What is a heart valve replacement?
A heart valve replacement is a surgical procedure performed by a cardiac or cardiovascular surgeon or interventional radiologist performed under sedation or a general anaesthetic. Some heart valve repair surgeries may be performed under a local anaesthetic with sedation.
The aim of a heart valve replacement is as its name suggests – to replace a severely malfunctioning or damaged valve with a synthetic or animal tissue substitute. Mildly damaged or malfunctioning heart valves can be repaired without needing to replace the entire valve. Procedures may include valve access via the major veins and arteries, with small incisions to the chest, or with open heart surgery. Some surgeons are specialised in robotic-assisted heart valve replacement.
Valves may either not close properly, allowing a small but often significant amount of blood to flow in the wrong direction (valvular regurgitation) or become infected and swell, stopping the flow of blood. Symptoms differ according to damaged valve type. Causes are multiple; these are discussed further on.
It should be mentioned that symptomatic valvular heart disease may be a contraindication to airline travel. Your treating physician could be asked to provide an assessment for your flight provider. If given the all-clear, short-haul flights, possibly in combination with other modes of transport could be advised. Remedazo can help you to arrange alternative transportation or help find medical equipment such as an approved oxygen concentrator, as well as a medical professional to accompany you on your flight.
Why do I need a heart valve replacement?
Heart valves can be defective from a young age due to congenital disorders. They also degenerate in later life due to the ageing process. Degeneration is sped up through a lack of oxygen to the heart, certain disorders such as Marfan disease, atherosclerosis and calcium deposits, an unhealthy lifestyle, heart disease and infection.
Early stage, asymptomatic heart valve disorders do not always require treatment and can merely be observed during biannual or annual visits to your cardiologist. Pharmaceutical treatment may also be enough to prevent surgery in some cases. However, when symptoms appear and the heart begins to enlarge due to overwork, and when these symptoms are caused by valve regurgitation or valve stenosis, valve surgery is necessary. Failure to do so can increase the risk of heart attack, pulmonary embolism and stroke. In the case of valvular disorders, heart attack is due to compromised blood flow and oxygen supply in combination with overwork; strokes are the result of damaged aortic and mitral valves forming small blood clots that travel via the aorta to the brain. Furthermore, pulmonary embolism is the result of a blood clot (in this case formed by damaged tricuspid and pulmonary valves) that make their way into the blood vessels of the lung. These 3 pathologies are medical emergencies.
Valves are surrounded and supported by a ring of tissue (the annulus). Inside this ring are thin membranes called leaflets that flap open or closed and allow blood to travel through the heart in one direction. Where the supportive ring of the valve has widened the leaflets are unable to completely fill the wider gap when closed; blood leaks backwards (regurgitation). An annuloplasty reshapes, tighten and reinforces the annulus. If the leaflets have become stiff or begin to stick together, this gap will become narrower, compromising blood flow. This condition is known as valvular stenosis. Valvuloplasty and valvotomy procedures treat stenosis, often with inflatable balloons.
Leaflets may develop small holes or tear. This is another cause of blood regurgitation. Alternatively, heart valve leaflets may be too large, either as a result of your genes or because of stretching over time. The leaflets then bulge backwards and cause regurgitation. Small fibres are attached to heart valve leaflets that control their movement. These may rupture or elongate, causing prolapse and subsequent regurgitation. In mitral valves, new minimally invasive surgery in the form of NeoChord valve repair is possible via thoracotomy. It is often possible to repair many of the above conditions. Reparative surgery is always preferred over valve replacement as no foreign tissue or material is involved.
Wherever damage is significant, complete replacement of the valve is necessary and a heart valve prosthesis must be inserted. A mechanical prosthesis is often recommended in middle-aged patients as these last for many years; however, as a foreign material, life-long anticoagulant medication must be taken. In some children with aortic valve degeneration one of the patient’s healthy valves is removed and used to replace the damaged one. Tissue valves (biologic or bioprosthetic valves) are produced from cow heart tissue or pig valves and do not require life-long anticoagulants; however, they do not last for much more that 15 years. You will be able to specify the type if any of these options is in conflict with your religious or personal beliefs.
In order to understand why a particular valvular disorder produces particular symptoms and may require different techniques or treatment, it is important to understand a little about how these heart valves work.
The human heart has 4 valves that prevent blood from flowing the wrong way into, through and out of the heart. The heart is split into 4 chambers: the right and left atria and the right and left ventricle. The right and left sides of the heart are separated by a solid wall called the septum.
The heart is a pump consisting of two different sections – right and left. The right section takes in deoxygenated (low oxygen) blood from tissues all over the body and pushes this blood to the lungs. The left section takes in freshly oxygenated blood from the lungs and pushes this blood into tissues all over the body. If this was shown as a simple line diagram, the lungs would be drawn between the right ventricle and the left atrium. One can say that the right side of the heart deals with low-oxygen blood and low levels of pressure and the left side with high-oxygen blood and high levels of pressure.
