Heart valve surgery and procedures are performed to repair or replace a valve in the heart that is not working properly because of valvular heart disease (also called heart valve disease). Heart valve surgery is open-heart surgery through the breastbone, into the chest. It is a major operation that can last two hours or longer and recovery often takes several weeks. There are newer, less invasive procedures suitable for some types of valvular heart disease, but they are only done at certain hospitals.
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Why it's done
You may need heart valve surgery if there’s a problem with one or more of your heart valves. Heart valves control the blood flow in and out of your heart. Damaged or faulty valves can affect how well your heart pumps blood around your body.
Your valves may:
. Be narrow or tight (stenosis)
. Not close properly and leak (regurgitation)
Heart valve surgery can repair or replace faulty heart valves. If there’s a problem with your heart valves, you may not have any symptoms at first. You’ll usually only have surgery if your heart valves are badly damaged or causing symptoms. Heart valve surgery can ease your symptoms and improve your quantity and quality of life.
Before the procedure
If you smoke, you should stop at least two weeks before your surgery. Smoking can contribute to blood clotting and breathing problems.
Approximately a week before your surgery, you may be asked to visit your hospital’s pre-admission unit. The risks and benefits of the procedure will be explained to you and you will be asked to sign a consent form. At this appointment, tests may include:
. Blood work
. Urine sample
. Electrocardiogram (ECG)
. Chest X-ray.
Please inform your healthcare team if you:
. Have ever had a reaction to any contrast dye, iodine, or any serious allergic reaction (for example, from a bee sting or from eating shellfish).
. Have asthma.
. Are allergic to any medication.
. Have any bleeding problems or are taking blood-thinning medication.
. Have a history of kidney problems or diabetes.
. Have body piercings on your chest or abdomen.
. Have had any recent change in your health.
. Are – or may be – pregnant.
Most patients are admitted to the hospital the day before their procedure. The night before, you will be asked to bathe to cleanse or disinfect your skin. Preparation for surgery may include:
. Washing the area to be operated on with an antiseptic cleanser.
. Clipping the hair on your chest.
. Not eating or drinking after midnight to reduce the risk of vomiting while you are unconscious.
Chief of cardiac surgery unit
Department of Surgery
Markaz Tebbi Kodakan
Tehran University of Medical Sciences
Tehran – Iran
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Side effects and Complications
Side-effects of heart valve surgery
It’s normal to have some side-effects after heart surgery. These are the unwanted but mostly temporary effects that you may get after having the procedure. Everyone responds differently, but afterwards you may:
. Have a small amount of fluid leaking from your wound
. Feel some discomfort in your chest and also in your muscles such as your shoulders, back and neck.
. Feel very tired
. Have a low appetite
. Feel emotional and upset, having ‘good days and less good days’
. Have trouble concentrating
. Get constipated (the painkillers you’re taking can have this effect)
. Have difficulty sleeping at night
. Notice a ticking noise in your chest if you’ve had a mechanical valve replacement (although you will have this permanently, you will get used to it)
. Have a small lump at the top of your wound, it might feel numb and itchy – this will go down and ease as it gradually heals.
If you’re worried about these or any other symptoms, contact your GP.
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Complications of heart valve surgery
All medical procedures carry some risks. Your surgeon will explain these to you when discussing your options with you. Complications are when problems occur during or after the procedure. Possible complications of heart valve surgery may include:
. An infection
. Blood clots
. Heart rhythm disturbances (arrhythmia)
. Problems with your kidneys
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During the procedure
Surgical valve repairs and replacements are done under a general anesthetic so you will be asleep throughout the operation.
During conventional surgery, the surgeons will stop your heart while they work on the valve or valves. You will be hooked up to a heart-lung machine that takes over the pumping action of your heart, so that your body continues to receive a flow of oxygen-rich blood.
. The surgery will take at least two hours or longer, depending upon the number of valves that need to be repaired or replaced.
. You will wake up in the recovery room or an intensive care unit (ICU).
