Valve reconstruction/replacement

8/2/2019 Valve reconstruction/replacement

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I.INTRODUCTION

Healthy heart valves are important for good blood circulation and for

maintaining a healthy heart. Healthy heart keeps the blood flowing and prevents

the blood from backing up. Unfortunately sometimes the valves can be damaged

not allowing enough blood to flow through them or allowing blood to leak back

against the flow. In such case valve repair or valve replacement become

necessary to preserve the functions of heart.

II.DEFINITION OF VALVULAR HEART DISEASE

Valvular heart disease encompasses those diseases charecterized by abnormal

mobility or closure of the heart valves,causing obstruction or regurgitation of

flow through the valve.

III.RELATED ANATOMY

The heart is a pump made of muscle tissue. The heart has four pumping

chambers: two upper chambers, called atria, and two lower chambers, called


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ventricles. The right atrium pumps blood into the right ventricle, which then

pumps the blood into the lungs .

From the lungs, the blood flows back into the left atrium, is pumped into the leftventricle, and then is pumped through the aorta out to the rest of the body and

the coronary arteries. Once the atria have pumped their entire blood load into

the ventricles, they relax while the ventricles pump the blood out to the lungs

and to the rest of the body.

In order to keep the blood flowing forward during its journey through the heart,

there are valves between each of the heart's pumping chambers.

tricuspid valve - located between the right atrium and the right ventricle pulmonary (or pulmonic) valve - located between the right ventricle and

the pulmonary artery

mitral valve - located between the left atrium and the left ventricle aortic valve - located between the left ventricle and the aorta

IV.INDICATIONS OF VALVULAR SURGERY

Valves are very delicate structures that can be damaged for variety of reasons.

Inflammation of valves , as seen indisease such as rheumatic heart disease Infections of valve as endocarditis Calcification and stiffness of valves due to chronic or continual long

term wear and tear

Defects from birth or congenital malformations Changes in heart valve causing major heart symptoms, such as chest pain

(angina), shortness of breath, fainting spells (syncope), or heart failure.

Tests show that the changes in your heart valve are beginning to seriouslyaffect heart function
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Aortic insufficiency Aortic stenosis Mitral regurgitation - acute Mitral regurgitation - chronic Mitral stenosis Mitral valve prolapse Pulmonary valve stenosis Tricuspid regurgitation

V.VALVE RECONSTRUCTION

The repair of a cardiac valve is referred to as valvuloplasty.

TYPES OF VALVULOPLASTY

The type of valvuloplasty depends on the cause and type of valve dysfunction.

1.Commissurotomy

Repair may be made to the commissures between the leaflets in a procedure

known as commissurotomy.

2.Annuloplasty

Repair to the annulus of the valve is known as annuloplasty.

3.Chordoplasty

Repair to theleaflets, or to the chordae is known as chordoplasty

1.COMMISSUROTOMY

The most common valvuloplasty procedure is commissurotomy.Each valve has

leaflets, the site where the leaflets meet is called the commissure. The leaflets

may adhere to one another and close the commissure (ie, stenosis). Less

commonly, the leaflets fuse in such a way that, in addition to stenosis, the
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leaflets are also prevented from closing completely, resulting in a backward

flow of blood (ie, regurgitation). A commissurotomy is the procedure performed

to separate the fused leaflets.

A.TYPES OF COMMISSUROTOMY

(a)Closed commissurotomyClosed commissurotomies do not require cardiopulmonary bypass.

The valve is not directly visualized. The patient receives a general anesthetic, a

midsternal incision is made, a small hole is cut into the heart, and the surgeons

finger or a dilator is used to break open the commissure. This type of

commissurotomy has been performed for mitral, aortic, tricuspid, and

pulmonary valve disease.

(i)Balloon valvuloplasty

Balloon valvuloplasty is a form of closed commissurotomy.

Procedure

Balloon valvuloplasty is most commonly used for mitral and aortic valve

stenosis, Balloon valvuloplasty also has been used for tricuspid and pulmonic

valve stenosis.

