Mechanical Aortic Valve Replacement

Anatomy and Physiology

MAVR is a surgical procedure that replaces a diseased or malfunctioning aortic valve with a mechanical prosthesis. The success of this procedure depends on a deep understanding of the intricate anatomy of the aortic valve and heart. 

Aortic Valve

The aortic valve lies between the left ventricle and the aorta, regulating blood flow from the heart to the systemic circulation. Usually, the aortic valve consists of 3 cusps—the right coronary cusp (RCC), left coronary cusp (LCC), and noncoronary cusp (NCC). These cusps open during systole to allow blood flow into the aorta and close during diastole to prevent backflow into the left ventricle. In adults, the normal aortic valve area is 3 to 4 cm². Anatomical variants such as the bicuspid aortic valve present in 1% to 2% of the population can complicate MAVR procedures.[3] 

Leaflets (Cusps)

The leaflets, or cusps, are the valve's primary sealing mechanism, forming the boundary between the left ventricle and the aorta, ensuring efficient blood flow during systole, and preventing regurgitation during diastole. In a trileaflet valve, the NCC is usually the largest leaflet, handling most of the systolic flow. The leaflets have fibrous surfaces known as lunulae, which are crucial for their coaptation. A nodule of Arantius, thickening at the center of the leaflet edges, ensures the valve's competence during closure. The leaflets also form a spherical shape with the aortic walls, creating the sinuses of Valsalva, which are key to maintaining valve function and coronary blood flow. The LCC covers the left coronary sinus and the origin of the left main coronary artery, the RCC covers the right coronary sinus and the origin of the right coronary artery, and the NCC covers the noncoronary sinus towards the interatrial septum.[4] 

Annulus

The annulus is a circular, fibrous ring that forms the foundation of the aortic valve. This structure anchors the valve cusps and provides the necessary stability for valve function. During MAVR, the mechanical prosthesis is anchored to this annular base. The annulus represents the boundary where the aortic valve leaflets are attached and is crucial for determining the size and position of the prosthesis. Echocardiography and imaging techniques measure the annulus to guide prosthesis sizing in surgical aortic valve replacement and transcatheter aortic valve replacement. The annulus marks the smallest orifice through which blood is ejected from the left ventricle, highlighting its importance in maintaining effective cardiac output.

Sinuses of Valsalva

The sinuses of Valsalva are 3 dilated pockets in the aortic root, located just above the valve cusps. These sinuses play a critical role in coronary blood flow and valve function. The right and left sinuses contain the origins of the right and left coronary arteries, while the noncoronary sinus does not house a coronary artery. The sinuses extend from the leaflet insertions to the sinotubular junction (STJ) and are essential for ensuring proper valve closure and preventing the cusps from sticking to the aortic wall. The walls of these sinuses are composed of thin aortic tissue, with the base containing varying amounts of ventricular tissue. The sinuses allow for the efficient closure of the valve and contribute to coronary perfusion during diastole.

Commissures

Commissures are where the valve cusps attach to the aortic wall, forming a crown-like structure critical for the valve's stability and function. The commissures are typically located at or slightly below the STJ. The areas beneath the commissures, known as interleaflet triangles, consist of fibrous or muscular tissue. These structures contribute to the valve's structural integrity and proper coaptation, ensuring one-way blood flow. The interleaflet triangle between the NCC and LCC is continuous with the anterior mitral leaflet, forming the aortomitral curtain. In contrast, the triangle between the NCC and RCC is continuous with the membranous interventricular septum, where surgical incisions can disrupt the heart's conduction system and cause arrhythmias.

Sinotubular Junction

The STJ is a noncircular, scalloped structure marking the boundary between the aortic root and the ascending aorta that is vital in maintaining the geometry of the valve cusps and the valve's overall function. The coronary ostia, openings for the coronary arteries, are typically located just below this junction. During MAVR, avoiding interference with the normal function of the valve and the coronary arteries when placing the prosthesis is crucial.

Left Ventricle

The heart's main pumping chamber is the left ventricle, pushing oxygenated blood into the aorta through the aortic valve. The relationship between the aortic valve and the left ventricular outflow tract is crucial in MAVR. The alignment and positioning of the mechanical valve are critical to maintaining efficient blood flow and minimizing the risk of complications such as left ventricular outflow obstruction.