Right-sided heart valve replacement
The right atrium sits at the top of the heart and the right ventricle below it. They are separated by the tricuspid valve. Blood flows into the right atrium via the superior vena cava - a thick vein that brings blood into the heart from all over the body. This blood has low levels of oxygen as the tissues of the body have already extracted it. At an electrical signal, the muscle of the atrium contracts, increasing its inner pressure. The pressure inside the right atrium becomes higher than the pressure in the right ventricle below it. This pressure causes the tissue leaflets to flap open and let the blood flow from the right atrium into the right ventricle below.
The function of the right ventricle is to push this deoxygenated blood into the lungs. That blood can then be filled with oxygen. Blood travels from the right ventricle to the lungs via the pulmonary artery. The pulmonary artery begins inside the wall of the right ventricle. The right ventricle and pulmonary artery are separated by the pulmonary valve which, like all healthy heart valves, acts as a one-way door.
Once the right ventricle has filled with blood, the pressure balance between the atrium above and the ventricle below changes and the tricuspid valve snaps shut. A further electrical signal causes the muscle of the ventricle to contract. The pressure inside the ventricle remains higher than that of the atrium so the tricuspid valve remains closed; however, the pressure in the pulmonary artery is lower and the pulmonary valve is pushed open. Blood flows out of the right ventricle and into the pulmonary artery. When enough blood has emptied from the right ventricle, the pressure shifts again and the pulmonary valve snaps shut.
The right side of the heart does not have to deal with very high pressures as it serves to push blood only into the lungs. This means right-sided heart valve replacements in adults are less common when compared to left-sided valve surgeries.
Why do I need a tricuspid valve replacement (TVR)?
The tricuspid valve is not a common cause of heart valve replacement surgery. Reasons for damage can be congenital and valve repair and replacement surgeries are more likely to be performed on children. In adults, infective endocarditis may be a cause, as is rheumatic heart disease.
Damage to the tricuspid valve causes shortness of breath and fatigue because deoxygenated blood stays in the tissues for longer. This ‘used’ blood has difficulty getting through the tricuspid valve because of stenosis (narrowing of the valve) or regurgitation. When blood travels in the wrong direction - back into the right atrium - it slows the incoming blood flow and parts of the lower body can swell. A lack of oxygen in the tissues means that the lips and extremities may even seem a little blue.
Why do I need a pulmonary valve replacement (PVR)?
Pulmonary valve replacement is also uncommon and the two most common causes for this surgery are pulmonary hypertension and congenital heart defects such as tetralogy of Fallot. Infective endocarditis and rheumatic heart disease are also possible causes. Pulmonary hypertension means that the pressure within the lungs is so high that regurgitation back into the right ventricle from the pulmonary artery occurs. Over time, the valve that separates them can become damaged.
Pulmonary insufficiency is caused by long-term pulmonary hypertension and the symptoms require time to develop. Heart valve disorders can produce pulmonary hypertension and vice versa. Later-stage disease will show a larger right ventricle as the heart must pump much harder to overcome the increased pressure of the pulmonary artery. This increased activity can eventually cause the right ventricle to fail. The symptoms of pulmonary hypertension are very similar to those of tricuspid valve pathology.
Left-sided heart valve replacement
The left atrium sits at the top of the heart and the left ventricle below it. They are separated by the mitral valve. Blood flows into the left atrium via 2 pulmonary veins that bring freshly oxygenated blood into the heart from the lungs. At an electrical signal, the muscle of the left atrium contracts, increasing its inner pressure. The pressure inside the left atrium becomes higher than the pressure within the left ventricle and the mitral valve is pushed open. This thin sheet of tissue flaps opens to let the blood flow from the left atrium into the left ventricle below.
The function of the left ventricle is to push this oxygenated blood into all of the tissues of the body so that they can function. Blood travels from the left ventricle to the body via the aorta which opens into the left ventricle. The left ventricle and aorta are separated by the aortic valve which acts as a one-way door.
Once the left ventricle has filled with blood, the pressure balance between the atrium above and the ventricle below changes and the mitral valve snaps shut. A further electrical signal causes the muscle of the ventricle to contract. The pressure inside the ventricle remains higher than that of the atrium above, so the mitral valve remains closed; however, the pressure in the aorta is lower and the aortic valve is pushed open. Blood flows out of the left ventricle and into the aorta and so through the rest of the body. This requires significant force. When enough blood has emptied from the left ventricle, the pressure shifts again and the aortic valve snaps shut.
The left side of the heart must create huge pressures that are able to push blood from the centre of the chest into the brain, fingertips and toes and all the tissues and organs between. The aorta is also the body’s largest artery and susceptible to atherosclerosis. It is also more likely to be affected by endocarditis. Because of this, right-sided valve replacements are more common in older populations.
