VALVE SURGERIES

ANATOMY AND PHYSIOLOGY A heart valve normally allows blood flow in only one direction through the heart. The four valves commonly represented in a mammalian heart determine the pathway of blood flow through the heart. A heart valve opens or closes incumbent upon differential blood pressure on each side. The four valves in the heart are:

The two atrioventricular (AV) valves, which are between the atria and the ventricles, are the mitral valve and the tricuspid valve. The two semilunar (SL) valves, which are in the arteries leaving the heart, are the aortic valve and the pulmonary valve.

A form of heart disease occurs when a valve malfunctions and allows some blood to flow in the wrong direction. This is called regurgitation. ATRIOVENTRICULAR VALVES These are small valves that prevent backflow from the ventricles into the atrium during systole. They are anchored to the wall of the ventricle by chordae tendineae, which prevent the valve from inverting. The chordae tendineae are attached to papillary muscles that cause tension to better hold the valve. Together, the papillary muscles and the chordae tendineae are known as the subvalvular apparatus. The function of the subvalvular apparatus is to keep the valves from prolapsing into the atria when they close. The subvalvular apparatus have no effect on the opening and closure of the valves, however. This is caused entirely by the pressure gradient across the valve. The peculiar insertion of chords on the leaflet free margin however provides systolic stress sharing between chords according to their different thickness. The closure of the AV valves is heard as the first heart sound (S1). MITRAL VALVE Also known as the "bicuspid valve" because it contains two flaps, the mitral valve gets its name from the resemblance to a bishop's mitre (a type of hat). It allows the blood to flow from the left atrium into the left ventricle. It is on the left side of the heart and has two cusps. A common complication of rheumatic fever is thickening and stenosis of the mitral valve. TRICUSPID VALVE The tricuspid valve is the three-flapped valve on the right side of the heart, between the right atrium and the right ventricle which stops the backflow of blood between the two. It has three cusps. SEMILUNAR VALVES These are located at the base of both the pulmonary trunk (pulmonary artery) and the aorta, the two arteries taking blood out of the ventricles. These valves permit blood to be forced into the arteries, but prevent backflow of blood from the arteries into the ventricles. These valves do not have chordae tendineae, and are more similar to valves in veins than atrioventricular valves. AORTIC VALVE

The aortic valve lies between the left ventricle and the aorta. The aortic valve has three cusps. During ventricular systole, pressure rises in the left ventricle. When the pressure in the left ventricle rises above the pressure in the aorta, the aortic valve opens, allowing blood to exit the left ventricle into the aorta. When ventricular systole ends, pressure in the left ventricle rapidly drops. When the pressure in the left ventricle decreases, the aortic pressure forces the aortic valve to close. The closure of the aortic valve contributes the A2 component of the second heart sound (S2). The most common congenital abnormality of the heart is the bicuspid aortic valve. In this condition, instead of three cusps, the aortic valve has two cusps. This condition is often undiagnosed until the person develops calcific aorticstenosis. Aortic stenosis occurs in this condition usually in patients in their 40s or 50s, an average of over 10 years earlier than in people with normal aortic valves. PULMONARY VALVE The pulmonary valve (sometimes referred to as the pulmonic valve) is the semilunar valve of the heart that lies between the right ventricle and the pulmonary artery, and has three cusps. Similar to the aortic valve, the pulmonary valve opens in ventricular systole, when the pressure in the right ventricle rises above the pressure in the pulmonary artery. At the end of ventricular systole, when the pressure in the right ventricle falls rapidly, the pressure in the pulmonary artery will close the pulmonary valve. The closure of the pulmonary valve contributes the P2 component of the second heart sound (S2). The right heart is a low-pressure system, so the P2 component of the second heart sound is usually softer than the A2 component of the second heart sound. However, it is physiologically normal in some young people to hear both components separated during inhalation. Heart valves can develop one or both of these problems:

The valve opening becomes narrow (stenotic) which limits the amount of blood pumped to the rest of the body. The valve does not close completely (valve insufficiency or regurgitation) which means that blood can flow backward instead of only forward. Backward blood flow reduces your heart's ability to pump blood to the rest of your body. This also causes a buildup of back pressure in your heart and lungs.

