INOVA HEALTH SYSTEM : TREATMENT OPTIONS : CARDIAC VALVE REPLACEMENT/REPAIR

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CARDIAC VALVE REPLACEMENT/REPAIR

For more information about cardiac valves, see our "About Heart Valves and Heart Valve Disease" section under "What is Heart Disease."

Technological advances have produced greater precision and accuracy in diagnosing and treating heart valve disorders. Newer imaging techniques can scan the heart and identify specific problems affecting the cardiac valves and other structures. Newer, less invasive surgical techniques have also evolved that employ voice-activated computers, robotic devices to manipulate instruments inside the body, endoscopic ("keyhole") access to the heart, and space-age technology that minimizes extraneous movements.

Many of these advances are especially suited to heart valve surgery and can be used to repair an existing valve or replace it with a substitute valve prosthesis. The growing number of available surgical procedures allows patients to benefit from the specific surgical intervention that is best suited to their needs. Many of these new techniques also promote faster recovery from surgery. As with any cardiac procedure, a careful evaluation of the valve leaflets and surrounding tissue is performed before the surgeon selects the best operative technique for the patient.

What is the difference between heart valve repair surgery and heart valve replacement surgery?

A heart valve repair can be performed on a valve that is too narrow to allow sufficient blood to flow through the valve opening (stenosis) or on a valve that cannot close tightly enough to prevent back flow of blood (insufficiency). The mitral valve is especially suited to reparative techniques because its component parts ? any of which may be the cause of the valve?s malfunction ? often can be repaired.

Repair of a stenotic valve may involve cutting or separating the valve leaflets, or other components, to widen the valve opening. Repair of an insufficient valve may be achieved by narrowing or shortening the supporting structures to allow the valve to close tightly, or by inserting one of a variety of prosthetic rings to reshape a deformed valve.

The terms annuloplasty and valvuloplasty are often used to categorize the type of repair. An annuloplasty describes a procedure performed on the valve annulus, the ring of tissue that supports the valve leaflets. A valvuloplasty is a broad category that refers to reconstructing one or more components of the valve; the leaflets, annulus, chordae tendineae and/or papillary muscles that anchor the leaflets to the heart wall. For example, excess leaflet tissue can be removed or a dilated annulus can be made smaller with stitches.

In addition to the surgical procedures, percutaneous balloon valvuloplasty is a non-surgical treatment option that is performed for heart valve stenosis. This procedure is performed in the cardiac catheterization laboratory by cardiologists trained in adult and/or pediatric valve procedures. The cardiologist threads a balloon-tipped catheter through a large artery into the narrowed valve opening. The balloon is inflated, thereby enlarging the valve orifice.

A heart valve replacement is performed when a diseased valve that cannot be repaired is removed and replaced with a substitute mechanical or biological valve. (See the tables for a description of commonly used mechanical and biological valves.) Mechanical valves are constructed of durable materials such as Dacron, titanium, and pyrolytic carbon; they are very sturdy and can be expected to last a lifetime. Mechanical valves require the long-term use of anticoagulation medication to prevent formation of blood clots on the valve prosthesis.

Biological valves are made of tissue taken from pigs, cows or human donors. Often they do not require anticoagulation medication, but their durability is not as long lasting as mechanical valves. Biological valves are recommended for elderly patients, or for individuals with bleeding disorders, for patients with anticipated difficulty taking anticoagulation medication. Biological valves may be more suitable in women of childbearing age because the anticoagulant medication commonly taken for mechanical valves crosses the placental barrier and may affect the fetus. Many factors relating to the individual patient and to the specific valve problem are considered in selecting either a mechanical or biological valve.

Another biological valve substitute is an allograft, which refers to tissue from one persons body that is placed in another person. Allografts (formerly known as homografts) are procured under sterile conditions in an operating room from cadavers that have no history of communicable disease, malignancy, diabetes, hypertension, hyperlipidemia, or previous open heart surgery. Allografts are assessed for proper function, measured, treated with antibiotic solution, and frozen in a bag surrounded by liquid nitrogen for long term storage. When needed for surgery, the appropriate size graft is selected, thawed and implanted.