Mitral balloon valvuloplasty involves advancing one or two catheters into the

right atrium, through the atrial septum into the left atrium, across the mitral

valve into the left ventricle, and out into the aorta. A guide wire is placed

through each catheter, and the original catheter is removed. A large balloon

catheter is then placed over the guide wire and positioned with the balloon

across the mitral valve. The balloon is then inflated with a dilute angiographic

solution. When two balloons are used, they are inflated simultaneously. The

advantage of two balloons is that they are each smaller than the one large


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balloon often used, making smaller atrial septal defects. As the balloons are

inflated, they usually do not completely occlude the mitral valve, thereby

permitting some forward flow of blood during the inflation period.

Some possible complications include

Regurgitation bleeding from the catheter insertion sites emboli resulting in complications such as strokes left-to-right atrial shunts through an atrial septal defect caused by the

procedure Restenosis

(b) Open commissurotomy

Open commissurotomies are performed with direct visualization of the valve.

Procedure

The patient is under general anesthesia, and a median sternotomy or left

thoracic incision is made. Cardiopulmonary bypass is initiated, and an incision

is made into the heart. A finger, scalpel, balloon, or dilator may be used to open

the commissures. An added advantage of direct visualization of the valve is that

thrombus may be identified and removed, calcifications can be seen, and if the

valve has chordae or papillary muscles, they may be surgically repaired.

Most commonly used for mitral and aortic valve stenosis, balloon valvuloplasty

also has been used for tricuspid and pulmonic valve stenosis.

2.ANNULOPLASTY

Annuloplasty is the repair of the valve annulus (ie, junction of the valve leaflets

and the muscular heart wall).


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Procedure

General anesthesia and cardiopulmonary bypass are required for all

annuloplasties.The procedure narrows the diameter of the valves orifice and is

useful for the treatment of valvular regurgitation. There are two annuloplasty

techniques.

One technique uses an annuloplasty ring . The leaflets of the valve are sutured

to a ring, creating an annulus of the desired size. When the ring is in place, the

tension created by the moving blood and contracting heart is borne by the ring

rather than by the valve or a suture line, and progressive regurgitation is

prevented by the repair.

The other technique involves tacking the valve leaflets to the atrium with

sutures or taking tucks to tighten the annulus. Because the valves leaflets and

the suture lines are subjected to the direct forces of the blood and heart muscle

movement, the repair may degenerate more quickly than with the annuloplasty

ring technique.

3.LEAFLET REPAIRDamage to cardiac valve leaflets may result from stretching, shortening,or

tearing. Leaflet repair is for elongated, ballooning, or other excess tissue leaflets

and removal of the extra tissue. The elongated tissue may be folded over onto

itself (ie, tucked) and sutured (ie, leaflet plication). A wedge of tissue may be

cut from the middle of the leaflet and the gap sutured closed (ie., leaflet

resection). Short leaflets are most often repaired by chordoplasty. After theshort chordae are released, the leaflets often unfurl and can resume their normal

function of closing the valve during systole. A piece of pericardium may also be

sutured to extend the leaflet. A pericardial patch may be used to repair holes of

the leaflet.


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Chordoplasty

Chordoplasty is the repair of the chordae tendineae. The mitral valve is involved

with chordoplasty (because it has the chordate tendineae), seldom is

chordoplasty required for the tricuspid valve.

Regurgitation may be caused by stretched, torn, or shortened chordae tendineae.

Stretched chordae tendineae can be shortened, torn ones can be reattached to the

leaflet, and shortened ones can be elongated. Regurgitation may also be caused

by stretched papillary muscles, which can be shortened.

B.COMPLICATIONS OF VALVULOPLASTY

Ventricular perforation Acute aortic regurgitation Atrial septal defect Embolism Heart failure Damage to the heart valve Hemorrhage

VI.VALVE REPLACEMENT

Prosthetic valve replacement began in the 1960s. When valvuloplasty or valve

repair is not a viable alternative, such as when the annulus or leaflets of the

valve are immobilized by calcifications, valve replacement is performed.