Why do I need a mitral valve replacement (MVR)?
Mitral valve replacement is also a common heart valve repair and replacement surgery. Mitral valve damage is often the result a damaged aortic valve that regurgitates blood back into the heart and increased pressure in the left ventricle. This pressure can damage the mitral valve leaflets. Causes of mitral insufficiency also include primary mitral valve prolapse where the leaflets of the valve are overly stretchy and do not close properly. Unlike the right side of the heart, calcifications often form on left-sided valves that narrow and stiffen them. As with all types of heart valve dysfunction, rheumatic fever, congenital syndromes and infective endocarditis can be damaging.
Mitral insufficiency symptoms can be acute and a medical emergency. Chronic forms need time to present with symptoms and are often detected during medical check-ups. Over time, signs of congestive heart disease such as heart muscle stiffness, high blood pressure, fatigue and swelling in the lower limbs will appear.
Why do I need an aortic valve replacement (AVR)?
Aortic valve degeneration is a common cause of heart valve replacement surgery and widening of the base (root) of the aortic valve is the most common valvular disease. It is also one of the most serious. Aortic stenosis or calcification and subsequent stiffness of the aortic valve are very much associated with the combination of male gender, older age and high blood pressure. As with all types of heart valve dysfunction, rheumatic fever, congenital syndromes and infective endocarditis can be a cause.
While acute aortic valve insufficiency does occur, the chronic form is more likely. Again, this develops slowly and may only be detected during a medical check-up. However, where the root of the aortic valve is dilated, aortic aneurysm and aortic dissection are high-risk factors.
Can I prevent heart valve replacement?
As already mentioned, some heart valve replacements are due to congenital factors that simply cannot be prevented.
Blood pressure medication and treatment of some of the causes of heart valve insufficiency such as pulmonary hypertension and cholesterol-lowering drugs may help to prevent further damage.
In the case of infective endocarditis, the most common infection is due to staphylococcus and streptococcus bacteria released into the blood stream from areas of colonisation in the mouth, throat and upper respiratory tract. One well-known association is between low levels of oral hygiene and dental treatment, where wounds made during tooth repair and extraction allow these bacteria to enter the circulatory system. Furthermore, where streptococcus infection is not properly treated, acute rheumatic fever may follow. Good levels of oral hygiene and prompt treatment of bacterial infections is therefore very important.
Healthy heart advice also applies to heart valve replacement prevention in the case of left-sided valves that have the tendency to suffer from calcification. Healthy diets high in non-processed fresh foods, low in saturated fats and sugars and with plenty of fresh fruit and vegetables is preventive. Regular exercise and stopping smoking if you do so will also greatly contribute to tissue quality.
As importantly, regular health check-ups that include medical imaging, and resting and exercise electrocardiogram can detect the earliest signs and perhaps make the important difference between repair and replacement. Remedazo arranges full medical check-ups for every physiological system, carefully planning appointments with specialists, supplying all transportation and extending the trip for further treatment or leisure if you so desire.
How do I prepare for a heart valve replacement? What can I expect?
If you are reading this article you may have already been diagnosed with heart valve disease after your general practitioner or cardiologist detected a heart murmur. You have probably undergone further diagnostic tests or are perhaps looking for a complete diagnostic and surgical solution. Finding the right treatment centre with experienced and highly specialised surgeons can be overwhelming.
With Remedazo, you are able to speak openly with up to 3 highly-renowned heart specialists with extensive experience, training and knowledge concerning a range of (or very specific) techniques that include transcatheter, robotic-assisted or keyhole (minimally invasive) valve replacement. These surgeries will be described in detail further on.
It is also very possible that your heart valve insufficiency has no symptoms and you have been advised to wait for surgery. Remedazo arranges complete health checks that cover all physiological systems and include personal appointments with a range of specialists at excellently equipped hospitals. If health problems are detected or your heart valve disorder begins to present with symptoms, rapid treatment can be arranged during the same visit or at a later date according to your preferences, and with your choice of Remedazo partnered specialist, hospital and budget.
Pre-travel heart valve replacement preparation
Preparation for heart valve replacement requires specific advice based upon your current level of health. For example, increased exercise that makes the body stronger before any type of surgery may or may not be advised. A healthy, protein-rich diet and full dental check-up is essential and you may or may not need to start or stop certain medication. Any smoking habit should be stopped immediately; all heart surgeries involve compromised oxygen supply and smoking can severely increase the risk of surgical and postoperative complications. Your surgeon may refuse to operate if you do not cease a smoking habit before heart valve surgery.
Initial diagnosis will probably have included tests such as an electrocardiogram and ultrasound transthoracic echocardiography where a flat probe (transducer) is moved around the skin of the chest above the heart to produce images of the heart on a screen. This may be part of a stress test where you are asked to exercise or take medicine to make the heart work harder and ultrasound is immediately used to detect or rule out other problems such as coronary heart disease.
