Heart Valve Program
Heart Home | Invasive | Non-invasive & Diagnostic | Heart Surgery | Heart Valve | Cardiac Rehab | Atrial Fibrillation
Introduction
Welcome to a program that will help you understand heart valve surgery. The goals of this program include helping you understand the problem with your heart valve, what potential solutions exist to fix your valve, what risks are involved, and what outcomes following surgery may be expected. This program serves to assist you in understanding basic principals of heart valve surgery and hopes to better prepare you for your meeting with your valve surgeon.
We will go through the principals on how the heart works, common heart valve problems that may exist, principals of aortic valve surgery, principals of mitral valve surgery, general types of valve products, how to prepare for a valve operation and finally recovering after your operation.
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The heart is one of the most important organs of the human body and at the center of the entire circulatory system.
The heart is a muscular organ that is comprised of four chambers and four valves. There are two top chambers, called atria, and two bottom chambers, called ventricles, each with their specific function. In general the atria are responsible for receiving blood and the ventricles are responsible for pumping the blood.
The “blue blood” or deoxygenated blood comes to the heart via the right atrium then goes through the tricuspid valve to the right ventricle. The right ventricle then pumps this blue blood to the lungs. The lungs then oxygenate the blood and the “red blood” or oxygenated blood is delivered to the left atrium. The left atrium then delivers the red blood through the mitral valve to the left ventricle. The left ventricle is in a sense the true motor of the heart and the main pumping chamber. The left ventricle forcefully pumps the blood through the aortic valve to the rest of the body via the aorta, the main blood vessel of the body.
Each of the heart valves are made of thin pieces of tissues called leaflets. They form a one-way valve responsible for allowing the blood to move only in a forward direction. Problems may arise when either the valve cannot open properly (blockage) or when the valve does not close properly (leakage). Either of these problems results in an abnormal strain on the heart muscle resulting in secondary problems that often result in symptoms.
We will now review some of the common problems that can occur with your heart valves.
Common Heart Valve Problems
Your heart valves open and close over 100,000 times per day and nearly 42 million times per year throughout your entire life. Problems of wear-and-tear on your heart valves are the most common cause of problems. These problems can be magnified by abnormal valves from birth, the simple degenerative affect of aging, long-term affects secondary to childhood infections such as rheumatic fever, and even heart attacks could affect the functioning of certain valves. Each of these factors may predispose the valve to deteriorate and result in an inability to either open or close effectively.
Stenosis refers to the problem when the valve becomes damaged and has an inability to open effectively. This is most commonly caused by an accumulation of calcium on or around the valve leaflets that prevent the normal opening function. Over time, this may lead to narrowing of the valve orifice and can result in strain on the heart chambers. It necessitates the heart to work harder and harder to pump the same amount of blood through a progressively smaller opening resulting in impairing the heart’s ability to pump effectively.
Regurgitation or insufficiency refers to the inability to close effectively. This results in blood leaking backwards into the chamber before the valve. This also results in the heart having to work harder to pump the blood in the forward direction, which can result in undo strain on the heart’s ability to function properly.
In either of the two types of problems affecting the heart valves, this may result in the heart to struggle to beat and work harder to move the same amount of blood and oxygen throughout the body, as it would do so under normal conditions. This can lead to weakening of the heart muscle, and possibly even enlargement of the heart resulting in some patients developing congestive heart failure.
Many common symptoms of valve problems include shortness of breath, fatigue, swelling of the ankles or feet, chest pain or pressure, dizziness, and palpitations or irregular heart rhythm.
The presence of either valve stenosis or regurgitation can occur together in one valve or in a combination of multiple valves. The specific type of valve problem relates to the severity and significance of symptoms and strain on the heart. The treatment of valvular disease involves either replacing the existing valve with an artificial valve or repairing the valve using special techniques and one’s own natural tissues.
The two most common valves involved in heart valve surgery are the aortic valve and the mitral valve.
