Seminar valve reconstruction and replacement

SEMINAR ON

VALVE RECONSTRUCTION

AND REPLACEMENT

PRESENTED BY,UMADEVI.K

IIND YEAR MSC NURSINGTHE OXFORD COLLEGE OF NURSING

04/11/2023 Template copyright www.brainybetty.com 2005

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INTRODUCTION Valve reconstruction has proved to be an

effective, reproducible and durable treatment for life-threatening Cardiac diseases.In the United States, surgeons perform about 99,000 heart valve operations each year. Nearly all of these operations are done to repair or replace the mitral or aortic valves. These valves are on the left side of the heart, which works harder than the right. They control the flow of oxygen-rich blood from the lungs to the rest of the body.If valve damage is mild, doctors may be able to treat it with medicines. If damage to the valve is severe, surgery to repair or replace the valve may be needed.


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HEART VALVES


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HEART VALVE REPAIR

Heart valve repair is a surgical technique used to fix defects in heart valves in valvular heart diseases, and provides an alternative to valve replacement.


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GENERAL TECHNIQUES TO REPAIR VALVES

COMMISSUROTOMY For narrowed valves, where the

leaflets are thickened and perhaps stuck together. The surgeon opens the valve by cutting the points where the leaflets meet.


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COMMISURE


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VALVULOPLASTY

Valvuloplasty is the widening of a

stenotic valve using a balloon

catheter


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RING ANNULOPLASTY

When a valve loses its shape and

strength, it's unable to close tightly.

An annuloplasty gives the leaflets

support through ring-like devices

that your surgeon attaches around

the outside of the valve opening.


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RESHAPING The surgeon cuts out a section of a

leaflet. Once the leaflet is sewn back together, the valve can close properly.

DECALCIFICATION Decalcification removes calcium buildup

from the leaflets. Once the calcium is removed, the leaflets can close properly.

REPAIR OF STRUCTURAL SUPPORT which replaces or shortens the cords

that give the valves support (these cords are called the chordae tendineae and the papillary muscles). When the cords are the right length, the valve can close properly.


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PATCHING The surgeon covers holes or tears in

the leaflets with a tissue patch.


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TYPES

Mitral valve repair

Aortic valve repair

Tricuspid valve repair

Pulmonary valve repair


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MITRAL VALVE REPAIR

http://en.wikipedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg


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Mitral valve repair is a cardiac

surgery procedure performed by

cardiac surgeons to treat stenosis

(narrowing) or regurgitation

(leakage) of the mitral valve. The

mitral valve is the "inflow valve" for

the left side of the heart.



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HISTORY

In 1923 Dr. Elliott Cutler of the Peter Bent

Brigham Hospital performed the world’s

first successful heart valve surgery - a

mitral valve repair. The patient was a 12-

year-old girl with rheumatic mitral

stenosis.

Replacement of the mitral valve with an

artificial valve in the 1960s



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TECHNIQUES

ANNULOPLASTY Inserting a cloth-covered ring

around the valve to bring the leaflets into contact with each other

QUADRANGULAR RESECTION removal of redundant/loose

segments of the leaflets



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QUADRANGULAR RESECTION


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RE-SUSPENSION of the leaflets with

artificial (Gore-Tex) cords.

http://en.wikipedia.org/wiki/Gore-Tex


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INDICATIONS Bacterial endocarditis

Mitral regurgitation may also occur as a

result of ischemic heart disease (coronary

artery disease) or non-ischemic heart

disease (dilated cardiomyopathy).

Surgery for MR is recommended when

Patient have symptoms of heart failure, or

when ejection fraction drops below 55%


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MITRAL VALVE DAMAGE Examples of serious damage or complicated

conditions that might lead to mitral valve replacement include:

Extensive ballooning of the mitral valve (rather than a single flap that puffs up).

Severe hardening (calcification) of the valve.

Prolapse (bulging) of the valve at an unusual location.

