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Your aortic valve is one of the heart’s most important structures, helping blood flow in the right direction. It sits between your heart’s main pumping chamber and the aorta, the large artery that carries blood to the rest of your body. Each time your heart beats, your aortic valve opens to let blood out and then closes to prevent it from flowing backward. When it’s working well, you don’t notice it at all, but it plays a vital role in keeping your body supplied with oxygen-rich blood. However, conditions such as aortic stenosis (narrowing), aortic regurgitation (leaking) or if it is damaged through infection (also called endocarditis) disrupt this process and place extra strain on your heart acutely or over time.
One common problem is called aortic stenosis, where your valve becomes stiff or narrowed. This means it doesn’t open fully, making it harder for blood to leave your heart. As a result, your heart has to work harder to push blood through the smaller opening. Over time, you might notice symptoms like feeling tired, short of breath, or experiencing chest discomfort, especially during activity.
Another condition is aortic regurgitation, which happens when your valve doesn’t close properly. In this case, some blood leaks backward into your heart instead of moving forward through your body. This can cause your heart to handle extra volume of blood, which may lead to symptoms such as fatigue, breathlessness, or a noticeable, sometimes pounding heartbeat.
The severity of your valve condition is assessed using a combination of your doctor’s physical examination and detailed imaging, most commonly an echocardiogram (heart ultrasound). These tests help your healthcare team understand how well your valve is functioning and how your heart is responding. Your doctor will also assess the severity of the valve problem itself, how narrowed (stenotic) or leaky (regurgitant) the valve is. Heart valve disease is often described in stages to help doctors understand how serious it is and when treatment might be needed. In the early stage , the valve has started to change and may not be working perfectly, but symptoms are usually not present and the condition is often mild to moderate.
On occasions the aortic valve disease may become severe but the person may still feel completely well. Even without symptoms, the heart can begin to show signs of strain, which is why regular monitoring is important. Understanding these stages helps ensure that treatment is given at the right time, before symptoms develop and complications occur.
Decisions about whether and when to treat your valve condition are based on several important factors. One of the most important is whether you are experiencing symptoms, such as breathlessness, fatigue, chest discomfort, or reduced exercise tolerance. Even subtle changes in how you feel can provide valuable clues about how your heart is coping. Equally important is how your heart is adapting to the valve disease.
Over time, the heart may enlarge (dilate), thicken (hypertrophy), or begin to weaken if it is under strain. Identifying these changes early helps guide the timing of treatment before permanent damage occurs. Valve disease can also affect how blood flows through your lungs or the rest of your body. For example, pressure may build up in the lungs or circulation, which can contribute to symptoms and indicate more advanced disease. Finally, your doctor will consider any changes in your heart rhythm, such as the development of irregular heartbeats (arrhythmias), which can occur as a result of valve disease and may influence treatment decisions.
Native Aortic Valve Endocarditis
Native aortic valve endocarditis is a serious infection of your own (natural) aortic valve. It develops when bacteria enter the bloodstream and attach to the valve, where they multiply and damage the heart tissue. The bacteria may enter the blood from dental infections or procedures, skin infections, intravenous drug use, or other infections elsewhere in the body. People with existing heart valve disease (like aortic stenosis or aortic regurgitation) or certain congenital heart conditions are at a higher risk, although the infection can occasionally occur in people with previously healthy valves.
As the infection progresses, it can destroy the valve, causing it to leak severely and making it difficult for the heart to pump blood effectively. Pieces of infected material can also break away and travel through the bloodstream, increasing the risk of stroke or infection in other organs. Without prompt treatment, native aortic valve endocarditis can become life-threatening, so early diagnosis and specialist care are essential.
One of the most serious complications is an aortic root abscess. This happens when the infection spreads beyond the valve into the tissues around it, creating a pocket of infection within the heart. An aortic root abscess can weaken the structures supporting the valve, damage the heart’s electrical system causing abnormal heart rhythms, and make the infection much harder to control with antibiotics alone. Because of these risks, an aortic root abscess usually requires urgent surgery to prevent further damage and improve the chances of a full recovery.
