CABG with Valve replacement
What is heart valve repair or replacement surgery?
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. Some reasons why heart valves become stenotic include infection (such as rheumatic fever or staphylococcus infections) andaging. If one or more valves become insufficient (leaky), blood leaks backwards, which means that less amount of blood is pumped in the proper direction. Based on your symptoms and overall condition of your heart, your doctor may decide that the diseased valve(s) needs to be surgically repaired or replaced.
Highly invasive procedure
Traditionally, repair or replacement of heart valves has involved open-heart surgery, which means that the chest is opened in the operating room and the heart stopped for a time so that the surgeon may repair or replace the valve(s). In order to open the chest, the breastbone, or sternum, is cut in half and spread apart. Once the heart is exposed, large tubes are inserted into the heart so that the blood can be pumped through the body during the surgery by a cardiopulmonary bypass machine (heart-lung machine). The bypass machine is necessary to pump blood because the heart is stopped and kept still while the surgeon performs the valve repair or replacement procedure.
Minimally invasive procedures (MIP)
Newer, less invasive techniques have been developed to replace or repair heart valves. Minimally invasive procedures make smaller incisions which means less pain in the post-surgery period and shorter hospital stay. Balloon valvuloplasty is one such procedure. It is used to treat some cases of valve stenosis and is done as part of a catheterization procedure, rather than as part of open heart surgery. In this procedure, your doctor inserts a long, thin tube (catheter) with a balloon in the tip into your arm or groin and guides it to your heart. Your doctor inserts the balloon in the valve and inflates the balloon to open or stretch the valve. The balloon is then deflated and removed. You may need additional procedures over time to treat the narrowed valve.
Transcatheter aortic valve replacement, or TAVR, is a new alternative for some cases of aortic valve stenosis. This hybrid procedure typically is done by a cardiac surgeon and an interventional cardiologist.
The diseased valve may be repaired using a ring to support a person’s own valve, or the entire valve may be removed and replaced by an artificial valve. Artificial valves may be mechanical (made of metal or plastic) or tissue (made from animal valves or human valves taken from cadavers).
Other related procedures that may be used to assess the heart include resting and exercise electrocardiogram (ECG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and ultrafast CT scan. Please see these procedures for additional information.
Valves of the heart
To better understand how valvular heart disease affects the heart, a review of basic heart anatomy and valve function follows.
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 ventricles. The right atrium pumps blood into the right ventricle, which then pumps the blood into the lungs where wastes such as carbon dioxide are given off and oxygen and other nutrients are taken into the blood.
From the lungs, the blood flows back into the left atrium, is pumped into the left ventricle, and then is pumped through the aorta out to the rest of the body and the coronary arteries. When the atria are contracting, the ventricles are relaxed in order to receive the blood from the atria. Once the blood from the atria has passed into the ventricles, the atria 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.
Reasons for the procedure
Valve repair or replacement surgery is performed to correct the problems caused by one or more diseased heart valves. There may be other reasons for your doctor to recommend heart valve repair or replacement surgery.
Types of valve disease and their treatment
i. Aortic valve disease is a condition in which the valve between the main pumping chamber of your heart (left ventricle) and the main artery to your body (aorta) doesn’t work properly. Aortic valve disease sometimes may be a condition present at birth (congenital heart disease), or it may result from other causes.
Types of aortic valve disease include:
- Aortic valve stenosis — In this condition, the aortic valve opening is narrowed. This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and the rest of your body. When the aortic valve is obstructed, your heart needs to work harder to pump blood to your body. Eventually, this extra work limits the amount of blood it can pump and may weaken your heart muscle.
- If you have severe aortic valve stenosis, you’ll usually need surgery to replace the valve. Left untreated, aortic valve stenosis can lead to serious heart problems.
