Mitral Valve Replacement

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Mitral valve replacement is surgical procedure in which the diseased mitral valve of the heart is replaced by a mechanical valve or biological tissue valve.

Purpose

The mitral valve controls the blood flow between the left atrium (upper chamber) and left ventricle (lower chamber) of the heart. When the mitral valve functions correctly, blood flows in one direction only—from the atrium to the ventricle. When the valve becomes diseased or weakened, blood can backflow from the ventricle to the atrium when the ventricle contracts (systole). The mitral valve also can become narrowed, preventing the flow of blood from the left atrium into the left ventricle during ventricular filling (diastole). In mitral valve prolapse, one or more of the mitral valve’s cusps protrude back into the left atrium during ventricular contraction. Mitral valve repair is the preferred operation to correct these conditions and improve the function of the diseased valve so that it correctly controls the amount and direction of blood flow. When mitral valve repair is not possible, mitral valve replacement is performed. The defective mitral valve is surgically removed and a new mechanical valve or biological tissue valve (from a pig, cow, or human cadaver) is put into place to correctly control blood flow.

Demographics

Mitral valve prolapse is the most common heart valve defect. In the United States it is present in about 2-6% of the population. The defect is believed to have an inherited component and is seen twice as often in women as in men. Having this condition does not

KEY TERMS

Annulus— A ring-shaped structure.

Anticoagulants— Drugs that are given to slow blood clot formation.

Biological tissue valve— An autograft is a valve that comes from the patient, usually the pulmonary valve. An autologous pericardial valve is constructed from the patient’s pericardium (the fibrous sac that surrounds the heart and the roots of the great vessels and also forms the outer layer of the heart wall) at the time of surgery. A homograft (or allograft) valve is a valve harvested from a human cadaver. A porcine (pig) or bovine (cow) heterograft is animal tissue valve that is made acceptable to the body by destroying antigenicity so that the body will not reject the foreign tissue.

Cardiac catheterization— A diagnostic procedure (using a catheter inserted through a vein and threaded through the circulatory system to the heart) which does a comprehensive examination of how the heart and its blood vessels function.

Cardiopulmonary bypass— Use of the heart-lung machine to provide systemic circulation cardiac out-put and ventilation of the blood.

Doppler echocardiography— A testing technique that uses Doppler ultrasound technology to evaluate the pattern and direction of blood flow in the heart.

Endocarditis— Infection of the heart endocardium tissue, the inner most tissue and structures of the heart.

Mechanical valve— There are three types of mechanical valve: ball valve, disk valve, and bileaflet valve.

NYHA heart failure classification— A classification system for heart failure developed by the New York Heart Association. It includes the following four categories: I, symptoms with more than ordinary activity; II, symptoms with ordinary activity; III, symptoms with minimal activity; IV, symptoms at rest.

Rheumatic carditis— Inflammation of the heart muscle associated with acute rheumatic fever.

Rheumatic fever— An inflammatory disease that arises as a complication of untreated or inadequately treated strep throat infection. Rheumatic fever can seriously damage the heart valves.

Sternotomy— A surgical opening into the thoracic cavity through the sternum (breastbone).

Systemic circulation— Circulation supplied by the aorta including all tissue and organ beds, except the alveolar sacs of the lungs used for gas exchange and respiration.

Thromboemboli— Blood clots that develop in the circulation and lodge in capillary beds of tissues and organs.

Transesophageal echocardiography— A diagnostic test using an ultrasound device that is passed into the esophagus of the patient to create a clear image of the heart muscle and other parts of the heart.

automatically mean that mitral insufficiency will develop, and even when it does, mitral valve repair is often preferable to valve replacement. Patients with a history of rheumatic fever, coronary artery disease, infective endocarditis, or collagen vascular disease also may develop mitral insufficiency.

Mitral valve stenosis almost always is the result of having rheumatic fever in childhood. Rheumatic fever occurs in some people after a group A streptococcal throat infection (commonly called strep throat). Genetics appears to play a role in determining who develops rheumatic fever after a strep infection, with women more likely than men to progress to the disease. After rheumatic fever subsides, there is usually a latency period of 10-20 years before symptoms of mitral valve stenosis appear. The prevalence of mitral valve stenosis has declined in the United States because there has been a decline in the number of cases of rheumatic fever. In the United States in 2005, about one case of rheumatic fever occurred for every 100,000 people. Rheumatic fever is much more common in developing countries (100-150 cases per 100,000 in India, for example), and thus the rate of mitral valve stenosis is also higher. Mitral valve stenosis may be present at birth (congenital); however, it rarely occurs alone but rather in conjunction with other heart defects. Again, repair is preferable to replacement of the mitral valve.