Aortic Valve Surgery
The aortic valve is normally comprised of three leaflets but in some cases people are born with two leaflets. The aortic valve is located between the left ventricle or main pumping chamber of the heart and the aorta, or the main vessel of the heart responsible for pumping blood to the rest of the body. Aortic valve disease can be either stenosis or regurgitation. Most commonly, as one ages, calcification develops on the aortic valve leading toward stenosis or blockage of the valve. This results in excessive strain on the left ventricle to pump blood through a progressively smaller opening. This may lead to chest pressure or pain and even congestive heart failure. In either stenosis or regurgitation of the aortic valve, these symptoms may occur. The heart, like any other muscle, begins to fatigue when an abnormal workload is being placed on it.
Most commonly, when the aortic valve is damaged by either stenosis or regurgitation, the solution is to excise or remove the existing diseased valve and replace it with an artificial valve.
The procedure involves supporting your heart with a heart-lung machine that allows your surgeon to fix your valve and repair your heart in a protected and relaxed state. The commonly chosen artificially valve types include tissue valves or mechanical valves and these will be discussed later. Your surgeon will review the specific problem that you have with your valve and the ideal valve solution suited to your problem.
Mitral Valve Surgery
The mitral valve has two main leaflets and it is located between the left atrium and the left ventricle. It functions much like a pair of french doors that open and close and meet in the middle. It is a one-way valve bringing oxygenated blood from the lungs that arrives in the left atrium, delivered through the mitral valve into the left ventricle. When the left ventricle contracts it squeezes blood out through the aortic valve while the mitral valve closes.
The mitral valve is the most commonly damaged valve of all heart valves. Mitral valve problems can either be mitral stenosis or regurgitation. When stenosis of the mitral valve occurs, often the main solution is to replace the mitral valve with either a tissue valve or a mechanical valve. Mitral regurgitation, or leakage of the mitral valve, may require replacement but often times may be ideally repaired using your own tissues.
Mitral valve repair involves reconstructing the valve using your own tissues. If we revisit the analogy of two French doors closing in the middle, problems that can arise in mitral regurgitation may involve the doors (leaflets) themselves, or the doorframe (mitral annulus). Often times in may be a problem of both. In either case, it involves either repairing the leaflets (doors) themselves, or reinforcing the annulus (doorframe). This then results in the two mitral leaflets closing together again as normal. The reinforcement of the annulus (doorframe) involves the placement of special stitches and reinforcing these stitches with a special ring or band made of specially woven cloth material that protects the optimal integrity of the valve repair.
Mitral valve surgery requires taking over the work of your heart with the heart-lung machine and resting your heart in a protected environment in order to repair or replace your mitral valve. The heart is then allowed to function more normally with the valve fixed and the circulation within your heart flowing more normally.
Artificial Valve Types
When performing valve surgery the valves may be repaired or replaced. The aortic valve is replaced in the vast majority of cases. In the rare case, with aortic regurgitation, the valve may be repaired which is at the discretion of your surgeon. The mitral valve may be repaired or replaced, but in mitral regurgitation more commonly the valve may be repairable but this is also at the discretion of your surgeon.
When valves are replaced, there are two general types of artificial valves. These are tissue valves or mechanical valves.
Tissues Valves: Tissue valves are made of either cow or pig tissue, commonly known as “pig valves”. These function very similar to the natural valves and due to the pliable nature of these tissue valves they usually do not require long-term blood thinning medications such as Coumadin. The two types of tissue valves available include stented tissue valves and stentless tissue valves. The most commonly used are stented tissue valves where the valve is mounted on an artificial sewing ring. Stentless tissue valves, lack this plastic or metal frame. The choice between these two types of valves is at the discretion of your surgeon. Most tissue valves now last between 10-20 years.
Mechanical Valves: Mechanical valves are made of metal alloys or carbon. They are strong, durable, and last for long periods of time. However, due to the artificial nature of the metallic leaflets of the mechanical valve, they are prone to blood clots and therefore all patients with mechanical valves are required to take blood-thinning medications such as Coumadin lifelong.