Allografts have excellent hemodynamics. (Their function resembles that of natural valves.) They rarely create blood clots and have a lower incidence of postoperative infection. They are especially suitable for young women and children, and they may be advantageous for patients with recurrent inflammation of the heart wall (called endocarditis). Tissue failure can occur (as with any biologic valve replacement surgery), but the onset is rarely sudden and does not progress rapidly, as compared with biologic (or mechanical) valves.

Another form of biologic valve replacement is accomplished with autografts. Autografts refer to tissue from the patient's own body. Tissue is removed from one location and placed in another location. For example, a patient's pulmonary valve may be removed and used to replace the patient's diseased aortic valve. This a commonly known as the Ross Procedure. An allograft then is used to replace the excised pulmonary valve. This procedure may be performed when the surgeon decides that using the patient's own tissue for the aortic surgery will achieve the most effective outcome. Because autografts are the patient?s own tissue, they do not have to be specially treated.


Hancock Valves (biological valves)	St. Jude Mechanical Valves

Freestyle Valves

Biological Valve Prosthesis

Name: Carpentier- Edwards; Hancock
Type: Porcine aortic valve (excised pig aortic valve)
Advantages: rarely required; Rare clot formation; Good blood flow through valve; Inaudible
Disadvantages: Durable, but less so than mechanical valves. May degenerate more rapidly in very young or patients with kidney failure

Name: Carpentier- Edwards
Type: Pericardial tissue valve (bovine pericardium that is cut and shaped into a tri-leaflet valve).
Advantages: Anticoagulation rarely required; Rare clot formation; Good blood flow through the valve; Inaudible
Disadvantages: Less durable; May degenerate more rapidly in very young or patients with hypertension

Name: Medtronic Hancock Valve
Type: Porcine aortic or mitral valve
Advantages: Improved blood flow, excellent freedom from structural valve deterioration, particularly in the elderly.
Disadvantages: Anticoagulation therapy; possible clot formation. Not appropriate for patients on hemodialysis or patients with a small hypertrophic left ventricle.

Name: Medtronic Freestyle Aortic
Type: Root Bioprosthesis stentless tissue valve
Advantage: Improved blood flow. Good choice for aortic valve with small annulus.

Mechanical Valve Prostheses
Name: St Jude Medical
Type: Double leaflet, tilting disk
Advantage: Long-term durability; Excellent bloodflow through valve Disadvantage: Anticoagulation therapy; Possible clot formation; Some noise

Name: Medtronic- Hall; Omniscience
Type: Single leaflet, tilting disk
Advantage: Long-term durability; Excellent bloodflow through valve Disadvantage: Anticoagulation therapy; Possible clot formation; Some noise

Annuloplasty Rings
Name: Carpentier-Edwards Ring
Type: Rigid
Advantages: Reshapes annulus
Disadvantages: No disadvantages

Name: Carpentier-Edwards Ring
Type: Semi-rigid
Advantages: Allows both remodeling and flexibility of annulus Disadvantage: No disadvantages

What are the surgical options?

Choose a specific type of cardiac valve disease for more information about its surgical options:

Aortic valve disease Mitral valve disease Pulmonary valve disease Tricuspid valve disease

Valve heart surgery: The procedure

Patients will be asked to come to the hospital's Same Day Admission Program a day or two before surgery to have lab work, a chest x-ray, an EKG and a physical exam. A nurse practitioner or physician assistant will talk with you about the risks of surgery and ask you to sign a consent form. You and your family will also be told about what to expect while you are in the hospital. An anesthesiologist will speak with you about your medical history and will explain how medication will be given to keep you asleep free of pain during you surgery.

Patients will also be asked to do the following:

Stop taking aspirin or certain other medications 5 days before surgery, since they can cause excessive bleeding during surgery. If you smoke, stop immediately. Do not eat anything after midnight the night before surgery. Take a shower with a special soap the night before surgery to help prevent infection.

Click here for a day-by-day outline of what you can expect during your stay at the hospital.

