Valvular Heart Disease

Valvular heart disease is a common heart condition caused by malfunctioning heart valves. There are 4 valves in the heart that function to keep blood moving in one direction. When a valve is diseased or abnormal and doesn't close completely, blood can back up instead of going forward. This is called regurgitation or "leaky valve". When a valve opening is too narrow, the heart has to work harder to pump the blood throughout the body. This narrowing of the valve opening is called stenosis. Valvular Heart Disease is a serious condition that causes the heart to work harder. If left untreated Valvular Heart Disease can lead to Congestive Heart Failure, Cardiomyopathy, and even death.

Many patients with Valvular Heart Disease can successfully control their symptoms with medications, however medications cannot cure diseased or abnormal heart valves.

In some cases, patients are unable to tolerate the side effects of the medications or do not respond to the medications and require further intervention. In other cases, the valves are so diseased or abnormal there is no other option except to repair or replace the valve.

Heart valve surgery may be an option for these patients. Traditionally the surgery has been performed through a long chest incision with the breastbone or sternum split and ribs spread apart. Minimally invasive techniques for repairing or replacing diseased or abnormal valves have been developed that require a much smaller incision with partial or no splitting of the breastbone.

Heart Valves

The main function of the heart valves is to regulate and prevent the backflow of the blood.

There are four important valves in the heart. Move your cursor over the labels to find out more.

Tricuspid Valve

The tricuspid valve regulates blood flow between the right atrium and the right ventricle.

It prevents the backflow of blood to the right atrium when the right ventricle pumps blood to the lungs.

Mitral Valve

The mitral valve regulates the blood flow between the left atriuma and the left ventricle.

It prevents the backflow of blood to the left atrium when the left ventricle pumps blood through the aorta to the rest of the body.

Pulmonary Valve

The pulmonary valve regulates the de--oxygenated blood from the right ventricle to the lungs for purification.

Aortic Valve

The aortic valve regulates the oxygenated blood pumped from the left ventricle to the rest of the body.

The left side of the heart has to work harder than the right side because it functions to pump blood to the entire body, not just to the lungs. Because the Mitral and Aortic valves regulate blood flow in the left side of the heart, these valves are the most commonly replaced valves accounting for 98% of all valve replacement surgeries.

What is Valvular Heart Disease?

Valvular Heart Disease is a condition where one or more valves in the heart do not function properly. There are four valves in the heart that open and close to keep blood flowing in one direction. Malfunctioning valves can cause blood to back up instead of moving forward in one direction. This is referred to as regurgitation. Some valves have stiffened and narrowed over time making it more difficult to pump blood through the narrowed opening. This is referred to as stenosis. These conditions cause the heart to try and pump harder to move the same amount of blood. Over time, this extra workload takes it toll on the heart weakening the heart muscle, a condition called Cardiomyopathy. Left untreated, Valvular Heart Disease will ultimately lead to heart failure.

Risk factors for Valvular Heart Disease include the following:

• Untreated strep throat that leads to Rheumatic fever
• Infection in the lining of the heart and valves called Infective Endocarditis
• Advancing age causing weakening of the valves or calcification of the valves
• Congenital heart disorders (occurring at birth)
• Coronary Artery Disease
• Myocardial Infarction or heart attack

Signs and Symptoms of Valvular Heart Disease may be mild, moderate, or severe and can include the following:

• Shortness of breath
• Swelling of lower extremities or abdomen
• Arrhythmia: fast or irregular heart beat
• Wet cough
• Palpitations
• Tiredness or lethargy
• Syncope or fainting
• Light-headed or faint
• Chest pain
• Blood clots
• No symptoms at all

A Cardiologist should evaluate all heart conditions for proper diagnosis and treatment.

Your Cardiologist will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include some or all of the following:

• (EKG or ECG) Electrocardiogram
  EKG is a test to measure the electrical activity of the heart and provides your doctor with information about your heart rate, rhythm, size of the heart chambers and previous damage to the heart. It is non-invasive and painless and is performed by attaching electrodes to various parts of the body
  
  
• Cardiac Catheterization:
  This is a surgical procedure performed by inserting a catheter into an artery in the arm or leg and advancing it into the heart. A dye is then injected and x-ray pictures are taken of the heart showing your doctor if any heart valves are damaged
  
  
• Chest X-Ray:
  A form of electromagnetic radiation that is used to take pictures of bones. Non-invasive and painless, a chest x-ray can show signs of an enlarged heart
  