Treatment depends on how advanced the infection is. In some patients, the infection can be successfully treated with several weeks of intravenous antibiotics. However, many people require surgery because the valve has been damaged, the infection is not responding to antibiotics, or complications such as an aortic root abscess have developed. Surgery may involve replacing the damaged aortic valve or, in more complex cases, removing all infected tissue and rebuilding the affected part of the heart. This can include reconstructing the left ventricular outflow tract (the channel through which blood leaves the heart) using a bovine pericardial patch before replacing the valve. If the infection has caused extensive damage, the entire aortic root may need to be replaced using either a donated human valve and root (homograft) or a specially designed artificial valve and graft. These are highly specialised operations that often performed by heart surgeons with extensive experience in aortic surgery and complex infective endocarditis surgery, offering patients the best opportunity for a successful recovery and long-term health.
Bicuspid aortic valve (BAV) is a condition some people are born with, where the heart’s aortic valve has two flaps instead of the usual three. It is quite common, affecting about 1 to 2 out of every 100 people. BAV can run in families. If one person has it, there is about a 1 in 10 chance that a close family member (such as a parent, sibling, or child) may also have it. Because of this, doctors often recommend that close relatives have a simple heart scan called an echocardiogram to check for the condition. People with BAV may develop problems with the valve over time. The valve can become: Narrowed (stenosis), making it harder for blood to flow out of the heart of Leaky (regurgitation), allowing blood to flow backward. Separately, some people may also develop a widening (aneurysm) of the main artery (aorta). Importantly, changes in the valve and changes in the aorta do not always happen at the same speed. A smaller group of people with BAV (about 10–15%) mainly have a leaky valve. These patients are often younger and more commonly male.
In many people with BAV, the main blood vessel leaving the heart (the aorta) can also become enlarged. This is known as BAV aortopathy. The enlargement can occur in different parts of the aorta, including the root (closest to the heart), the ascending aorta (the most common area, affecting around 60–70% of patients), the aortic arch, or a combination of these areas. Although most people with BAV will never experience serious complications, a small number may develop a condition called an aortic dissection, which is a tear in the wall of the aorta. This occurs in 5% or fewer patients over a lifetime. The risk is higher in people who also have problems with the valve itself, such as narrowing (stenosis) or leakage (regurgitation). In particular, patients with a leaky valve may have a higher risk of complications compared to those with a narrowed valve.
The reason this happens is not fully due to the valve alone. In many patients, the wall of the aorta is naturally weaker or more prone to stretching. This may be related to inherited factors, as BAV can run in families. In addition, the way blood flows through a bicuspid valve can create abnormal stress on the aortic wall, which may contribute to the aorta enlarging earlier in life.
Because BAV often affects younger patients, treatment decisions are made with long-term outcomes in mind. If the aorta becomes significantly enlarged (typically around 4.5 to 5.0 cm) or is growing quickly, surgery may be recommended. In many cases, surgeons will repair or replace both the valve and the affected part of the aorta at the same time. This approach can provide a more durable, long-term solution, particularly in patients with additional risk factors such as a family history of aortic disease, faster aortic growth, or a leaking valve.
Aortic valve replacement is one of the most commonly performed heart operations. It involves replacing a damaged valve with an artificial one, which can be either a biological (“tissue”) valve or a mechanical (“metal”) valve. Traditionally, these replacement valves are stitched into place using sutures. This is because the natural valve opening (called the annulus) is soft and flexible, while the artificial valve is firm. The stitches help secure the new valve tightly in position and ensure there are no gaps. To achieve a good fit, the replacement valve is usually chosen to be slightly smaller than the natural opening, and the stitches help bring everything together securely. Newer types of valves, known as rapid deployment or sutureless valves, offer an alternative approach. These valves are designed to expand on their own once positioned inside the heart. Using technology similar to that used in stents and minimally invasive valve procedures, the valve gently opens up, fits snugly into place, and stays secure without the need for multiple stitches. In selected cases, particularly in younger patients, another option called the Ross procedure may be offered. This is a more complex operation in which the patient’s own pulmonary valve (the valve on the right side of the heart) is used to replace the diseased aortic valve and part of the aorta. The pulmonary valve is then replaced with a donated human valve (called a homograft). Because the new aortic valve is the patient’s own living tissue, it can grow and function very naturally, making it an attractive option for carefully chosen patients.