Transthoracic echocardiograms are not able to give a satisfactory view of the aortic valve and a transoesophageal echocardiography is preferred. You will not be able to eat of drink before this test. An intravenous catheter is inserted, a little sedation administered, and the back of the throat made numb with a local anaesthetic spray. Children are always given a general anaesthetic for this procedure. A mouth guard is placed in your mouth and you are asked to lie on your side. The ultrasound probe is inserted into the oesophagus, the lower part of which lays close to the heart, and all 4 heart valves as well as the structure and function of the left and right atria can be assessed.
Occasionally, an initial suspicion of heart valve disease – or any heart disorder – will send you for a chest x-ray to look at the size of your heart, although images of more specific areas can be unclear. When abnormalities are found with or without ultrasound, further testing is necessary. Methods include cardiac MRI with an intravenous injection of contrast dye for better viewing of the heart, and perhaps cardiac catheterisation that proceeds in much the same way as an angiography. Via a catheter placed in your groin, arm or sometimes the neck that is threaded via the artery into the heart, internal structures can be viewed in real-time. Your interventional radiologist will carry out direct diagnostic tests, measuring valvular regurgitation (back-flow), valvular root size and evaluating any damage. Cardiac catheterisation can also detect or rule out other heart disorders.
Your diagnosis may require heart valve replacement or heart valve repair surgery. This diagnosis may or may not be accompanied by coronary heart disease, in which case a single procedure is used to treat both conditions. More information on the types of treatment for heart valve disease is found below.
You will need to share all medical reports in preparation for your 3 free Second Opinions. Remedazo always respects your right to privacy and only passes details on to your selected specialists. Unless a complete set of diagnostic tests has been provided it is not possible to indicate which surgical procedure best suits your condition. Additional tests can be arranged at home or with Remedazo. We will ensure your treatment follows as soon as is medically advised.
Approximately 2 weeks before your heart valve replacement surgery you need to ask your home doctor to take blood for a preoperative blood test. Remedazo will inform you well beforehand which tests your doctor will need to take blood for. Some blood-thinning medications need to be temporarily stopped, others do not. Our or your own doctor will advise you what to do. A pre-surgical meeting with your treating doctor may lead to further or repeated testing, depending on how recently your diagnosis was made.
Valvuloplasty
Heart valves that cannot open properly due to stenosis (narrowing) can be repaired via a balloon valvuloplasty or balloon valvotomy. This technique uses a balloon to inflate the inside the valve and widen the opening. Valvuloplasty works best for mitral valve stenosis and is a minimally invasive procedure prepared for and carried out in much the same way as an angioplasty.
A valvuloplasty under angiography involves a local anaesthetic and perhaps sedation. You must remain flat in bed for approximately 4 hours after surgery to ensure the incision into the artery (usually in the groin but sometimes in one or both arms) is closed. Sometimes, access to the artery is temporarily left in place and you will need to remain in bed for longer. This procedure involves an overnight stay in the hospital during which you will be carefully monitored by specialist medical staff in the cardiology department. Your intravenous catheter and arterial catheter will be removed the following morning. Drink lots of fluids once you have arrived in your hospital room to flush out contrast dye used during the procedure. You will be transported home after the surgeon is satisfied with your progress with written instructions in your language of choice.
Your wound must be kept dry so showers instead of baths are necessary for a few days. It is possible to fly home 3 days after discharge from the hospital. Full recovery from a successful valvuloplasty takes between 1 to 2 weeks.
Transcatheter valve replacement and repair
Also similar to angioplasty is the transcatheter valve replacement (TVR) or intervention (TVI). This technique can be performed on all 4 valves but is most commonly performed to treat aortic valve disorders. A transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve intervention (TAVI) uses similar techniques to angioplasty. Other options are TMVI/R (mitral valve), TPVR/I (pulmonary valve) and TTVR/I (tricuspid valve) surgeries. You may need to select an interventional radiologist with extensive but very specific experience as some of these surgery types are uncommon. Remedazo can put you in touch with experienced interventional radiologists specialised in one or more techniques.
TVR and TVI are associated with shorter hospital stays and a more rapid recovery than open procedures yet they are primarily reserved for patients considered too frail to undergo more invasive surgeries. This attitude seems to be changing as more recent clinical studies show that low-risk and younger patients can also benefit. Preparation is more intensive than in angioplasty. The use of conscious sedation, also referred to as deep sedation, means you will barely be aware of what is going on around you. An oxygen mask will be placed on your face. As general anaesthesia in older patients with heart problems can have a higher risk of complications both during surgery and after, conscious sedation puts less strain on the heart while making the experience less uncomfortable for the patient. However, approximately 1 in 7 patients will need to be anaesthetised at some point during the operation, often due to excessive movement. This is why it is important that you do not eat or drink as per the instructions for those who must undergo a general anaesthetic.