CAUSES Heart valve disease can develop: before birth (congenital), be acquired during your lifetime, or be the result of an infection. Acquired heart valve disease is the most common. Sometimes the cause is unknown, but it involves changes in the structure of your heart valves as a result of mineral deposits on the valve or surrounding tissue. Infective heart valve disease causes changes to your valves because of diseases, such as rheumatic fever or infections.

RISK FACTORS There are risk factors you can control and risk factors you can't control.

Advancing age and congenital heart problems (present from birth) are factors beyond your control. Factors you can control include infections and untreated strep throat, which can lead to rheumatic fever.

SYMPTOMS: There are a number of symptoms that may indicate heart valve disease, including:

Shortness of breath or difficulty catching your breath, especially after you have been active or when you lie down flat in bed. Often feeling dizzy or too weak to perform your normal activities. Pressure or weight in your chest, especially when you are active or when you go out into cold air. Heart palpitations or a feeling that your heart is beating irregularly, skipping beats, or flipflopping in your chest. Swelling in your ankles, feet, or belly. Sudden weight gain with possibly as much as 2 to 3 pounds in 1 day. Symptoms can range from mild to none at all and do not always indicate the seriousness of heart valve disease.

VALVE SURGERIES
Heart valve surgery is done to replace or repair heart valves that are not working correctly. Most valve replacements involve the aortic and mitral valves.

Valve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis (homograft from human tissue or xenograft e.g. from pig). It is an alternative to valve repair. There are four procedures:

Aortic valve replacement Mitral valve replacement Tricuspid valve replacement Pulmonary valve replacement

Current aortic valve replacement approaches include open heart surgery, minimally invasive cardiac surgery (MICS) and minimally invasive, catheter-based (percutaneous) aortic valve replacement. Other valve procedures involve:

Annuloplasty. In this procedure, your surgeon tightens the ring of tissue around the valve to help the valve flaps (leaflets) come together. Sometimes your surgeon will implant a ring where the leaflets meet to make the valve opening smaller so the leaflets can come together. Repair of structural support. In this procedure, your surgeon replaces or shortens the cords that support the valves (chordae tendineae and papillary muscles) to repair the structural

support. When the cords and muscles are the right length, the valve leaflet edges meet and eliminate the leak.

Valve leaflet repair. In valve leaflet repair, your surgeon surgically separates cuts or pleats a valve flap (leaflet) to repair a floppy or prolapsed valve leaflet. VALVE REPLACEMENT PROCEDURE Cardiac monitoring is instituted and general anesthesia is provided. The surgeon uses a sternotomy to access the heart and great blood vessels. Anticoagulation is given as cannulae are inserted into the large vessels of the heart, femoral vessels, or a combination. Cardiopulmonary bypass is instituted. Once the pericardium has been opened, the patient is put on a cardiopulmonary bypass machine, also known as the heart-lung machine. This machine takes over the task of breathing for the patient and pumping their blood around while the surgeon replaces the heart valve. The heart is arrested as the cross clamp is applied to the ascending aorta to stop blood flow through the organ. The surgeon opens the heart to visualize the mitral valve. He/she may expose the mitral valve by opening the right atrium and then opening the atrial septum. Another approach requires a large left atrium that can be opened directly, making the mitral valve visible. For aortic valve, the incision is taken on the aorta. Next, the surgeon cuts the diseased valve away from the valve annulus (outer ring). The annulus is sized so that the proper size of valve can be selected for the patient's anatomy. Sutures are applied around the valve annulus, the valve is sutured into place, and tied into position. The atrial septum is closed with suture or left to heal naturally, and the heart is closed with sutures. Deairing of the heart is performed prior to removal of the cross clamp. When the cross clamp is removed, deairing continues to ensure that no air is delivered to the systemic circulation. At this time a transesophageal echocardiogram (TEE) may be used to test that the valve is functioning correctly and that the heart is free of air. . Once the valve is in place and the aorta has been closed, the patient is taken off the heart-lung machine. Transesophageal echocardiogram (TEE, an ultra-sound of the heart done through the esophagus) can be used to verify that the new valve is functioning properly. Once the surgeon is satisfied that the valve is working correctly, cardiopulmonary bypass is terminated, anticoagulation is reversed, and the cannulae are removed from the vessels. Pacing wires are usually put in place, so that the heart can be manually paced should any complications arise after surgery. Drainage tubes are also inserted to drain fluids from the chest and pericardium following surgery. These are usually removed within 36 hours while the pacing wires are generally left in place until right before the patient is discharged from the hospital. The sternotomy is

