights of stairs. This is done to assess your fitness to be discharged home and your independent mobility. You will have regular blood tests and chest x rays. Electrolytes are frequently replaced with intravenous infusions.

Most patients are expected to be discharged after 7 days. You will receive discharge education from your nurse who will give you information about incisions, dressings, showering etc. A pharmacist will visit you to discuss your medications which might have changed a little bit. You must remember to take your discharge file with you, which will include all your instructions regarding follow up appointments,a medication list and other material. You should carry this file with you when you visit your cardiologist or cardiac surgeon for follow up at 4-6 weeks

You will have a dressing on your chest incision. You should remove it after 4 weeks under a running shower. You can remove it earlier if it starts to come off or breaks. If you have any concerns about the wound please visit your GP or notify Dr Joshi.

You should arrange an appointment to see Dr Joshi in 6-8 weeks and your cardiologist in 8 weeks. You should visit your GP within a week after being discharged from hospital.

Dr Joshi will see you for follow up after 6 weeks and then your long term follow up is organised by your cardiologist and GP. Echocardiogram is done once or twice a year to monitor the function of your heart and is done as seen necessary by your cardiologist. If you are on warfarin then your GP will guide you regarding frequency of blood tests and dosage of warfarin.

The advantage of this operation is that patients don’t require warfarin or stronger blood thinners. Due to placement of a polyester graft you will be on aspirin after surgery.