- Aortic valve regurgitation — or aortic regurgitation — is a condition that occurs when your heart’s aortic valve doesn’t close tightly. Aortic valve regurgitation allows some of the blood that was just pumped out of your heart’s main pumping chamber (left ventricle) to leak back into it.The leakage may prevent your heart from efficiently pumping blood to the rest of your body. As a result, you may feel fatigued and short of breath.
- Aortic valve regurgitation can develop suddenly or over decades. Once aortic valve regurgitation becomes severe, surgery is often required to repair or replace the aortic valve.
ii. In mitral valve disease, the mitral valve, which is located between your left heart chambers (left atrium and left ventricle), doesn’t work properly.
Types of mitral valve disease include:
- Mitral valve regurgitation — also called mitral regurgitation, mitral insufficiency or mitral incompetence — is a condition in which your heart’s mitral valve doesn’t close tightly, allowing blood to flow backward in your heart. As a result, blood can’t move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.
- Treatment of mitral valve regurgitation depends on how severe your condition is, whether it’s getting worse and whether you have symptoms. For mild leakage, treatment may not be necessary.
- Mitral valve regurgitation can be treated either by a surgery or through mitral valve replacement. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias). Even people without symptoms should be seen and evaluated by a cardiologist and surgeon specializing in mitral valve disease to determine whether early intervention may be beneficial.
- The most common cause of blood leakage is mitral valve prolapse, in which the leaflets bulge back into the left atrium as your heart contracts.
- Mitral valve stenosis — or mitral stenosis — is a narrowing of the heart’s mitral valve. This abnormal valve doesn’t open properly, blocking blood flow into the main pumping chamber of your heart (left ventricle). Mitral valve stenosis can make you tired and short of breath, among other problems.
The main cause of mitral valve stenosis is an infection called rheumatic fever, which is related to strep infections. Rheumatic fever is still common in developing countries, and can scar the mitral valve. Left untreated, mitral valve stenosis can lead to serious heart complications.
iii. Pulmonary valve disease refers to any disorder of your heart’s pulmonary valve, which is responsible for keeping blood from your heart flowing properly to your lungs. Pulmonary valve disease can refer to a leaky valve (pulmonary regurgitation) or a narrowed valve (pulmonary stenosis). Treatment depends on the type of pulmonary valve disease you have and its severity.
iv. Tricuspid valve disease is a condition in which the valve between the two right heart chambers (right ventricle and right atrium) doesn’t function properly. Tricuspid valve disease often occurs with other heart valve problems.
Several types of tricuspid valve disease exist, including:
- Tricuspid valve regurgitation — In this condition, the tricuspid valve doesn’t close properly and blood flows back into your heart’s upper right chamber (right atrium).
- Tricuspid valve stenosis — In this condition, the tricuspid valve is narrowed, decreasing the amount of blood that can flow through it from the right atrium to the right ventricle.
- Tricuspid atresia — This is a heart defect present at birth (congenital) in which one of the valves (tricuspid valve) between two of the heart’s chambers isn’t formed. Instead, there’s solid tissue between the chambers.
- If your baby is born with tricuspid atresia, blood can’t flow through the heart and into the lungs to pick up oxygen as it normally would. The result is the lungs can’t supply the rest of your baby’s body with the oxygen it needs. Babies with tricuspid atresia tire easily, are often short of breath and have blue-tinged skin.
- Tricuspid atresia is treated with surgery. Most babies with tricuspid atresia who have surgery will live well into adulthood, though follow-up surgeries are often needed.
- Ebstein’s anomaly is a condition in which a malformed tricuspid valve sits lower than normal in the right ventricle, causing blood to flow back into the right atrium (tricuspid regurgitation).
If the heart valve(s) becomes damaged or diseased, a person may experience the following symptoms:
- Chest pain.
- Breathing difficulties.
- Edema (swelling) of the feet, ankles, or abdomen.
- Rapid weight gain due to fluid retention.
Risks of the procedure
Possible risks associated with heart valve repair or replacement surgery include, but are not limited to, the following:
- Bleeding during or after the surgery.
