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Aortic valve repair is performed because severe aortic valvular disease uncorrected mortality rates are dismal. Half of the patients presenting with aortic stenosis may be dead within two years. Surgical and non-surgical catheter-based approaches are utilized for aortic valve repair. Main repair indications for both stenosis and insufficiency include severe symptomatic disease and severe asymptomatic disease if the patient's ejection fraction is less than 50% or if the patient has a concomitant indication for cardiac surgery. This activity reviews the evaluation and treatment of aortic valve disease and highlights the role of the interprofessional team in evaluating and treating this condition. Objectives: Identify the anatomical structures relevant to bioprosthetic aortic valve replacement. Describe the standard operative technique for performing a safe, durable bioprosthetic aortic valve replacement. Summarize potential complications of bioprosthetic aortic valve replacement. Outline some interprofessional team strategies for improving care coordination and communication to advance identify indications for bioprosthetic aortic valve replacement and improve outcomes. Access free multiple choice questions on this topic.

Considering the constant stress on the four valves of the human heart, beating an average 80 times per minute for over 70 years for over 3 billion beats, on the whole, human heart valves perform amazingly well. Less than 2% of the population is estimated to suffer valvular disease.[1] The history of the treatment of valvular disease is marked by daring innovation and multidisciplinary collaboration; from the days of closed digital commissurotomies (sticking a surgeon’s finger through a heart valve) to homemade balls in cages to the pathophysiologic connection between treating strep throat with antibiotics and preventing rheumatic heart disease decades into the future. These historical episodes have something to teach about progress in healthcare. However, this article will focus on surgical aortic valve replacement (SAVR) for stenosis, insufficiency, or endocarditis using bioprosthetic valves. The interested reader is invited to peruse closely related content, especially surgical aortic valve replacement, surgical aortic valve repair, stentless pulmonary autograft/homograft aortic valve replacement (Ross procedure), minimally invasive aortic valve surgery, and transcatheter aortic valve replacement (TAVR), as well as more general treatments of aortic valve disease and prosthetic valves.[2][3][4][3][5][6][7][8][9][10][11]

Given the variety of valves on the market, it was recognized early that a common language was needed to compare products and outcomes. The American Association of Thoracic Surgeons (AATS) and the Society of Thoracic Surgeons (STS) maintain an Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity, which updated its latest definition in terms in 1996.[31] The guidelines recognize hospital mortality before a patient’s discharge as distinct from 30-day mortality, also known as operative mortality. Valve-related mortality is mortality due to one of the below morbid categories not related to progressive heart failure. The recognized morbid categories are as follows. Structural valve deterioration (SVD) is stipulated as any change intrinsic to the valve leading to stenosis or insufficiency, including calcification, fracture, tear, and suture disruption but excludes prosthetic valve endocarditis (PVE) and thrombotic dysfunction, which comprise their own mutually exclusive categories. Nonstructural dysfunction is not intrinsic to the valve leading to stenosis or insufficiency, including obstruction from improper placement, a leak from improper sizing, and hemolytic anemia (an indicator of the leak). A bleeding event is an event that leads to hospitalization, transfusion, or death, but does not require taking anticoagulation.[31] An old study reporting ten years follow up of one particular mechanical valve now unavailable gives representative rates of these complications for the aortic valve position.[32] Structural valve deterioration 0 events/patient years Nonstructural dysfunction 0.2 to 0.8 events/patient years Thrombotic events 0.0 to 0.2 events/patient years Embolic events 1.4 to 2.5 events/patient years Bleeding events 0.8 to 2.5 events/patient years Endocarditis events 0.4 to 0.7 events/patient years Reoperation 0.3 to 1.8 events/patient years

Structural valve deterioration 0 events/patient years Nonstructural dysfunction 0.2 to 0.8 events/patient years Thrombotic events 0.0 to 0.2 events/patient years Embolic events 1.4 to 2.5 events/patient years Bleeding events 0.8 to 2.5 events/patient years Endocarditis events 0.4 to 0.7 events/patient years Reoperation 0.3 to 1.8 events/patient years By comparison, representative statistics for bioprosthetic valves at twelve years in the aortic position include 87% freedom from valve-related mortality, 84% freedom from reoperation, 93% freedom from SVD explantation for patients over 60 years old, and 76% freedom from SVD explantation for patients under 60 years old.[33] A 25-year study of another bioprosthetic valve, albeit in the mitral position, also gives representative outcomes: thromboembolism 0.5%/valve year, bleeding event 0.7%/valve year, endocarditis 0.4%/valve year, and SVD 2.3%/valve year.[34] SVD is the most common cause of reoperation for bioprosthetic valves, especially after seven or eight years. Freedom from SVD at ten years is cited to be between 70% and 90%, while at fifteen years, it is cited to be 50% to 80%.[23]

Complex health care interventions such as cardiac valve replacement demand excellence in nontechnical domains such as communication, human factors, teamwork, safety culture, and optimizing the operative environment. There is an increasing consensus backed by data that attention to these issues is essential to achieving high-quality interventions.[39]