Description

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 re-operation after about 10-15 years. Women who may want to have children after a valve replacement should usually receive a biological tissue valve, because the anticoagulant warfarin (Coumadin) most often prescribed for patients with mechanical valves is associated with fetal birth defects. Aspirin can be substituted for warfarin in certain circumstances.

Mitral valve replacement is done under general anesthesia with continuous cardiac monitoring. Uncomplicated mitral valve surgery normally takes 2-3 hours. To replace the mitral valve, the surgeon breaks the breastbone (sternum) to gain access to the heart and large blood vessels. Anticoagulation drugs are given as cannulae are inserted into the large veins. Cardiopulmonary bypass (use of a heart-lung machine) is instituted. The heartbeat is stopped as blood vessels are clamped to prevent blood flow through the heart. The surgeon opens the heart to see the mitral valve. He/she may expose the mitral valve by opening the right atrium and then opening the atrial septum (tissue dividing the atria). Another approach requires a large left atrium that can be opened directly, making the mitral valve visible.

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.

De-airing of the heart is performed before removal of the clamps. When the clamps are removed, de-airing continues to ensure that no air enters 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. If the surgeon is not satisfied with the repair, mitral valve replacement is performed. 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 blood vessels. 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.

Diagnosis/Preparation

Mitral valve stenosis is diagnosed by history, physical examination, listening to the sounds of the heart (cardiac auscultation), chest x ray, and ECG. Patients may have no symptoms of a valve disorder or may have shortness of breath (dyspnea), fatigue, or frank pulmonary edema. Other patients present with atrial fibrillation (a cardiac arrhythmia) or an embolic event. Doppler echocardiography is the preferred diagnostic tool for evaluation of mitral valve stenosis, and it can be performed in conjunction with noninvasive exercise testing by treadmill or bicycle. Cardiac catheterization is reserved for patients who demonstrate discrepancies in Doppler testing. Both left-and right-heart catheterization should be performed in the presence of elevated pulmonary artery pressures.

A diagnosis of mitral insufficiency requires a detailed patient history. Listening to the heart (auscultation) reveals the presence of a third heart sound. Chest x ray and ECG provide additional information. Again, Doppler echocardiography provides valuable information. Exercise testing with Doppler echocardiography can show the true severity of the disease.

After initial findings, patients may be followed with repeat visits and testing to monitor disease progress. If the patient has reached NYHA Class III or IV, replacement is considered. Severe pulmonary hypertension with pulmonary artery systolic pressures greater than 60 mm Hg is considered an indication for surgery. Left ventricular ejection fraction (a measure of blood output with each heartbeat) less than 60% normal also is an indication for surgery.

Aftercare

The patient receives continued cardiac monitoring in the intensive care unit and usually remains in intensive care for 24–48 hours after surgery. Ventilation support is discontinued when the patient is able to breathe on his/her own. If mechanical circulatory support and inotropic agents (a substance that influences the force of muscle contractions, e.g. digitalis) were needed during the surgical procedure, they are discontinued as cardiac function recovers. Tubes draining blood from the chest cavity are removed as bleeding from the surgical procedure decreases. Prophylactic antibiotics are given to prevent infective endocarditis and the recurrence of rheumatic car

Both mechanical and biological tissue valves require anticoagulation therapy after surgery, and while patients are hospitalized their anticoagulant status is monitored and dosages are adjusted accordingly. Patients with biological tissue valves can discontinue anticoagulation therapy within three months of valve replacement surgery, but those with mechanical valves must take an anticoagulant (aspirin, warfarin, or a

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cardiothoracic and cardiovascular surgeons provide surgical treatment. Surgeons are trained during the residency to perform these procedures. Medical centers that perform cardiac surgery are able to provide mitral valve replacement.

combination of the two) for the rest of their lives. These patients are regularly monitored for INR values (a measure of the clotting potential of their blood).

If the patient recovers normally, discharge from the hospital occurs within a week of surgery. At discharge, the patient is given specific instructions about wound care and infection recognition, as well as contact information for the physician and guidelines about when a visit to the emergency room is indicated. Within three to four weeks after discharge, the patient is seen for follow-up office visit with the physician, at which time physical status will have improved for evaluation. Thereafter, asymptomatic, uncomplicated patients are seen at yearly intervals. Few limitations are placed on patient activity once recovery is complete.

Risks

There are always risks associated with general anesthesia and cardiopulmonary bypass. Risks specifically associated with mitral valve replacement include embolism, bleeding, and operative valvular endocarditis. Hemolysis (the breakdown of red blood cells) is associated with certain types of mechanical valves, but is not a contraindication for implantation.

Normal results

Patients treated by mitral valve replacement for mitral insufficiency can expect relief of symptoms. For patients who received mechanical valves, anticoagulation therapy is continued for life. Since thromboembolic complications are associated with initial implant of biological tissue valves, patients who received this type of valve take an anticoagulant for three months after surgery. If non-cardiac surgery or dental care is needed, the anticoagulation therapy is adjusted to prevent bleeding complications.