- Blood clots that can cause heart attack, stroke, or lung problems.
- Infection at the incision site.
- Breathing problems.
- Dysrhythmias/arrhythmias (abnormal heart rhythms).
If you are pregnant or suspect that you may be pregnant, you should notify your health care provider. If you are lactating, or breastfeeding, you should notify your health care provider. Patients who are allergic to or sensitive to medications, contrast dyes, iodine, or latex should notify their doctor. There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
Before the procedure
- Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
- You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
- In addition to a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
- You will be asked to fast for eight hours before the procedure, generally after midnight. This is because the procedure is performed using a general anesthetic (you are put to sleep). You may be able to have occasional sips of water until two hours before the operation.
- If you are pregnant or suspect that you are pregnant, you should notify your doctor.
- Notify your doctor if you are sensitive or allergic to any medications, iodine, latex, tape, or anesthetic agents (local and general).
- Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
- Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure.
- Your doctor may request a blood test before the procedure to determine how long it takes your blood to clot.
- Notify your doctor if you have a pacemaker.
- Your doctor might want to know about your teeth, for example, notify your doctor if you wear dentures or have caps or a plate.
- If you smoke, you should stop smoking as soon as possible prior to the procedure. This is because smoking increases your chances of a serious chest infection and slows down the time your wounds will take to heal. Smoking can also increase your risk of blood clots. Quitting smoking may improve your chances for a successful recovery from surgery and benefit your overall health status.
- Based on your medical condition, your doctor may request other specific preparation.
Anesthesia assessment or evaluation refers to the series of interviews, physical examinations, and laboratory tests that are generally used to assess the general fitness of patients scheduled for surgery and to determine the need for special precautions or additional testing.
The evaluation is usually done in the hospital where the operation is scheduled, or in a separate facility attached to the hospital. The timing of the evaluation is affected by two major variables: the invasiveness of the operation to be performed and the patient’s overall physical condition. An invasive operation or procedure is the one that requires the surgeon to insert a needle, catheter, or instrument into the body or a part of the body. Surgical procedures are classified as high, medium, or low in invasiveness. Procedures that involve opening the chest, abdomen, or skull are usually considered highly invasive. CABG is a highly invasive procedure.
A mnemonic has been suggested for pre-anesthetic assessment, to ensure that all aspects are covered. It runs alphabetically:
A – Affirmative history; Airway
B – Blood hemoglobin, blood loss estimation, and blood availability; Breathing
C – Clinical examination; Co-morbidities
D – Drugs being used by the patient; Details of previous anesthesia and surgeries
E – Evaluate investigations; End point to take up the case for surgery
F – Fluid status; Fasting
G – Give physical status; Get consent
Patients may have a meeting with their anesthetist a day before the surgery and ask all kinds of questions pertaining to the surgery, and provide all information as mentioned above.
During the procedure
Heart valve repair or replacement surgery requires a stay in a hospital. Procedure may vary depending on your condition and your doctor’s practices.
Generally, heart valve repair or replacement follows this process:
- You will be asked to remove any jewellery or other objects that may interfere with the procedure.
- You will be asked to remove your clothing and will be given a gown to wear.
- You will be asked to empty your bladder prior to the procedure.
- An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.
- You will be positioned on the operating table, lying on your back.
- The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube will be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.
- A catheter will be inserted into your bladder to drain urine.
- The skin over the surgical site will be cleansed with an antiseptic solution.
- The doctor will make an incision (cut) down the center of the chest from just below the Adam’s apple to just above the navel.
- The sternum (breastbone) will be divided in half with a special operating instrument. The doctor will separates the two halves of the breastbone and spread them apart to expose the heart.
- In order to perform the valve repair or replacement, the heart must be stopped to allow the doctor to perform the very delicate procedure. Tubes will be inserted into the heart so that the blood can be pumped through your body by a cardiopulmonary bypass machine.
