Severe aortic valve stenosis is often neglected and poorly treated in the general population. This negative approach leads to numerous unnecessary deaths every year. Minimally invasive Aortic Valve Replacement techniques are currently available for its treatment and can restore a normal life span and a better quality of life even in the the oldest and frail patient. Most patients can return to their homes and families in two to three days after surgery with very little discomfort. This article will educate you to recognize the advantages of minimally invasive aortic valve surgery and will teach you important tips and questions to ask your doctors when a minimally invasive aortic valve replacement is necessary.
Frank calcific aortic valve stenosis (AS) is quite frequent in our population. A clear increase in prevalence is seen with age: 1-3% in patients aged 65-75 years, 2-4% in those aged 75-85 years, 4% in patients older than 85 years. It is, without a question, a disease of the elderly with the exception of patients with bicuspid aortic valves who present with severe AS or Aortic Insufficiency (leaky valve) two decades earlier and the rare case of rheumatic valve disease. Most of them are diagnosed because of their symptoms of Congestive Heart Failure (shortness of breath and fatigue), angina (chest pain) and syncope (fainting spells) or because of an obvious and loud systolic murmur.
The current guidelines of the American College of Cardiology are very clear about therapeutic options on these patients. Severe symptomatic aortic stenosis is a lethal obstruction to outflow that needs effective mechanical relief in the form of aortic valve replacement. There is NO medical treatment for this disease. Without surgery three quarters of these patients will die within three years of symptom onset. Further, there is some urgency about undertaking this procedure once symptoms ensue, since several reports have been published of sudden death within three months of onset of symptoms. The well-established 25% per year mortality rate in symptomatic patients with severe AS who do not undergo aortic valve replacement supports the inference that withholding surgery imposes a mortality risk of about 2% per month. With the advent of minimally invasive aortic valve replacement techniques, it is absurd that so many patients are not referred promptly to a skilled valve surgeon to undergo a lifesaving operation.
In spite of these very well-established statistical data and the availability of minimally invasive aortic valve replacement techniques, severe aortic valve stenosis continues to be a grossly "neglected child" in our medical community. A good example is the all-too-common case of the little old lady who complains of worsening shortness of breath and ankle swelling. Her doctor prescribes some Lasix (a diuretic)and she gets better. Two months later she shows up in the emergency room with recurrent symptoms that resolve with IV Lasix. An Echocardiogram is obtained at this time and it shows severe or moderate-to-severe AS (Aortic Valve Area of 1.1 cm2 or less). This elderly patient and her family are reassured that some more Lasix will do the trick and that, after all, we do not want to rock the boat with a "dangerous" open heart operation. Few more months go by and the family will call the office to let us know that Grandma has passed away and...well... to thank us for the wonderful care we had for her.
There is a widespread and WRONG perception that surgery would not be a good option in an elderly and otherwise functional patient. If we go back to the mortality rates I discussed, medical therapy is, by far, the most dangerous choice. The life expectancy of AS patients after a traditional or a minimally invasive aortic valve replacement is the same as any cohort of patients without the diagnosis of AS. At one of my seminars, a local internist asked me if I would change my therapeutic indications in an old lady with several comorbidities (diabetes, hypertension, history of TIA's). My answer was: "Let's suppose this hypothetical lady with her comorbidities has mildly symptomatic colon cancer (constipation) instead of severe AS....Would you be willing to send her home with a few fleet enemas instead of a referral to a general surgeon to undergo a "dangerous" colon resection? I don't think so!!!" Symptomatic severe AS, I might add, does kill you much faster than early colon CA.
Let's now consider our surgical options. A well-meaning relative will ask: "Isn't Grandma too old and frail to withstand open heart surgery?" My answer is: "No. Grandma is too old and frail to withstand severe aortic valve stenosis. Let me show the statistics on this condition!!!" The way I perform a minimally invasive aortic valve replacement in my service has dramatically changed the impact of this operation on the overall patient's experience and on the speed of recovery. Most patients will be able to leave the hospital by their third postoperative day. The surgical incision is about 2" in length and is carried out through the third intercostal space. There is no bone cutting involved and this is a great advantage for wound healing in patients with advanced osteoporosis. Further, infection of these minithoracotomies is exceedingly rare.
The entire minimally invasive aortic valve replacement operation and all the necessary connections to the heart-lung machine are carried out through this tiny incision.The prosthetic valve can be easily tied to the aortic annulus and it is right at the center of my operative field. I routinely use the same incision for Atrial Septal Defect repair, Mitral and Tricuspid Valve repair, excision of atrial myxoma, perimembranous Ventricular Septal Defect repair, septal myectomy.
In female patients many of these minimally invasive aortic valve surgery operations can be performed through an incision hidden in the skin fold underneath the right breast with excellent cosmetic results. Once the minimally invasive aortic valve replacement is completed and prior to the wound closure, I inject 0.25% marcaine solution in the intercostal spaces above and below the minithoracotomy. Marcaine has a much longer half-life than lidocaine and the patient will be fairly pain-free for at least 10-14 hours. These intercostal nerve blocks will expedite extubation and postoperative recovery. Two drains are inserted in the pleural and pericardial space and the wound is closed in layers with a subcuticular skin closure. Our patient recovers in the ICU and is extubated within the next 4-6 hours.
On postoperative day #1 the drains are removed and most patients are transferred out of the ICU and start ambulation and physical therapy. Their average length of stay in the hospital is three days. They are then discharged home with specific arrangements for a visiting nurse and a visiting physical therapy service. They return to my office in two weeks for a follow-up visit and by that time they are instructed to resume their normal level of activity and their visits to the referring physician. I hope this article will help more colleagues, patients and concerned families achieve a real contemporary perception of what can be done for AS patients of all ages. Minimally invasive aortic valve replacement techniques make a dramatic difference in the way our patients recover after surgery. This low-impact, patient-centered approach to aortic stenosis affords excellent outcomes and restores a normal life expectancy and improved quality of life in the vast majority of treated patients. I strongly encourage you to present this information to anybody who is affected by Aortic Valve Stenosis or has an unexplained onset of shortness of breath, fatigue. Start a discussion about the best therapeutic options available for this and other conditions.