Patients who undergo mitral valve replacement for mitral stenosis can expect excellent improvement of symptoms. Those patients with symptoms consistent with NYHA class IV before surgery have better

QUESTIONS TO ASK THE DOCTOR

• Is mitral valve replacement the best treatment option for my condition? Why is it preferable to mitral valve repair?
• How many of these procedures has the surgeon performed in the last year? in the last five years?
• What is the surgeon’s morbidity and mortality rate with mitral valve replacement?
• What type of replacement valve, biological tissue or mechanical, is best for me?
• What are the pros and cons of each valve type?
• What type of follow-up care is required during the first year after valve implant and for the rest of m life?
• What types of complications are associated with this surgery?

outcome after mitral valve replacement compared to no treatment.

Morbidity and mortality rates

Mitral valve replacement carries a 5% risk of death in young, healthy patients. With increased age, additional medical problems, or pulmonary hypertension the risk of death increases substantially. Post-replacement the five-year survival is 80%. Patients over the age of 75 have poorer outcomes when mitral valve replacement is used to treat mitral insufficiency.

Alternatives

Mitral valve replacement is considered only after mitral valve repair has proved inadequate or inappropriate. An asymptomatic patient with a history of rheumatic fever can be treated with prophylactic antibiotics and followed until symptoms are appear. If atrial fibrillation develops, drugs may be used to regulate heart rhythm. Anticoagulation therapy is employed to avoid systemic emboli during periods of atrial fibrillation.

Resources

BOOKS

ICON Health Publications. The Official Patient’s Source-ook on Mitral-Valve Prolapse. San Diego, CA: ICON Health Publications, 2006.

PERIODICALS

Bonow, R., et al. “ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease.” Circulation. 114 (2006) e84-e231. http://circ.ahajournals.org/cgi/reprint/114/5/e84.

ORGANIZATIONS

American Heart Association. 7272 Greenville Avenue, Dallas, TX 75231. (800) 242-8721. http://www.americanheart.org.

Mitral Valve Repair Center at Mount Sinai Hospital. 1190 Fifth Avenue, New York, NY 10029 (212) 659-6820. http://www.mitralvalverepair.org.

Allison Joan Spiwak, MSBME

Tish Davidson, A. M.

Mitral valve replacement

Definition

Mitral valve replacement is a surgical procedure in which the diseased mitral valve of the heart is replaced by a mechanical or biological tissue valve.

Purpose

The mitral valve can become diseased, preventing it from adequately controlling the direction of the flow of blood between the left atrium and left ventricle. It also can become insufficient (regurgitant) and allow blood to flow backwards into the left atrium from the left ventricle during ventricular contraction (systole). In addition, the mitral valve can become stenotic (narrowed), preventing the flow of blood from the left atrium into the left ventricle during ventricular filling (diastole). In mitral valve prolapse, one or more of the mitral valve's cusps protrude back into the left atrium during ventricular contraction. Mitral valve replacement is performed to remove the diseased valve and provide a new mechanical valve or biological tissue valve that correctly controls the direction of blood flow.

Demographics

Approximately 65,000 valve repairs and replacements are performed in the United States each year.

Twice as many women as men are affected by mitral valve stenosis. About 60% of patients with mitral valve stenosis have had rheumatic fever. After rheumatic fever there is usually a latency period of 10–20 years before symptoms of mitral valve stenosis appear. The prevalence of mitral valve stenosis has declined in the United States because there has been a decline in the number of cases of rheumatic fever. Mitral valve stenosis may be present at birth (congenital); however, it rarely occurs alone but rather in conjunction with other heart defects.

Mitral valve prolapse is the most common condition of the heart valves, and is present in about 2% of the general population. Recent studies indicate that similar numbers of men and women have mitral valve prolapse. Having this condition does not guarantee that mitral insufficiency will develop. Patients with a history of rheumatic fever, coronary artery disease, infective endocarditis, or collagen vascular disease also may develop mitral insufficiency.

Description

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. 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.

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 surgeon is satisfied that the valve is working correctly, cardiopulmonary bypass is terminated, anticoagulation is reversed, and the cannulae are removed from the vessels. 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.

Diagnosis/Preparation

Mitral valve stenosis is diagnosed by history, physical examination , listening to the sounds of the heart (cardiac auscultation), chest x ray , and ECG. Patients may have no symptoms of a valve disorder or may have shortness of breath (dyspnea), fatigue, or frank pulmonary edema. Other patients present with atrial fibrillation (a cardiac arrhythmia) or an embolic event. Doppler echocardiography is the preferred diagnostic tool for evaluation of mitral valve stenosis, and it can be performed in conjunction with non-invasive exercise testing by treadmill or bicycle. Cardiac catheterization is reserved for patients who demonstrate discrepancies in Doppler testing. Both left- and right-heart catheterization should be performed in the presence of elevated pulmonary artery pressures.