What is a heart-lung machine?

During valve surgery, the heart is stopped for a short period of time with special drugs. This is known as cardioplegia. Stopping the heart allows the surgeon to perform the necessary surgical maneuvers with greater precision. A heart-lung machine is used to replace the functions of the heart and lungs. Through special tubing, the machine receives blood that is returning to the heart from all parts of the body and provides the blood with fresh oxygen from the machine?s oxygenator, that mimics the function of the lungs. Then, like the heart, the machine pumps blood back into the aorta and throughout the body with the exception of the heart and lungs, which are "bypassed" by the heart-lung machine (thus the term, "cardiopulmonary bypass"). With the heart motionless and containing little blood to obscure vision, the surgeon can proceed with the planned heart surgery. During surgery for valve disease and congenital heart disease, the surgeon may also need to open the heart and drain any remaining blood to visualize the cardiac interior.

To prevent blood clots, or thrombosis, within the heart-lung machine circuit, the blood is first anticoagulated with a drug called heparin. In addition, during cardiopulmonary bypass, the heart and the entire body may be cooled to lower the metabolic rate and oxygen consumption while the surgery is performed. Chemicals may also be used to slow the metabolism of the heart and reduce its need for oxygen.

When the surgery is completed, the use of the cooling agents and chemicals to slow the heart's metabolism is discontinued. The heart is then restarted.

What is cardioplegia?

When a patient is placed on the heart-lung machine, the heart and body are cooled to reduce the heart's metabolic requirements and oxygen consumption. Chemical agents can be infused into the heart to reduce further the metabolic requirements and oxygen consumption of the heart by quickly causing the heart to stop beating. These chemical agents, and the cardiac standstill they produce, are called cardioplegia (meaning "cardiac paralysis"). Without these chemical agents, the heart will continue to quiver or remain in a state of ventricular fibrillation while the surgery takes place. This situation wastes the heart?s energy resources that are needed when the heart resumes beating again.

Cardioplegia, or cardiac paralysis, allows the surgeon to perform delicate procedures on a quiet, motionless heart. Periodically the chemical agents are reinfused into the heart in a solution of oxygenated blood. Thus, repeat infusions of blood cardioplegia solution replenish oxygen to the heart while it remains at a standstill. (For some patients whose blood is affected by cold temperatures, oxygen is replenished in a special clear cardioplegia solution that does not contain blood.)

Once the surgery is complete, the cardioplegia agents are flushed out of the heart with warm, non-cazrdioplegic blood. The heart resumes contraction, and the heart-lung machine is discontinued. If the heart does not resume contracting quickly, a small electrical shock is given to the heart. Or, if the heart beats too slowly, a temporary pacemaker can trigger the normal heart rhythm to resume. When any irregular heart rhythm is noted, appropriate and immediate actions are taken to correct the disturbance.

Surgery without the heart-lung machine

The use of the heart-lung machine is common for the most heart procedures, but occasionally some heart operations can be performed without stopping the heart. This avoids the use of the heart-lung machine because the heart continues to beat and supplies blood to the entire body. Although the heart-lung machine may not be required, it is readily available if the surgeon decides to use it. The decision to use, or not use, the heart-lung machine is based on many factors including patient safety and selection of the most appropriate surgical technique.

Heart Valve Surgery: The procedure

Each member of the heart surgery team plays a vital role in your care. The cardiac surgeon and surgical assistants perform the surgery with support from specially trained nurses. The anesthesiologist monitors the delivery of anesthesia and makes sure you are asleep and pain free. The perfusionist operates the heart-lung machine that keeps your blood circulating

During heart valve surgery, the problem valve/valves will be repaired or replaced.

To get to your heart the surgeon will usually make an incision down the middle of your chest and separate the breastbone. Some patients will be canidates for minimally invasive procedures. You will be placed on the heart-lung machine.

To replace the diseased valve, an incision will be made in your heart or in the aorta. Part or all of the diseased valve will be repaired or removed. If the valve is being replaced, a valve of the correct type and size will be fitted and then sewn into place. Refer to each specific procedure for more information.

