This article covers:
Basic Structure Of The Heart
Reasons for Heart Valve Replacement Surgery
Types of Heart Valve Replacement Surgeries
- Open Heart Surgery
- Minimally-invasive Surgery
- Transcatheter heart valve replacement
- Replacement Valves
Preparing for the Procedure
What to Expect After the Procedure
Risks of Heart Valve Replacement Surgery
Heart valve replacement surgery is one of the most common surgeries cardiac surgeons and some specialized cardiologists perform to fix problems with the heart valves and restore the heart’s function. To understand heart valve replacement surgery, you need to understand the basic structure and function of the heart.
Basic Structure of the Heart
The heart is a bag of muscle that pumps blood to all parts of your body. The heart has four chambers – two atria (singular: atrium) and two ventricles. The atria lie above the ventricles, where they receive blood into the heart while the ventricles pump blood away from the heart.
Each atrium is connected to one ventricle on one side through a passageway enclosed by a valve. The valve between the right atrium and ventricle is called the tricuspid valve while the valve between the left atrium and ventricle is called the bicuspid valve.
The left ventricle pumps blood through a large vessel called the aorta, which supplies blood to all the body tissues through several arterial branches. The valve enclosing the passageway between the left ventricle and the aorta is called the aortic valve. Similarly, the right ventricle pumps blood to the lungs through the pulmonary artery to receive oxygen. The valve between these two structures is called the pulmonic or pulmonary valve.
Reasons for Heart Valve Replacement Surgery
When your heart valves fail to close or open when required, blood flow within the heart is impaired and this puts your heart and your health in danger. This diseased valve may either be repaired or replaced.
Problems with the heart valves may include stenosis; in which case the valve thickens and becomes too narrow, impairing flow of blood through the passage. When this happens, your heart will exert more effort in pumping the same amount of blood through the valve, and this puts the heart in a lot of pressure.
Valves may also be too leaky or incompetent, in which case the valve does not close when it should, causing blood to flow backwards. When this happens, insufficient amount of blood is pumped to the tissues or lungs, leading to short supply of oxygen to the tissues.
Valve defects often present with symptoms of heart dysfunction, which include:
- Shortness of breath
- Chest pain
- Lightheadedness
- Palpitations
- Swelling of your ankles, feet, of neck
- Fluid retention in all parts of your body.
In moderate to severe cases of heart valve defect, your doctor may recommend heart valve repair or replacement surgery. Your doctor will discuss the pros and cons of valve repair and replacement to decide which is most appropriate for you. In cases where repair will not restore heart function adequately, or if repair fails after it is attempted, your doctor may recommend heart valve replacement.
Types of Heart Valve Replacement Surgeries
There are three methods of replacing any of the defective heart valves – open heart surgery, minimally invasive surgery, and transcatheter valve replacement.
Open Heart Surgery
Open heart surgery is the most common method for heart valve replacement. This surgery involves making a 6-8 inch incision in your chest, splitting your breast bone down its center from top to bottom to gain access to your heart. Before starting this procedure, your doctor will administer an anesthetic drug to keep you unconscious while the procedure is being carried out.
During the surgery, your doctor will stop your heart and divert your heart through tubes to a heart-lung or bypass machine to perform the job of pumping blood through your body for the period of the surgery. Then the damaged valve is removed and replaced with a new one.
After the replacement has been completed, your doctor will shock your heart with small paddles that transfer electric current to restart it. This allows blood flowing through the bypass machine to re-enter your heart. Then, the doctor observes if the new valves are working fine, as the heart resumes its function.
Minimally-invasive Surgery
This surgery is called so because the incisions are not as wide or large as those of the open-heart technique. This technique involves making small incisions in your chest and passing long instruments through them to perform the surgery. The surgeon views the inside of your chest through a long tube-like instrument passed through one of the incisions and connected to a screen. This surgery is also called thoracoscopic surgery.
Another example of a minimally invasive surgery for heart valve replacement is robotic surgery; in which case, the surgeon performs the surgery using robotic arms which he or she controls using a console. This surgery also uses tiny incisions in your chest with the surgeon visualizing the inside of your chest on a screen.
Minimally-invasive surgery has several advantages over traditional, open-heart surgery. These include a shorter hospital stay, faster recovery, and minimal pain.
Transcatheter heart valve replacement
Transcatheter valve replacement is a more recent technique. In this operation, the surgeon passes a thin tube called a catheter through an incision in your leg. The tube courses through a leg vein into your heart. Your doctor subsequently uses the tube to direct replacement of the defective heart valve.
This technique does not require any incisions in your chest and your breastbone will not be cut to expose your heart. The procedure is done using a catheter.
Catheter-based heart valve replacement surgery is performed in a catheterization laboratory, or cath lab, by interventional cardiologists. It also has same advantages as minimally-invasive surgery over the traditional, open-heart surgery, including shorter hospital stay, faster recovery, and minimal incisions and pain.
Replacement Valves
There are two main types of valves doctors replace defective ones with: mechanical and biological valves.
Mechanical valves are usually carbon, plastic, or metallic. These types of valves last a long time but may increase your risk of having blood clots. Therefore, after replacing your heart valves with these kinds of valves, doctors usually place you on a life-long course of blood thinners.