. You will stay in the hospital for about a week.
. How quickly you recover from surgery will partly depend on how healthy you were before the surgery.
If you have minimally invasive surgery, your heart will not be stopped and a heart-lung machine will not be used. Your hospital stay will probably be shorter and your recovery quicker than conventional open-heart surgery.
What happens during heart valve surgery?
Depending on the problem, there are a several different procedures for repairing or replacing valves.
Surgical procedures are generally used for problems with the mitral or tricuspid valves.
. Commissurotomy is a treatment for a tight valve. The valve flaps (leaflets) are cut to loosen the valve slightly, allowing blood to pass easily.
. Annuloplasty is done for a leaky valve. There is a ring of fibrous tissue at the base of the heart valve called the annulus. To repair an enlarged annulus, sutures are sewn around the ring to make the opening smaller. Or, a ring-like device is attached around the outside of the valve opening to support the valve so it can close more tightly.
. Valvulotomy is a procedure to enlarge narrowed heart valves. It can also be done with the help of a balloon.
Percutaneous or catheter-based procedures are done without any incisions in the chest or stopping the heart. Instead, a thin flexible tube called a catheter is inserted into a blood vessel in your groin or arm and then threaded through the blood vessels into your heart.
. Percutaneous or balloon valvuloplasty/valvotomy is used for stiffened or narrowed (stenosed) pulmonary, mitral or aortic valves. A balloon tip on the end of the catheter is positioned in the narrowed valve and inflated to enlarge the opening.
. Percutaneous mitral valve repair methods - such as edge-to-edge repair - can fix a leaky mitral valve in a patient who is considered high risk for surgery. A catheter holding a clip is inserted into the groin and up into the left side of the heart. The open clip is positioned beyond the leaky valve and then pulled back so it catches the flaps (leaflets) of the mitral valve. Once closed, the clip holds the leaflets together and stops the valve from leaking.
If your heart valve is too badly damaged to be repaired, surgery may be needed to replace it with a new mechanical or biological valve. Age is generally a factor in deciding which type to use – biological valves are generally preferred for older people. You and your doctor will discuss the options and decide which is best for you and your circumstances.
. Mechanical valves made of long-lasting metals, carbon, ceramics and plastic were the first to be used in valve replacement surgery. They have been refined and improved since being introduced in the 1960s.
. The major advantage of a mechanical valve is durability – they can last a long time.
. A fabric ring is used to sew the valve to heart tissue.
. Mechanical valves can lead to blood clots which may in turn cause a heart attack or stroke. To prevent clots, people with mechanical valves must take blood-thinning medications (anticoagulants) every day for the rest of their lives. This can have implications for women of childbearing age or for people who have a history of major bleeding. Depending on the type of blood thinners, you may require routine blood-testing to monitor your INR (international normalized ratio) to measure your blood’s tendency to clot.
. A mechanical valve makes a soft clicking sound when it closes. This can bother some people.
. Biological (also called bioprosthetic) or tissue valves are specially prepared natural valves that come from human donors or animals.
. Animal source valves (a xenograph) – usually cows or pigs – are similar to valves in the human heart. They are tolerated well and are less likely to form blood clots than mechanical valves.
. Human heart valves from a donated heart (an allograft or homograft) are tolerated well and tend to last longer than animal valves. Using human valves is uncommon.
. Valves can come from your own tissue (an autograft). In a Ross (or switch) procedure, your functioning pulmonary valve is used to replace your damaged aortic valve. Your pulmonary valve is then replaced with a donated one.
. People with biological valves need to take blood thinners in the short term.
. Biological valves are not as durable as mechanical valves. They are more durable in the aortic position and in older patients.
Unlike conventional surgery, minimally invasive surgery does not involve sawing through the breastbone and opening the chest. It doesn’t require stopping your heart or using a heart-lung machine. The surgeon watches your heart on a video screen and operates using long-handled surgical tools inserted through small incisions. In some cases, robotic arms are used. Minimally invasive valve repair and replacement is suitable for some types of valvular heart disease, but is only available in some hospitals. It may also be called endoscopic or robotic heart surgery.
