International Journal of Surgery (2008) 6, 169e174

www.theijs.com

REVIEW

Aortic valve surgery: What is the future?

Narcis Hudorović*

University Department of Endo and Vascular Surgery, University Hospital ‘‘Sestre milosrdnice’’,
Vinogradska 29, 10000 Zagreb, Croatia

Available online 1 May 2007

KEYWORDS Abstract Modern surgical treatment for aortic valve disease has undergone significant im-
Aortic valve provements in all areas of this procedure. Successful treatment strategies for cardiovascular
replacement; diseases have often been initiated and driven by surgeons. Radical excision of diseased tissue,
Stented aortic valve; repair and replacement strategies lead to long-term successful treatment of the underlying
Surgery diseases and clearly improved patient outcome. In highly developed nations, valve surgery will
be increasing applied in older people, with more co-morbidities and a higher incidence of con-
comitant coronary artery disease. Cardiovascular surgeons will be facing increased competi-
tion from the catheter-based procedures; these are already applied clinically, and their
numbers will rise in near future. Right now interventional cardiologists supported by some car-
diac surgeons are on their way to transform some conventional open surgical procedures into
catheter-based less invasive interventions, such as valve repair and replacement. Cardiovascu-
lar surgery is undergoing a rapid transformation; socio-economic factors and recent advances
in medical technology contribute to these changes. Further developments will come, and sur-
geons with all their expertise in the treatment of valvular heart disease need to be part of it.
Cardiovascular surgeons have to adapt the exciting new approaches of transapical and trans-
femoral transcatheter valve implantation techniques.
ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Introduction a standard suturing technique has been the only definitive

Conventional aortic valve replacement is a routine pro-
cedure that has been performed safely for decades. The
majority of patients present with severely calcifying aortic
valve stenosis, accounting for approximately 10e30% of
cardiac surgical workload. Resection of all calcified tissue
with subsequent prosthetic heart valve implantation using
* Tel.: þ385 1 46 40 774; fax: þ385 1 37 68 292.
E-mail address: narcis.hudorovic@zg.htnet.hr
therapy. Excellent hemodynamic outcome and functional
results are achieved, and good long-term performance of
conventional prostheses has been proven by numerous
studies. It is of interest to note that there obviously is
a major cohort of patients with both severe aortic and
mitral valve disease who are not being referred to surgery
usually for the reason that the operative risks are consid-
ered to be too high. According to a recent survey of the
European Society of Cardiology in 2003, only one-third of
these patients underwent surgery. This non-referral might
be related to:

1743-9191/$ - see front matter ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2007.04.009
170
(a) subjective lack of symptoms of older patients who
would like to avoid open heart surgery;
(b) the assumption of family physicians or cardiologists of
a prohibitive operative risk, especially in older patients
with several severe co-morbidities.
In the second half of the 20th century, an unprece-
dented prolongation of human life has been observed.
Average life expectancy in the countries of the European
Union (EU) rose almost 9 years from 1960 to 2000 (Fig. 1),
and the increase was most marked in less developed EU
countries.
The surgeons will be treating an increasing number of
aged people; The United States expects that the aged
population (>65 years) will double by 2040; by that time
it will reach 77 million, more than a quarter of total US
population. Cardiovascular consequences are obvious: de-
generative heart disease (aortic stenosis, mitral regurgita-
tion, heart failure, total AV block) will be encountered
more frequently than before, and surgery will assume ex-
ceedingly complex proportion in this population with multi-
focal atherosclerosis. This fact is well reflected in the
recent European Survey by Bruce Keogh,1 where the major
increase has been observed in the segment of combined
CABG and valve procedures.
In view of increasing patient risk profiles, cardiovascular
surgeons should eventually rethink their whole conven-
tional strategy. This may include the evaluation and
eventually adoption of new technical developments such
as transcatheter valve implantation techniques into routine
practice. Potential steps to minimize the risk of aortic valve
surgery are obvious:
(a) a minimally invasive access avoiding sternotomy;
(b) valve implantation on the beating heart avoiding
cardiac arrest;
(c) off-pump valve implantation.
Balloon aortic valvuloplasty had been used as an alter-
native approach to non-surgical candidates. However, this
treatment was associated with a high mortality and
especially morbidity rate, and a high return of symptoms
Figure 1 Life expectancy for men and women, EU 15, 1960e
2000. Source: Eurostar
N. Hudorović
and restenosis within months of the procedure,2 and has
been abandoned.
Apparently new transcatheter aortic valve implantation
techniques have been developed by different groups. The
continuous efforts of the two cardiologists, Cribier and
Bonhoeffer, led to the first successful percutaneous aortic
and pulmonary valve implantation, which paved the way for
further implants and studies during the past 4 years.
Despite being at an early stage of development, several
devices have already been introduced into clinical practice
at selected centers. A number of different devices (maybe
20 or more) currently are under development. In parallel,
several experimental studies on the in vivo function of new
devices have been performed. Several of these studies deal
with some technical aspects of transcatheter valve implan-
tation with special focus on the surgical therapy using
a transapical approach.3e6
Materials and methods
In highly developed nations of Europe and North America,
catheter interventions greatly outnumber the operative
treatment of coronary atherosclerosis (Figs. 2 and 3). The
growth of invasive cardiology does not remain limited to
PTCA and stenting of the coronary arteries.
Percutaneous balloon mitral valvotomy is already estab-
lished as a primary treatment of mitral stenosis,7 although
the same technique is very unsatisfactory in the treatment
of aortic stenosis. Hence, the concept of non-surgical valve
replacement has evolved. Extension to the aortic valve was
inevitable and was most probably behind the initial interest
in the pulmonary valve, since percutaneous valve therapy
developed initially with aortic valve replacement, described
in 1992 in a swine model.8 Early experimental work in
animals9e11 paved the way for use in man, but Cribier
et al.12 is credited with the first human percutaneous trans-
catheter implantation of aortic valve prosthesis for calcific
aortic stenosis. Since then, many operators and teams,
both cardiological and surgical, throughout the world have
enthusiastically embarked on programs of non-invasive or
minimally invasive aortic valve replacement. Several models
of stent-fixed valve have been developed and newer modifi-
cations are introduced almost on a daily basis.13
Figure 2 CABG procedures in the USA SRS database, 1993 to
June 2002.
Aortic valve surgery
Figure 3 Decrease of CAB procedures in the UK. Source: United Kingdom Cardiac Surgical Register trends in cardiac surgery
1877e2001 (n Z 578,051).
In the initial procedures, the catheter-mounted valved
stents were delivered into the aortic annulus by an antegrade
trans-septal approach, but this method was technically
difficult to master, especially with regard to the ability to
accurate intra-annular positioning and was abandoned in favor
of a retrograde arterial method. Peripheral vascular access in
patients with diseased or small iliac-femoral vessels will be
a stumbling block in many elderly patients. Additionally, these
transcatheter-based methods have some other limitations
which include risk of embolization due to pre-dilatation and
detachment or fragmentation of atherosclerotic plaques,
migration of the valved stent, paravalvular leakage and,
probably, limited durability of the prosthesis.14,15
Up to now, percutaneous aortic valve insertion has
allegedly been carried out on a compassionate basis in
patients considered to be ‘‘extremely high-risk’’ for surgical
aortic valve replacement. However, significant paravalvular
regurgitation and early mortality characterize the experi-
ence thus far, and this raises many questions about the
indications and may have important ethical implications.
Although the concept of percutaneous replacement of