General anaesthesia is always used in children. Remedazo has access to world-renowned paediatric interventional radiologists and paediatric anaesthetists with excellent skills, knowledge and experience in the field of congenital heart defects. In addition, Remedazo’s empathic and holistic approach includes paediatric nursing staff and homecare professionals, child-friendly accommodation for small to large family groups, transportation, housekeeping and interpreter services to make this challenging time just that little bit less daunting.
Preoperative preparation includes the placement of 1 or 2 intravenous catheters (one in each arm) and an arterial catheter. You will then be sedated. A transoesophageal ultrasound probe will be inserted into your throat; you will not be aware of this.
The groin area – or possibly the upper chest - is disinfected and sterile drapes are placed to cover your body, leaving only the disinfected area visible. If you prefer a single-sex surgical team, Remedazo can arrange this request.
Catheter access is most commonly via the groin but your surgeon may choose to opt for the upper chest (subclavian artery). A catheter is carefully guided to the site of the faulty valve by way of a blunt guidewire, x-ray and ultrasound. Contrast dye is injected for imaging purposes and special filters are placed to stop debris from entering the circulation. The damaged valve is pushed open through the expansion of an inflatable balloon. This is why certain procedures are sometimes referred to as valve-in-valve replacements.
The new bioprosthetic heart valve is surrounded by metal meshwork. The valve is placed on the end of a balloon catheter. This smaller catheter slides through the sheath. Much care is taken to position the valve in exactly the right place. When the surgeon is confident of the position of the catheter, another balloon under the new valve is inflated and the new valve is pushed outwards. The meshwork springs open and pushes the valve ring into position. As it is difficult to do this when the heart is full of blood the heart is electrically paced so that the right ventricle contracts and relaxes extremely rapidly – around 200 beats per minute; it has no time to fill with blood. Less blood exits the heart, less blood enters the heart, and it is easier to place the valve. This also means short periods of decreased oxygen that may cause complications after surgery such as confusion and acute kidney failure in more frail individuals and in smokers.
Uncomplicated transcatheter valve replacement involves a 1 to 3 night stay in the cardiology department. You must remain flat in bed for approximately 6 hours after surgery as access to the artery is temporarily left in place. During this time you will be carefully monitored by specialist medical staff in the cardiology department. Your intravenous catheter and arterial catheter will be removed on the morning of discharge. Drink lots of fluids once your anaesthetist says you may so you can flush out the contrast dye used during the procedure. You will be transported home after your surgeon is satisfied with your progress with written instructions in your language of choice.
Your wound must be kept dry so showers instead of baths are necessary for a few days. It is possible to fly home 3 days after discharge. You will need to take (additional) blood-thinning medication for approximately 3 months. Full recovery from a successful TVR takes 2 to 4 weeks. If you feel ready, you can return to work after 14 days.
Minimally-invasive valve surgery
While previously heart surgery always required large incisions through the bone of the sternum that required long recovery times, new techniques such as the above-mentioned TVR and annuloplasty mean that it is possible to provide less intensive treatments. Heart valves are difficult to reach and the pumping motion of the heart as well as the body’s need for oxygen mean that the heart needs to be stopped for often long periods of time. In order to keep the rest of the body oxygenated, a cardiopulmonary bypass machine or heart-lung machine is necessary. Minimally invasive (MI) valve replacements are so called due to smaller incisions but still require cardiopulmonary bypass. MI surgeries are common in all surgical fields and include techniques such as laparoscopy, angioplasty and thoracoscopy that reduce incision size and use small instruments to operate at a slight distance. In addition, instruments can be operated at an even greater distance during robotic-assisted surgeries.
Minimally invasive procedures are also possible for children with congenital heart valve defects. Remedazo has access to world-renowned paediatric interventional radiologists and paediatric anaesthetists with excellent skills, knowledge and experience in the field of congenital heart defects. In addition, Remedazo’s empathic and holistic approach includes paediatric nursing staff and homecare professionals, child-friendly accommodation for small to large family groups, transportation, housekeeping and interpreter services to make this challenging time just that little bit less daunting.
During MI heart valve replacement surgery, one lung must remain flat. This is achieved through a special breathing tube that can close off one lung but allows the other to function under the support of a ventilator or breathing machine. For this reason, not everyone is able to undergo this type of operation as only half of the lung capacity is available. If you are already experiencing shortness of breath when relaxed or if you have not yet stopped smoking, this may not be the right surgery for you. Other options can be discussed with your chosen specialist.
