Should I have surgery to replace my aortic valve?

Introduction

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This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.

Key points in making your decision

You and your doctor will likely base the decision to replace your aortic valve on whether you have symptoms—chest pain, shortness of breath, fainting, or lightheadedness. Such symptoms indicate that the stenosis (narrowing) in the valve is severe, and prompt replacement is needed to prevent permanent heart damage.

The decision whether to have surgery is more complicated if you have severe aortic valve stenosis but have not yet developed symptoms. If you don't have symptoms, valve replacement may not be recommended unless you are having heart surgery for another condition.

Consider the following when making your decision:

• Replacing the aortic valve is the only effective treatment once symptoms have developed.
• If you have symptoms, the risks of not replacing the valve are greater than the risks of surgery unless you have additional health problems that make surgery too dangerous.
• Once you have symptoms, if you don't have the valve replaced, you may dramatically shorten your life. About 75% to 80% of people who have symptoms of severe aortic valve stenosis die within 3 to 5 years if they do not have valve replacement surgery. In contrast, most people who have valve replacement have a normal life expectancy.¹
• Valve replacement surgery is a straightforward procedure with a high rate of success and low risk of complications.
• Valve replacement surgery is high-risk for people who have a failing left ventricle and who have had a heart attack.²
• If you do not have symptoms, your doctor may recommend that you wait to replace the valve until symptoms develop.

Medical Information

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What is aortic valve stenosis?

Aortic valve stenosis is a narrowing of the aortic valve. The aortic valve allows blood to flow from the heart's lower left chamber (ventricle) into the aorta. Stenosis prevents the valve from opening properly, forcing the heart to work harder to pump blood through the valve. This causes pressure to build up in the left ventricle and thickens the heart muscle. The heart can compensate for aortic valve stenosis and the resulting pressure overload for a long time. Eventually, however, the heart will not be able to maintain the extra effort needed to pump blood through the narrowed valve, resulting in heart failure.

What are the symptoms of aortic valve stenosis?

Aortic valve stenosis generally progresses slowly. For many years, even decades, you will not feel any symptoms from the heart's effort to overcome aortic valve stenosis. But at some point, the valve will become so narrow (usually at least one-quarter of its normal size) that symptoms develop, including:

• Chest pain (angina) or discomfort, often described as a heavy, tight feeling in the chest or a burning, choking, or constricting feeling that may spread to the arms, shoulders, or neck. Chest pain is often brought on by exertion, when the workload on the heart increases.
• Dizziness, fainting, or loss of consciousness, often after periods of activity.
• Signs of heart failure, such as fatigue and shortness of breath with activity.
• Rapid or irregular heartbeat (arrhythmia).
• Palpitations (an uncomfortable awareness of the heart beating rapidly or irregularly).

Is surgery the only treatment for aortic valve stenosis?

Once you develop symptoms, surgery to replace the aortic valve is the only effective treatment. Your doctor may prescribe medicines to treat your symptoms, but once the valve is damaged, it needs to be replaced.

However, balloon valvuloplasty, a procedure to enlarge the valve opening, may be an option for children, teens, or young adults in their 20s who were born with a bicuspid aortic valve (which has two flaps instead of three). Sometimes this procedure is used as a temporary fix for people who are older or very ill for whom open-heart surgery is too great a risk.

For a balloon valvuloplasty, a thin flexible tube called a catheter is inserted through an artery in the groin or arm and threaded into the heart. Once the tube reaches the narrowed heart valve, a balloon at the end of the tube is inflated, which enlarges the valve. There is a high risk that the valve will become narrowed again (restenosis) within 6 months after this procedure. Also, the procedure does not increase survival when it is done in older adults.

Why is it important to wait for symptoms to develop before having surgery?

Timing is essential—if you have valve surgery too soon, you will be subjecting yourself to the risk of surgery before it is necessary, and you will be increasing the chance that you will need another new valve in the future (because current replacement valves do not last forever). On the other hand, if you wait too long to replace the valve, your heart may become permanently damaged, resulting in heart failure.

Is it ever beneficial to have surgery before symptoms develop?

Although the "wait for symptoms" rule applies to the majority of people, some experts believe that a few people may benefit from valve replacement surgery before they develop symptoms, particularly those who are at risk for sudden death.

While sudden death is extremely rare before symptoms appear, it has occurred. Sudden death is impossible to predict. However, people who experience low blood pressure (hypotension) when they exercise, have developed serious problems with their left ventricle as a result of aortic stenosis, or have severe stenosis (a very narrow valve) are at a higher risk of sudden death. Sudden death in people who have aortic stenosis is closely associated with heart failure.