closed. Permanent stainless steel wires are used to hold the sternum bone together. The skin incision is closed with sutures, and sterile bandages are applied to the wound A heart valve is a structure within the heart that prevents the backflow of blood by opening and closing with each heartbeat. Replacement heart valves are either mechanical or biological tissue valves. For patients under the age of 65, the mechanical valve offers superior longevity, but the use of this type of valve requires that the patient take an anticoagulation drug for the rest of his/her life. The biological tissue valve does not require anticoagulation therapy, but this type of valve is prone to deterioration leading to reoperation , particularly in those under the age of 50. Women who may want to have children after a valve replacement should usually receive a biological tissue valve, because the anticoagulant (Coumadin/warfarin) most often prescribed for patients with mechanical valves is associated with fetal birth defects. Aspirin can be substituted for warfarin in certain circumstances. TYPES OF VALVES USED The replacement valve may be: MechanicalIt is made entirely out of artificial materials. Made of man-made materials, such as titanium or ceramic. These valves last the longest, but you will need to take bloodthinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life. The advantage to mechanical heart valves is their sturdiness. They are designed to last for many years. There are also drawbacks. Due to the artificial material involved, people who receive these valves will need to take life-long blood-thinner medication (anticoagulants) to prevent clots from forming in the mechanical valve. These clots can increase the risk for a stroke. Also, some people report a valve ticking sound that is usually not bothersome. It is the sound of the valve leaflets opening and closing. There are three main types of mechanical valve (Bloomfield, 2002): - Ball valves are made from a silastic ball that sits in a sewing ring and is enclosed by a metal cage. The ball is pushed forward as the pressure of blood behind it rises - Disc valves are made from a single graphite disc coated with pyrolite carbon. This tilts between two struts of housing made of stainless steel or titanium. Modifications of this type of valve have been made over the years, but concern has been raised about their durability and function (Bloomfield, 2002) - Bileaflet valves have two semicircular leaflets that open and close, allowing blood to flow through three openings (Bloomfield, 2002).

BioprostheticThis valve is made out of a combination of artificial materials and tissues from a pig, cow, or other animal. Made of human or animal tissue. These valves last 10 to 12 years, but you may not need to take blood thinners for life. The advantage of biological heart valves is that most people do not need to take life-long blood thinners, unless they have other conditions (such as atrial fibrillation) that warrant it. Biologic valves, traditionally, were not considered as durable as mechanical valves, especially in younger people. Previously available biologic valves usually needed to be replaced after about 10 years. However, some studies show that

some biologic valves may last at least 17 years without decline in function. This represents a new milestone in the durability of biologic valves Homograft or allograftThe valve is harvested from a donated human heart. Homografts are ideal heart valves for aortic valve replacement, especially when the aortic root is diseased or there is infection. The heart's natural anatomy is preserved and patients do not need to take life-long blood thinners. However, the limited availability is a drawback in some settings. Ross procedure (self-donated)In selected patients less than 50 years of age, another one of the patients own heart valves, the pulmonic valve, may be removed from its original location and sewn in to take the place of the faulty aortic valve. A homograft is then sewn in to take the original place of the pulmonic valve. Transcatheter Aortic Valve Implantation (TAVI)A bioprosthetic valve is implanted from a catheter-based delivery system via a small incision in either the groin or the side of the chest.