Damage to the valve from infection (endocarditis)


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CARIOMYAPATHY AND REGURGITATION


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PROCEDURE During valve surgery, patient is given

general anesthesia.

Surgeon makes a large incision in patient chest.

Patient placed on a heart-lung machine during the surgery.

Blood is circulated outside of the body and oxygen is added to it using a heart-lung (cardiopulmonary bypass) machine.


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LEFT VENTRICULAR VENT


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TO PROTECT THE HEART MUSCLE FROM DAMAGE DURING

SURGERY TO REPLACE THE HEART VALVE, THE HEART MAY

BE COOLED.

IN ADDITION, A CARDIOPLEGIA SOLUTION (WHICH IS A

FLUID WITH HIGH CONCENTRATIONS OF POTASSIUM AND

MAGNESIUM) IS INTRODUCED TO STOP THE HEART

COMPLETELY.THE DAMAGED MITRAL VALVE IS EITHER

REPAIRED OR REMOVED AND REPLACED WITH AN ARTIFICIAL

(PROSTHETIC) HEART VALVE.


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AORTIC VALVE REPAIR

Aortic valve repair is a surgical

procedure used to correct some

aortic valve disorders as an

alternative to aortic valve

replacement.


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INDICATIONS

Aortic valve repair is most commonly

performed in patients with aortic

regurgitation caused by;

a dilated aortic annulus

conjoined cusp prolapse in bicuspid aortic

valves (BAV)

single cusp prolapse in tricuspid aortic

valves, and

aortic valve cusp perforation from

endocarditis


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DILATED AORTIC ANNULUS


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BICUSPID AORTIC VALVE


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TECHNIQUES

There are two surgical techniques of aortic-valve repair:

The Reimplantation-Technique (David-

Procedure)

The Remodeling-Technique (Yacoub-

Procedure)


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PROCEDURE A complete median sternotomy is performed.

In patients requiring only aortic valve repair, a complete median sternotomy is performed through a limited 8 cm skin incision

After establishing cardiopulmonary bypass, a transverse aortotomy is performed 2 cm above the sinotubular junction.

For better visualization, the aorta can be completely transected and suspended with stay sutures positioned above the commissures to better visualize the anatomy.


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SINOTUBULAR JUNCTION


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SPECIFIC APPROACHES

1.annular dialatation

This type of AR is caused by a dilated

aortic annulus resulting in a sagging of the

belly of the cusp resulting in lack of central

cusp apposition. Reduction annuloplasty

corrects the problem by increasing the

surface area of cusp coaptation.


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ILLUSTRATION DEMONSTRATING PLEDGETED COMMISSUROPLASTY

http://www.ctsnet.org/sites/default/files/graphics/experts/Adult/mckellar/figure_1.gif


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Intraoperative photograph prior to repair. Note: loss of cusp coaptation. The pledgeted sutures are stay sutures for improved exposure.


http://www.ctsnet.org/sites/default/files/graphics/experts/Adult/mckellar/figure_1b.gif


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Intraoperative photograph following pledgeted commissuroplasty


http://www.ctsnet.org/sites/default/files/graphics/experts/Adult/mckellar/figure_1c.gif


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2. BICUSPID AORTIC VALVE

This type of AR results from the

prolapse of the conjoint cusp. The

usual conjoint cusp is a fusion of the

right and left coronary cusps. The

goal of the correction is to shorten

the redundant conjoint cusp thus

elevating the free margin of the cusp

to coapt with the other non-

prolapsing cusp.



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ILLUSTRATION DEMONSTRATING BICUSPID VALVE WITH CONJOINT CUSP

PROLAPSE AND SUBSEQUENT SHORTENING



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Intraoperative photograph after

resection of a central triangle of

redundant prolapsing conjoint cusp.

The first interrupted suture

reapproximating the cut edges of

the cusp is being placed.




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CUSP PROLAPSE IN TRICUSPID VALVE

This type of AR is caused by the

prolapse of one or more cusps. The

free margin is elongated. This can

occur by rupture of a small

fenestration. The goal of this repair

is to shorten the free margin to meet

the other cusps.



