The aortic valve is one of the four valves in our heart. It is located on the left side of the heart, within the left ventricle chamber, where the main artery of our body, the aorta, connects with the left ventricle. Blood that enters the left ventricle through the mitral valve is then pumped through the aortic valve into the body when the heart contracts. The aortic valve opens during the contraction phase of the heart (systole) and closes during the relaxation phase (diastole). When it closes, it prevents blood from flowing backward into the left ventricle.
The aortic valve consists of three crescent-shaped leaflets. In some cases, two of these leaflets are fused together during fetal development, resulting in a naturally bicuspid aortic valve. This is actually the most common congenital heart anomaly. Over time, this condition is often associated with enlargement of the aortic wall, known as an aortic aneurysm.
Today, the most common aortic valve disease is aortic stenosis. As people age, the leaflets that make up the aortic valve can calcify, causing the valve to lose its flexibility and the valve area to narrow. The exact cause is not fully understood, and it is generally considered a disease of older adults. Congenital bicuspid aortic valves can also calcify over time.
Calcification of the aortic valve usually occurs alongside a narrowing of the valve area. Aortic valves that begin to calcify often remain clinically silent for a long time. This condition is frequently discovered during routine clinical examinations or evaluations for other medical reasons. Symptoms start to appear once the narrowing becomes severe. The main symptoms include shortness of breath with exertion, chest pain, palpitations, and sudden fainting. Once these symptoms appear, the patient should undergo surgery without delay.
The crescent-shaped leaflets that make up the aortic valve normally come together perfectly during diastole, ensuring that no blood flows back into the ventricle. If these leaflets are damaged in any way, or if the aortic root to which they attach becomes dilated, the leaflets cannot close fully, allowing some blood to leak back into the ventricle during diastole. This condition is called aortic valve regurgitation. Infection-related deformities can also affect the leaflets, which is a dangerous situation requiring immediate surgery.
Congenital bicuspid aortic valves can sometimes lead not to stenosis but to aortic regurgitation. In these cases, dilation of the ascending aorta often accompanies the valve problem, and both the valve and the aorta must be addressed surgically.
Rheumatic aortic valve disease often presents with both stenosis and regurgitation.
Clinically, aortic regurgitation may remain asymptomatic for a long time. Increases in heart rate with exertion can mask the signs of regurgitation, leading to gradual and silent enlargement of the heart. If this enlargement progresses unnoticed, the heart’s contractile performance can drop significantly. Therefore, patients with aortic regurgitation should be closely monitored, and even in the absence of obvious symptoms, surgery should be considered once heart enlargement begins.
Surgical treatment for aortic regurgitation usually involves valve replacement. In some cases, repair is possible, but patient selection is critical for success. If regurgitation is accompanied by dilation of the ascending aorta, both the valve and the aorta should be replaced. Since the coronary arteries originate just above the aortic valve, they are detached from the diseased aorta and reimplanted into the new aortic root. This procedure is known as the Bentall operation.
Traditionally, aortic valve surgeries were performed via sternotomy, involving cutting the breastbone. This approach allows both valve surgery and interventions on the dilated aorta, such as for aortic aneurysms. However, the longer recovery and delayed return to normal activity, combined with the growing demand for less invasive procedures and better cosmetic outcomes, have driven cardiac surgeons to develop techniques that are as effective as conventional surgery but involve smaller or alternative incisions. Minimal Invasive Aortic Valve Surgery has emerged from this pursuit.
Minimal invasive aortic valve surgery can be performed using two different approaches. The first is called partial sternotomy, or a J-shaped partial incision of the sternum. In this technique, instead of cutting the entire breastbone, only the portion necessary to access the aorta—the main artery of the heart—is incised, leaving the section over the heart intact. A small incision (about 7 cm) is made on the front of the chest, and the underlying bone is partially cut, allowing easy access to both the aorta and the aortic valve.
This method is generally preferred because it provides good access not only to the aortic valve but also to the ascending aorta. Procedures such as the Bentall operation can also be performed through this incision. Even though the sternum is partially cut, the technique closely resembles standard aortic valve surgery, which is why it is the most commonly applied method in minimal invasive aortic valve surgery.
With this new technique, aortic valve surgery can now be performed without any incision in the breastbone. In this minimal invasive approach, a small incision (about 4 cm) is made on the right side of the chest, usually under the collarbone, allowing access to the aorta and aortic valve through the spaces between the ribs. In some suitable patients, the incision can also be made around the breast tissue.
An additional small incision (2–3 cm) is made in the right groin to access the femoral artery and vein. Through cannulas placed in these vessels, the patient is connected to the heart-lung machine. Using specially designed surgical instruments, the heart is temporarily stopped and the aorta is opened to reach the aortic valve. Every step of the procedure is performed under camera guidance, displayed on a large monitor that provides a clear and detailed view of the heart and aorta. The camera system has a crucial feature: with special glasses worn during surgery, the images appear in 3D, just like a robotic system. These high-resolution, magnified images allow surgeons to see extremely fine details that are not visible to the naked eye. The depth perception provided by the 3D view ensures that the surgery is performed with the highest level of safety.
The incision is not made to visualize the heart or valve directly, but rather to serve as a pathway for introducing the replacement valve into the body. Therefore, the incisions are much smaller than those in conventional minimal invasive surgeries, resulting in excellent cosmetic outcomes. Because the ribs are not spread with retractors, post-operative pain is significantly reduced.
Smaller incisions also mean less manipulation of the heart, resulting in less surgical trauma. Since the breastbone is not cut, there is no need for strict bed rest post-surgery. Less blood is required during and after the procedure. Patients can return to work in as little as two weeks and can even drive soon after. The risk of sternal infection—a major concern in traditional surgery—is eliminated. Overall, the recovery period is dramatically shortened, from 2–3 months in conventional surgery to just 2–3 weeks with this approach.
In this method, the patient’s diseased aortic valve is completely removed. Instead of using a mechanical or biological prosthetic valve, three semilunar-shaped leaflets are created from the patient’s own pericardium, the membrane surrounding the heart. These newly constructed leaflets are then sutured in place of the patient’s original aortic valve, effectively reconstructing a fully functional, native-like valve.
Minimally Invasive Aortic Valve Replacement – In recent years, the procedure commonly referred to as TAVI, or “transcatheter aortic valve replacement,” has become increasingly recognized as a treatment option for patients with aortic stenosis. It offers a valuable alternative for patients in whom conventional open-heart surgery carries high risk.
In this procedure, an artificial aortic valve is typically advanced through the femoral artery and positioned inside the patient’s calcified aortic valve, where it is then expanded. The patient’s own calcified valve remains in place, being “trapped” between the aortic wall and the newly implanted valve. Unlike traditional surgical valve replacement, where the diseased valve is completely removed and replaced, TAVI leaves the old valve in place and opens the new valve within it. This method is frequently used for patients with high surgical risk.
With my cardiac surgery team, available 24/7, we have been performing all types of aortic valve procedures with very high success rates for many years.
If you have a heart valve problem that requires surgery, you can consult us to learn more about minimally invasive endoscopic aortic valve surgery.
''The aortic valve is one of the four valves in our heart. It is located on the left side of the heart, within the left ventricle chamber, where the main artery of our body, the aorta, connects with the left ventricle.''
The aortic valve consists of three crescent-shaped leaflets. In some cases, two of these leaflets may be fused together during fetal development.