A.SELECTION OF PROSTHESIS

Durability-The prosthetic valve should last for the probable life span ofthe patient. At the present time an unmounted homograft in the aortic

position is the most durable. Mechanical valves endure for up to 10 yrs

while biological valves calcify within 6 yrs.

Hemodynamic efficiency-The valves should be sensitive to low gradientsfor easy flow at the atrioventricular sites.The blood flow area should be

adequate with minimal turbulence.


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Thrombogenicity- Mechanical valves are highly thrombogenic because ofblood turbulence at its interface with the device.Life long administration

of anticoagulant such as warfarin is mandatory after insertion of

mechanical valves.Tissue valves are less thrombogenic and do not require

anticoagulant therapy.

Tissue compatibility- There is no problem with rejection orincompatibility with any of the three categories of valve prosthesis.

Ease of insertion-Mechanical and biological valves require the sametechnical approach in their surgical implantation.The implantation of

homografts requires specialized experience and skill.

Cost effective- There is less difference in the cost of the differentvarieties of prosthesis.

Free of infection-There should be rare chance to develop infection likeendocarditis.

Silence-The click sound of the mechanical valve does not appear to worrypatients.Tissue valves are totally silent.

B.TYPES OF VALVULAR PROSTHESIS

There are two types of prosthetic valves used.They are

1,Mechanical valves

2.Biological or tissue valves

1.Mechanical valves

Ball and cage valveA ball moves freely within a 3 or 4 sided metallic cage mounted on a circular

sewing ring. These have the disadvantage of cage protrusion with possible

irritation of the ventricular septum and obstruction of the left ventricular

outflow tract.


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Eg:Starr-Edwards,Smeloff-Cutter.

Pivoting disc or Tilting discA freefloating , lens shaped disk mounted on a circular sewing ring. There is

less hemolysis and less likelihood of outflow tract obstruction.

Example:Medtronic -Hall, Bjork-shiley.

Bi-leafnersTwo semicircular leaflets mounted on a circular sewing ring that opens

centrally. It is functionally efficient with lowest index of thrombogenicity

amongst the mechanical valves.

Example:St.Jude medical,Carbomodics.

Advantages of mechanical valves

Long term durability Good hemodynamics

Disadvantages of mechanical valves

Lifetime anticoagulation therapy Audible click Risk of thromboembolism Infections are harder to treat.

2.Biological or tissue valves

Calf pericardium,dura matter or pig valve are mounted on a titanium farme

covered in Dacron. The tissues are fixed in glutar aldehyde and sterility is

maintained by formaldehyde.The deleterious effects of sterilization include

disintegration or calcification of the valve within 5 to 7 years. Improvement in

durability has accompanied glutaraldehyde fixation sterilization methods.


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Tissue valves are less likely to generate thromboemboli, and long-term

anticoagulation is not required.Tissue valves are not as durable as mechanical

valves and require replacement more frequently.

Example:Ionescu-Shiley valve-calf pericardium

Hancock or carpentier Edwards valve:pig valves

Tissue (ie, biologic) valves are of three types

Xenografts Homografts Autografts

(1)Xenografts

Xenografts are tissue valves, most are from pigs (porcine), but valves from

cows (bovine) may also be used. Their viability is 7 to 10 years. They do not

generate thrombi, thereby eliminating the need for longterm anticoagulation.

They are used for women of childbearing age because the potential

complications of long-term anticoagulation associated with menses, placental

transfer to a fetus.Xenografts also are used for patients older than 70 years of

age, patients with a history of peptic ulcer disease,and others who cannot

tolerate long-term anticoagulation. Xenografts are used for all tricuspid valve

replacements.