The main reasons for aortic valve surgery are to relieve symptoms, help you live longer, and reduce the risk of serious complications. The operation involves replacing your damaged valve with a new one. This can be either a mechanical valve (made from durable man-made materials) or a tissue valve (usually made from cow or pig tissue). Your doctor will help you decide which option is best for you. Aortic valve replacement is performed under general anaesthetic, which means you will be asleep throughout the procedure. Most patients stay in hospital for around 5 to 7 days. During the operation, the surgeon makes an incision in the centre of the chest to reach the heart. This is usually through a smaller incision (lower mini-sternotomy) of around 10–12 cm which we can offer excellent cosmetic results. The breastbone is carefully opened to allow access to the heart. To safely perform the surgery, the heart is temporarily slowed or stopped using medication. At the same time, a heart-lung machine takes over the job of pumping blood and supplying oxygen to the body. The surgeon then opens the heart, removes the damaged valve, and carefully positions the new valve in place. Once the new valve is secure, blood flow is returned to the heart and the heart is restarted. The breastbone is then closed, and the skin is stitched using dissolvable sutures.The operation usually takes around 3 to 4 hours.
Tissue (biological) valves are commonly used to replace the aortic valve and are made from natural materials, usually cow or pig tissue. These valves are carefully attached to the heart using stitches. The main advantage of a tissue valve is that it carries a lower risk of blood clot formation compared to mechanical valves, which means patients usually do not need to take long-term blood-thinning medication and have a lower risk of complications such as bleeding and stroke. The main disadvantage is that tissue valves do not last forever and will gradually wear out over time. How long they last depends largely on the patient’s age. In younger patients, the valve may wear out within only a few years, whereas in middle-aged patients it typically lasts around 10 to 15 years. In patients over the age of 70, tissue valves often last even longer. For this reason, tissue valves are generally recommended for patients over the age of 60, as they provide a good balance between durability and avoiding the need for lifelong medication.
New technology sutured bovine bioprosthetic valves claim that they can offer longer durability due to better decalcification process and build-in technology for future valve-in-valve TAVI procedures and as such, they could be offered to patients of <60 years of age. The Edwards Inspiris Resillia valve has demonstrated very good durability for over 10 years and hemodynamic performance after an equivalent of 25 years of simulated in vitro accelerated wear testing, however, hard evidence to support this statement (>20 years durability) are still missing due to the fact that this technology is new and longterm durability data are still awaited.
Some tissue (biological) valves made from cow tissue are designed to be placed in the heart without stitches. These are called sutureless or rapid deployment valves. Because no stitches are needed, the operation can be quicker. This means the heart spends less time under stress during surgery, which may help improve recovery and overall outcomes. These valves also do not have a bulky sewing ring. This allows surgeons to place a slightly larger valve, which can improve blood flow, especially in patients with a smaller aortic valve area. The valve is easier to insert, which means surgery can often be performed through smaller cuts. This is known as minimally invasive surgery and may lead to less pain, quicker recovery, and a smaller scar. At Oxford, we commonly use the Perceval valve, a well-established sutureless valve with excellent results. It has been shown to provide good performance and supports a faster and smoother recovery for many patients. Another advantage of this type of valve is that it can make future treatments easier. If the valve wears out over time, it may be possible to treat it with a less invasive procedure called TAVI, using the existing valve as a guide.These valves are usually suitable for patients over the age of 55 who are choosing a tissue valve. They can also be helpful in more complex operations or repeat heart surgeries. However, this type of valve is not suitable for everyone. It is generally not recommended for patients with a bicuspid (abnormally shaped) aortic valve or a significantly enlarged aortic root. It is also not suitable for patients with an allergy to nickel. Your surgeon will help decide if this type of valve is right for you based on your individual condition.