There are several types of mechanical valves, but all work in the similar fashion of opening and closing metal doors to permit the flow of blood in one direction. These mechanical valves are mounted on a sewing ring much like the stented valves discussed above. The choice of the type of mechanical valve will be at the discretion of your surgeon.
Preparing for Your Operation
Upon the detailed review by your surgeon regarding your specific valvular problem, the proposed surgical solutions, the specific risks and outcomes catered to you, you will undergo pre-operative testing to ensure the most optimal outcome from your valve surgery.
The typical tests required prior to heart valve surgery include a heart ultrasound or “echocardiogram”, a heart catheterization or “angiogram”, and specific additional tests that include a chest x-ray, EKG or electrocardiogram, and blood work.
The details of the risks and benefits of surgery will be reviewed with you by your surgeon. In general the risks of all heart operations, including valve operations, include bleeding, infection, stroke, and heart dysfunction. The degree of risk is dependent one’s specific pre-existing medical risks and one’s age. These will all be discussed with you in detail by your surgeon prior to surgery.
In general, you will be admitted on the same day of surgery, or in special circumstances the night before surgery at the discretion of your surgeon. Prior to transferring to the operating room, you will be given a relaxing agent to make the experience as pleasant and calm as possible. In the operating room, you will be placed in full and complete general anesthesia for the duration of the procedure.
Heart valve surgery can take between 3-6 hours depending on the complexity and extent of surgery required. The total stay in hospital is often between 3-5 days depending on the complexity and extent of the surgery required.
Recovery After our Operation
Immediately following your valve surgery, you will be transferred to the Cardiovascular Intensive Care Unit for close observation for the first 12-24 hours or more following surgery. As you awake from anesthesia, you will be greeted by a friendly intensive care nurse that will cater to your every need and ensure that you are without pain. As you awaken from anesthesia, you will be removed from the breathing machine. Following surgery there will be a few draining tubes from the lower portion of your incision that will be removed within 24-48 hours.
Once you are deemed stable, you will be transferred to a specific post cardiac surgery monitoring unit where you will be watched by a highly trained team of nurses and therapists to ensure your speedy and effective recovery. The absolute key to success at recovery from heart surgery in the immediate postoperative period includes aggressive breathing exercises and lots of walking. This will ensure good circulation and reducing the chance of problems such as pneumonia. Once you are able to ambulate well without the need of oxygen and you are otherwise deemed stable, you will be discharged.
Upon discharge, you will be given very specific dietary and exercise instructions by the team. In general, dietary recommendations are simple to follow and consist of a healthy normal balanced diet. The tissues take time to heal, and the common recommendation is to avoid heavy lifting or driving for at least four weeks. Your surgeon will give specific instructions to you and these should be strictly followed.
Upon discharge, you will be given very specific prescriptions as your medications will likely change after your surgery. It is important to stay on these specific medications until your heart surgeon or your cardiologist sees you in the postoperative period. Following successful recovery immediately following your operation, you will be enrolled in a cardiac rehabilitation exercise program that will assist you in regaining your full strength and return you to complete normal activities.
In general, most patients often have drastic improvement in there quality of life and their lifestyle following heart valve surgery once the hindering symptoms of valve disease have been lifted. It remains very important that you follow your doctor’s guidance for resuming activities such as household tasks, exercise, driving, and returning to work.
Once you have undergone valve surgery, it remains imperative that you take antibiotics prior to certain invasive medical procedures including dental work or any form of surgery in order to reduce the risk of infection of your new repaired or replaced valve.
Once you have fully recovered and begin traveling, it is recommended that you keep your valve ID card along with a current list of your medications on you at all times. Airport security systems have no adverse affects on heart valves and these will likely not activate any alarm systems. Magnets and even MRI examinations usually are safe after your heart valve surgery. It is always important to check with a physician prior to any procedures.
It is our hope that with this information, you feel more informed and better prepared to embrace your heart valve surgery directed at improving your overall outlook and quality of life.