(2)Homografts

Homografts, or allografts (ie, human valves), are obtained from cadaver tissue

donations. The aortic valve and a portion of the aorta or the pulmonic valve and

a portion of the pulmonary artery are harvested and stored cryogenically.

Homografts are not always available and are very expensive. Homografts


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last for about 10 to 15 years, somewhat longer than xenografts.Homografts are

not thrombogenic and are resistant to subacute bacterial endocarditis. They are

used for aortic and pulmonic valve replacement.

(3)Autografts

Autografts (ie, autologous valves) are obtained by excising the patients own

pulmonic valve and a portion of the pulmonary artery for use as the aortic valve.

Anticoagulation is unnecessary because the valve is the patients own tissue and

is not thrombogenic. The autograft is an alternative for children (it may grow as

the child grows), women of childbearing age, young adults,patients with ahistory of peptic ulcer disease, and those who cannot tolerate anticoagulation.

Aortic valve autografts have remained viable for more than 20 years.Most aortic

valve autograft procedures are double valve replacement procedures.

Advantages of biological valve

Low incidence of thromboembolism No long-term anticoagulant therapy Good hemodynamics Silent Infections are easier to treat.

Disadvantages of biological valves

Prone to deterioration. Frequent replacement is reuired.

C.PROCEDURE OF VALVE REPLACEMENT

General anesthesia and cardiopulmonary bypass are used for all valve

replacements. Most procedures are performed through a median sternotomy (ie,

incision through the sternum), although the mitral valve may be approached


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through a right thoracotomy incision. After the valve is visualized, the leaflets

and other valve structures, such as the chordae and papillary muscles, are

removed. Some surgeons leave the posterior mitral valve leaflet, its chordae,

and papillary muscles in place to help maintain the shape and function of the

left ventricle after mitral valve replacement. Sutures are placed around the

annulus and then into the valve prosthesis. The replacement valve is slid down

the suture into position and tied into place . The incision is closed, and the

surgeon evaluates the function of the heart and the quality of the prosthetic

repair. The patient is weaned from cardiopulmonary bypass, and surgery is

completed.

VII.NURSING MANAGEMENT

Pre operative management

Explain the procedure to patient and offer opportunities to ask anyquestions about the procedure.

Patient is asked to sign a consent form that gives permission to do thetest.

Complete physical examination to ensure that client is in good healthbefore undergoing the procedure.

Blood tests and other diagnostic tests are performed. Fasting needed for eight hours before the procedure, generally after

midnight.

Notify physician if sensitive to or allergic to any medications, iodine,latex, tape, or anesthetic agents (local and general).

Notify physician of all medications (prescription and over-the-counter)and herbal supplements that patient is taking.

Notify physician if any history of bleeding disorders or if taking anyanticoagulant medications, aspirin, or other medications that affect blood


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clotting. It may be necessary to stop some of these medications prior to

the procedure.

Blood test done prior to the procedure to determine the clotting time. Notify physician if patient has a pacemaker. Instruct patient to stop smoking as soon as possible prior to the

procedure, if they have the habit of smoking. This may improve the

chances for a successful recovery from surgery and this benefit overall

health status.

PREOPERATIVE NURSING MANAGEMENT

1.Activity intolerance related to insufficient oxygenation and decreased cardiac

output.

Interventions

Monitor cardiorespiratory response to activity (pulse rate,respiration andBP)

Encourage alternative rest and activity periods to conserve energy. Encourage patients to choose activities that gradually build endurance to

increase cardiac

Assist the patient to establish realistic activity goals to promote feelingsof accomplishments.

2.Excess fluid volume related to incompetent valves

Interventions

Monitor for any edema. Assess respiratory status for any dyspnea or other symptoms. Monitor vital signs. Check daily weight. Administer prescribed diuretics. Provide sodium restricted diet.


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3.Decreased cardiac output related to valvular incompetence

Interventions

Monitor vital signs Assess cardiovascular status. Monitor for any cardiac dysrrhythmias. Administer inotrops as per order. Maintain head elevation to reduce venous return and reduce oxygen

demand .