  
• Echocardiogram:
  Echocardiogram is a test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than x-ray images and involves no radiation exposure. These ultrasound images help identify abnormalities in the heart muscle and valves, and find any fluid that may surround the heart

Management of Valvular Heart Disease depends on the following:

• Type of disease
• Severity of symptoms
• Underlying cause
• Your overall health

The goals of treatment for Valvular Heart Disease are:

• Decrease workload on the heart
• Restore normal heart rhythm
• Prevent blood clots and strokes

Conservative Management Includes:

• Lifestyle Modifications
• Medications

Lifestyle Modifications

Healthy life choices will improve your overall health and your heart health and can help you slow the progression of your heart disease. Some heart healthy choices include:

• Healthy Diet Choices – Eating a low fat, low salt, low cholesterol diet while avoiding excessive intake of alcohol and caffeine
  
  
• Don't Smoke – If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit
  
  
• Reduce stress through exercise – Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of wellbeing. Always discuss with your doctor before beginning any new exercise program
  
  
• Weight Loss – Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice

Medications

Along with life style modification for heart health, medications are needed to control symptoms of Valvular Heart Disease. More than one medication may be prescribed. Some common medications are listed on the left. Move your cursor over the medications to find out more.

• Anticoagulants or Thrombolytic agents – These blood-thinning medicines may be prescribed to prevent the formation of blood clots and reduce the risk of stroke in patients with Valvular Heart Disease
  
  
• Digitalis – Digitalis makes the heart contract harder and is used when the heart's pumping function has been weakened; it also slows some fast heart rhythms
  
  
• Ace Inhibitors – Ace (angiotensin converting enzyme) inhibitors are used to treat heart failure by lowering blood pressure. This is achieved by inhibiting the formation of a chemical called angiotensin that raises blood pressure by causing arteries to constrict
  
  
• Beta-blockers – Beta-blockers work by slowing down the heart rate and decreasing the force of the heart muscle. This reduces the heart's need for oxygen and improves the supply of blood to the heart muscle
  
  
• Calcium Channel Blockers – Calcium Channel Blockers reduce the frequency and severity of chest pain. They reduce the muscle tension in the coronary arteries, expanding them and creating more room. They also slightly relax the heart muscle, reducing the heart's need for oxygen and reducing blood pressure
  
  
• Diuretics – Diuretics, also referred to as water pills, increase the excretion of fluids in the body through the urine helping to prevent fluid build-up and congestion in the lungs
  
  
• Antibiotics – Anti-infective agents such as antibiotics may be prescribed prior to invasive medical or dental procedure to prevent a serious infection called bacterial endocarditis

Many Valvular Heart Disease patients have good results from medication and lifestyle changes. However, some patients are unable to tolerate the side effects of the medications used to treat the condition and others continue to have symptoms despite medical intervention. In some cases, the valve is so diseased the only option is surgical repair or replacement of the valve.

If conservative treatment options are unsuccessful in treating your Valvular Heart Disease and you are a candidate for the procedure, your surgeon may recommend a surgery called Minimally Invasive Heart Valve surgery.

The smaller incisions with Minimally Invasive Heart Valve surgery mean that fewer tissues are cut resulting in quicker healing and recovery.

• Smaller incision
• Less trauma
• Less blood loss
• Accelerated recovery
• Shortened hospital stay
• Decreased postoperative pain

It is important for you to discuss all options of treatment with your surgeon, as Minimally Invasive Valve Replacement surgery is just one option currently available for the treatment of Valvular Heart Disease.

If your surgeon decides to replace the diseased valve as opposed to repairing the valve, there are two types of prosthetic valves that can be used.

• Mechanical: Mechanical valves are manufactured. They are highly durable and won't wear out. However, because of their tendency to cause blood clots, you will be required to take blood thinners for the rest of your life
  
  
• Biological: Biological valves are heart valves that have been taken from an animal, usually a pig, or from a cadaver. These valves are less durable than mechanical valves and may require replacement after 10-15 years. There is a decreased risk of developing blood clots with biological valves so patients do not require life long blood thinners. Normally, you will be given blood thinners for the first 6 -12 weeks while you are healing from surgery. The decision of which type of valve to use is usually based on the following:
  • Surgeon's preference
  • Patient's preference regarding long term use of blood thinners and chance of re-operation
  • Patient's lifestyle
  • Individual risks
  • Age

Minimally Invasive Heart Valve surgery is performed by Cardiothoracic surgeons in the operating room with the patient under general anesthesia. The operation usually takes about 3-4 hours.