Ascending Aorta and Coronary Arteries

The ascending aorta begins immediately after the aortic valve and carries oxygenated blood to the rest of the body. The right and left coronary arteries originate from the sinuses of Valsalva and provide blood supply to the heart muscle. During MAVR, it is essential to avoid obstructing these arteries to ensure adequate blood flow to the myocardium.

Indications

MAVR is a surgical procedure indicated for patients with aortic valve disease when the native valve is severely dysfunctional and requires replacement. The incidence of aortic valve disease increases with age; 1 in 8 people aged 75 and older have moderate to severe valvular heart disease.[5] The primary conditions warranting MAVR include aortic stenosis, aortic regurgitation, and some cases of complex congenital heart disease. The choice of a mechanical valve is influenced by patient-specific factors such as age, life expectancy, the need for long-term anticoagulation, and lifestyle. Indications for MAVR are varied (and include but are not necessarily limited to) aortic stenosis, aortic regurgitation, or a congenital bicuspid aortic valve—as part of a comprehensive repair for congenital cardiac disease, or when reoperation for a failed bioprosthetic valve is required. 

Aortic Stenosis

Aortic stenosis is a potentially serious condition that affects blood flow from the heart to the rest of the body. Calcification and atherosclerosis of the valve are the most common causes of aortic stenosis.[6] Aortic stenosis is the most common type of valvular heart disease in older adults. The natural history of aortic stenosis usually begins with an asymptomatic period, with symptoms having developed once the valve is critically stenosed. The progression of the stenotic valve and timing of symptom onset varies from patient to patient. Symptomatic individuals with severe stenosis have a poor prognosis. Ross first described the higher mortality rate after the onset of cardiac symptoms in 1968.[7] 

Asymptomatic severe aortic stenosis: MAVR may be considered in asymptomatic individuals with severe aortic stenosis if there is evidence of left ventricular dysfunction, very high gradients, or rapid progression of stenosis.

Severe aortic stenosis: The most common indication for MAVR is severe aortic stenosis, characterized by significant narrowing of the aortic valve, which restricts blood flow from the left ventricle to the aorta. Patients typically present with symptoms such as chest pain, shortness of breath, syncope, or heart failure. Over the past 6 decades, SAVR has become a gold standard for patients who are high-risk.[8] Indications for aortic valve replacement have changed tremendously. Results from a series of landmark clinical trials have shown a beneficial effect in those who are intermediate- to low-risk.[9] Surgical valve replacement is indicated when symptoms are present, or the left ventricular function is compromised. Transthoracic (TTE) and transesophageal echocardiography (TEE) are the best tools for evaluating aortic valve morphology. The American Society of Echocardiography outlines strict criteria for severe aortic stenosis and the need for aortic valve replacement. Severe aortic stenosis is described as:

• Aortic valve area of less than or equal to 1.0 cm²
• Mean transvalvular aortic gradient greater or equal to 40 mm Hg
• The maximum aortic jet velocity is greater than or equal to 4 m/s across the valve [10]

The stages and recommendations for aortic valve replacement in patients with valvular stenosis are:

• Severe high-gradient aortic stenosis with symptoms by either history or exercise testing (stage D1)
• Asymptomatic with severe stenosis (stage C2) and left ventricular ejection fraction <50 % 
• Severe stenosis (stage C or D) undergoing other cardiac surgery 
• Asymptomatic with severe stenosis and low surgical risk
• Asymptomatic with severe stenosis and decreased exercise tolerance or fall in systemic blood pressure [11][12]

Aortic Regurgitation

Individuals with mild to moderate aortic regurgitation typically remain asymptomatic, with a minimal risk of adverse events. Continuous monitoring of patients with chronic aortic regurgitation through clinical assessments and echocardiography is imperative, focusing on symptom changes, regurgitation severity, and left ventricular systolic dysfunction.

Acute aortic regurgitation: MAVR is also indicated in cases of acute aortic regurgitation, often due to endocarditis, aortic dissection, or trauma. The sudden onset of severe regurgitation can rapidly lead to hemodynamic instability and necessitates urgent surgical intervention.

Severe aortic regurgitation: MAVR is indicated in patients with severe aortic regurgitation, where the aortic valve fails to close properly, causing blood to leak back into the left ventricle during diastole. This condition can lead to left ventricular dilation, hypertrophy, and eventually heart failure. MAVR is recommended in symptomatic individuals or those with evidence of left ventricular dysfunction (ejection fraction <50%) or significant dilation.