If a previously implanted tissue (biological) valve starts to wear out or fail over time, there are effective treatment options available. Your heart team will carefully assess your situation and discuss the most appropriate and safest treatment option for you. Patient with a failing valve (whether it was originally implanted during open-heart surgery or through a less invasive, percutaneous TAVI procedure) may be suitable for further treatment. Traditionally, this would involve another operation to replace the valve (known as redo aortic valve replacement surgery). While this is still sometimes the best option, many patients today can be treated with a less invasive approach. This newer option is called a “valve-in-valve” TAVI procedure. In this treatment, a new biological valve is placed inside the existing worn-out valve using a catheter (a thin tube), usually inserted through a blood vessel in the groin. This avoids the need for another major open-heart operation leading to a shorter recovery time, less discomfort and often lower risk compared to repeat open-heart surgery in suitable patients. Not everyone is suitable for this approach, and the decision depends on several factors, including the type and size of the existing valve, your overall health, and your individual anatomy.
There are several excellent mechanical heart valves available today, and they all perform very well. These valves are made from strong, specially treated materials such as carbon-coated metal, designed to last a lifetime. The main advantage of a mechanical valve is its exceptional durability. Unlike tissue valves, mechanical valves do not wear out over time. For many patients—especially younger individuals, this means that another valve replacement operation is unlikely to be needed in the future.
However, there are some important considerations. Because the valve is made from artificial materials, blood can sometimes form clots on its surface. If a clot develops, it can affect how the valve works or potentially lead to serious complications such as a stroke. To reduce this risk, patients with a mechanical valve must take lifelong anticoagulant (blood-thinning) medication, such as Warfarin. This treatment is very effective but requires regular blood tests to ensure the dosage is correct.
Even with careful use of anticoagulation, there remains a small but important risk of blood clots or bleeding complications. For this reason, choosing a mechanical valve involves balancing the benefit of long-term durability against the need for lifelong medication and monitoring.
Your heart team will discuss these factors with you in detail to help decide whether a mechanical or tissue valve is the best option for your individual lifestyle and medical needs.anticoagulants.
Aortic valve repair is a modern surgical technique used to treat certain problems of the aortic valve, particularly when the valve is leaking (a condition known as aortic regurgitation). Instead of replacing the valve, the surgeon carefully reshapes and restores your own valve so that it works properly again. One of the main advantages of this approach is that it preserves your natural valve, allowing for excellent blood flow and often avoiding the need for long-term blood-thinning medication.
Not all aortic valves can be repaired, and the success of the procedure depends on the structure of the valve and the underlying cause of the problem. In addition, this is a highly specialised operation and is best performed by surgeons with specific expertise in aortic valve and aortic root surgery. For this reason, patients are usually referred to centres and surgeons with a dedicated interest in this field.
Patients with a normal three-leaflet (tricuspid) aortic valve that has become leaky can often be treated very successfully with repair techniques, with excellent long-term results. Aortic valve repair can also be offered to selected younger patients who are born with an abnormal valve, such as a bicuspid aortic valve (a valve with two leaflets instead of three). In these cases, repair can restore good valve function and delay or even avoid the need for valve replacement for many years.
Here are some procedures surgeons may use to repair your aortic valve:
- Commissurotomy, which is used for narrowed valves, where the cusps (the leaflets that make up the valve) are thickened and perhaps stuck together. The surgeon opens the valve by cutting the points where the cusps meet.
- Valvuloplasty, which strengthens the cusps to provide more support and to let the valve close tightly.
- Reshaping, where the surgeon cuts out a section of a cusp. Once the cusp is sewn back together, the valve can close properly.
- Decalcification, removes calcium which has built up on the cusps. Once the calcium is removed, the cusps can close properly.
- Patching, where the surgeon covers holes or tears in the cusps with a tissue patch.
