Aortic Valve Repair in India and UAE | Complete Patient Guide

• ELIGIBILITY — SURGICAL AORTIC VALVE REPAIR (SAVR):

• Severe aortic regurgitation with cusp prolapse, leaflet perforation, or annular dilatation amenable to cusp resuspension, pericardial patch augmentation, or ring annuloplasty

• Bicuspid valve with cusp fusion (commissurotomy) or prolapse (free-margin plication, triangular resection)

• Aortic root dilatation with competent cusps: valve-sparing root replacement (David or Yacoub reimplantation technique)

• Symptomatic severe aortic stenosis in younger or low-surgical-risk patients where valve preservation is anatomically feasible (e.g., Ozaki leaflet reconstruction using autologous pericardium)

• Asymptomatic severe aortic regurgitation with progressive LV dilatation (LVESD >50 mm or indexed LVESD >25 mm/m²) or EF declining below 55%

• ELIGIBILITY — TRANSCATHETER / HYBRID OPTIONS:

• High or prohibitive surgical risk patients (STS-PROM ≥8% or EuroSCORE II ≥6%) with severe aortic stenosis: TAVR with balloon-expandable (SAPIEN 3) or self-expanding (Evolut PRO+) valve systems

• Valve-in-valve TAVR for degenerated biological prostheses

• REQUIRED DIAGNOSTIC WORKUP:

• Transthoracic echocardiography (TTE): valve morphology, cusp number, mean gradient, valve area (AVA by continuity equation), regurgitant volume and fraction, LV dimensions and EF

• Transesophageal echocardiography (TEE): 3D cusp anatomy, coaptation depth, annular dimensions — essential for surgical repair planning

• Cardiac CT angiography (CCTA, ECG-gated, ≥256-slice): annular sizing for TAVR; aortic root and ascending aorta geometry; coronary artery evaluation

• Coronary angiography or CT-FFR: to identify concomitant CAD requiring bypass

• Cardiac MRI: precise quantification of regurgitant fraction and LV volumes when echocardiographic windows are suboptimal

• Pulmonary function tests and renal function panel: perioperative risk stratification

• Blood tests: CBC, CMP, coagulation profile, HbA1c, infectious serology (HIV, HBsAg, HCV)

• CONTRAINDICATIONS / HIGH-RISK FLAGS:

• Heavily calcified, immobile cusps with dense annular calcification (not amenable to repair; proceed to replacement)

• Active infective endocarditis with annular abscess (relative — staged repair considered after antibiotic consolidation)

• Severe uncorrectable coagulopathy

• Porcelain aorta (renders conventional cardiopulmonary bypass high-risk; TAVR preferred)

• Life expectancy <1 year from non-cardiac comorbidities

• Frailty index scoring (Clinical Frailty Scale ≥6) without robust support system for rehabilitation

SURGICAL AORTIC VALVE REPAIR — TECHNIQUES:

1. Cusp Repair Techniques (for Aortic Regurgitation):

• Free-margin resuspension: prolapsed cusp is re-anchored centrally with PTFE (Gore-Tex) sutures, restoring coaptation height

• Triangular resection: removal of a triangular prolapsing segment with direct re-approximation

• Pericardial patch augmentation: autologous or glutaraldehyde-fixed pericardium used to extend a retracted or perforated cusp to achieve adequate coaptation surface

• Decalcification and shaving: careful endarterectomy of cusp calcifications to restore cusp mobility (feasible in selected cases)

• Commissurotomy: incision of fused commissures in bicuspid valve stenosis

2. Annular Stabilization:

• Subcommissural annuloplasty (Cabrol sutures): purse-string reduction of the interleaflet triangles to reduce annular dilatation

• External annuloplasty rings (Hagl, Lansac): reinforce and downsize the ventriculo-aortic junction to restore geometric coaptation — now considered standard in repair programs aiming for durable results