A diagnosis of mitral insufficiency requires a detailed patient history. Listening to the heart (auscultation) reveals the presence of a third heart sound. Chest x ray and ECG provide additional information. Again, Doppler echocardiography provides valuable information. Exercise testing with Doppler echocardiography can show the true severity of the disease.

After initial findings, patients may be followed with repeat visits and testing to monitor disease progress. If the patient has reached NYHA Class III or IV, replacement is considered. Severe pulmonary hypertension with pulmonary artery systolic pressures greater than 60 mm Hg is considered an indication for surgery. Left ventricular ejection fraction (a measure of output) less than 60% also is an indication for surgery.

Aftercare

The patient receives continued cardiac monitoring in the intensive care unit and usually remains in intensive care for 24–48 hours after surgery. Ventilation support is discontinued when the patient is able to breathe on his/her own. If mechanical circulatory support and inotropic agents (a substance that influences the force of muscle contractions, e.g. digitalis) were needed during the surgical procedure, they are discontinued as cardiac function recovers. Tubes draining blood from the chest cavity are removed as bleeding from the surgical procedure decreases. Prophylactic antibiotics are given to prevent infective endocarditis and the recurrence of rheumatic carditis.

Both mechanical and biological tissue valves require anticoagulation therapy after surgery, and while patients are hospitalized their anticoagulant status is monitored and dosages are adjusted accordingly. Patients with biological tissue valves can discontinue anticoagulation therapy within three months of implantation, but those with mechanical valves must take an anticoagulant (aspirin, warfarin, or a combination of the two) for the rest of their lives. These patients are regularly monitored for INR values, which are maintained between 2.0 and 4.5.

If the patient recovers normally, discharge from the hospital occurs within a week of surgery. At discharge, the patient is given specific instructions about wound care and infection recognition, as well as contact information for the physician and guidelines about when a visit to the emergency room is indicated. Within three or four weeks after discharge, the patient is seen for follow-up office visit with the physician, at which time physical status will have improved for evaluation. Thereafter, asymptomatic, uncomplicated patients are seen at yearly intervals. Few limitations are placed on patient activity once recovery is complete.

Risks

There are always risks associated with general anesthesia and cardiopulmonary bypass. Risks specifically associated with mitral valve replacement include embolism, bleeding, and operative valvular endocarditis. Hemolysis (the breakdown of red blood cells) is associated with certain types of mechanical valves, but is not a contraindication for implantation.

Normal results

Patients treated by mitral valve replacement for mitral insufficiency can expect relief of symptoms. Improvement in myocardial function is not likely, but the current status is preserved. For patients who received mechanical valves, anticoagulation therapy is continued lifelong to elevate the INR to between 2.0 and 4.5, depending on the type of mechanical valve implanted. Since thromboembolic complications are associated with initial implant of biological tissue valves, patients who received this type of valve take an anticoagulant for three months after surgery to maintain an INR of 2.0–3.0. If non-cardiac surgery or dental care is needed, the anticoagulation therapy is adjusted to prevent bleeding complications.

Patients who undergo mitral valve replacement for mitral stenosis can expect excellent improvement of symptoms. Those patients with symptoms consistent with NYHA class IV before surgery have better outcome after mitral valve replacement compared to no treatment.

Morbidity and mortality rates

Mitral valve replacement carries a less than 5% risk of death in young, healthy patients. With increased age, additional medical problems, or pulmonary hypertension the risk of death increases to 10–20%. Post-replacement the five year survival is 80%. Patients over the age of 75 have poorer outcomes when mitral valve replacement is used to treat mitral insufficiency.

Alternatives

The asymptomatic patient with a history of rheumatic fever can be treated with prophylactic antibiotics and followed until symptoms are appear. If atrial fibrillation develops, antiarrhythmic medications can be used for treatment. Atrial defibrillation may relieve atrial fibrillation. Anticoagulants may be prescribed to prevent the occurrence of systemic embolization. The patient with symptoms may benefit from percutaneous mitral balloon valvotomy. Surgery to perform a commissurotomy may be used instead of valve replacement.

Mitral valve insufficiency or prolapse that develops atrial fibrillation should be treated with drugs to regulate the heart rhythm or atrial defibrillation. Anticoagulation therapy is employed to avoid systemic emboli during periods of atrial fibrillation. Mitral valve repair maybe beneficial instead of mitral valve replacement.