Severe aortic regurgitation is quantified as follows:

• Vena contracta ≥0.6 cm
• Holodiastolic reversal of blood flow
• Regurgita
• Regurgitant fraction ≥50%
• Effective regurgitant orifice ≥0.3 cm² 

The American Heart Association class I indications for aortic valve replacement in patients with aortic regurgitation are: 

• Symptomatic with severe aortic regurgitation
• Asymptomatic with severe aortic regurgitation and an ejection fraction ≤55%
• Asymptomatic, undergoing other cardiac surgery [13]  

Congenital Aortic Valve Disease

Bicuspid aortic valve: Patients with bicuspid aortic valve disease may develop significant aortic stenosis or regurgitation over time, requiring MAVR. The decision to opt for a mechanical valve is based on the patient's age, the need for reoperation, and life expectancy.

Complex congenital heart defects: In some patients with complex congenital heart conditions, MAVR may be required as part of a broader surgical repair or reconstruction strategy.

Reoperation for Failed Bioprosthetic Valve

Structural valve deterioration: In younger patients or those with a history of failed bioprosthetic valves due to structural valve deterioration, MAVR may be preferred as mechanical valves offer greater durability and reduce the likelihood of future reoperations.

Patient Selection Criteria

Several factors influence the selection of a mechanical valve over a bioprosthetic valve:

• Age and life expectancy: Mechanical valves are preferred in younger patients due to their durability and long lifespan. For patients 60 and older, the longevity of a mechanical valve outweighs the need for long-term anticoagulation.
• Anticoagulation tolerance: Since mechanical valves require lifelong anticoagulation with warfarin to prevent thromboembolism, patient compliance and the ability to manage anticoagulation therapy are crucial considerations.
• Lifestyle considerations: Patients with active lifestyles or those at high risk for reoperation may benefit from the durability of a mechanical valve despite the need for anticoagulation.

A mechanical valve is preferable over a bioprosthetic valve in the following patients:

• Surgical aortic valve replacement in patients aged <55
• No contraindication to anticoagulation with vitamin K antagonist
• An existing indication for anticoagulation, like a prosthetic mechanical valve at a different location
• High risk of morbidity and mortality with the intervention [14]

The following are predictors of poor outcomes in patients undergoing aortic valve replacement:

• Concomitant cardiac diseases: These can further compromise myocardial function, such as poor left ventricular ejection fraction, previous cardiac surgery, and associated coronary artery disease.
• Neurological dysfunction
• Chronic lung disease or terminal end-organ lung dysfunction
• Liver cirrhosis or terminal end-organ liver dysfunction
• Renal insufficiency
• Recent stroke within the last 6 months
• Severe pulmonary hypertension with right ventricular dysfunction
• Echocardiographic evidence of an intracardiac mass, thrombus, or vegetation
• Life expectancy of less than 12 months owing to a noncardiac cause
• Myocardial infarction within the last 30 days [15][16]

Contraindications

MAVR is a critical intervention for patients with severe aortic valve disease, but it is not suitable for everyone. Contraindications to MAVR can be absolute or relative and often involve patient-specific factors that increase the risk of poor outcomes or complications. The key contraindications are:

Absolute Contraindications

Inability to adhere to anticoagulation therapy: MAVR requires lifelong anticoagulation with medications like warfarin to prevent thromboembolic events. Patients who are unable or unwilling to comply with anticoagulation therapy or who have a history of nonadherence are at high risk for valve thrombosis and embolic events. A bioprosthetic valve, which generally does not require long-term anticoagulation, may be more appropriate for these patients.

Active infection: Patients with active endocarditis or other systemic infections are contraindicated for MAVR until the infection is fully treated. Placing a prosthetic valve in the presence of an active infection significantly increases the risk of prosthetic valve endocarditis, which can be life-threatening.

Severe bleeding disorders: Patients with conditions that predispose them to bleeding, such as hemophilia, severe thrombocytopenia, or other coagulopathies, may not be suitable candidates for MAVR due to the need for long-term anticoagulation. The risk of life-threatening bleeding complications outweighs the benefits of the procedure in these cases.

Relative Contraindications

Advanced age or frailty: While age alone is not an absolute contraindication, patients who are at an advanced age or frail may not tolerate the anticoagulation therapy required after MAVR or may have a limited life expectancy, making the procedure's risks outweigh its potential benefits; in such cases, a bioprosthetic valve might be preferred.