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Intraoperative photograph demonstrating

completed repair of cusp prolapse in

tricuspid valve. Repair was performed by

plicating prolapsed cusp and pledgeted

commissuroplasty.




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CUSP PERFORATION

This type of AR is caused by infective

endocarditis or iatrogenic perforation.

The goal of this repair is to patch the

defect in the cusp.

An autologous pericardial patch is

prepared and used to cover the defect

with either running or interrupted 6-0

polypropylene suture



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PLICATION SUTURE


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Illustration demonstrating cusp

perforation and subsequent patch

repair.



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Intraoperative photograph

demonstrating cusp perforation prior

to repair.



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Intraoperative photograph following

patch repair of cusp perforation with

non-fixed autologous pericardium.

http://www.ctsnet.org/sites/default/files/graphics/experts/Adult/mckellar/figure_4c.gif


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TRICUSPID VALVE REPAIR Depending on the extent of valve disease,

Patient need to have the valve repaired or replaced.

To repair the valve, surgeon may perform a commissurotomy or implant a valve ring.

A commissurotomy is performed for a tight

valve (stenosis). The valve leaflets are cut to loosen the valve slightly, allowing blood to pass easily.

Another type of valve repair is a valve ring annuloplasty, which is sewn in place when the valve is leaking (regurgitant or insufficient). The valve leaflets are tucked in place with the ring.


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HEART VALVE REPLACEMENT

Heart valve replacement surgery

involves the removal of the badly

damaged valve. The valve is

replaced with a plastic or metal

mechanical valve, or a bioprosthetic

valve, which is usually made from

pig tissue. The damaged valve is cut

out, and the new valve is sewn into

place


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KINDS OF VALVES USED FOR VALVE REPLACEMENT:

Mechanical valves, which are usually made

from materials such as plastic, carbon, or

metal. Mechanical valves are strong, and

they last a long time

Biological valves : which are made from

animal tissue (called a xenograft) or taken

from the human tissue of a donated heart

(called an allograft or homograft).

Sometimes, a patient's own tissue can be used

for valve replacement (called an autograft)


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INDICATIONS

Surgery to repair or replace the mitral valve

is often required in MR. Surgery is generally

done for mitral valve prolapse (MVP) only

when MR is present.

Conditions that are most likely to require

surgery include:

Sudden (acute) MR.

MR with symptoms of heart failure.

MR with mild-to-moderate left ventricular

dysfunction (ejection fraction less than 55%)


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CONDITIONS THAT MAY REQUIRE SURGERY INCLUDE:

MR with an irregular heartbeat (atrial fibrillation) but no symptoms and no signs of functional damage to the left ventricle.

MR with elevated blood pressure in the lungs (pulmonary hypertension) but no symptoms and no signs of functional damage to the left ventricle.

MR with mild to severe left ventricular dysfunction, no symptoms, and a high likelihood of preserving some of the related structures of the mitral valve.


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COMPLICATIONS

People who receive a mechanical heart valve

are more likely than those who receive a

bioprosthetic heart valve to develop blood

clots in the heart. The clots may break loose,

travel to the brain , and cause a stroke. So if

patient received a mechanical heart valve to

treat severe MR, patient need to take

medicine for the rest of your life to prevent

clots from forming (anticoagulant medicine).


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PREOPERATIVE CARE Most patients are admitted to the hospital the day

before surgery or, in some cases, on the morning

of surgery.

The night before surgery, patient should take

bathe to reduce the amount of germs on skin.

After admitted to the hospital, the area to be

operated on will be washed, scrubbed with

antiseptic, and, if needed, shaved.


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Patient is asked not to eat or drink after

midnight the night before surgery.

An electrocardiogram (ECG or EKG) ,

blood tests, urine tests, and a chest x-ray

should be done.

A (mild tranquilizer) is given before taken

into the operating room.