Resources

books

Hensley, Frederick A., Donald E. Martin, and Glenn P. Gravlee, eds. A Practical Approach to Cardiac Anesthesia. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

Topol, Eric J., ed. Textbook of Interventional Cardiology. Philadelphia: W. B. Saunders, 2002.

periodicals

Bonow, R., et al. "ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease." Journal of the American Collge of Cardiology 32 (November 1998): 1486–1582.

Brown, Katherine Kay. "Minimally Invasive Valve Surgery." Critical Care Nursing Quarterly 20 (February 1998): 40–52.

Sadovsky, Richard. "Using Warfarin After Heart Valve Replacement." American Family Physician 61 (April 1, 2000): 2219.

Allison Joan Spiwak, MSBME

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Cardiothoracic and cardiovascular surgeons provide surgical treatment. Surgeons are trained during the residency to perform these procedures. Medical centers that perform cardiac surgery are able to provide mitral valve replacement.

QUESTIONS TO ASK THE DOCTOR

• Is mitral valve replacement the best treatment option for my condition?
• How many of these procedures has the surgeon performed in the last year? in the last five years?
• What is the surgeon's morbidity and mortality rate with mitral valve replacement?
• What type of replacement valve, biological tissue or mechanical, is best for me?
• What are the pros and cons of each valve type?
• What type of follow-up care is required during the first year after valve implant and for the rest of my life?
• What types of complications are associated with this surgery?

Aortic Valve Replacement

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Aortic valve replacement is the insertion of a mechanical or tissue valve in place of the diseased biological aortic valve.

Purpose

Aortic valve replacement is necessary when the aortic valve has become diseased. The aortic valve can suffer from insufficiency (inability to perform adequatedly) or stenosis (narrowing). An insufficient valve is leaky and allows blood to flow backward from the aorta to the left ventricle during diastole, which occurs when the ventricles fill with blood. A stenotic valve prevents the forward-moving flow of blood from the left ventricle to the aorta, during systole, which is the time period when the heart is contracting.

Either situation can result in heart failure and an enlarged left ventricle. With aortic stenosis, the symptoms of angina pectoris, fainting, and congestive heart failure will develop with the severity of the narrowing. There is an increased rate of sudden death of patients with aortic stenosis. Dyspnea (labored breathing), fatigue, and palpitations are late symptoms of aortic insufficiency. Angina pectoris is associated with the latest stages of aortic insufficiency.

Demographics

Congenital birth defects involving a bicuspid aortic valve can develop stenosis. These patients may become symptomatic in mid-teen years through age 65. Patients with a history of rheumatic fever have a disposition for aortic stenosis, but may live symptom

KEY TERMS

Antithrombic— Preventing clot formation.

Biological tissue valve— A replacement heart valve that is harvested from the patient (autograft), a human cadaver (homograft or allograft), or other animal, such as a pig (heterograft).

Diastole— Period between contractions of the heart.

Hemolysis— Separation of hemoglobin from the red blood cells.

Mechanical valve— An artificial device used to replace the patient’s heart valve. They include three types: ball valve, disk valve, and bileaflet valve.

Systole— Period while the heart is contracting.

free for more than four decades. Calcification of the aortic valve tends to effect an older population with 30% of patients over age 85 having stenosis at autopsy.

Patients with aortic stenosis who have angina, dyspnea, or fainting are candidates for aortic valve replacement. Asymptomatic patients undergoing coronary artery bypass grafting should be treated with aortic valve replacement, but otherwise are not candidates for preventive aortic valve replacement.

Patients with a history of rheumatic fever or syphilitic aortitis (inflammation of the aorta) face the possibility of developing aortic insufficiency. Successful treatment has decreased this causative relationship. Primary causes of aortic valve disease include bacterial endocarditis, trauma, aortic dissection, and congenital diseases.

Patients showing acute symptoms, including pulmonary edema, heart rhythm problems, or circulatory collapse, are candidates for aortic valve replacement. Chronic pathologies are recommended for surgery when patients appear symptomatic, demonstrating angina and dyspnea. Asymptomatic patients also must be monitored for heart dysfunction. Left ventricular dimensions greater than 2 in (50 mm) at diastole or 3 in (70 mm) at systole are indications for replacement when aortic insufficiency is diagnosed.