Severe comorbidities: Patients with significant comorbidities, such as advanced chronic kidney disease, liver disease, or pulmonary hypertension, may have a higher risk of complications from the surgery and the required anticoagulation. These conditions may tilt the balance toward opting for a bioprosthetic valve or even nonsurgical management.

Pregnancy or desire for future pregnancy: Warfarin, the anticoagulant commonly used after MAVR, is teratogenic and poses significant risks during pregnancy. Women of childbearing age who desire pregnancy may be better candidates for a bioprosthetic valve, which requires shorter-term or no anticoagulation, reducing the risks associated with pregnancy.

History of thromboembolism despite adequate anticoagulation: Patients who have experienced thromboembolic events while on therapeutic anticoagulation present a challenging situation. The risk of recurrent embolic events with a mechanical valve may be deemed too high, necessitating consideration of alternative treatments.

Equipment

The following equipment is required for the MAVR procedure:

• Cardiopulmonary bypass machine
• The valve prostheses of various sizes
• Transesophageal echocardiography
• Surgical instruments

Personnel

An interprofessional heart team evaluates and prepares the patient for the procedure. 

The heart team includes:

• Cardiologist and interventional cardiologist
• Cardiothoracic surgeons
• Cardiac anesthesiologist 
• Nurses
• Coordinator
• Intensivist

The following staff is needed to carry out aortic valve replacement:

• Cardiothoracic surgeon
• Cardiac anesthesiologist
• Perfusionist
• Nurses
• Industry representative (for newer valves)

Technique or Treatment

Aortic Valve Replacement Methods

Aortic valve replacement has been shown to substantially improve survival in patients with symptomatic severe aortic disease, which has formed the basis for recommending this procedure in such circumstances.[17] Currently, 2 techniques are being used for aortic valve replacement: the surgical aortic valve replacement, SAVR, and the TAVR approaches. TAVR is the minimally invasive surgical technique for aortic valve replacement for patients who are not candidates for SAVR.

Surgical aortic valve replacement can be performed via the following methods: 

• Minimally invasive SAVR
• Right anterior minithoracotomy 
• Ministernotomy
• Conventional sternotomy and valve replacement [18][19]

Transcatheter aortic valve replacement can be performed using the following:

• Two United States Food and Drug Administration-approved valves are available:
  • SAPIEN valves (Edwards Lifesciences) 
  • CORE-valves (Medtronic): The newest generation Medtronic valve is the EVOLUTE-R, which can self-expand and reposition after deployment.[20]  

Valve Types

The 3 primary types of artificial heart valves are mechanical, bioprosthetic, and tissue-engineered. Mechanical valves are made from strong, durable materials. Bioprosthetic valves are derived from animal tissue (porcine valves) or flexible material like bovine pericardium. Tissue-engineered valves are cultivated in vitro by seeding human cells onto a scaffold. This activity focuses on mechanical heart valves, of which there are 3 types:

Caged ball valve: The first artificial heart valve featured a metal cage with a silicone elastomer ball. As the heart contracts and chamber pressure exceeds that of the atrium, the ball rises, blocking blood flow. When pressure drops, the ball falls, allowing blood flow. Due to a high risk of clotting and adverse hemodynamic effects, caged ball valves are no longer used.

Tilting disc valve: This valve features a metal ring holding a disc covered by fabric for suturing. When chamber pressure drops, the valve opens to allow blood flow and closes to prevent backflow. The Medtronic-Hall model is the most widely used tilting disc design in the United States.

Bileaflet valve: The most common mechanical valve prosthesis consists of 2 semicircular leaflets. This valve is the least thrombogenic among mechanical valves and is characterized by its washing regurgitant blood jets.[21]

Procedural Techniques

MAVR is a sophisticated procedure aimed at addressing severe aortic valve disease. The choice between SAVR and TAVR depends on patient-specific factors, including their overall health and suitability for surgery.

Surgical Aortic Valve Replacement

SAVR is performed through a median sternotomy, where the chest is opened to access the heart. After opening the pericardium, cardiopulmonary bypass is established using cannulation of the aorta and venous system to manage circulation during surgery. A left ventricular vent is inserted to maintain a dry field, typically through the right superior pulmonary vein, left atrium, or mitral valve.