If I'm older, should I still have surgery?

Most people who develop symptoms of aortic valve stenosis are older than 65. Age alone should not prevent people from having valve replacement surgery.³ Other health problems may increase the risks of surgery, including coronary artery disease, heart failure, advanced cancer, or a neurological problem from a previous stroke. If you have other serious health problems, it is also important to consider whether surgery will improve your quality of life and chances of survival.

What are the risks of surgery?

The surgery is relatively low-risk. In people who do not have left ventricular heart failure, the death rate from surgery ranges from 2% to 5% overall and is as low as 1% in people who are younger than 70. The death rate is higher (8% to 20%) in people who have left ventricular heart failure and other markers of poor heart function.⁴

What new problems could develop after surgery?

Even if valve replacement surgery restores your heart to normal function, you may have the following problems after surgery:

• An increased risk of blood clots, which can break off and cause a stroke or heart attack. You will need to take blood-thinning medicines (anticoagulants) right after surgery to help prevent blood clots. If you receive a mechanical valve rather than one that is made from animal or human tissue, you will need to take anticoagulants for as long as you have that valve.
• A need for another replacement valve. Current replacement valves do not last forever, meaning that you may need to replace your valve again in the future.
• Incomplete relief from symptoms. Some types of valves do not have openings as wide as a normal valve for a person your size and can limit the valve's effectiveness in relieving your symptoms.
• A malfunctioning valve. There is a chance that the valve will malfunction, so you will need to periodically monitor how well your valve is working.

You will also need to take antibiotics to prevent infection when you have certain procedures, such as dental work or surgery.

Heart surgery, such as valve surgery, also can cause irregular heartbeat (atrial fibrillation), which can cause clots to form and increases your risk of heart attack and stroke.

If you need more information, see the topic Aortic Valve Stenosis.

Your Information

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Your choices are:

• Have surgery to replace your aortic valve.
• Do not have surgery.

The decision about whether to have surgery takes into account your personal feelings and the medical facts.

Deciding about surgery to replace the aortic valve

Reasons to have surgery

Reasons not to have surgery

You have symptoms of severe stenosis. Surgery is the only effective treatment for aortic valve stenosis once symptoms develop. Replacing a damaged aortic valve may prevent permanent heart damage. Not replacing the valve may dramatically shorten your life. Most people who have valve replacement have a normal life expectancy. You are not having symptoms but are having open-heart surgery for another condition, such as coronary heart disease or other valve problems. Are there other reasons you might want to have surgery?

You do not yet have symptoms. You are a teen or young adult in your 20s with a bicuspid aortic valve, and balloon valvuloplasty is an option. You have severe heart damage or other serious health problems that make surgery too risky. Valve replacement will correct problems relating to stenosis but will not treat other heart conditions. You are in very poor health, and surgery will not improve your life expectancy and quality of life. Are there other reasons you might not want to have surgery?

These personal stories may help you make your decision.

Wise Health Decision

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Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about having valve replacement surgery. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I have symptoms of severe aortic valve stenosis.	Yes	No	Unsure
I have severe stenosis but no symptoms.	Yes	No	Unsure
I have mild stenosis but no symptoms.	Yes	No	Unsure
I'm not yet having symptoms of severe stenosis, but I need surgery for another heart problem.	Yes	No	Unsure
I do not have other health problems that increase my risks from surgery.	Yes	No	Unsure
I have other health problems that make surgery too risky.	Yes	No	NA*
I have other serious health problems and don't feel surgery will improve my quality of life.	Yes	No	NA
If I have surgery, chances are good I'll live a normal life span.	Yes	No	NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to have or not to have surgery.

Check the box below that represents your overall impression about your decision.

Leaning toward having surgery

Leaning toward NOT having surgery

Return to the topic Aortic Valve Stenosis.

References

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Citations

1. Bonow RO, et al. (1998). ACC/AHA guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). Journal of the American College of Cardiology, 32(5): 1486–1588.

2. Powell DE (2000). Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction. Archives of Internal Medicine, 160(9): 1337–1341.

3. Aikawa K, Otto C (2001). Timing of surgery in aortic stenosis. Progress in Cardiovascular Diseases, 43(6): 477–493.

4. Bonow RO, Braunwald E (2004). Aortic stenosis section of Valvular heart disease. In E Braunwald et al., eds., Heart Disease, 7th ed., vol. 2, pp. 1582–1592. Philadelphia: Saunders.

Credits

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Author	Robin Parks, MS
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman
Primary Medical Reviewer	E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer	George Philippides, MD - Cardiology
Last Updated	November 17, 2005