I Have A Mild Narrowing Of My Aortic Valve. Should I Have This Replaced During Bypass Sugery?

Question: I have a mild narrowing of my aortic valve. My doctor wants me to have my valve replaced while I am having my bypass surgery. Is this a good idea?

Answer: This is a very common problem because narrowing of the aortic valve occurs very commonly in people who have coronary artery disease, because the risk factors for coronary disease and aortic stenosis -- or aortic narrowing, aortic valve narrowing --they're the same risk factors, so we see this quite commonly. And therefore, many patients need to have both procedures done at the same time.

The aortic valve is your outflow valve from your heart, and when your heart squeezes to pump blood out to your body, that valve is supposed to open as a one-way valve and then shut. But with aging, and some of these risk factors that we know about that can cause coronary disease, that valve also begins to become thickened and behave like a rusty gate; it does not want to open properly.

If the valve is severely narrowed and really rusty, then by definition that valve needs to be replaced now, because the risk of having the surgery without a replacement of the valve is quite high, and the risks are lower by also taking care of the valve at the same time, so your heart can function normally.

If the valve is not severely narrowed, but what we call moderate narrowing, moderate stenosis, it's less clear; but most cardiologists and surgeons would believe that replacing the valve when it's on the verge of becoming severe would be the right thing to do at the time of bypass surgery because that valve will get worse with time, and the last thing you want is to have the need for a second operation in four or five years.

Now you've got a nice bypass operation, you're doing fine, and then over the course of the next couple years, that valve becomes a problem and you need a second operation, that's going to be a risky procedure, the second operation, because the surgeon asks to get into your heart, in and around where those bypass grafts are that he or she has been putting in and that are supplying the fuel to your heart.

Those are your fuel lines and your lifelines for your heart, and you don't want to damage those. So if there's any likelihood that you'll need a second operation in the near future, we don't want to do that. And that's why the valve should be replaced if it's moderately or severely narrowed.

You've got the problem where it's not severely narrowed, it's mild, and it's very difficult to predict which of those mildly narrowed, early rusty valves are going to get worse with time, but some will. And the ones that will can be identified pretty well by having the surgeon look at the valve at the time of the bypass operation.

Because he or she will be able to visualize a valve, and if it looks like it's going through this thickening and calcification process for calcium deposits forming on the valve, that's a valve that's much more likely to cause problems in the future.

And we would recommend that after careful inspection of the valve, if it looks like that, that the valve also get replaced at the time of the bypass operation.

And that can be assessed also pre-operatively, with echocardiograms and CT scans, and I suspect if your doctor is recommending that you have this done, even though the valve is only mildly narrowed now, it's probably because the valve doesn't look good on the echo. It may be very thick and very calcified.

But have a good discussion with your cardiologists and your surgeons about the pros and cons of having that valve replaced. Under most circumstances it may be better to get it done now, instead of waiting for what may be a second operation in the future.

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