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SurgSpace

03 / Cardiac Surgery · open

Aortic valve replacement

Cutting out a stone-stiff valve and sewing in a new one, with the coronary openings watching from millimetres away.

Indication: Severe symptomatic aortic stenosis or regurgitation; the symptomatic stenotic valve is a countdown, not a diagnosis.

Part of Cardiac Surgery →4 stages3 complications to knowopen

Read the imaging first

Pathology
Gross pathology photograph of an excised heavily calcified aortic valve
Gross pathology · rheumatic aortic stenosis, the valve the surgeon excises
Operative photo
A cardiac surgery operating room with the team, perfusion equipment and monitors in view
Inside the cardiac OR · surgeon, perfusion console and the bypass circuit

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Bypass and aortotomy

Sternotomy, onto bypass, cross-clamp, cardioplegia, then the aorta is opened just above the valve.

🔧 Scalpel🔧 Metzenbaum scissors🔧 DeBakey forcepsExplore anatomy: Coronary circulation

Watch for: Injury to the right coronary artery near the aortotomy

Why are we operating?

Aortic valve replacement swaps a failing valve for a prosthesis: in severe symptomatic stenosis it removes the fixed obstruction the left ventricle has been paying for, and in severe regurgitation it stops the volume overload dilating that ventricle. Symptoms in severe aortic stenosis carry a grim untreated prognosis, which is why symptomatic severe AS is an indication to act, not observe.

Pulls toward surgery

Severe symptomatic aortic stenosisSevere AS with a declining ventricle even without symptomsSevere aortic regurgitation with symptoms or dilating LVValve disease needing surgery at the time of other cardiac surgery

Gives the team pause

TAVI as the rival pathway, decided by the heart teamA calcified (porcelain) aorta hostile to clampingFrailty that the operation would spend rather than serve

Shared foundations

Cardiopulmonary bypass

Most cardiac operations need a still, empty heart. The bypass circuit takes over the circulation so the heart can be stopped: taught once here, referenced by every operation that uses it.

Understand it once, in the specialty hub

Cardioplegia & myocardial protection

A stopped heart must also be a protected heart. Cardioplegia is how the myocardium survives the cross-clamp.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Bypass and aortotomy

    Why is the aortotomy's placement so deliberate?

    The transverse opening in the ascending aorta must give a working view of the valve while staying clear of the right coronary ostium and leaving healthy aorta for closure: the incision is planned like a door hinge, because it will be sewn shut under pressure at the end.

  • Excising the valve

    Why is decalcifying the annulus the operation's most delicate passage?

    Calcium is chiselled from a ring whose neighbours are unforgiving: the conduction bundle beneath the right and non-coronary commissure (heart block), the anterior mitral leaflet in continuity, and the aortic wall itself. Every fragment is also a potential embolus, so the field is guarded and irrigated like the crime scene it could become.

  • Sizing and implanting

    What makes a well-implanted valve, beyond stitches?

    Size and seat: an undersized prosthesis leaves a permanent gradient (patient-prosthesis mismatch), an ill-seated one leaks around its sewing ring. The sutures spaced around the annulus, tied with the valve seated flat, are a geometry exercise where any single missed bite becomes a paravalvular jet on the TEE.

  • Closing and weaning

    What is the TEE adjudicating before bypass ends?

    Three verdicts: the new valve's gradient and any paravalvular leak, air out of the heart before it reaches the coronaries or brain, and the ventricle's behaviour off the machine. Heart block earning the pacing wires their keep is the fourth, expected verdict after annular calcium work.

Decision points

  • Mechanical or biological prosthesis for a 58-year-old?

    • Mechanical

      Lasts a lifetime, at the price of lifelong warfarin: the durability answer for younger patients willing to hold the anticoagulation contract.

    • Bioprosthesis

      No warfarin, but structural degeneration over 10-20 years: the answer that trades a future reintervention (perhaps valve-in-valve TAVI) for present freedom.

    The choice is a decade-scale life negotiation, not a technical one: bleeding risk, pregnancy plans, occupation and the patient's view of reoperation all vote. The heart team frames it; the patient decides it.

  • The completion TEE shows a moderate paravalvular leak. Accept or go back on?

    • Back on bypass and fix now

      A significant leak found in theatre is repaired in theatre: the same finding a week later means haemolysis, heart failure and a redo sternotomy.

    • Accept and observe

      Only for trivial jets: the TEE's grading is precisely what separates 'expected suture-line seepage' from 'unfinished operation'.

    The cheapest reoperation is the one that happens before the chest closes: the completion echo is the operation's quality gate, and its findings are acted on while every option is still open.

Leaving the OR

The handoff

Procedure
AVR: 23 mm bioprosthesis for severe calcific AS
Bypass / clamp
88 min / 62 min
Echo
Mean gradient 9 mmHg, no paravalvular leak, good LV
Rhythm
Sinus with first-degree block; ventricular pacing wires tested
Watch for
Heart block progression, drain output, tamponade physiology

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. ICU arrivalThe standard cardiac surgical evening: rewarming, drains, pressures, and rhythm on the monitor treated as data, not decoration.
  2. POD 0-1Extubation and pressor weaning; the conduction system's sulking (block, bradycardia) is why the wires stay until the rhythm proves itself.
  3. POD 2-4Drains and wires out on criteria; postoperative AF's classic window; anticoagulation started per prosthesis type.
  4. DischargeEndocarditis prophylaxis education, valve clinic follow-up, and for mechanical valves an INR relationship that lasts a lifetime.
Continue this patient as a case

Watch it done

Find Aortic valve replacement videos on YouTube

What can go wrong

Postoperative bleedingSurgical-site infectionVenous thromboembolism
Live this operation as a case →Live this operation as a case →OR Prep this operationReview the instruments