What is it?
Aortic insufficiency is a pathological condition in which the aortic valve does not close completely, allowing the blood to flow backwards, instead of proceeding in the correct direction from the heart to the arteries throughout the body, forcing the heart to exert more effort than normal to compensate for this defect, thus causing a dilation of the ventricle and thickening of the heart muscle over time.
Aortic insufficiency can develop suddenly or evolve gradually over time. It is therefore an insidious disease because the heart automatically activates some compensation mechanisms, and patients may not even present symptoms for years. When the insufficiency is mild or moderate, the disease can run without causing problems. If aortic insufficiency is severe and not adequately treated, it can lead to heart failure, left ventricular dilation and dysfunction, and decreased life expectancy. In these cases, surgery becomes necessary to repair or replace the diseased aortic valve.
Causes and risk factors
Possible causes of the disease include:
Congenital valve disease (bicuspid, unicuspid, tetracuspid).
Valve calcification: valve damage due to calcium deposits that, over time, thicken the valve leaflets, which are no longer able to move properly.
Rheumatic fever, a disease that has become rare in Italy, but still present in developing countries.
Endocarditis, a localized infection in the heart with possible involvement of the valves. Dilatation of the ascending aorta (aneurysm) secondary to hypertension or to some rare diseases (Marfan Syndrome, Lupus Eritematosus) that condition an enlargement of the aorta and the aortic valve.
Trauma leading to aortic wall rupture in the vicinity of the valve.
A cardiological examination and a series of diagnostic tests such as echocardiography or echocolordoppler make it possible to define the cause of the disease, specify its severity and evaluate the patient's general clinical condition.
Which are the symptoms?
- sense of fatigue and weakness mainly from exertion
- breathlessness on exertion or lying down
- swelling of the ankles and feet
- malaise and sense of oppression
- sense of dizziness and fainting
How is it diagnosed?
Aortic insufficiency is diagnosed by transthoracic echocardiogram.
How is it treated?
In the early stages of the disease, especially in patients with mild impairment, adherence to a healthy lifestyle and periodic clinical monitoring are recommended. Sometimes appropriate medical therapy is indicated to treat symptoms early (diuretics and antihypertensives), although medications cannot correct the valve defect.
However, when surgery is necessary as the only solution to treat aortic valve insufficiency, the options are as follows:
aortic valve replacement
aortic valve repair.
The goal of surgery is to improve heart function, reduce symptoms and/or avoid possible future complications. This indication is appropriate even in the absence of symptoms, when there is a need for surgery for concomitant cardiac disease.
Aortic valve replacement
Replacement is indicated in most cases of insufficiency, with removal of the native valve and subsequent implantation of a prosthesis that may be:
mechanical, robust and durable enough to be considered a permanent solution. The metal materials comprising it require the patient to follow an anticoagulant therapy for life to prevent the formation of clots (embolism).
organic, composed of material of animal origin. This feature, on the one hand, does not require the patient to follow an anticoagulant therapy, but on the other hand, exposes the prosthesis to wear with the possible need for a reoperation over the years.
Aortic valve repair
Restorative surgeries are infrequent and are only performed in a few centers of excellence that specialize in aortic valve repair. In addition, repair surgery is not indicated for all patients with aortic insufficiency. The reparative techniques are different in relation to the type of valvulopathy, but in general, they are aimed to adjust the valve and restore its original anatomical structure, without the implantation of prosthesis.
The surgical approaches that can be used are different in terms of invasiveness are as follows:
traditional surgery, performed with total sternotomy
mini-invasive intervention in partial upper sternotomy or ministernotomy: it is the most common technique invilving shorter skin incisions and allowing to leave intact a part of the sternum.
mini-invasive intervention in right anterior minithoracotomy: it is accessed through the second intercostal space, with a skin incision of about 5 cm, without damaging any bone structure (sternum and ribs).
Minimally invasive surgery compared to traditional surgery has shown better clinical results, especially on the reduction of postoperative bleeding, reduction of time spent in intensive care and overall hospital stay, with consequent reduction of convalescence time and resumption of normal life after surgery. For minimally invasive surgery, it is always essential to refer to a center of excellence.
Currently, valve implantation techniques without extracorporeal circulation (TAVI) are available only in the case of malfunction and/or degeneration of a valve bioprosthesis.
All possible options and aspects related to each individual patient, however, should be discussed and deepened with the cardiac surgeon before the operation.
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