Prior to the surgery, the patient is placed on the operating table on their back. The incision area is shaved and scrubbed with antiseptic. You will be given a general anesthetic so you will be asleep and not feel any pain. You will have a tube down your throat attached to a ventilator to help you breathe during the surgery.

• The surgeon makes either a horizontal incision over the right side of the chest or a small vertical incision down the center of the chest. The incisions made are much shorter in minimally invasive surgery than the traditional method of a long chest incision
• The patient's heart is stopped and blood is rerouted to the cardiopulmonary bypass machine, which does the work of the heart and lungs so the surgeon can work on a non-beating heart with a bloodless surgical field
• The surgeon now cuts the heart open to access the diseased valves and surrounding structures
• Your surgeon will decide at this point either to repair the valve or replace the diseased valve.
• If the valve is to be replaced, your surgeon will cut around the valve to release it from the tendons that hold it to the heart
• Your surgeon will now insert the new valve and suture it in place
• Temporary pacer wires are placed on the heart surface exiting through the skin. If necessary, the wires can be attached to a pacer machine to keep your heartbeat regular. The wires are usually removed after a few days
• Once the valve has been repaired or replaced, the heart is restarted with controlled electrical shocks and the patient taken off of the bypass machine
• The surgeon then closes the incision and covers it with a sterile dressing

Post Operative Guidelines

After Minimally Invasive Valve Replacement surgery you will be taken to ICU for close observation for up to 24 hours.

You will have a breathing tube in place and will not be able to talk. Usually the breathing tube is removed after 6-8 hours and you will be breathing on your own.

You will have chest tubes in place to drain fluid from around the heart and lungs.

You will be hooked up to monitors for nursing staff to evaluate your heart rate and blood pressure.

You will likely be in the hospital about 2-3 days and may be able to return to work in 2-3 weeks.

Common post-operative guidelines following Minimally Invasive Heart Valve surgery include the following:

• You will be encouraged to cough and deep breathe. You may be given a Spirometer, a device for breathing exercises to keep fluid out of your lungs
• Your surgeon may give you activity restrictions such as no lifting over 10 lbs. for a few months if your breastbone was cut during the surgery
• Once all your tubes have been removed, you will be encouraged to shower daily and wash your incision with a mild soap to prevent infection
• You will be encouraged to walk, gradually increasing the distance and frequency. Your doctor may recommend an outpatient cardiac rehabilitation program for exercise and education
• You will have soreness and bruising around the incision site. You will be given pain medication to keep you comfortable
• Your doctor will restart your blood-thinning medicines for several months to prevent blood clots from forming and reduce the risk of stroke while you are healing
• If your heart valve was replaced with a mechanical valve, you will require blood-thinning medication for the rest of your life
• You must notify your doctor before undergoing any invasive medical or dental procedures. All heart valve surgery patients will require antibiotic medications prior to certain dental or medical procedures to prevent a serious infection of the heart and valves called bacterial endocarditis
• You may be prescribed Prednisone, an anti-inflammatory steroid medicine, to reduce inflammation after the surgery
• Diuretics may be prescribed to prevent fluid retention
• Follow-up visits with your doctor are very important for management of your medications. You will require blood tests periodically if you are on blood thinners to ensure the dose you are taking is safe
• You will need someone to drive you home after you are released

Contact your doctor immediately if you have a fever, chills, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

Risks & Complications

• As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages
• It is important that you are informed of these risks before the procedure takes place

Most patients do not have complications after Minimally Invasive Heart Valve surgery; however complications can occur and depend on what type of procedure your doctor performs as well as the patient's health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Minimally Invasive Heart Valve surgery.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reaction to medications
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attack, strokes, kidney failure, pneumonia, bladder infections
• Complications from incision site such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Specific complications for Minimally Invasive Heart Valve surgery include:

• Blood clots that can cause heart attack, stroke, or lung problems
• Arrhythmias or irregular heart beat
• Endocarditis: the new valve can become infected and inflamed
• Blood vessel or heart damage requiring an operation for repair

Risk factors that can increase the chance of complications following Minimally Invasive Heart Valve surgery include:

• Diabetes
• History of kidney disease
• Poor cardiac function
• Extensive heart disease
• Poor nutrition
• Smoking
• Obesity
• Age (over 75)
• Alcoholism
• Chronic Illness
• Steroid Use