heart valves appears promising, it is clear that this
technology is in its infancy with a manifest inability to
achieve consistent results, which have, up to now, failed to
meet the expectations.16
Percutaneous, catheter-based treatments of mitral
insufficiency, both by edge-edge repair and reduction of
posterior leaflet of the mitral valve via coronary sinus,17 are
being explored, and one can assume that these develop-
ments, heavily sponsored by industry, will lead to larger
clinical trials in the near future. Pulmonary valve replace-
ment by catheter technique is already established in the
pediatric population,18 and percutaneous aortic valve
replacement is being developed.19
In recent years, three approaches have evolved as
potential access routes to the aortic valve.
171
Antegrade femoral venous route
The antegrade femoral venous route has the advantage that
may allow passage of large-profile valved stents and an
antegrade crossing of the aortic valve. However, the severe
disadvantages include a long and tortuous route from the
femoral vein to the aortic valve, necessity to cross and
dilate the atrial septum, and the need to cross the mitral
valve with the potential to induce acute mitral insufficiency
by pushing against the anterior mitral leaflet. In high-risk
patients the latter is often associated with severe reduction
in cardiac output due to the creation of a high-grade mitral
valve insufficiency.20
Retrograde arterial route
The retrograde arterial approach requires retrograde cross-
ing of the stenotic aortic valve and is limited to a low-
profile system (24 F in diameter). Frequently it results in
vascular trauma,20 especially in older patients with their
high incidence of peripheral artery as well as atheroscle-
rotic disease in the thoracic and abdominal aorta.
Transapical route
The transapical approach seems to offer many potential
advantages including that the native valve is crossed in an
antegrade fashion; it permits a shorter and stiffer delivery
system for more precise positioning and placement of the
stented bioprosthesis. In addition, the lateral minithora-
cotomy and the transapical approach have been used by
Freiburg group,21 as well as apico-aortic conduit implanta-
tions, both with and without extracorporeal circulation.
The study on 6 months’ follow-up results after transapi-
cal aortic valve implantation by the group from Vancouver
172
is at the forefront of clinical application. They performed
the first successful human transapical aortic valve implan-
tations using an oversizing technique, starting in November
2005 on a compassionate-use basis in patients deemed as
having an excessive operative risk. Recently their initial re-
sults in seven patients have been published.6,22 The infor-
mation on persistently good valve function after hospital
discharge probably is the most important message from
this publication. Good valve function had already been
proven in patients receiving a 23 mm CribiereEdwards pros-
thesis via transfemoral approach from 2002 onwards by
Cribier (Fig. 4).23
The stringent application of the oversizing concept of
2e3 mm by the Vancouver group, implanting a 26 mm pros-
thesis only, has led to more successful hemodynamic and
clinical outcomes. Further clinical studies under ethical
approval for operable but high-risk patients are under way.
The Lausanne group focuses on a specific device for left
ventricular apical closure when using such new minimally
invasive transapical techniques.24 The authors demon-
strated the effectiveness of device closure after transapical
access, with the occluder consisting of two square heads
squeezing the ventricle wall in between them, sealing the
ventricular defect. A third element, a semi rigid guide
wire, is secured to the device for driving the deployment.
The superior results when using a cuffed device are clear
indicators of a further technical development in this field.
Transapical access usually can be performed without prob-
lems when using Teflon reinforced purse-string sutures.
Fragile tissue, however, may lead to technical difficulties,
especially when closing larger holes while being off-pump
in high-risk patients.
One of the most important aspects of the transapical
approach is the unlimited feasibility even in the presence
of large sheaths, up to 30 F or more. With the help of stan-
dard purse-string sutures or a closure device, there is no
real limitation on size. This will allow surgeons to implant
the most advanced, possibly cuffed prosthesis to achieve
Figure 4 Schematic illustration of transapical aortic valve
implantation. The prosthesis is being dilated at the annular
level within the native aortic valve cusps. Transapical sheath
insertion is secured with a purse-string suture.
N. Hudorović
optimal results in comparison to the transfemoral ap-
proaches with their potential size limitations.
Discussion
Development of valve prosthesis has been stagnant in the
recent years, and no major breakthroughs are presently
visible. Durable mechanical valves still need anticoagula-
tion and are prone to thrombosis and embolism; a truly
antithrombogenic mechanical valve has not been yet de-
veloped, in spite of the remarkable progress in heparin
bonding. Biological valves are still not durable, and are
used in exceeding numbers, due to the aging population
being subjected to valve replacement. Recent statistics25
show that in the UK almost half of those patients with aortic
valve replacement receive biological valves. Homografts,
due to the difficulties in obtaining good valves, play a mini-
mal role and their numbers are not expected to rise in the
future.
Surgeons are the most experienced physicians offering
definitive treatment for aortic valve disease. To further
direct the development, surgeons have to actively take part
in the developments designing future joint inclusion criteria