- Once the blood has been completely diverted into the bypass machine for pumping, the heart will be stopped by injecting it with a cold solution.
- When the heart has stopped, the doctor will perform the procedure by removing the diseased valve and putting in the artificial valve, in the case of a valve replacement. For a valve repair, the procedure performed will depend on the type of valve problem that exists, for example, separation of fused valve leaflets, repair of torn leaflets, and/or the reshaping of valve parts to ensure better function.
- Once the procedure has been completed, the blood circulating through the bypass machine will be allowed to reenter your heart and the tubes to the machine removed. Your heart will be shocked with small paddles to restart its electrical activity.
- Once your heart is beating again, the doctor will observe the heart to assess the function of the heart and the valves.
- Temporary wires for pacing may be inserted into the heart. These wires can be attached to a pacemaker and your heart can be paced, if needed, during the initial recovery period.
- The sternum will be rejoined and sewn together with small wires.
- The skin over the sternum will be sewn back together. The incision will be closed with sutures or surgical staples.
- Tubes will be inserted into your chest to drain blood and other fluids from around the heart. These tubes will be connected to a suction device to drain fluids away from the heart.
- A tube will be inserted through your mouth or nose into your stomach to drain stomach fluids.
- A sterile bandage or dressing will be applied.
After the procedure
In the hospital
After the surgery you may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored for several days. Alternatively, you may be taken directly to the ICU from the operating room. You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Heart valve repair or replacement surgery generally requires an in-hospital stay of several days or longer.
You will most likely have a tube in your throat so that your breathing can be assisted with a ventilator (breathing machine) until you are stable enough to breathe on your own. As you wake up from the anesthesia more and start to breathe by yourself, the breathing machine will be adjusted to allow you to take over more of the breathing. When you are awake enough to breathe completely by yourself and to be able to cough, the breathing tube will be removed. The stomach tube will also likely be removed at this time.
After the breathing tube is out, your nurse will assist you to cough and take deep breaths every two hours. This will be uncomfortable due to soreness, but it is extremely important that you do this in order to keep mucus from collecting in your lungs and possibly causing pneumonia.
You will be given pain medication if you are hurting, and you should ask for the medication before you become extremely uncomfortable. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.
You may be on special IV drips to help your blood pressure and your heart and to control any problems with bleeding. As your condition stabilizes, these drips will be gradually decreased and turned off as your condition allows.
Once the breathing and stomach tubes have been removed and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as you tolerate them.
When your doctor determines that you are ready, you will be moved from the ICU to a postsurgical unit or acute care unit. Your recovery will continue to progress. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as you tolerate them.
Arrangements will be made for a follow-up visit with your doctor.
Care for your wound
Once you are home, it will be important to keep the surgical area clean and dry to avoid infection. Your doctor will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, in the event they were not removed before leaving the hospital.
Make sure you protect the surgical area from the sun. You will have a scar where the surgeon cut down your breastbone. This is red at first, but will gradually fade over time.
To ease any soreness where the cut was made, you may need to continue taking painkillers at home.
For the first three to six weeks, you will probably feel tired. By the end of six weeks, you should be able to do most of the things you want to. By three months, you are likely to have regained full health. Remember you should not drive until your doctor tells you to. Other activity restrictions may apply.
The recovery time after valve replacement surgery varies from person to person and will depend on:
- Your age.
- Your overall health and fitness.
- How well you were before the operation.
After your CABG, you should feel relief from most of your symptoms, such as chest pain. Research has shown that 83% of the people who underwent the procedure are free of heart-related symptoms for the next five years, and 63% for the next 10 yeaCABG is not a cure for coronary artery disease. To get the most out of the procedure, try to live a healthy lifestyle and make sure you take any prescribed medication as directed by your GP.
Notify your doctor to report any of the following after the procedure
- Fever and/or chills.
- Redness, swelling, or bleeding or other drainages from the incision site.
- Increase in pain around the incision site.
Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.