Often, atherosclerosis or fragile arteries can rule out transcatheter valve repair or replacement and the transcutaneous (through the skin) approach will be advised. Access to the heart during minimally invasive valve surgery is obtained through a 5 to 12 cm incision either in the middle of the chest (sternum) or between2 ribs (intercostal space), usually in combination with small 2 cm incisions for video- or robotic-assisted cameras and instruments. Robotic-assisted surgeries require up to 5 small incisions.
The location and size of the largest incisions determine the type of operation. A left or right minithoracotomy is a horizontal incision made between the ribs on either side of the sternum. A hemisternotomy is an incision that runs vertically through a section (approximately one third) of the sternum but not all. In open heart surgery, the entire sternum is sawn through and this incision type is called a total sternotomy.
Multiple incision types are used by cardiothoracic surgeons for transcutaneous minimally invasive heart valve replacement. Choice depends on which valve is to be repaired or replaced, your personal anatomy and your selected surgeon’s specialism.
Preparation includes 1 or 2 intravenous catheters, a central venous catheter and an arterial catheter. A regional anaesthesia procedure with or without catheter for postoperative pain management may be part of your immediate preoperative preparation. After the administration of a general anaesthetic the special breathing tube is placed into the airway as well as the probe of a transoesophageal echocardiogram machine. Even where cameras are used, ultrasound gives an overall view of the inside of the heart as the surgeon works and helps to guide the many cannulas that must be used. A urinary catheter is inserted after you are asleep. Defibrillator pads are placed on your chest outside of the operating site. These are to restart your heart after the heart valve has been replaced.
The chest and groin areas are disinfected and sterile drapes placed to cover your body, leaving only the disinfected areas visible. If you prefer a single-sex surgical team, Remedazo can arrange this request.
Incisions are made either in the centre of the chest or between the ribs; the surgeon carefully positions his instruments close to the heart. Two catheters are inserted through the groin. One is inserted into the femoral vein, the other into the femoral artery. The venous catheter follows a network of large veins to enter the vena cava. The arterial catheter is inserted into the femoral artery and guided into the aorta. If atherosclerosis is present, an arterial femoral catheter will not be used. Instead, a cannula is placed directly into the aorta.
The heart lung machine, connected to the cannulas, then takes over the role of the heart and keeps your blood at the right temperature, filters it, and oxygenates and feeds the body tissues during the operation. It is then time to stop the heart with cardioplegic drugs. Your body is also cooled down. This is to protect your brain and other organs by reducing their need for oxygen and energy.
The surgeon can then make small a cut into the heart close to the valve and insert viewing and instrument ports. He or she repairs or replaces the affected valve and closes the incision into the heart. This portion of the operation alone can take 2 to 3 hours. When done, small wires are placed inside the chest wall that can be connected to an electrical pacemaker if necessary. The heart is then restarted using a defibrillator machine on the pre-placed defibrillator pads.
The cardiopulmonary bypass machine rewarms your blood to body temperature as the surgeon makes sure no air is left in the heart. When he or she is satisfied, the heart-lung machine is disconnected from the cannulas and they are removed. Heart function is then restored.
Unlike TVR, MI heart valve replacement surgery places thoracic drains in order to remove fluids from the operating site. Fluid can create pressure on the heart or become infected. In combination with incisions through the skin and muscle, an increased need for pain control and a full general anaesthetic, MI surgery means a longer hospital stay and recovery than transcatheter surgery. Furthermore, this technique needs a very experienced, well-trained surgeon as there is little space to work in and less access. Your time on the heart-lung machine will be longer than with a larger incision. However, minimally invasive surgery requires less recovery than total sternotomy and has less complications and less postoperative pain. Additionally, robot-assisted techniques slightly reduce the length of time you remain on the ventilator after the operation, reduce the risk of heart arrhythmias, and decrease risk of post-operative stroke and blood transfusion. Robotic-assisted surgery may also reduce your hospital stay by around 24 hours.
After your surgery you will not be woken up straight away but brought to the intensive care department under general anaesthetic. Approximately 3 to 5 hours later the decision will be made by the intensive care physician to gently wake you up and take out your breathing tube. You may drink water after 4 hours and will be offered a light meal within a few hours of waking. Pain is controlled with intravenous medication.
You will remain in the intensive care department for 1 to 2 nights under careful monitoring. A physiotherapist will visit to help you with breathing exercises and help you to sit up. You should be able to get out of bed within 24 hours of being woken from the general anaesthetic. Before your return to a surgical ward the chest drains will be removed.
Upon arrival at the cardiology department your urinary catheter will be removed. Intravenous and arterial catheters are usually left in place. If your heart does not show any signs of arrhythmia (irregular heartbeat) the pacing wires placed on the outside of the heart will be removed. This is an unpleasant sensation but not associated with pain. Your surgeon will make regular visits and prescribe anticoagulant medication that must be taken as instructed. Regular blood tests, using blood taken from the arterial catheter, are required; sometime during the 24 hours after your arrival in the cardiology ward the arterial catheter will be taken out of your wrist.