and performing comparative and eventually randomized
clinical trials; in parallel, retraining with the new catheter-
based techniques will be required. Last but not the least
‘‘the transapical approach may be the first clear pathway
for cardiovascular surgeons to acquire and use catheter-
based and image-guidance skills, especially in the procedure
starts to replace traditional surgical valve replacement in
higher risk patients’’.26
Cardiovascular care is rapidly moving toward catheter-
based technologies, and many cardiovascular surgeons are
looking for ways to become involved. Endovascular tech-
niques are not currently part of the standard cardiovascular
surgeon’s practice, nor are catheter skills part of the
required residency training program curriculum.27
Endoluminal grafting for aortic valvular disease is an
involved process and cannot be learned in a weekend or
even in a month-long course. In addition to wire skills,
vascular access for aortic valve procedures is an important
consideration, and involves skills such as retroperitoneal
conduits, management of delivery complications and bra-
chialefemoral wires. Aortic valvular endografting also
offers a unique opportunity for hybrid procedures involving
great-vessel debranching and deployment of an endolumi-
nal graft into the aortic arch (Fig. 5).
An endovascular approach for aortic valve replacement
still presents several limitations that can be summarized as
follows:
(1) the size of the valve is limited by the delivery sheath di-
ameter, therefore, only small stented valves can be
implanted;
(2) the precise positioning of the stented valve onto the
aortic annulus or in supra-annular position is cumber-
some because it is very difficult to properly drive long
and stiff catheters into the arterial tree.
One potential solution is the off-pump trans left ventri-
cle approach (Fig. 6).
Aortic valve surgery
Figure 5 Hybrid procedure involving a debranching of the
great vessels and placement of an endoluminal graft into the
aortic arch.
Recent developments of sutureless devices for endovas-
cular repair of interatrial septal defects could provide the
right tool to easily and safely close the ventricle access.
Those devices, however, have been developed to deal with
ventricular pressure and therefore a technical improve-
ment is needed to ensure the hemostasis. Nevertheless it is
one of the few extremely innovative techniques that have
emerged in recent years that yet may even revolutionize
the whole of cardiovascular surgical practice. Patient
selection criteria should remain at present for high-risk
Figure 6 Schematic representation of the aortic valve re-
placement with the left transventricular approach.
173
candidates although this may be changed after future
successful studies. In addition, this is an emerging field
for the further establishment of a true team approach;
surgeons and cardiologists are working together in a hybrid
operation theatre. Eventually a new specialty of patient
and disease oriented physicians, and aortic heart valve
specialists will emerge by this example.
Access to high-quality imaging for endovascular proce-
dures such as an endovascular suite with a ceiling-mounted
C-arm is usually not available to the cardiovascular sur-
geon. Oftentimes access to these imaging modalities is
controlled by other specialists who are not interested in
involving the cardiovascular surgeon.
There are competitive and economic roadblocks to
cardiovascular retraining. The already established inter-
ventionists may not be eager to train or share revenues with
the cardiovascular surgeon. Another economic roadblock is
practice income. To adequately learn endovascular tech-
niques and become proficient in catheter-based therapies
takes a long time, sometimes 6 months or more. It will take
a significant commitment on behalf of busy practicing car-
diovascular surgeons to develop the necessary skill-set to
become proficient in catheter-based therapies.28
Despite all the excitement, there are still pitfalls in
the new transcatheter techniques. Newer valves may
come up with additional cuffs that would lead to a better
seal around the prosthesis toward potentially severely
calcified native aortic valve cusps and annulus. In
addition, a cuff material with gradual dilative properties
or even active sticking properties toward the calcified
annulus may be advantageous. Further technical devel-
opments will evolve in the future, leading to better
functional outcomes. In aortic surgery, various methods
of aortic valve repair in the dilated aortic root are
gaining acceptance, but the absolute numbers will prob-
ably remain low, due to the rarity of the condition
(normal, tricuspid aortic valve with isolated dilatation
of sinus portion of the ascending aorta). The Ross
procedure is very popular in children and young adults,
but the absolute numbers remain low, due to the relative
complexity of the surgical correction and the necessity to
implant the prosthesis in the pulmonary position, with
uncertain long-term results.29
Tissue engineering has played a major role in the
development of autologous-cell, bench-engineered valve
prosthesis. Numerous publications have addressed this
problem, and many animal studies have demonstrated the
possibility of constructing a non-thrombogenic valve pros-
thesis from autologous or homologous cells, derived from
various sources.29,30
Nevertheless, lasting function has been demonstrated
only in the low-pressure circulation, and human implants
have been rare. This field is expected to grow in future,
although technical problems remain substantial. A major
capital investment will be necessary to provide cardiovas-
cular surgeons with a workable tissue-engineered valve.
Conflict of interest
None.
Ethical approval
Not required.
174 N. Hudorović

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