MINIMALLY INVASIVE VALVE SURGERY

Minimally invasive heart valve surgery is a technique that uses smaller incisions to repair or replace heart valves. This means there is less pain. Minimally invasive surgery also reduces the length of the hospital stay and the recovery time. Minimally invasive heart surgery (also called keyhole surgery) is performed through small incisions, sometimes using specialized surgical instruments. The incision used for minimally invasive heart surgery is about 3 to 4 inches instead of the 6- to 8-inch incision required for traditional surgery. Minimally invasive valve surgery can only be done in certain patients. This type of surgery cannot be done in patients

With severe valve damage Who need more than one valve repaired or replaced Who have clogged arteries (atherosclerosis) Who are obese

Robotically Assisted Heart Surgery Robotically assisted heart surgery, also called closed-chest heart surgery, is a type of minimally invasive surgery. The cardiac surgeon uses a specially designed computer console to control surgical instruments on thin robotic arms. Robotically assisted technology allows surgeons to perform certain types of complex heart surgeries with smaller incisions and precise motion control, offering patients excellent outcomes. In robotic surgery, small incisionsless than 2 inchesare used, compared with the 3- to 4- inch incision used in traditional minimally invasive heart surgery. In some cases, minimally invasive valve surgery can be done using a robot. Robotic surgery does not require a large incision in the chest. It is not available at all hospitals, and patients with severe valve damage cannot have the procedure. The Texas Heart Institute has a robot.

With robotic surgery, the surgeon has a control console, a side cart with 3 robotic arms, a special vision system, and instruments. A computer translates the surgeon's natural hand and wrist movements made on the control console to instruments that have been placed inside the patient through small incisions. The robot's controls can read even the tiniest of movements the surgeon makes. Robotic surgery can reduce the time it takes to do valve surgery, as well as shorten the hospital stay and recovery time.

Benefits of Minimally Invasive Surgical Techniques The benefits of minimally invasive and robotic heart surgery techniques include:

Small incisions Small scars Other possible benefits may include: Shorter hospital stay after surgery: The average stay is 3 to 5 days after minimally invasive surgery, while the average stay after traditional heart surgery is 7 to 10 days Low risk of infection Low risk of bleeding and blood transfusion Shorter recovery time and faster return to normal activities/work: The average recovery time after minimally invasive surgery is 1 to 4 weeks, while the average recovery time after traditional heart surgery is 6 to 8 weeks. The recovery time and return to regular activities is shorter for patients who undergo robotically assisted heart surgery. Division of the breastbone is not needed for robotically assisted heart surgery. Minimally Invasive Valve Surgery Valve surgeries, including valve repairs and valve replacements, are the most common type of minimally invasive surgery.

BALLOON VALVOTOMY
During a balloon valvotomy, a specially designed catheter is inserted into a blood vessel in the groin and guided to the heart. The tip is directed inside the narrowed heart valve. Once there, a tiny balloon is inflated and deflated several times to widen the valve opening. Once the cardiologist is satisfied the valve has been widened enough, the balloon is removed. During the procedure, the cardiologist may perform an echocardiogram (ultrasound of the heart) to get a better picture of the valve. New research-based, non-surgical procedures to treat regurgitation (leaky valves) are being tested and may provide additional treatment options using a catheter for valve disease in the future.

VALVE REPAIR
The surgeon will perform any of the following types of valve repair procedures.

Commissurotomy. Fused valve leaflets, or flaps, are separated to widen the valve opening. Decalcification. Calcium deposits are removed to allow the leaflets to be more flexible and close properly. Reshape leaflets. If one of the leaflets is floppy, a segment may be cut out and the leaflet sewn back together, allowing the valve to close more tightly. This procedure is called quadrangular resection. Chordal transfer. If a leaflet of the mitral valve has prolapse (floppy; lacking support), the chordae are transferred from one leaflet to the other. Then, the leaflet where the chordae was removed is repaired by quandrangular resection (see above). Annulus support. If the valve annulus (the ring of tissue supporting the valve) is too wide, it may be reshaped or tightened by sewing a ring structure around the annulus. The ring may be made of tissue or synthetic material. Patched leaflets. The surgeon may use tissue patches to repair any leaflets with tears or holes. The advantages of heart valve repair surgery include:

decreased need for life-long blood thinner (anticoagulant) medication preserved heart muscle strength