Biological valves are derived from animal tissue and they last for about 15 to 20 years. Biologic valves also include valves obtained from a donor human heart. While these types of valves don’t last as long as mechanical valves, they have lesser risk of developing blood clots.
You and your doctor will discuss the pros and cons of each type of valve to determine which will be best for you.
Preparing for the Procedure
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- Before scheduling the surgery, your doctor will explain to you the steps involved in the procedure; the potential risks during and after the procedure; and the lifestyle changes you need to make after the surgery.
- Your doctor will perform a physical examination and order some laboratory investigations to ensure you are healthy enough to undergo the procedure. These laboratory investigations include blood and urine tests to check your blood cell counts, liver function, and kidney function, chest X-ray, and electrocardiogram (EKG).
- You should also tell your doctor about any medicines or supplements you take. These include any over-the-counter medicines and prescription drugs you are taking. Tell your doctor if you are taking any blood thinners, aspirin, or other medicines which may affect blood thinning. Your doctor will give you recommendations about whether to stop taking them before surgery, when to stop taking them before surgery if you should, and when to start taking them after surgery.
- Tell your doctor if you have allergies to any medicine, latex material, or anesthetic drugs.
- Tell your doctor about any medical conditions you have been diagnosed of or for which you take medicines. If you smoke, your doctor will advise you stop at least 3 weeks before surgery to prevent blood clots and respiratory problems after the surgery and to speed up your recovery.
- Your doctor will give you a list of items you should come to the hospital with: these include some of your medicines, comfortable clothing, music devices or books to help you feel relaxed, personal care items, and a copy of your advance medical directive. Your doctor will advise that you remove jewelry, eyeglasses, contact lenses, nail polish, and dentures before the surgery.
- Your doctors will ask you to sign a consent form, which gives them your permission to do the surgery. Read the form carefully and ask your doctor if any information is not clear.
- The night before the procedure, you will wash your body with a special soap your doctor recommends to eliminate germs from your skin. Also, your doctor will ask you to abstain from food or drinks for 8 hours prior to the surgery, or generally after midnight.
What to Expect After the Procedure
In the Hospital
After the heart valve replacement surgery, you will spend several days in the intensive care unit (ICU) receiving intravenous fluids and nutrition, with certain machines connected to your body to display your EKG tracings, heart rate, blood pressure, breath rate, and other vital signs.
For a few hours after the surgery, you may still be semi-conscious from the effects of the anesthetic medicine administered. As a result, your doctors may place a tube in your throat to help you breath till you wake up and can optimally breathe on your own.
You will also have some tubes draining urine from your bladder and blood from your chest while in the ICU. You may also receive oxygen if your blood oxygen content, as displayed on the monitor, is below a certain mark. You may also receive intravenous medicines to help control your blood pressure, prevent bleeding, and control the pain.
When the ICU team is satisfied with your initial recovery a few days after the surgery, you will be transferred to the regular hospital ward for further monitoring and management. In the regular ward, all your medicines may converted from intravenous to oral forms.
How long you stay in the ICU and hospital depends on the type of heart valve replacement surgery you had and your post-operative health condition. Hospital stay is typically shorter with minimally-invasive surgery and transcatheter replacement than with open-heart surgery.
During your hospital stay, your doctors will monitor your vital signs and examine the sites of incisions for any infection.
Before your surgical team discharges you from the hospital, your healthcare providers will have you increase your physical activity level by walking around your hospital room. You may also be asked to engage in an exercise or cardiac rehabilitation program to expedite your recovery. Your doctors will also schedule follow-up visits for you.
Additionally, your doctor will advise you to observe the incision sites for any sign of infection while at home. This recovery plan will also include instructions on how to care for the incision wounds, how you should take your medications, and what lifestyle changes to make.
At Home
Follow your doctor’s bathing instructions and activity recommendations, and ensure you keep the surgical sites clean and dry.
The incision in your breastbone may take up to 6 to 8 weeks to heal. However, it may take up to 3 months before you begin to feel normal and free from all your initial symptoms. If your job does not involve a lot of physical exertion, you may be back to work in 6-8 weeks. However, if your job requires intense physical exertion; you may be fit to return to work after 3 months.
Contact your doctor immediately if you experience any of these symptoms at home:
- Fever of 100.4°F (38°C) or greater – this may suggest an infection
- Increasing redness, swelling, or pain in the incision sites.
- Bleeding from the incision sites
- Bleeding from any catheter sites
- Difficulty breathing
- Swelling in the feet and ankles
- Palpitations
Risks of Heart Valve Replacement Surgery
Heart valve replacement surgery, like all surgeries, comes with some risks. These risks may be related to the surgical technique or the anesthesia used. Possible risks of heart valve replacement surgery include:
- Bleeding during surgery
- Bleeding after surgery
- Blood clots
- Infection
- Breathing problems
- Abnormal heart rhythms, also called arrhythmias
- Pneumonia
- Sub-optimal function of new valve
Discuss your concerns regarding these risks before the day of the surgery.
Dr Mahadevan Ramachandran, a cardiac surgeon with over 15 years of independent experience in the premier hospitals of Kerala. He is currently working as Chief Consultant Cardiac Surgeon at the following hospitals:
Total Cardiac Care, Thiruvananthapuram
Cosmopolitan Hospital, Thiruvananthapuram
Azeezia Medical College, Kollam
NIMS Medicity, Neyyantinkara
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