The next step involves cooling the patient to a bladder temperature of 32 °C. The aorta is then cross-clamped, and cardioplegia is administered through either a retrograde coronary sinus catheter or an antegrade cannula in the aortic root to arrest the heart and protect the myocardium. If there is aortic valve regurgitation, cardioplegia may be directly administered into the coronary ostia to prevent left ventricular dilation.

A hockey stick incision is made in the aorta, extending up to the noncoronary sinus of Valsalva, just above the aortic annulus. The valve leaflets are excised starting at the commissure between the right and noncoronary sinus. Calcifications are removed with a Rongeur, and the left ventricle is flushed and suctioned to eliminate debris, which could lead to complications such as stroke.

The annulus is measured using a sizer to select the appropriate prosthetic valve size. The new valve is attached to the annulus with pledgeted or nonpledgeted sutures. Pledgeted sutures are used for friable annuli and are placed in a horizontal mattress fashion, while nonpledgeted sutures may be used in horizontal mattresses or interrupted patterns. Suturing begins at the commissure between the left and right coronary cusps, proceeding in a specific order to avoid damaging the conduction tissue.

Once all sutures are in place and the prosthesis is positioned supraannularly, the aorta is closed with 4-0 polypropylene sutures in 2 layers. If needed, a patch enlargement using pericardial or Dacron material may be performed to reduce tension on the suture line. Strong suction is applied to the cardioplegia cannula postclosure for de-airing, and the aortic cross-clamp is released. Transesophageal echocardiography is used to ensure there is no residual air and that the valve functions correctly.

Transcatheter Aortic Valve Replacement

TAVR is most commonly performed via the transfemoral approach, where the catheter is inserted through the femoral artery in the groin. Depending on the patient's anatomy, alternative access routes include the transapical (through the chest wall) or transaortic (through a small incision in the chest) approaches. The procedure begins with a balloon valvuloplasty, where a balloon is inflated inside the narrowed aortic valve to widen the valve opening; this prepares the site for the new valve.

The new valve is crimped onto a balloon or self-expanding stent and delivered via the catheter to the aortic valve site. The balloon is inflated, or the stent is expanded, positioning the new valve within the diseased valve, which remains in place and holds the new valve in position. The valve is carefully positioned, and its function is checked using imaging techniques like fluoroscopy and echocardiography. Adjustments may be made to ensure optimal placement. Once the valve is seated correctly and functioning, the delivery system is removed. Hemostasis is achieved at the access site, and the procedure is concluded.

Complications

MAVR is a life-saving procedure for patients with severe aortic valve disease, but it carries a range of potential complications that must be carefully managed. These complications can be categorized into immediate postoperative, long-term, and anticoagulation-related issues.

Immediate Postoperative Complications

Bleeding: This is the most common complication due to the need for anticoagulation. Postoperative bleeding may require reoperation and is a major cause of early morbidity.

Thromboembolism: Despite anticoagulation, thrombus formation can occur on the mechanical valve, leading to embolic events such as stroke or systemic embolism. Mechanical aortic valves are more prone to thromboembolic complications compared to bioprosthetic valves (1%-2% vs 0.7%) and bleeding complications due to the requirement of long-term anticoagulation to avoid thromboembolic events, eg stroke, acute leg ischemia, or visceral embolization.

Paravalvular leak: A small amount of blood can flow around the valve between the sewing ring and the native tissue, leading to a paravalvular leak. If severe, this can result in hemolysis, heart failure, or the need for reoperation.

Infection: Prosthetic valve endocarditis is a serious complication that can occur early or late after MAVR, requiring prompt antibiotic therapy and may necessitate reoperation.

Long-Term Complications

Structural deterioration: Unlike bioprosthetic valves, mechanical valves are designed to last a lifetime. However, mechanical parts can wear out over time, leading to valve malfunction—though this is rare.

Valve thrombosis: Mechanical valves are prone to thrombosis, particularly if anticoagulation levels are subtherapeutic. Valve thrombosis can lead to acute valve obstruction, which is a surgical emergency.

Hemolysis: Blood cells can be damaged as they pass through the mechanical valve, leading to hemolytic anemia. Mild hemolysis is common, but severe cases may require additional interventions. Blood work usually reveals anemia in patients with mechanical aortic valves.[22]

Anticoagulation-related complications: Lifelong anticoagulation with warfarin or other agents is required to prevent thromboembolism. However, this increases the risk of bleeding complications, including intracranial hemorrhage, gastrointestinal bleeding, and other bleeding events. Maintaining a balance between preventing clotting and avoiding excessive bleeding is a significant challenge.