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PROCEDURE

During valve repair or replacement surgery, the breastbone is divided, the heart is stopped, and blood is sent through a heart-lung machine.

Because the heart or the aorta must be opened, heart valve surgery is open heart surgery. After hooked up to the heart-lung machine, heart is stopped and cooled.

Next, a cut is made into the heart or aorta, depending on which valve is being repaired or replaced.


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Once the surgeon has finished the repair or replacement, the heart is then started again, and are disconnected from the heart-lung machine.

The surgery can take anywhere from 2 to 4 hours or more, depending on the number of valves that need to be repaired or replaced.


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POST OPERATIVE CARE Recovery from heart valve surgery

usually involves a few days in an intensive care unit (ICU) of a hospital. Full recovery from heart valve surgery can take several months.

Recovery includes healing of the surgical incision, gradually building physical endurance, and exercising.

Patient should resume most of normal activities.


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Continue to monitor patient condition.

Watch out for symptoms of blood

clots and infections.

An artificial valve may need to be replaced after a period of time. Should be informed.


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RISKS Effects from the operation itself (such as

bleeding, infection, and risks associated with anesthesia). These risks are low.

Blood clotting caused by the new valve. Replacement with a mechanical valve requires lifelong treatment with medicine to prevent blood clots (anticoagulant).

Infection in the new valve. Infection is more common with valve replacement than with valve repair.

Failure of the new valve. Valve failure is more common with valve replacement than with valve repair. Bioprosthetic valves last for about 8 to 15 years.


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RECOVERY TIME

Patient has to stay in the hospital for

about a week, including at least 1 to 3 days

in the Intensive Care Unit (ICU).

Recovery after valve surgery may take a

long time, depending on how healthy

patient were before the operation. Patient

have to rest and limit your activities.

Patient have to begin an exercise program

or to join a cardiac rehabilitation program.


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OUTCOME AND FOLLOW UP Most valve repair and replacement operations are

successful. The outcome of mitral valve replacement depends on a person's overall health, including other health conditions.

In some rare cases, a valve repair may fail and another operation may be needed.

Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Mechanical valves may also fail, so patients should alert their doctor if they are having any symptoms of valve failure.

Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives. Because these medicines increase the risk of bleeding within the body, patient should always wear a medical alert bracelet and inform doctor or dentist about taking a blood-thinning medicine.


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Bacteria can enter the bloodstream during

these procedures. If bacteria get into a

repaired or artificial valve, it can lead to a

serious condition called bacterial endocarditis.

Antibiotics can prevent bacterial endocarditis.

Patients with mechanical valves say they

sometimes hear a quiet clicking sound in their

chest. This is just the sound of the new valve

opening and closing, In fact, it is a sign that

the new valve is working the way it should.


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MINIMALLY INVASIVE VALVE SURGERY

Minimally invasive heart valve

surgery is a technique that uses

smaller incisions to repair or replace

heart valves. This means there is

less pain. Minimally invasive surgery

also reduces the length of the

hospital stay and the recovery time


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INDICATIONS Minimally invasive valve surgery can only

be done in certain patients. This type of

surgery cannot be done in patients

With severe valve damage

Who need more than one valve repaired or

replaced

Who have clogged arteries (atherosclerosis)

Who are obese


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TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)

Transcatheter aortic valve implantation is

a minimally invasive procedure to repair a

damaged or diseased aortic valve. A

catheter is inserted into an artery in the

groin and threaded to the heart. A balloon

at the end of the catheter, with a

replacement valve folded around it,

delivers the new valve to take the place of

the old.


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CONCLUSION Heart valve repair or replacement surgery is

a treatment option for valvular heart

disease. When heart valves become damaged

or diseased, they may not function properly.

Conditions which may cause heart valve

dysfunction are valvular stenosis and

valvular insufficiency (regurgitation).When

one (or more) valve(s) becomes stenotic

(stiff), the heart muscle must work harder to

pump the blood through the valve.


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THANK UUUUUUUUUUUUUU…………….

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Seminar valve reconstruction and replacement

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