PROGNOSIS Most valve repair and replacement operations are successful. In some rare cases, a valve repair may fail and another operation may be needed. Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Mechanical valves may also fail, so patients should alert their doctor if they are having any symptoms of valve failure. Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives. Because these medicines increase the risk of bleeding within the body, you should always wear a medical alert bracelet and tell your doctor or dentist that you are taking a blood-thinning medicine. COMPLICATIONS

Bleeding: The risk of bleeding is associated with the administration of blood-thinning medications after valve surgery. As outlined by the Harvard Medical School Patient Education Center, blood thinners are administered to patients with biological artificial valves for a period of eight to 12 weeks, and for life to patients who have received mechanical artificial valves. The patients needing blood-thinning medication are closely followed by their physicians through repeated blood tests to ensure that they are not overmedicated and thus at higher risk for bleeding. In fact, the Harvard Medical School Patient Education Center reports that approximately 1 to 2 percent of patients with artificial mechanical valves experience an episode of life-threatening bleeding per year.

Heart attack Infection According to the Brigham's and Women's Hospital, all patients who have undergone heart valve surgery are at increased risk for infection of the valves. Before undergoing dental, urological or gynecological procedures, these patients must alert their treating doctors to their previous heart surgery so that they can receive prophylactic antibiotics. Minor trauma during these procedures gives bacteria access to the blood stream. Bacteria find abnormal and replaced valves a fertile breeding ground. The resulting valve infection is called endocarditis.

Surgical Failure The American Heart Association lists surgical failure as a potential long-term consequence of heart valve surgery. In the case of the surgical repair of the mitral valve, the failure, if present, is detected soon after the operation during early postoperative follow-up. If the valve has been replaced by a biological artificial valve, failure is almost inevitable and long-term follow-up is necessary to detect any deterioration of the function of the replace valve.

Irregular heart rhythm (arrhythmia) Stroke Surgery needed for a new valve, in some instances, if the heart valve fails over time

NURSING INTERVENTIONS The principles of nursing care for this group of patients are similar to those undergoing other forms of cardiac surgery. There are special considerations for patients who may already have chronic arrhythmias, altered left ventricular function and pulmonary hypertension. Great care is required with fluid management and haemodynamic monitoring. Nurses can help patients understand the nature of their disease and the risks and benefits of surgery. While medical treatment may provide symptomatic control and surgery can offer improved long-term outcomes, there is an important role for secondary prevention for these patients who may not be perceived as having the same risks as those with coronary artery disease. Incision Care It is normal to have some discomfort, bruising, numbness, swelling and itching at your incision site for several weeks after the surgery. Be sure to follow the instructions from your doctor or nurse for proper incision care. A shower or gentle washing of the incision site is usually recommended. Tub baths are typically not allowed because they can affect your circulation. To help prevent infection, avoid using creams or lotions around the incision site until otherwise directed by your doctor. The wires holding your sternum together are permanent. Dissolvable stitches will usually disappear within one to three weeks but can remain up to six weeks, depending on the type of stitches you have.