In many patients, the problem is not only the valve itself but also the surrounding part of the heart called the aortic root. When this area becomes enlarged, it can cause the valve to leak. For this reason, aortic valve repair is often performed together with surgery on the aortic root. This may involve reshaping the aortic root (known as the Yacoub remodeling procedure) or reimplanting the valve within a new supporting structure (known as the David procedure). These techniques aim to restore normal valve function while also strengthening the aorta, with excellent long-term outcomes when performed in experienced centres.
Overall, aortic valve repair offers an effective and durable treatment option for selected patients, particularly younger individuals, by preserving the natural valve, providing excellent function, and postponing the need for valve replacement. Your heart team will carefully assess your individual condition and discuss whether this approach is suitable for you.
Transcatheter Aortic Valve Implantation (TAVI), also known as Transcatheter Aortic Valve Replacement (TAVR),is a minimally invasive procedure used to treat a narrowed or damaged aortic valve, most commonly due to aortic stenosis. Instead of removing the old valve during open-heart surgery, a new valve is inserted inside the existing diseased valve. The new valve is delivered through a thin tube (catheter), usually inserted via an artery in the groin, and expanded into place after the old valve has been gently stretched open. Because TAVI does not require opening the chest or stopping the heart, it is generally associated with a shorter recovery time, less discomfort, and a quicker return to normal activities compared to traditional surgery. Many patients are able to go home within a few days of the procedure.
TAVI was originally developed for patients who were considered too high risk for open-heart surgery, particularly those in their 80s or 90s or with significant medical conditions. However, over the past decade, advances in technology and growing clinical experience have expanded its use. Today, TAVI is also offered to selected patients in their 70s and even younger individuals who are considered at intermediate or, in some cases, lower surgical risk. Current evidence shows that TAVI provides excellent outcomes, with significant improvement in symptoms such as breathlessness and fatigue, as well as quality of life. Modern valves are highly reliable, and results in appropriately selected patients are comparable to traditional surgical valve replacement.
Despite these advances, TAVI is not suitable for everyone. Factors such as age, overall health, anatomy of the heart and blood vessels, and the type of valve disease all play an important role in deciding the best treatment. In younger patients, particularly those under 65–70 years of age, surgical valve replacement is often still preferred due to the longer-term durability of surgical valves. Your care will be guided by a specialised heart team, who will carefully assess your condition and recommend the most appropriate and safest treatment option tailored to you.
The Oxford TAVI team has been working together since the early introduction of this technology in 2009 and now performs hundreds of TAVI procedures each year, making it one of the most experienced programmes in the region. At Oxford University Hospitals NHS Foundation Trust, every patient referred for TAVI is carefully reviewed by a dedicated, specialist multidisciplinary team. This team includes cardiologists, cardiac surgeons, imaging specialists, and other experts who work together to assess each case in detail. Treatment decisions are always individualised, taking into account your overall health, heart condition, and personal circumstances. This team-based approach ensures that every patient receives the safest, most appropriate, and most effective treatment tailored specifically to their needs.
When transcatheter aortic valve implantation (TAVI) is performed through the groin (known as the transfemoral approach), the procedure is usually carried out under local anaesthetic with light sedation. This means the area at the top of the leg is numbed, and most patients remain comfortable and do not require a full general anaesthetic. A thin tube (catheter) is inserted into the artery in the groin and carefully guided up to the heart. The new valve, which is mounted on a small balloon or self-expanding frame, is positioned inside the diseased aortic valve. Once in place, the new valve is expanded and immediately begins to function, pushing the old valve aside. After the procedure, patients are monitored in a specialised recovery or high-dependency area. Recovery is usually quick, and most patients are able to sit up, walk, and return home within 1-2 days. In some patients, the arteries in the groin may not be suitable for this approach. In these cases, TAVI can be performed through an alternative route, such as the artery under the collarbone (called the transaxillary approach). This is also a minimally invasive technique and allows the procedure to be performed safely without the need for open-heart surgery. Your heart team will carefully assess your blood vessels and overall condition to determine the safest and most appropriate access route for your procedure.