Description

While receiving general anesthesia in preparation for the surgery, the patient’s cardiac function will be monitored. A sternotomy (incision into the sternum) or thoracotomy may be used to expose the heart, with the thoracotomy providing a smaller incision through the ribs. Minimally invasive techniques may also be used, utilizing a partial sternotomy or a lateral minithoracotomy. These approaches seem to decrease patient recovery time, as well as decreasing potential complications. Anticoagulant is administered in preparation for cardiopulmonary bypass. Cardiopulmonary bypass is instituted by exposing and cannulating (putting tubes into) the great blood vessels of the heart, or by cannulating the femoral artery and vein. A combination of cannulation sites may also be used. The heart is stopped after the aorta is clamped. The base of the aorta root is opened, and the diseased valve is removed. Sutures are placed in the aortic rim and into the replacement valve. The replacement valve can be either mechanical or biological tissue. The replacement valve will be sized prior to implant to ensure that it fits the patient based on the size of the aortic valve annulus. Once seated, the valve is secured by tying the individual sutures. The heart is then deaired. The cross clamp is removed and the heart is allowed to beat as deairing continues by manipulation of the left ventricle. Cardiopulmonary bypass is terminated, the tubes are removed, and drugs to reverse anticoagulation are administered.

A heart valve prevents the flow of blood backward during heartbeats. Replacement heart valves can be mechanical or biological tissue valves. For patients younger than 65 years of age, the mechanical valve offers superior longevity. Anticoagulant medication is required for the life of the patient implanted with a mechanical valve. The biological tissue valve does not require anticoagulation but suffers from deterioration, leading to reoperation, particularly in those under age 50. Women considering bearing children should be treated with biological tissue valves because the anticoagulant of choice with mechanical valves, warfarin, is associated with developmental effects in the fetus. Aspirin can be substituted in certain circumstances.

Diagnosis/Preparation

Initial diagnosis by auscultation (listening) is done with a stethoscope. Additional procedures associated with diagnosis to judge severity of the lesion include chest x ray, echocardiography, and angiography with cardiac catheterization. In the absence of angiography, magnetic resonance imaging (MRI) or computed tomographic (CT) imaging may be used.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Hospitals with cardiac surgery services provide aortic valve replacement. Specialization is required for young adults and pediatric patients. Cardiovascular and cardiac surgeons are trained to provide this treatment and the initial follow-up care. These surgeons are trained in their cardiac surgical residency to evaluate and perform these procedures and to care for the patient during the postoperative period.

Aftercare

The patient will have continuous cardiac monitoring performed in the intensive care unit (ICU) postoperatively. Medications or mechanical circulatory assist may be instituted during the surgery or postoperatively to help the heart provide the necessary cardiac output to sustain the pulmonary and systemic circulations. These will be discontinued as cardiac function improves. As the patient is able to breathe without assistance, ventilatory support will be discontinued. Drainage tubes allow blood to be collected from the chest cavity during healing and are removed as blood flow decreases. Prophylactic antibiotics are given. Anticoagulation (warfarin, aspirin, or a combination) therapy is instituted and continued for patients who have received a mechanical valve. The ICU stay is approximately three days with a final hospital discharge occurring within a week after the procedure.

The patient receive wound care instructions prior to leaving the hospital. The instructions include how to recognize such adverse conditions as infection or valve malfunction, contact information for the surgeon, and guidelines on when to return to the emergency room.

Risks

There are unassociated risks with general anesthetic and cardiopulmonary bypass. Risks associated with aortic valve replacement include embolism, bleeding, and operative valvular endocarditis. Hemolysis is associated with certain types of mechanical valves, but is not a contraindication for implantation.

Normal results

Myocardial function typically improves rapidly, with decrease in left ventricle enlargement and size of the inner chamber over several months, allowing the

QUESTIONS TO ASK THE DOCTOR

• What type of valve is best suited for me?
• What are the pros and cons associated with each type of valve for a person with my disease and/or associated diseases?
• Why am I a candidate for valve replacement?
• Are there any other more suitable alternative procedures?
• If I am a female interested in having children or am currently pregnant, are there additional options?
• How often has the surgeon performed this procedure and what are the morbidity/mortality statistics for this surgeon and institution?
• If I have an associated disease or complicated scenario, does the surgeon have experience wollow-up care?

heart to return to normal dimensions. Anticoagulation therapy will be continued, depending on the type of mechanical valve implanted. Implantation of biological tissue valves are associated with the formation of blood clots. If non-cardiac surgery or dental care is needed, the anticoagulant medication will be adjusted to prevent bleeding complications.

Morbidity and mortality rates

There is a 3–5% hospital mortality associated with aortic valve replacement. The average survival rate after five years is 85% for patients suffering from aortic stenosis who undergo aortic valve replacement. Structural valve deterioration can occur and is higher in mechanical valves during the first five years; however, biological tissue and mechanical valves have the same failure incidence at 10 years, with a 60% probability of death at 11 years as a result of valve-related complications. Patients with a mechanical valve are more likely to experience bleeding complications. Reoperation is more likely for patients treated with a biological tissue valve, but not significantly different when compared to their mechanical valve counterparts. This combines to an average rate of significant complications of 2–3% per year, with death rate of approximately 1% per year associated directly with the prosthesis.

