Aortic valve: New techniques in its replacement


Subsequently, alternative techniques have been developed in order to reduce sternal division by providing better chest stability and improving the aesthetic effect.

Over the last twenty years, with the use of minimally invasive techniques, the replacement of the aortic valve with medial sternotomy and extracorporeal circulation has changed. The goal is to reduce the size of the incision, postoperative pain, shorter hospital stay, less bleeding and minimize the risk of inflammation.

Of course, in all techniques, the careful selection of patients is paramount and the use of the IVF machine is required, which replaces the function of the heart and lungs during the operation.

In addition, preoperatively, patients should undergo a chest CT scan in addition to the usual preoperative examination to study the course of the ascending aorta and the adjacent large vessels.

Initially, then, the patient is introduced into the extracorporeal circulation in the following ways:
• Thigh-femoral bypass
• ascending aorta – right atrium bypass
• femoral artery bypass – right atrium

The valve can be accessed by:
• small j sternotomy extending to the right or left of the sternum.
• anterior right thoracotomy at the height of the third intercostal space.

Advantages of j sternotomy
• Very good exposure of large vessels.
• No special tools needed.
Aortic-right atrial catheterization centrally.
Both mammary arteries are preserved.
• In case of difficulties, a complete sternotomy can be performed easily.

Disadvantages of j sternotomy
• It is difficult to use reverse heart attack.
• Difficulty in dearing.
• Care must be taken in the installation of drains.
• Slight restriction on upper limb movement.

Advantages of right anterior thoracotomy
• Preservation of the sternum.
• Free mobility of the upper limbs.
• Excellent aesthetic result.
• Very good technique for unsupported and transdermal transcutaneous valves (TAVI)

Injury of the right internal mammary artery.
• Complications from femoral catheterization.

After the selection of the technique and the entry into the extracorporeal circulation, aortotomy is performed, the diseased valve is removed and a bioprosthetic, metal or even unsupported valve is placed.

The selection of the valve is based on certain criteria regarding the age of the patient, his biological condition, the concomitant diseases and finally with personal consultation of the patient with the treating physician after analyzing all the advantages and disadvantages of the selected valve.

In patients over 60 years of age, the placement of a biological prosthetic valve is preferred. In these cases there is no need to use anticoagulants resulting in a better quality of life and without the risk of bleeding.

The life expectancy of biological valves is between 10 and 15 years and in biological pericardial valves it can reach 25 years. In the second year, when a biological valve fails, a transdermal transcutaneous valve (TAVI) can be placed, that is, a new valve is inserted through the femoral artery into the pre-existing aortic biological valve.

The rest of the postoperative course remains the same. Postoperatively the patient can be discharged from the hospital on the fourth or fifth postoperative day and there is no statistical difference in postoperative complications with complete mid-sternotomy.

Apostolos Tsolakis Cardiac Surgeon
Scientific Associate HYGEIA

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