Aortic Valve Repair Surgery: What Should Patients Know in 2021?
Written By: Adam Pick, Patient Advocate & Author
Medical Expert: Dr. Marc Gerdisch, Chief of Cardiac Surgery at Franciscan Health
Page last updated: July 15, 2021
When diagnosed with severe aortic valve disease, there can be an immediate tendency for patients to think that a heart valve replacement is the only treatment to restore cardiac function. However, aortic valve repair can be a very effective and long-term treatment for patients. Unfortunately, many patients are unaware of aortic valve repair techniques and the surgeons who specialize in this newer form of heart valve therapy.
To learn more about the innovations specific to aortic valve repair surgery, we interviewed Dr. Marc Gerdisch, the Chief of Cardiac Surgery at Franciscan Health in Indianapolis, Indiana. During his 27-year career, Dr. Gerdisch has performed over 4,000 heart valve procedures. His specialties include aortic valve repair, mitral valve repair, minimally-invasive surgery and atrial fibrillation. In addition, Dr. Gerdisch has performed successful heart valve surgery on over 120 patients in the HeartValveSurgery.com community.
Key Learnings About Aortic Valve Repair from Dr. Gerdisch
There were so many great points shared by Dr. Gerdisch in this video interview. Here are the key considerations for patients who may be considering aortic valve surgery:
- Aortic valve repair has been in development for the past 30 years. This unique therapy to reconstruct a defective aortic valve was pioneered by Dr. Alain Carpentier, the “Father of Modern Heart Valve Surgery”, for the treatment of aortic regurgitation, a leaking heart valve. Dr. Gerdisch traveled to France to learn mitral and aortic valve repair techniques from Dr. Carpentier.
Dr. Marc Gerdisch with Dr. Alain Carpentier (France)
- New aortic valve repair techniques have been developed by world-renowned physicians including Dr. Tirone David, who enhanced the approach to repairing the aortic annulus, the frame around the aortic valve. This is very important given the relationship among tricuspid/bicuspid aortic valves and the aortic root.
- Addressing the aortic valve leaflets was the next innovation specific to improving the aortic valve repair procedure. Two physicians – Dr. Hans-Joachim Schaefers and Dr. Gebrine El Khoury – developed a series of techniques to enhance leaflet integrity during-and-after an aortic valve repair procedure.
- The association of the aortic valve and the aortic root is critical for patients to understand. There are many considerations specific to the aorta and aortic root that might impact aortic valve function and potential for repair. Those considerations include: geometry, embryology, pathology, aneurysms, form and function.
- The benefits of an aortic valve repair mirror the benefits of mitral valve repair such as better survival, better quality of life and longer life expectancy. Aortic valve replacements procedures – while very effective for treating aortic stenosis – have a risk of stroke, risk of infection, shorter life expectancy and potential blood thinner use.
- The majority of leaking aortic valves can now be repaired instead of replaced. Unfortunately, aortic valve repair techniques are not well known or practiced. According to Dr. Gerdisch, only 27% to 35% of aortic valves that can be repaired are repaired – even in cardiac centers of excellence.
- The new HAART annuloplasty device, which is an innovative aortic valve ring to support the annulus and position the leaflets, is helping make aortic valve repair procedures more reproducible and available to patients.
HAART Annuloplasty Ring
- Aortic valve repair is both “art” and “science”. Specifically, the “science” broadens the availability and surgeon skill sets to practice and treat aortic regurgitation using aortic valve repair procedures.
- Dr. Gerdisch’s best piece of advice for patients with leaking aortic valves is to deeply understand the degree of the problem. That may require patients to have additional testing – beyond a regular echocardiogram or transesophageal echocardiography (TEE) – using magnetic resonance imaging (MRI) and 4D-flow.
Thanks Dr. Gerdisch & Franciscan Health!
Many thanks to Dr. Gerdisch for taking the time to educate our patient community about the innovations and advantages of aortic valve repair techniques for treating leaky aortic valves. We also want to thank Dr. Gerdisch and the entire Franciscan Health team for taking such great care of patients from our community!
- See 120+ Patient Reviews for Dr. Marc Gerdisch
- Breakthrough Innovation: HAART Annuloplasty Ring for Aortic Valve Repair
- Doctor Q&A: Rapid Recovery Protocol with Dr. Marc Gerdisch
- Minimally-Invasive Mitral Valve Repair: What Should Patients Know?
Keep on tickin!
P.S. For the hearing impaired members of our community, I have provided a written transcript of this video about aortic valve repair below.
Adam Pick: Hi, everybody, it’s Adam with heartvalvesurgery.com, and this is a special surgeon question-and-answer session all about aortic valve repair. I’m thrilled to be joined by Dr. Marc Gerdisch who’s the chief of cardiac surgery at Franciscan Health in Indianapolis, Indiana. During his fantastic career, Dr. Gerdisch has performed over 6,000 cardiac procedures, of which more than 4,000 involved some form of heart valve repair or heart valve replacement. Dr. Gerdisch, as always, it’s great to see you again.
Dr. Marc Gerdisch: Thanks, Adam. Always a pleasure to talk to you, really fun to see you.