Alternatives

Balloon valvotomy may provide short-term relief of aortic stenosis, but is considered a temporary treatment until valve replacement can be accomplished. Aortic valve repair by direct commissurotomy may also be successful for some cases of aortic stenosis. Medical treatment for inoperable patients with severe aortic stenosis is used to relive pulmonary congestion and prevent atrial fibrillation.

Severe aortic insufficiency can be treated with medical therapy. Pharmaceuticals to decrease blood pressure, along with diuretics and vasodilators, are helpful in patients with aortic insufficiency.

Resources

BOOKS

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Libby, P., et al. Braunwald’s Heart Disease. 8th ed. Philadelphia: Saunders, 2007.

Townsend, C. M., et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Walther T, Falk V, and F. Mohr. “Minimally Invasive Surgery for Valve Disease.” Current Problems in Cardiology 31, No. 6 (June 2006): 399–437.

Allison Joan Spiwak, MSBME

Rosalyn Carson-DeWitt, MD

Aortofemoral bypass seePeripheral vascular bypass surgery

Apheres seeTransfusion

Apicoectomy seeRoot canal treatment

Aortic valve replacement

Definition

Aortic valve replacement is the insertion of a mechanical or tissue valve in place of the diseased native aortic valve.

Purpose

Aortic valve replacement is necessary when the aortic valve has become diseased. The aortic valve can suffer from insufficiency (inability to perform adequately) or stenosis. An insufficient valve is leaky and allows blood flow retrograde from the aorta to the left ventricle during diastole. A stenotic valve prevents the flow of blood antegrade from the left ventricle to the aorta, during systole.

Either situation can result in heart failure and an enlarged left ventricle. With aortic stenosis (narrowing), angina pectoris, fainting, and congestive heart failure will develop with the severity of the narrowing. There is an increased rate of sudden death of patients with aortic stenosis. Dyspnea (labored breathing), fatigue, and palpitations are late symptoms of aortic insufficiency. Angina pectoris is associated with the latest stages of aortic insufficiency.

Demographics

Congenital birth defects involving a bicuspid aortic valve can develop stenosis. These patients may become symptomatic in mid-teen years through age 65. Patients with a history rheumatic fever have a disposition for aortic stenosis, but may live symptom free for more then four decades. Calcification of the aortic valve tends to effect an older population with 30% of patients over age 85 having stenosis at autopsy.

Patients with aortic stenosis who have angina, dyspnea, or fainting are candidates for aortic valve replacement. Asymptomatic patients undergoing coronary artery bypass grafting should be treated with aortic valve replacement, but otherwise are not candidates for preventive aortic valve replacement.

Patients with a history of rheumatic fever or syphilitic aortitis (inflammation of the aorta) face the possibility of developing aortic insufficiency. Successful treatment has decreased this causative relationship. Primary causes of aortic disease commonly include bacterial endocarditis, trauma, aortic dissection, and congenital diseases.

Patients showing acute symptoms, including pulmonary edema, heart rhythm problems, or circulatory collapse, are candidates for aortic valve replacement. Chronic pathologies are recommended for surgery when patients appear symptomatic, demonstrating angina and dyspnea. Asymptomatic patients must be monitored for heart dysfunction. Left ventricular dimensions greater then 2 in (50 mm) at diastole or 3 in (70 mm) at systole are indications for replacement when aortic insufficiency is diagnosed.

Description

While receiving general anesthesia in preparation for the surgery, the patient's cardiac function will be monitored. A sternotomy (incision in the sternum) or thoracotomy may be used to expose the heart, with the thoracotomy providing a smaller incision through the ribs. Anticoagulant is administered in preparation for cardiopulmonary bypass. Cardiopulmonary bypass is instituted by exposing and cannulating (putting tubes in) the great blood vessels of the heart, or by cannulating the

femoral artery and vein. A combination of cannulation sites may also be used. The heart is stopped after the aorta is clamped. The aortic root is opened and the diseased valve is removed. Sutures are placed in the aortic rim and into the replacement valve. The replacement valve can be either mechanical or biological tissue. The replacement valve will be sized prior to implant to ensure that it fits the patient based on the size of the aortic valve annulus. Once seated, the valve is secured by tying the individual sutures. The heart is then deaired. The cross clamp is removed and the heart is allowed to beat as deairing continues by manipulation of the left ventricle. Cardiopulmonary bypass is terminated, the tubes are removed and drugs to reverse anticoagulation are administered.

A heart valve is an orifice that blood passes through in systole, and it is also an occluding (blocking) mechanism necessary to prevent the flow of blood during diastole. Heart valves can be mechanical or biological tissue valves. For patients younger then 65 years of age, the mechanical valve offers superior longevity. Anticoagulation is required for the life of the patient implanted with a mechanical valve. The biological tissue valve does not require anticoagulation but suffers from deterioration, leading to reoperation particularly in those under age 50. Women considering bearing children should be treated with biological tissue valves as the anticoagulant of choice with mechanical valves, warfarin, is associated with teterogenic effects in the fetus. Aspirin can be substituted in certain circumstances.