Promote bed rest4.Knowledge deficit regarding surgery, post operative care and life style

modifications

Interventions

Explain about the disease condition Explain the life style changes like smoking cessation. Explain about preoperative workups,surgery and post operative care. Introduce the patient to a post operative patient. Clarify doubts. Explain about the need of anticoagulant medication after surgery. Advice them to use medi alert card.

POSTOPERATIVE MANAGMENT

1.Decreased cardiac output related to blood loss and compromised myocardialfunction

Intervention

Assess for the cardiac status, BP, Heart rate, Central venouspressure, arterial pressure

Assess for the capillary refill and any signs of cyanosis


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Monitor vitals hourly Monitor intake and output. Administer blood transfusion if needed.

2.Risk for impaired gas exchange related to trauma of extensive chest surgery

Intervention

Assess for the respiratory rate , rhythm and movements Monitor the oxygen saturation levels

Assess for any signs of cyanosis and capillary refill Check for the ABG values. Provide fowlers position Administer oxygen as per the need

3.Pain related to operative trauma and pleural irritation caused by chest tubes

Intervention

Record nature type location duration of pain Assist patient to differentiate between surgical and anginal pain. Provide diversional therapy Reassure the patient. Encourage routine medication, dosing for the 1st 24 to 72 hours andobserve for side effects of lethargy, hypertension, tachycardia and

respiratory depression.

4.Risk for impaired renal perfusion related to decreased cardiac output ,

hemolysis or vasopressor drug therapy.

Intervention

Assess renal function


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Measure urine output half to one hour Measure urine specific gravity Monitor and report lab results, blood urea nitrogen, serum creatine,

urine and serum electrolytes.

Administer rapid acting diuretics or inotropic drugs5.Risk for infection related to invasive procedure

Interventions

Maintain aseptic technique Check vital signs. Remove invasive lines as early as possible. Send blood for CBC and culture. Give antibiotics as per order.

VIII.COMPLICATIONS OF VALVULAR REPLACEMENTS

Early complications

Prosthetic dislodgement due to suture disruption Embolism-Throbus,calcific debris,air Distortion of adjacent valve by too large prosthesis Myocardial perforation during insertion of prosthesis with serious

haemorrhage

MalfunctionEspecially in ball valve types prosthesis with protrusion of papillary

muscles, chordate or Teflon margin of ring into the device

Injury to adjacent structuresTrauma to conducting pathway,suture through coronary arteries

StenosisAll prosthetic valve replacements create a degree of stenosis when they

are implanted in the heart. Usually, the stenosis is mild and does not


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affect heart function. If valve replacement was for a stenotic valve, blood

flow through the heart is often improved.

Change in intracardiac blood pressureBefore surgery, the heart gradually adjusted to the pathology,but the

surgery abruptly corrects the way blood flows through the heart.

Complications unique to valve replacement are related to the sudden

changes in intracardiac blood pressures.

Heart failureThe signs and symptoms of the backward heart failure resolve in a few hours

or days. If valve replacement was for a regurgitant valve, it may take months

for the chamber into which blood had been regurgitating to achieve its

optimal postoperative function. The signs and symptoms of heart failure

resolve gradually as the heart function improves.

Late complications

Thromboembolism Bacterial endocarditis Paravalvular leak Hemolytic anaemia if prosthesis becomes regurgitant in aortic position Loss of ball in ball valves,loss of valve

IX.HEALTH EDUCATION

Long-term anticoagulant therapy after valve replacement.-Montly check up for INR (it should maintain 2.5 to 3.5)

-Advice them to take medicine at same time daily.

-Notify physician for any sie effects like bleeding,hematurea,gum

bleeding, severe headache or stomach pains, weekness, dizziness, altered

mental status, heametemesis,palpitation or chest pain.

-Avoid injuries

-Avoid NSAID.


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-Wear medi alert tag.