Anticoagulation Management Challenges

International normalized ratio monitoring: Patients with mechanical valves need regular monitoring of their international normalized ratio (INR) to ensure that anticoagulation is within the therapeutic range (usually INR 2.5-3.5 for aortic valve replacements). Deviations can lead to either thromboembolic or bleeding complications.

Drug interactions: Warfarin interacts with many medications, foods, and alcohol, making consistent INR control difficult. This requires careful management by patients and healthcare professionals.

Pregnancy: Anticoagulation during pregnancy is particularly challenging as warfarin is teratogenic, and alternative anticoagulants like low molecular weight heparin must be used, which requires close monitoring.

Clinical Significance

MAVR holds significant clinical importance as a life-saving intervention for patients with severe aortic valve disease, particularly aortic stenosis or aortic regurgitation when the native valve becomes dysfunctional. Here's a discussion of its clinical significance:

Durability and Longevity

One of MAVR's primary benefits is the durability of mechanical valves. These prosthetic valves are designed to last several decades, making them particularly advantageous for younger patients with a longer life expectancy. Unlike bioprosthetic valves, which typically last 10 to 20 years, mechanical valves reduce the likelihood of needing repeat surgeries, which carry increased risks.

Restoration of Hemodynamics

MAVR restores normal hemodynamics by replacing a malfunctioning valve, allowing unobstructed blood flow from the left ventricle into the aorta. This improvement alleviates symptoms such as dyspnea, fatigue, angina, and syncope, significantly improving the quality of life and exercise capacity for patients suffering from severe aortic valve disease.

Improved Survival

For patients with severe symptomatic aortic stenosis, untreated disease carries a poor prognosis with high mortality rates. MAVR can dramatically improve survival rates by addressing the underlying cause of heart failure and reducing the risk of sudden cardiac death. This is particularly critical in patients with severe aortic stenosis, where mortality without intervention is approximately 50% within 2 years of symptom onset.

High Risk of Thromboembolism

A significant clinical consideration for MAVR is the lifelong requirement for anticoagulation to prevent thromboembolism. Mechanical valves are highly thrombogenic, and without anticoagulation, patients are at risk for valve thrombosis and systemic embolization, including stroke. This necessitates meticulous management of anticoagulation therapy, typically with warfarin, which must be balanced against the risk of bleeding.

Impact on Patient Selection

The choice of a mechanical valve over a bioprosthetic valve is influenced by several factors, including patient age, lifestyle, and ability to adhere to anticoagulation therapy. Younger patients are generally preferred for MAVR due to the valve's longevity, while older patients or those at higher risk for bleeding may be better suited for a bioprosthetic valve. This decision-making process is critical and involves a multidisciplinary team approach.

Potential for Complications

Despite its benefits, MAVR carries risks such as bleeding, infection, and the potential for prosthetic valve dysfunction. Lifelong anticoagulation increases the risk of major bleeding events, which can be life-threatening. Additionally, mechanical valves can be prone to structural deterioration, though this is rare compared to bioprosthetic valves.

Enhanced Quality of Life

For many patients, MAVR results in significant symptomatic relief and improved quality of life. With the restoration of normal valve function, patients can often return to daily activities and maintain a level of physical exertion previously impossible due to symptoms.

Enhancing Healthcare Team Outcomes

Effective care for patients undergoing mechanical aortic valve replacement (MAVR) requires a multidisciplinary approach involving physicians, advanced clinicians, nurses, pharmacists, and other health professionals. Key skills include technical proficiency in surgical procedures, vigilant monitoring of anticoagulation therapy, and comprehensive patient education. Strategies to enhance care include early identification of potential complications, tailored anticoagulation plans, and regular follow-up.

Interprofessional communication and care coordination are essential for optimizing outcomes and ensuring patient safety. Physicians and advanced practitioners must collaborate closely with nurses to monitor postoperative recovery and manage anticoagulation therapy, while pharmacists ensure appropriate dosing and educate patients on medication adherence. Clear communication and shared decision-making across the care team enhance patient-centered care, improve clinical outcomes, and bolster team performance, ultimately leading to safer and more effective MAVR procedures.