Diagnosis/Preparation

Initial diagnosis by auscultation (listening) is done with a stethoscope . Additional procedures associated with diagnosis to judge severity of the lesion include chest x ray , echocardiography , and angiography with cardiac catheterization . In the absence of angiography, magnetic resonance imaging (MRI) or computed tomographic (CT) imaging may be used.

Aftercare

The patient will have continuous cardiac monitoring performed in the intensive care unit (ICU) postoperatively. Medications or mechanical circulatory assist may be instituted during the surgery or postoperatively to help the heart provide the necessary cardiac output to sustain the pulmonary and systemic circulations. These will be discontinued as cardiac function improves. As the patient is able to breathe without assistance, ventilatory support will be discontinued. Drainage tubes allow blood to be collected from the chest cavity during healing and are removed as blood flow decreases. Prophylaxis antibiotics are given. Anticoagulation (warfarin, aspirin, or a combination) therapy is instituted and continued for patients who have received a mechanical valve. The ICU stay is approximately three days with a final hospital discharge occurring within a week after the procedure.

The patient receive wound care instructions prior to leaving the hospital. The instructions include how to recognize such adverse conditions as infection or valve malfunction, contact information for the surgeon, and guidelines on when to return to the emergency room.

Risks

There are unassociated risks with general anesthetic and cardiopulmonary bypass. Risks associated with aortic valve replacement include embolism, bleeding, and operative valvular endocarditis. Hemolysis is associated with certain types of mechanical valves, but is not a contraindication for implantation.

Normal results

Myocardial function typically improves rapidly, with decrease in left ventricle enlargement and dilation over several months, allowing the heart to return to normal dimensions. Anticoagulation therapy will be continued to elevate the INR to between 2.0 and 4.5, depending on the type of mechanical valve implanted. Implantation of biological tissue valves with maintenance of an INR of 2.0–3.0 for the initial three months post implant are associated with blood clot complications. If non-cardiac surgery or dental care is needed the antithrombotic therapy will be adjusted to prevent bleeding complications.

Morbidity and mortality rates

There is a 3–5% hospital mortality associated with aortic valve replacement. There is an average survival rate of five years in 85% of patients suffering from aortic stenosis that undergo aortic valve replacement. Structural valve deterioration can occur and is higher in mechanical valves during the first five years; however, biological tissue and mechanical valves have the same failure incidence at 10 years, with a 60% probability of death at 11 years as a result of a valve-related complications. Patients with a mechanical valve are more likely to experience bleeding complications. Reoperation is more likely for patients treated with a biological tissue valve, but not significantly different when compared to their mechanical valve counterparts. This combines to an average rate of significant complications of 2–3% per year, with death rate of approximately 1% per year associated directly with the prosthesis.

Alternatives

Balloon valvotomy may provide short term relief of aortic stenosis, but is considered palliative until valve replacement can be accomplished. Aortic valve repair by direct commisurotimy may also be successful for some cases of aortic stenosis. Medical treatment for inoperable patients with severe aortic stenosis is used to relive pulmonary congestion and prevent atrial fibrillation.

Severe aortic insufficiency can be treated with medical therapy. Pharmaceuticals to decrease blood pressure, with diuretics and vasodilators, are helpful in patients with aortic insufficiency.

Resources

books

hensley, frederick a., donald e. martin, and glenn p. gravlee, eds. a practical approach to cardiac anesthesia. 3rd edition. philadelphia: lippincott williams & wilkins philadelphia, 2003.

periodicals

bonow r, et al. "acc/aha guidelines for the management of patients with valvular heart disease." jacc 32 (november 1998): 1486–588.

Allison Joan Spiwak, MSBME

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Hospitals with cardiac surgery services provide aortic valve replacement. Specialization is required for young adults and pediatric patients. Cardiovascular and cardiac surgeons are trained to provide this treatment and the initial follow-up care. These surgeons are trained in their cardiac surgical residency to evaluate and perform these procedures and to care for the patient during the post-operative period.

QUESTIONS TO ASK THE DOCTOR

• What type of valve is best suited for me?
• What are the pros and cons associated with each type of valve for a person with my disease and/or associated diseases?
• Why am I a candidate for valve replacement?
• Are there any other more suitable alternative procedures?
• If I am a female interested in having children, or currently pregnant are there additional options?
• How often has the surgeon performed this procedure and what are the morbidity/mortality statistics for this surgeon and institution?
• If I have an associated disease or complicated scenario does the surgeon have experience with follow-up care?