3. Valve-Sparing Aortic Root Replacement (VSARR):

• David Operation (reimplantation): the aortic root is excised, and the native valve is reimplanted inside a Dacron tube graft; achieves permanent annular stabilization

• Yacoub Operation (remodeling): preserves more physiological root geometry; typically combined with an annuloplasty ring for long-term stability

• Ideal for young patients with Marfan syndrome, bicuspid valve-associated root aneurysm, or idiopathic root dilatation with repairable cusps

4. Ozaki Aortic Valve Neocuspidization (AVNeo):

• All three native cusps are excised and replaced with precisely templated, glutaraldehyde-fixed autologous pericardial leaflets

• Avoids prosthetic implant, maintains near-normal hemodynamics; especially valuable in heavily calcified valves where conventional repair is unfeasible

• Medium-term data (5–8 years) show low mean gradients and good freedom from reintervention

SURGICAL AORTIC VALVE REPLACEMENT (SAVR):

• Mechanical prostheses (On-X, St. Jude Regent): chosen for patients under 60 years willing to accept anticoagulation with warfarin (or novel low-INR protocols with On-X)

• Biological prostheses (Carpentier-Edwards Perimount, Magna Ease; Medtronic Hancock; Inspiris Resilia with anti-calcification treatment): preferred for patients over 65, females of childbearing age, and those with anticoagulation contraindications; structural valve deterioration becomes relevant after 10–15 years

• Homograft / Ross Procedure: pulmonary autograft replaces the aortic valve; excellent hemodynamics and longevity in young patients; technically demanding biventricular procedure

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR):

• Indicated for intermediate-to-high surgical risk patients with severe aortic stenosis

• Transfemoral access preferred (percutaneous, no sternotomy); alternative access via transapical, transaortic, or subclavian routes when iliofemoral anatomy is unfavorable

• Devices available: SAPIEN 3 Ultra RESILIA (balloon-expandable), Evolut FX / PRO+ (self-expanding, supra-annular), ACURATE neo2 (self-expanding)

• Intraoperative guidance: fluoroscopy + TEE; CT-derived planning with dedicated sizing software (Siemens, Materialise)

• Valve-in-valve TAVR: resheathing capable devices allow repositioning; useful for degenerated surgical bioprostheses

SURGICAL ACCESS APPROACHES:

• Conventional median sternotomy: gold standard, full access

• Minimally invasive aortic valve surgery (MIAVS) via upper mini-sternotomy (J or T incision) or right anterior mini-thoracotomy (3–6 cm incision): reduced transfusion, shorter ICU stay, faster recovery, superior cosmesis; requires dedicated perfusion strategy (femoral or axillary cannulation)

• Robotic-assisted approaches: available at select advanced centers; video-endoscopic instrumentation through small port incisions

ANESTHESIA & PERFUSION:

• Cardiopulmonary bypass (CPB) with cold or del Nido cardioplegia for myocardial protection

• TEE-guided intraoperative monitoring throughout

• Cell salvage (autotransfusion) to minimize allogeneic blood use

• Enhanced Recovery After Cardiac Surgery (ERACS) protocols at advanced centers reduce opioid use and hospital length of stay

PRE-OPERATIVE PHASE (Weeks 1–2 before surgery):

• Step 1 — Remote Consultation: Upload all recent echocardiography reports, cardiac CT, coronary angiography, and outpatient letters to GAF Healthcare's secure patient portal. A GAF-affiliated senior cardiac surgeon reviews the records and provides a written surgical opinion and cost estimate within 48–72 hours.

• Step 2 — Visa & Travel Coordination: GAF Healthcare initiates e-Medical Visa application for India (typically approved in 3–5 business days) or UAE visit/medical visa coordination. Flight booking and airport reception are arranged.

• Step 3 — Pre-Admission Workup (on arrival, Days 1–2): Full cardiac assessment including repeat TTE/TEE, ECG-gated cardiac CT if not recently performed, coronary angiography if indicated, full blood panel (CBC, CMP, coagulation, HbA1c, infectious serology), anaesthesiology review, and cardiologist case conference. Medication optimization (beta-blockade, diuretic rationalization, bridging anticoagulation if needed).