Minimally invasive valve replacement involves a 5 to 8 night hospital stay depending on your preoperative symptoms and surgical results. The intravenous catheter is taken out 24 to 48 hours before discharge.
You will be transported home after your surgeon is satisfied with your progress with written instructions in your language of choice. Trained nursing staff is provided, as is help with meals and transportation to all follow-ups.
It is possible to fly home 3 days after discharge from the hospital; however, your surgeon may need to fill in a form for your airline which we will arrange. It is also advised not to travel alone. If necessary, we can provide medically-trained personnel to accompany you. Full recovery from a successful minithoracotomy or ministernotomy with valve replacement or repair requires 2 to 4 weeks. You can return to your daily activities in a month and most patients report they have much more energy to do so.
Sternotomy with cardiopulmonary bypass
Atherosclerosis or fragile arteries can rule out transcatheter valve repair or replacement and a transcutaneous (through the skin) operation will be required. Sometimes more than one valve needs to be treated or your surgeon may also have to unblock blocked coronary arteries. In these cases, if you are considered healthy enough, a full sternotomy is advised. This technique cuts a vertical incision of 15 to 25 cm in the middle of the chest.
Preparation includes 1 or 2 intravenous catheters, a central venous catheter and an arterial catheter. After the administration of a general anaesthetic, an endotracheal tube is placed into the airway as well as the probe of a transoesophageal ultrasound device. A urinary catheter is inserted after you are asleep.
The chest is disinfected and sterile drapes are placed to cover your body, leaving only the disinfected areas visible. If you prefer a single-sex surgical team, Remedazo can arrange this request.
The surgeon cuts through the sternum, muscle and membranes of the chest wall and heart. Preparation is made for the attachment of cannulas that bring blood into the heart-lung machine and back into the body. Two venous cannulas need to be inserted into each of the vena cava veins and connected to form a single tube in the right atrium. Your surgeon may opt to insert a catheter via the groin instead. The arterial cannula must be inserted into the aorta at the top of the heart. In a minority of cases this is achieved via the femoral artery at the groin. When the surgeon is confident that the sites of cannula attachment are not damaged he or she makes special stitches around the aorta. With the cardiopulmonary bypass machine ready a small incision is made in this major artery, the cannula is inserted and the stitches around it quickly pulled so that there are no gaps or leaks. The arterial cannula is then attached to the bypass machine. With much less pressure in the left side of the heart, the venous cannula can be placed and attached without these special stitches.
The heart-lung machine, now connected to both cannulas, takes over the role of the heart, keeping the blood at the right temperature, filtering it, and oxygenating and feeding the body tissues during the operation. The heart is then stopped with medication. During surgery, you will be cooled down. This is to protect your brain and other organs by reducing their need for oxygen and energy.
The surgeon makes a small cut into the heart close to the valve and replaces it with a mechanical, biosynthetic or biological one. Sometimes more than one valve needs treatment. This portion of the procedure can take between 1 to 3 hours – often much less than minimally invasive surgery. The incision in the heart is then closed and pacing wires are placed within the thorax wall. When this has been done the heart is restarted using defibrillator paddles applied directly to the heart muscle. Ultrasound checks the function of the new or repaired valve(s). When satisfied, the surgeon closes the chest. As the bone of the centre of the chest has been sawn through, lengths of wire need to be twisted to pull the two edges of bone closed. These titanium wires do not need to be removed and will not set of metal detector alarms.
The cardiopulmonary bypass machine then rewarms your blood to body temperature as the surgeon makes sure no air is left in the heart. When he or she is satisfied, the heart-lung machine is disconnected from the cannulas and they are removed. Cannula incisions are sewn closed. Heart function is then restored.
Open heart valve replacement surgery requires the placement of thoracic drains to remove fluids from the operating site. Fluid can create pressure on the heart or become infected. In combination with incisions through the skin and muscle, an increased need for pain control and a full general anaesthetic, this means a longer hospital stay and recovery than with transcatheter surgery.
After your surgery you will not be woken up straight away but brought to the intensive care department under general anaesthetic. After approximately 4 to 6 hours the decision will be made by the intensive care physician to gently wake you and take out your breathing tube. You may drink sips of water after a further 4 hours and will be offered a light meal within 8 hours of waking. Pain is controlled with intravenous medication. You will remain in the intensive care department for 1 to 3 nights under careful monitoring. A physiotherapist will visit at regular intervals to help you with breathing exercises and teach you how to sit up and get out of bed. You should be able to get out of bed within 48 hours of being woken from the general anaesthetic.
Upon arrival at the cardiology department, your urinary catheter will be removed. Intravenous and arterial catheters are usually left in place. If your heart does not show any signs of arrhythmia (irregular heartbeat), the pacing wires placed on the outside of the heart will be removed. This is an unpleasant sensation but not associated with pain. Your surgeon will make regular visits and prescribe anticoagulant medication that must be taken as instructed. Over the next 24 hours, the arterial catheter will be taken out of your wrist.