Explain the need for frequent follow-up appointments and bloodlaboratory studies

Provides teaching about any prescribed medication: the name of themedication, dosage,its actions, prescribed schedule, potential side effects,

and any drug-drug or drug-food interactions.

Patients with a mechanical valve prosthesis require education to preventbacterial endocarditis with antibiotic prophylaxis, which is prescribed

before all dental and surgical interventions.

Patients are discharged from the hospital in 3 to 7 days. Home care andoffice or clinic nurses reinforce all new information

self-care instructions with the patient and family for 4 to 8 weeks after theprocedure.

X.EVIDENCE BASED PRACTICE

Karl E. Hammermeister, Gulshan K. Sethi, William G. Henderson, Charles

Oprian, Tai Kim, and Shahbudin Rahimtoola for the Veterans AffairsCooperative Study on Valvular Heart Disease .med 1993; 328:1289-1296May

6, 1993

A Comparison of Outcomes in Men 11 Years after Heart-Valve

Replacement with a Mechanical Valve or Bioprosthesis

The study is to compare the outcomes of patients who receive two types of

valves,They randomly assigned 575 men scheduled to undergo aortic-valve or

mitral-valve replacement to receive either a mechanical or a bioprosthetic

valve. The primary end points were death from any cause and any valve-related

complication.During an average follow-up of 11 years, there was no difference

between the two groups in the probability of death from any cause or in the

probability of any valve-related complication .There was a much higher rate of

structural valve failure among patients who received bioprosthetic valves than
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among those who received mechanical valves. However, this difference was

offset by a higher rate of bleeding complications among patients with

mechanical valves than among those with bioprosthetic valves and by a greater

frequency of periprosthetic valvular regurgitation among patients with

mechanical mitral valves than among those with mitral bioprostheses

XI.CONCLUSION

No artificial valve is perfect as the healthy functional natural valve. Each

prosthetic valve has potential advantages and disadvantages which need to be

considered. The lifespan depends upon the lifestyle modifications. So as nurses

we should educate clients about post operative management.

XII.REFERANCE

1.Susan L. Woods etal, (2010),Cardiac Nursing, 6th

edition, wolters Kluwer

Lippincott Williams and wilkims publication, Philadelphia. Pg:-540-541

2.Ignatavicius,D.D.,Workman,M.L.&Mishler,M.A.(1991)Medicalsurgicalnursing,(2nd

ed),Philadelphia,Saunders publications.

3.Smeltzer ,S.C. &Bare,B.G.(2001)Brunner and suddarths medical surgicalnursing,(10

thed),Philadelphia,Lippincott.

4.Graber,B.&Bucher,L.92007)Lewis medical and surgical nursing,(10th

ed0,Misori,Elsvier publications,1102-1115.

4.Donna,D.M.&workman,L.(2006)Medical surgical nursing(2nd

ed),Philadelphia,Saunders publications,1665-1670.

5.Susan,C.D,(2007)Medical surgical nursing,Philadelphia,Saunderspublications.

6.Marks C and Marks P (1994) Fundamentals of cardiacsurgery.London.Chapman and Hall medical.

7. http://www.medicinenet.com/ccf/page2.htm

8.http://www.nejm.org/doi/full/10.1056/NEJM199305063281801
http://www.medicinenet.com/ccf/page2.htmhttp://www.nejm.org/doi/full/10.1056/NEJM199305063281801http://www.nejm.org/doi/full/10.1056/NEJM199305063281801http://www.nejm.org/doi/full/10.1056/NEJM199305063281801http://www.medicinenet.com/ccf/page2.htm


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9.http://stanfordhospital.org/healthLib/greystone/heartCenter/heartProcedures/heartValveRepairR

eplacementSurgery.html
http://www.nejm.org/doi/full/10.1056/NEJM199305063281801http://www.nejm.org/doi/full/10.1056/NEJM199305063281801http://www.nejm.org/doi/full/10.1056/NEJM199305063281801

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