Adam Pick: Yeah, so let’s get to educating the patients all about aortic valve repair. The first question coming to you, Dr. Gerdisch, is true or false: aortic valve repair has been around for over 30 years.
Dr. Marc Gerdisch: It’s true. Because it – aortic valve insufficiency or leaking valves, which is what we use aortic valve repair for, isn’t the dominant pathology that we encounter with aortic valve disease. It’s been a little bit ignored. It’s also a little bit more complicated than the other valves that we’ve repaired. In fact, I spent time with Alain Carpentier in the early ’90s in France learning mitral valve repair and about a decade after that, he started to talk about aortic valve repair. It didn’t quite catch on because we didn’t have good ways to structurally support the valve when we repaired them, but over 30 years ago, Dr. Tirone David was beginning to do the re-implantation technique which addressed not only the valve but the frame around it, the aortic root. That relationship between the aortic valve and the aortic root is extremely important to understand both in three-leafed valves and bicuspid valves.
When those valves are leaking, sometimes it’s because of changes in the geometry of the aortic root, which is the framework that the valve hangs on. Other times, it’s due to changes in the leaflets themselves. We had Dr. Tyrone David working on that and meanwhile, Dr. Yacoub in England was developing the Yacoub Technique, remodeling technique where parts of the aortic root were replaced and indeed, we could solve problems with the aortic valve in the same procedure. Then separately, the valve leaflets had to be addressed because those operations worked really well when the leaflets were intact, when the valve was leaking but the leaflets were okay. We needed better techniques with respect to how to address the leaflets themselves.
Most of those came from Dr. Schafers in Germany and El Khoury in Belgium who really developed a series of techniques that we could use on a regular basis to address the leaflets. It was a merging of addressing the root where the valve is affected by the shape and architecture of the root and being able to address the leaflets. That’s something that evolved slowly over more than three decades.
Adam Pick: Dr. Gerdisch, it’s fascinating to learn about the evolution of aortic valve repair. Another question that we have for you is yes or no: the functioning of the aortic valve and the aortic root are related.
Dr. Marc Gerdisch: It’s definitely true that the aortic root and the aortic valve are related. The aortic root, of course, is the first portion of the aorta that when the blood leaves the heart, it’s in the aortic root, then out to the aorta. In fact, the entire ascending aorta plays a role here, but the aortic root is particularly important. Changes in the shape or size of the aortic root will affect the aortic valve. The aortic valve leaflets drape on the inside of the aortic root. The aortic valve sits above the heart in the aortic root, and the leaflets are draping from the sides of the aortic root. You can imagine if the aortic root enlarges, the leaflets are pulled apart and the valve begins to leak.
It’s further also true that the aorta – parts of the aorta and the aortic valve have – are linked embryologically, so we think of the ascending aorta in terms of its embryologic relationship to the aortic valve, especially in bicuspid valves. All these things have to be considered when we look at a patient with aortic valve insufficiency. What is the role of the aortic root in the insufficiency? Is there pathology that needs to be addressed in the root itself? In other words, is the root so big that that’s the reason they need the operation, or is the ascending aorta so big that that’s the reason they need the operation? Conversely, if they need an operation to repair their aortic valve, does the aortic root reach dimensions where it would be appropriate to address the root because it’s enlarged? Does the ascending aorta reach those dimensions?
This is a continuous conversation, really, as you’re looking at the valve, looking at the aorta, talking to the patient, and it – other things that become integrated in that are the size of the patient, the age of the patient. All of those things help us determine whether we’re going to intervene on the root separately or the aorta separately and what we’re going to do for the aortic valve. It’s all related.
Adam Pick: Dr. Gerdisch, for the patients who might be hearing about aortic valve repair for the first time, what are the benefits of an aortic valve repair versus an aortic valve replacement?
Dr. Marc Gerdisch: The benefits of the aortic valve repair are very similar to the benefits of mitral valve repair. That’s why we’ve become so dedicated to the process. Again, great surgeons have already shown us with longitudinal data following patients that the patients who had their valve repaired had better survival than those who had their valve replaced. Now, valve replacement is still great; it’s still fabulous technology when people have a really diseased valve and then they get their valve replaced. That ensures a better life for them, a better quality of life and a longer life.
As it turns out, we can take it even a notch further by repairing the valve. Why does that happen? Why would we say that that’s the case? People have heard me say this before. When we replace a valve, although it’s a great thing, we trade diseases. You got your really bad valve for this really nice prosthetic valve, but every prosthetic valve carries with it a little risk of stroke, a little risk of other thrown embolism, a little risk of infection, and for bioprosthetic valves, they deteriorate, and for mechanical valves, you have to be on the blood thinner. Those issues, of course, conspire to cause difficulties for people All of that disappears if you can repair the valve. It was true for mitral valve surgery; it’s true for aortic valve surgery.
Adam Pick: Dr. Gerdisch, if I’m a patient, I’m hearing about these advantages of aortic valve repair. I might be curious how would I know if my valve could be repaired versus replaced?