Once the surgery on the valve is completed, the heart and body is re-warmed, and the heart is stimulated to contract in a regular manner. The heart-lung machine will be discontinued, and the heart and lungs will take over their normal functions.

After a stable heart rhythm resumes, the surgeon assesses the heart and surrounding tissue for hemostasis (control of bleeding and stability of the repair or replacement). Temporary wires are placed on the heart. These wires can be used if the heart rate becomes too slow (bradycardia) after surgery. They would be attached to a temporary, external pacemaker, and the heart can be paced to a faster heart rhythm, thus maintaining an adequate blood pressure and perfusion to the heart. If bypass grafts have been placed, they will also receive adequate blood flow. Chest tubes are also placed in the pericardial sac surrounding the heart to remove postoperative drainage.

After the surgery is complete, the cardiac surgeon once again reconfirms that all vital signs and the heart rhythm are stable, and the drainage from the chest tubes is evaluated for bleeding tendencies. Then, the breastbone is rejoined with stainless steel wires and the skin edges sewn back together. The breastbone will take approximately six weeks to heal.

Post Operative Care

Immediately after surgery you will go to the Intensive Care Unit (ICU) where you will be constantly monitored. You will stay in the ICU for approximately 8 to 24 hours. The primary goals of care during this time are to maintain stable vital signs and to avoid any possible complication.

Immediately after surgery, you will breath through a tube in your wind pipe connected to a breathing machine/respirator. Chest tubes will drain blood from your chest, and a catheter will be in your bladder to collect urine. A heart monitor will record your heart rate and rhythm. Intravenous (IV) lines will give you fluids and medications. All of these lines and tubes will be removed when you no longer need them.

When you leave the ICU you will go to another unit of the hospital called Cardiac Telemetry, where you will participate in your care under the guidance of the heart surgery team. It will be very important for you to be up and around as soon as possible. Most patients may be able to sit on the side of the bed the evening after surgery and sit in a chair the following morning. Your nurse will assist you with your first walk the same day. Taking deep breaths and coughing are also important for recovery and prevention of pneumonia. Coughing and deep breathing help your lungs to remove fluid that collects as a result of remaining in bed for an extended period of time. You will be instructed on how to use a breathing device called an incentive spirometer, which should be used every hour while you are awake.

Before you are ready to leave the hospital, you will be given a video to take home and a packet of information about recovery at home. The packet will contain information about activity, diet, and what to expect during the first weeks at home. Since you will not be able to drive a car for the first few weeks after surgery, you will need to arrange a ride home from the hospital.

Please note that prevention of bacterial endocarditis is a key to the success of the valve repair or replacement. Inform any dentist or physician who treats you about your history of valve replacement or repair. They may prescribe antibiotics to prevent an infection from settling in your heart.

Patients with a valve replacement

If you had a valve replacement, you should receive special instructions about taking Coumadin (anticoagulant) and about the need for regular laboratory follow-up to determine the appropriate level of anticoagulation. Insufficient anticoagulation therapy can increase the risk of blood clots forming on the mechanical valve and dislodging to another part of the body. In addition, be aware of the signs and symptoms of bleeding (therapeutic levels of Coumadin would be too high, thus causing bleeding tendencies): pink urine, black stools, excessive nosebleeds, unusual vaginal or anal bleeding, purple or red skin discoloration or bleeding gums. Report these symptoms to your cardiologist or the physician covering your anticoagulation therapy. Moreover, take Coumadin at the same time every day and never make up for a missed dose. Do not take aspirin or aspirin products, avoid excessive alcohol intake (it may cause bleeding) and carry an identification card indicating that you take a blood thinner and have had a heart valve repair or replacement.

Patients with prosthetic heart valves should also be alert to signs of prosthesis failure. Often the signs of value failure resemble the symptoms that occurred prior to the valve surgery and may include fatigue, weakness, lightheadedness, shortness of breath while lying down or during exertion, as well as chest pain (angina).

Click on recovery for more information about recovering from valve surgery after discharge.