. Transcatheter aortic valve implantation (TAVI) is also called transcatheter aortic valve replacement (TAVR). TAVI is a minimally invasive surgical valve replacement procedure that is used to treat symptomatic aortic valve stenosis, with two key differences from traditional valve replacement surgery. Rather than opening up the chest, TAVI is done through small incisions in the groin or chest. Instead of repairing, or removing and replacing the damaged aortic valve, a new aortic valve is implanted directly on top of the damaged one.
. The surgeon inserts a catheter containing a new, collapsible aortic valve through small incisions in the groin or chest.
. Using ultrasound and chest x-rays, the catheter is guided to the correct position in the heart and the new valve is implanted and expanded.
. Once the new valve is in place, it starts to control blood flow immediately.
. People who undergo TAVI tend to recover faster and have shorter hospital stays (average three to five days) than people who have open-heart valve surgery.
TAVI is usually considered for people who are at high risk for complications from open-heart surgery. Your healthcare team will assess your symptoms and overall health to determine if TAVI is an option for you.
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What to expect afterwards
After your operation, you may be taken to the hospital’s intensive care unit (ICU) or high dependency unit (HDU). When you wake up, you’ll be connected to machines that record the activity of your heart, lungs and other body systems. You may need a ventilator machine to help you breathe. When your medical team are happy that you’re recovering safely, they’ll move you to a surgical ward.
You’ll need pain relief as the anaesthetic wears off. You may be given patient-controlled analgesia (PCA) once you wake up. A PCA pump is connected to a drip in your arm and allows you to control how much pain-relief medicine you have.
You’ll be encouraged to get out of bed and move around as soon as possible. This will help to prevent chest infections and blood clots in your legs. A physiotherapist will visit you regularly after the operation to advise you on exercises to help your recovery.
You’ll be able to go home when you and your surgeon feel you’re ready. Many people are in hospital for around a week after heart valve surgery. Make sure someone can take you home and stay with you for a day or so.
Before you go home, your nurse will give you advice about caring for your healing wounds. You may be given a date for a follow-up appointment.
If you have wires in your breastbone from the operation, these will be permanent. The dissolvable stitches your surgeon used to close your skin wound will slowly dissolve over several weeks and don’t need to be removed.
Recovering from heart valve surgery
A full recovery from heart valve surgery can take two to three months. You’ll need to build up your activities gradually to get back to normal. Everyone recovers differently, so speak to your surgeon about when you can go back to work and your other usual activities.
There’s a lot you can do to help yourself. After your surgery, your doctor may recommend you take part in a cardiac rehabilitation programme. This programme will give you advice on:
. Diet and healthy eating
. How to reduce and manage stress
. How to stop smoking
. Returning to work
You shouldn’t drive for at least a month after your surgery. Don’t start driving again until you’ve checked with your surgeon first.
Contact the surgical ward if you have:
. Increasing tenderness or redness round your wound
. Persistent bleeding or pus coming from your wound
. A high temperature or fever, especially with weight loss or loss of appetite
. New or bad heart palpitations (a sensation of a skipping or thumping heartbeat)
. Difficulty breathing
. Chest pain that’s different from the pain in your wound
Remember you’ve been through a major operation, so expect to have good days and less good days. Be kind to yourself and accept help where it’s offered. Don’t worry if progress seems slow – you’ll gradually get back to your normal activities and feel well again.
Medicines after heart valve surgery
If you have a mechanical valve replacement, you’ll need to take a blood thinning medicine (an anticoagulant, usually warfarin). You’ll need to take this for the rest of your life to stop blood clots forming around your new valve.
If you have a tissue (biological) valve replacement, you usually only need to take anticoagulant medicines for a few months after your operation.
While you’re taking anticoagulants (warfarin), you’ll need to have regular blood tests. These are important to check you’re on the right dose. Talk to your surgeon for more information about what medicines you need to take after your operation.