• Step 4 — Surgical Planning Conference: Imaging reviewed in multidisciplinary heart team (surgeon, cardiologist, cardiac anesthesiologist, perfusionist). Repair versus replacement decision finalized. Intraoperative TEE plan confirmed.

INTRAOPERATIVE PHASE (Day 3–4, Surgical Day):

• Step 5 — Anesthesia induction with TEE probe placement; arterial line, central venous catheter, urinary catheter insertion.

• Step 6 — Surgical access: median sternotomy or minimally invasive approach (right anterior mini-thoracotomy or upper mini-sternotomy); femoral or central cannulation for cardiopulmonary bypass.

• Step 7 — Cardioplegic arrest; aortic cross-clamp applied; aortotomy performed under direct vision.

• Step 8 — Intraoperative valve assessment: cusp morphology quantified with caliper; repair maneuvers executed according to pre-planned strategy (cusp resuspension, annuloplasty, VSARR, or Ozaki neocuspidization).

• Step 9 — Intraoperative TEE immediately after de-airing and cross-clamp release: assessment of residual regurgitation (target: none or trivial), mean gradient, and LV function. Repair revision performed if result is suboptimal before closing.

• Step 10 — CPB weaning; hemostasis; chest closure with mediastinal drains; transfer to cardiac ICU.

POST-OPERATIVE PHASE — ICU (Days 1–3 post-op):

• Step 11 — Extubation target: within 4–8 hours of surgery under ERACS protocols (or next morning in complex cases).

• Step 12 — Hemodynamic monitoring: arterial line, central venous pressure, urine output targets >0.5 mL/kg/hr.

• Step 13 — Pain management: multimodal analgesia (parasternal blocks, NSAIDs, acetaminophen, minimal opioids).

• Step 14 — Anticoagulation initiation: heparin bridging (if mechanical valve or post-repair AF risk), transitioning to warfarin (mechanical) or aspirin (biological repair/replacement).

• Step 15 — Physiotherapy begins Day 1 post-op: deep breathing exercises, incentive spirometry, limb exercises in bed.

POST-OPERATIVE PHASE — STEP-DOWN WARD (Days 4–12):

• Step 16 — Drain removal (typically Day 1–2 post-op); ambulation beginning Day 2–3; sternal precautions counseled.

• Step 17 — Repeat echocardiogram (Days 5–7): confirms repair durability, LV recovery, absence of paravalvular leak or new pericardial effusion.

• Step 18 — Dietary normalization; diuretic weaning; optimized discharge medications prescribed (ACE inhibitor or ARB, beta-blocker, anticoagulant/antiplatelet as indicated).

• Step 19 — Discharge from hospital: typically Days 7–12 post-op. Discharge summary and imaging data provided in digital format for home cardiologist.

POST-DISCHARGE RECOVERY IN COUNTRY (Weeks 2–6):

• Step 20 — Outpatient review at 2 weeks post-op: wound check, suture/staple removal, ECG, blood panel (INR monitoring for anticoagulated patients), and echocardiography if any concerns.

• Step 21 — Cardiac rehabilitation begins: supervised low-intensity walking program, progressive activity escalation.

• Step 22 — Clearance for air travel (fit-to-fly assessment): short-haul flights permitted from approximately Week 4; long-haul flights (>6 hours) from Weeks 6–8. Clearance based on stable sternum (clinical assessment), INR within therapeutic range, no pericardial effusion on echo, and absence of arrhythmia.

LONG-TERM MILESTONES:

• 6 weeks: sternal precautions typically lifted; driving permitted

• 6–8 weeks: return to sedentary/desk work

• 3 months: return to moderate physical activity

• 6 months: full echocardiographic assessment of repair durability

• Annual echocardiography: lifelong surveillance for repair integrity, aortic root dimensions, and LV function