Open heart valve replacement involves a 7 to 10 night hospital stay depending on your preoperative symptoms and surgical results. The intravenous catheter is removed 24 to 48 hours before discharge.
You will be transported home after your surgeon is satisfied with your progress with written instructions in your language of choice. Trained nursing staff is provided, as is help with meals and transportation to all follow-ups.
It is possible to fly home 10 days after your operation; however, your surgeon may need to fill in a form for your airline which we will arrange. It is also advised not to travel alone. If necessary, we can provide medically-trained personnel to accompany you. Full recovery from a successful sternotomy with valve replacement or repair requires 1 to 3 months. You can return to your daily activities in 4 to 8 weeks if they do not involve strenuous activities and most report having much more energy to do so.
Benefits of heart valve replacement
If symptoms are present or threaten to occur, heart valve surgery is essential. While lifestyle changes can improve your health in so many ways, once a valve has become damaged it cannot heal itself. Ignoring the need when symptoms are not noticeable but diagnostic tests show moderate valve malfunction may mean that the valve and possibly your health will deteriorate to the point that your options for surgery become limited. Early detection also gives you the option for heart valve repair rather than replacement, preserving your own tissue rather than replacing it with synthetic or donor valves.
When the sole problem with your heart is a faulty valve and this is treated by an expert surgeon, blood flow through the heart is rapidly improved. This means better oxygen supply to the tissues, less work for the heart and a lower risk of developing other disorders associated either with lack of oxygen or high or low blood pressure. All heart surgery has risks; however, by treating a heart condition before it has the opportunity to worsen while you are still in good health can make a huge difference to the outcome and your future quality of life.
Paediatric heart valve replacement in cases of congenital heart valve disorders can delay the need for open heart procedures in the future. The importance of early intervention has led to new technology such as tiny mechanical heart valves for new-borns. With congenital heart defects, children fail to thrive. By restoring oxygen supply and creating less work for the heart, this does not need to be the case.
No good surgeon will advise heart valve surgery unless the pros outweigh the cons. Ask for up to 3 free Second Opinions with Remedazo and you can compare what top specialists say regarding your personal medical needs.
Disadvantages of heart valve replacement
The chance of postoperative infection is high and patients are administered antibiotics as a preventive measure both before surgery commences and after. Your chosen clinic’s cardiologists, cardiothoracic surgeons and trained nurses are trained to recognise the symptoms of infection very early on, as well as the many other potential complications.
All heart valve surgeries compromise the body’s blood supply for short or long periods of time. This is why cardiopulmonary bypass is necessary. In transcatheter procedures, rapid ventricular pacing reduces blood flow for seconds to minutes. In acute blood loss, the smaller arteries close and reduce blood flow to less important tissues, making sure the most crucial parts of the body can function. These include the brain and kidneys. Two risk factors of heart valve surgery are postoperative confusion that may last for hours or much longer and acute kidney failure. Contrast dye increases the risk of kidney problems. A small percentage of heart valve replacement patients may require temporary dialysis.
Other immediate risks of surgery are bleeding, arrhythmia and myocardial infarction (heart attack). This is why pacing wires are placed during many surgeries and why you will be carefully monitored either on a cardiology ward or in intensive care until your doctor feels you are able to move to a less critical environment. Blood transfusions may be required. If you are concerned about the use of donor blood you may be able to arrange autologous blood donation prior to surgery. Cardiopulmonary bypass machines are usually backed up by cell saver machines that salvage blood lost during surgery.
Follow-ups after heart valve replacement surgery need to be arranged at regular intervals and should include ultrasound, blood and exercise testing with electrocardiogram.
Bleeding is also a longer term complication due to the necessity of blood-thinning medications. Valves may become dislodged and require further surgery. It is extremely rare for the body to reject a biologic valve.
For these reasons we recommend you visit your local cardiologist upon returning home so he or she can keep an eye on your progress. We will provide you with a complete medical report to bring to your local treating physician.
Heart valve replacement alternatives
It is possible that you have been given a choice of one or more alternative treatments or have not yet made an appointment for your free e-consult and are simply browsing the possibilities.
All heart valve replacement surgical technique alternatives are listed above, yet clinical studies constantly introduce new methods, instruments and technologies that further improve outcome. Non-surgical heart valve replacement alternatives in the presence of symptoms that affect your day to day life do not exist; all of the above techniques are surgical.
Of course, there is no alternative for professional medical advice. Please call us to arrange your e-consult and the opportunity to speak personally with specialist (paediatric) cardiologists and (paediatric) cardiothoracic surgeons. You can discuss heart valve replacement options with them, ask for second or third opinions, and take the first step towards your personalised Remedazo holistic care package.
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