Dr. Marc Gerdisch: The question of whether a valve can be repaired or replaced is actually fairly complicated. I think the patient has to be ready to be patient. There’s going to be a fairly detailed conversation about the challenges of the repair and going over again what the benefits are for that specific patient. Some are very straightforward, and others are considerably more complicated. As we’ve progressed, same as we did with mitral valve repair where we went from very simple to very complex repairs, we’re in that same mode where we’re evolving techniques. We’re at a point now where the majority of leaking aortic valves can be repaired. That’s based on the introduction of three-dimensional modeling from CT scans that allowed us to decipher what the correct geometry would be of a normal aortic valve and then take whatever that patient’s valve looks like and work toward that. We have a really good feeling for that now when we look at the CT scans and the echos. We have a really good understanding of what the likelihood of repairing the valve is.
Adam Pick: Is it true that only a small number of aortic valves can be repaired?
Dr. Marc Gerdisch: It’s kind of true. It was true. I would say the first element of that is that only a small percentage of leaking aortic valves are repaired, and we’ve tried to address that. That’s a continuum. There are folks who go to the operating room for some other problem, but they have a moderately leaking aortic valve. It’s moderate; it’s not severe. It’s not the main reason they’re in the operating room. Often, those patients have their valve replaced because the surgeon is faced with a situation where they’re leaving behind a valve that’s leaking. Although it’s not a problem right then, it’s going to become a problem. Sometimes it’s related to the aorta; sometimes they’re treating the aorta and have a moderately leaking aortic valve. A lot of – pretty much all of those valves, quite honestly, should be repaired and persevered because that’s not too complicated.
When we move into the more difficult patients, the patients who are there primarily for their aortic valve, the insufficiency, we see a marked also further drop-off in the likelihood of the valve being repaired. Even in centers of excellence, it ranges between 27 and maybe 35% of those patients going to the operating room for their aortic valve insufficiency that are repaired. There was a bit of a gap, and we feel like we’ve made a lot of progress combining what’s been done already in the realm of aortic root architectural reconstruction with leaflet management, those skill sets I talked about earlier, largely Dr. Schafers in Germany who’s done an incredible job on educating us on how we can address leaflets.
Then finally now, we have an annuloplasty device that allows us to realign the geometry of the valve leaflets and demand of those leaflets that they are in the appropriate position to be repaired. Then we use those techniques to repair it. That’s been quite a leap for us in the sense that it allows us to repair valves that in the past generally were considered not repairable because now we can put the leaflets into the right architectural positioning and then use those techniques to get the leaflets to work again. We find that we’re broadening our ability to repair valves.
Adam Pick: Dr. Gerdisch, hearing you talk about aortic valve repair and the dimensions, it almost sounds like this is part art and part science. From a surgeon’s perspective, is that true?
Dr. Marc Gerdisch: Aortic valve repair is part art and part science, but that’s true of all valve repair. As you know, we’ve evolved in mitral valve repair surgery and often people refer to it in those terms. Certainly not every center is a center of excellence in mitral valve repair, and not every surgeon does extensive mitral valve repair. Similar to that, in aortic valve repair, we are fostering a series of steps and techniques that surgeons can follow to gain those skills and certainly for the less complex cases feel comfortable doing the operation. As is true of all valve repair, folks who have more complicated disease will end up in the hands of surgeons who are more experienced and devoted to the process. I think that the science part is the important part in the sense that it broadens the availability. It gives more patients the opportunity and more surgeons the skill set
Adam Pick: Quick question for the patients. I’m sure they’re wondering. What is your number one piece of advice for a patient who may be considering an aortic valve repair.
Dr. Marc Gerdisch: I think it’s really important for patients – any patient with leaking aortic valve, for them to understand the degree of the problem. That becomes a little bit complicated because the standard methodologies for measuring the leak in the aortic valve don’t always apply well. Patients who have leaking aortic valves sometimes need additional testing beyond a transthoracic echocardiogram and maybe even beyond a transesophogeal echocardiogram with MRI and what we call 4D flow. We have more sophisticated ways of looking at this.
This becomes very important because recent literature has pointed out to us that we probably shouldn’t be waiting for Class 1 indications for everybody, Class 1 indications meaning symptoms. If we look at the more subtle findings on echocardiography, we find that things like left ventricular and systolic diameter index, which is a fancy term, but it basically means that when the heart has squeezed the blood out, the dimensions of the heart at that point in somebody with aortic valvular insufficiency become important. If they’re either large or enlarging, that is probably a window of time where the conversation should be had. That even applies when valves are replaced, let alone the opportunity to have it repaired.
We’re going through a similar process that we’ve gone through in the past with other valve repairs understanding consequences for the patients. It’s super important that people understand how severe their aortic valvular insufficiency is, that it’s well-investigated, and that people are looking – their doctors are looking at the correct parameters for when they might start thinking about intervention.
Adam Pick: Dr. Gerdisch, I love the advice and for the patients out there, please, please, take your time to do your research and find a potential surgeon who can help you if an aortic valve repair is a possible treatment for you given all those great benefits you talked about, Dr. Gerdisch. On that note, as always, Dr. Gerdisch, I want to thank you for taking time away from your very busy practice there at Franciscan Health in Indianapolis, Indiana and sharing all this great educational information with our community today.