Fluid Retention After surgery, some people experience fluid retention that can overload the heart and make it work inefficiently. To prevent fluid retention, your physician may recommend dietary changes and/or medications. You can help monitor this at home by weighing yourself every morning. Report any sudden weight gain of three pounds or more in one day, or five pounds or more in one week. You should also contact your doctor if you experience unusual shortness of breath or swelling of your hands, ankles or stomach. Infection Bacteria can enter the bloodstream during dental and some surgical procedures and cause an infection known as bacterial endocarditis in the tissue surrounding the artificial heart valve. Although this occurs infrequently, you should consult your doctor before you have any dental or surgical procedure so antibiotics can prescribed. Also, be sure to tell your dentist and any other doctors that you have had heart valve surgery. Anticoagulants If you receive a mechanical heart valve, your doctor may prescribe an anticoagulant medication (blood thinner) to prevent blood clots from forming on or around the new valve. Your doctor will determine the level of anticoagulant that is right for you and closely monitor the levels with blood tests. You will need to take your medication as prescribed and follow up with blood tests as scheduled. Food, alcohol and other medications, including over-the-counter products, can affect your anticoagulation level. Follow your doctors recommendations to maintain healthy anticoagulation levels. Notify your dentist, oral surgeon or doctor that you are on an anticoagulant before having any dental or medical procedures. Adjustments may need to be made to your medication prior to any procedure. When taking anticoagulant medication, consult your doctor if any of the following occur: Excessive bruising Excessive bleeding Blood in your urine Bloody or black, tarry stool Unusual nosebleeds Bleeding gums Pregnancy or trying to become pregnant Fever or other illnesses that, include vomiting, diarrhea or infection In general, contact your doctor if you develop any of the following symptoms: Redness or drainage of your incision Shortness of breath Swelling of your feet or ankles Chest, jaw, shoulder or arm pain Bruising Excessive bleeding Blood in your urine Bloody or black, tarry stool Unusual nose bleeds Fever

Numbness or tingling in your arms or legs General weakness or loss of energy Blurred or loss of vision Unusual chest sensation FOLLOW-UP CARE After your heart valve surgery, it will be important for you to adhere to your doctors orders and advice for follow-up appointments as recommended. As always, ask your doctor if you have any questions about potential risks or if you have more questions about heart valve repair. Nurses can provide support for patients as they adapt to living with a prosthetic valve. Those with a mechanical prosthesis will start long-term anticoagulation therapy that will demand changes in lifestyle and self-management. The risks of native and prosthetic valve endocarditis should be raised with patients who are waiting for or who have had valve surgery; education about prophylactic antibiotic therapy for dental and other invasive procedures should be discussed. Hospital-acquired infection plays a greater role in infective endocarditis than has previously been emphasised. Good infection control practices in hospital can reinforce education messages given to valve patients who are learning to reduce the risk of developing infective endocarditis. Those undergoing surgical intervention require specialist support throughout their diagnosis and treatment. Surgery can affect the long-term outcomes for these patients, but quality of life and benefit from surgery is likely to be enhanced by effective patient education and by encouraging patients to be involved in decision-making. HEALTH EDUCATION:

Be sure to keep the incision site clean and dry Contact your physician if you experience fever; chills; redness, swelling or bleeding at the incision site; or extreme pain Do not lift, pull or push more than 5 to 10 pounds (2-4 Kg) until given clearance by your surgeon which means no lifting laundry baskets, small animals or any housework or yard work while you are healing If necessary, any sutures or surgical staples will be removed during your follow-up doctors appointment On average, patients return to work about 6 to 8 weeks following discharge from the hospital, but be sure to consult with your surgeon on when it is safe for you to return to your job When riding in a car with passenger-side airbags, it is safest to sit in the backseat the airbag deploy could damage your healing breastbone but if you cannot comfortably ride in the backseat try to sit as far back as possible from the airbag compartment You can shower daily but avoid soaking in the bathtub, hot tub or swimming pool until your incisions are completely healed You will not be able to drive until your surgeon has determined your breastbone has healed and it is safe for you to drive You will receive an updated, accurate list of your medications and any prescriptions you require; be sure to bring your medication list to each follow-up appointment with your doctor

BIBLIOGRAPHY http://www.wikipedia.com/ http://www.medtronic.com/patients/heart-valve-disease/index.htm http://uvahealth.com/services/heart/treatment/103224 http://www.hopkinsmedicine.org/heart_vascular_institute/clinical_services/specialty_ areas/valve_surgery.html http://www.medicinenet.com/heart_valve_disease_treatment/page3.htm http://www.livestrong.com/article/220181-complications-of-valve-surgery/ http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/465?ck=nck http://www.nursingtimes.net/surgical-management-of-aortic-and-mitral-valvedisease-an-overview/199449.article

VALVE SURGERIES

SUBMITTED TO: Mrs Shubhangi Jadhav Lecturer, BHCON. SUBMITTED BY: Diana Thomas Final Yr M.Sc. Nsg