CTVS Anesthesia

The Cardiothoracic Vascular Surgery (CTVS) Programme at the Asian Institute of Medical Sciences has achieved an eminent place as a dedicated centre for comprehensive surgical management of diseases of the heart, lungs and blood vessels.

Being a centre of excellence, it attracts the best surgical minds who work as a unified team to provide cardiothoracic surgical care of the highest professional standards to a large number of patients suffering from heart and/or lung ailments.

Availability of expert talent, latest technology and compassionate care make the cardiothoracic department achieve results which are comparable to the best in the world.

This handout is intended to provide you with general information about the Heart Valve Operation you are about to undergo. It is not a substitute for advice from your Heart Surgeon and therefore you must talk to her/ him before your operation so that you have enough information about the surgery to enable you to compare the benefits and risks.

Be sure to read all the information in this handout. If you do not understand anything please make a note of it and discuss it with your surgeon. You are encouraged to fully discuss with your surgeon:

  • The surgery to be done and why
  • The alternatives to surgery
  • The outcome you can expect

The decision to have your valve replaced or repaired should only be made after discussion with your cardiologist and heart surgeon. The decision is yours and should not be made in a hurry. Make the decision only when you are satisfied with the information you have received and believe you have been well informed.

Introduction

The heart is a pump with four valves [2 Inlet (mitral and tricuspid) and 2 Outlet (aortic and pulmonary) valves] that allow blood to flow in one direction only. Each valve must function normally to ensure that enough blood flows to the lungs, the body and the heart itself.

If a valve becomes severely damaged due to disease or the wear-and-tear of old age, it will put strain on the heart. Other organs such as the lungs, brain and kidneys can also be badly affected. People with a malfunctioning valve may need surgery to repair or replace it.

Such procedures have become common. The results of these operations at Asian Institute of Medical Sciences, Faridabad are amongst the best in the world.

Structure of the Aortic and Pulmonary Valves

The aortic and pulmonary valves are outlet valves. They have three cusps that attach to the corresponding ventricle which is called annulus. Stretching of the annulus and/or the cusps causes the valve to leak. In some cases, repair is possible. However, more commonly, the cusps are thickened, fused or calcified so much that replacement of the valve is necessary.

Structure of the Mitral and Tricuspid Valves

The mitral and tricuspid valves have leaflets that attach to annuli in the inlet part of the ventricles. The leaflets are held in place by strings called chordae that attach to special muscles in the ventricle called papillary muscles. In some cases, repair of abnormalities of the leaflets, annulus and/or chordae is possible. However, a valve with severe degeneration, thickening, destruction or calcification of the leaflets must be replaced.

Heart Valve Disease

The aortic and mitral valves are most commonly affected because they are subjected to high pressure. The tricuspid and pulmonary valves, which work in the low-pressure side of the heart, are less commonly involved. Two types of problem may affect heart valves: stenosis and regurgitation.

  • “Stenosis” means a narrowing or a stiffness of the valve that restricts blood flow through it. Aortic-valve stenosis makes the heart work harder, so it becomes thickened (hypertrophied). This thickening of the left ventricle may lead to permanent damage if the valve is not corrected. In mitral valve stenosis, the left ventricle does not fill properly and blood backs up into the lungs.
  • “Regurgitation” (also called insufficiency, incompetence or leakage) is due to failure of the valve to close properly, which allows blood to flow backwards. This means that the ventricle has to pump much more blood with each beat. This eventually causes the ventricle to enlarge or dilate, so that the muscle becomes stretched and thickened. Once the heart becomes over-stretched, recovery of normal function is less likely, even after the valve is repaired or replaced.
Symptoms:

Symptoms due to aortic valve stenosis occur when the left ventricle:

  • can no longer pump enough blood through the narrowed valve, causing light headedness or black outs
  • becomes so thick that its demand for oxygen exceeds its blood supply, causing pain like angina. In aortic-valve regurgitation, symptoms may only occur after heart dilatation has become severe. The main symptom is shortness of breath.

For a long time, the heart can compensate for a faulty valve. The appearance of symptoms means that the heart’s compensating mechanisms are no longer sufficient and the heart is starting to fail. Therefore, symptoms can happen quite late in the course of development of valve disease.

Anyone with evidence of valve disease, even if without symptoms, should have tests to determine the degree of valve malfunction and its effects on the heart. This is done primarily by clinical examination, echocardiography, ECG and chest X-ray examination. The aim is to determine the best time to operate, preferably before the effects on the heart have become irreversible.

Causes of Valve Disease:

Heart valve disease may be caused by:

  • Rheumatic fever, an immune response triggered by streptococcal bacteria, which can damage the heart valves and heart muscle. In our country, this the commonest cause of heart valve disease
  • Bacterial endocarditic, an infection of the inner lining of the heart, including the valves
  • Stretching of the valve due to weakness of its tissue
  • Abnormality of the valve and chordae, which can cause regurgitation
  • A build-up of calcium on the valve, often due to age or structural abnormality of the valve
  • Coronary artery disease and heart attack, which can affect the papillary muscles
  • A congenital defect, for example, one person in every 400 is born with an aortic valve that has two leaflets, instead of the normal three.
Before Surgery

To plan the best treatment, your surgeon needs to know your medical history, fully disclose health problems you have had. Some may interfere with surgery, anesthesia or aftercare. Tell your surgeon and the nurse (on admission to hospital) if you have had:

  • An allergy or bad reaction to antibiotics, anesthetics or other medicines
  • Allergy to surgical tapes or dressings
  • Prolonged bleeding or excessive bruising when injured
  • Problems with blood clots in the legs or lungs
  • Recent or long-term illness
  • Any problems with your teeth, such as tooth abscess
  • Psychological or psychiatric illness
  • Poor healing or bad scar formation after surgery
  • A stomach or duodenal ulcer
Medicines:

Give the surgeon a list of ALL medicines you are taking or have recently taken, including medicines prescribed by your family doctor and those bought without prescription, including vitamins and herbal therapies. Include medicines taken for long-term treatments, such as insulin, warfarin or contraceptive pills. In particular, tell your surgeon if you are taking medicines that increase the risk of bleeding, such as:

  • Aspirin and medicines containing aspirin (such as some cough syrups)
  • Blood thinning injection (such as Clexane and Fragmin)
  • Anti-inflammatory medicines (often used to treat arthritis)
  • Antiplatelet drugs other than aspirin (such as Plavix, Persantin and Ticlid)
  • Large doses of vitamin E.

These are often withheld before surgery, but they may be a part of your management, so cessation of some of them may not be advisable. Your surgeon will advise you of their use prior to your operation. Feel free to ask your surgeon any questions about medications.

Smoking:

Smoking damages the lungs and reduces lung function. Smoking increases surgical and anaesthetic risk and should be stopped for as long as possible before surgery. Smokers who do not quit should not expect to have good long-term results from heart valve surgery. Abnormal or diseased heart valves and artificial valves are prone to infection.

Therefore, it is very important that potential sources of infection (such as dental infection and skin ulcers) are properly treated and healed before valve surgery is performed. Have a dental check-up before surgery. To protect your valve, you must have antibiotic cover, which can be prescribed by your cardiologist, surgeon or local doctor.

Surgery to Replace a Heart Valve

The breastbone (sternum) is cut and the chest is opened. Soft tissues in front of the heart are parted, and the membrane surrounding the heart (pericardium) is opened. The heart is stopped and a heart-lung machine takes over the pumping of blood to the brain and other organs; this is called cardiopulmonary bypass.

The diseased valve is exposed through an incision in the heart or aorta. It is then partly or completely removed and the artificial valve is sewn into its place. The incision in the heart or aorta is closed.

The surgeon then restarts the heart so it resumes its normal rhythm. All air is removed from the heart, and then heart-lung machine support is withdrawn. The surgeon checks that the valve is functioning correctly and that the output of blood by the heart is normal. Any bleeding is stopped.

Tubes are placed within the chest to drain the blood and fluid that collect after surgery. Pacing wires are placed on the heart and the ends are brought through the skin. They are needed in case the rhythm needs to be corrected or the rate needs to be controlled  in several days, they will be gently removed.

The breastbone is closed, typically with stainless steel wire that is left in place, and the skin is closed with hidden sutures. Heart valve surgery usually takes from three to six hours.

Minimally Invasive Heart Valve Surgery

The surgeon may be able to replace the aortic or mitral valve through a smaller incision. The aortic valve may be repaired or replaced through a 10 to 15-centimetre incision in the breastbone. The mitral valve may be repaired or replaced through a small incision in the left or right side between the ribs.

In some cases, minimally invasive surgery may have the advantages of faster recovery and a slightly shorter hospital stay. However, this surgery is undertaken only in certain patients.

During minimally invasive valve replacement or repair, cardiopulmonary bypass is sometimes undertaken using veins in the neck and groin and the femoral artery in the groin.

Anesthesia:

Heart valve surgery is performed under general anesthesia. Anesthetic drugs are safe with few risks, but a few people may have reactions to them. If you have had a reaction to an anesthetic drug or any other drug, tell your anesthetist or surgeon. Your anesthetist will explain more about the anesthetic best for you.

Surgery to Repair a Heart Valve

Instead of replacing a diseased heart valve, the surgeon may be able to repair it. The repair is performed only if the surgeon believes the procedure is likely to restore acceptable, long-term function. This applies more often to the mitral and tricuspid valves than to the aortic valve.

As shown in the illustrations on the following page, the Mitral Valve may be repaired by:

  • Tightening the annulus, usually by insertion of a ring or band (annuloplasty), as shown in the illustration (right)
  • Modifying the leaflets by removal of excess tissue, as shown in the illustration (left)
  • Shortening or replacing the chordae (“heart strings”). The tricuspid valve may be repaired by tightening the annulus. Procedures on the leaflets or chordae are uncommon.

The aortic valve may be repaired by:

  • splitting the cusps where they have fused
  • modifying the annulus or attachment of the cusps; this can be done if the cusps are not diseased.
Replacement of A Heart Valve:

If a valve cannot be repaired, it has to be removed and then replaced with a valve of the appropriate size, as described above.

Recovery from Heart Valve Surgery

After surgery, you are cared for in an intensive care unit for the first 24 to 48 hours. As you recover, you are transferred to a ward and attended by specially trained nurses and physiotherapists until you are ready for discharge. Your physiotherapist will start you on a simple exercise program, including deep breathing exercises and coughing. Coughing and exercise reduce the risk of pneumonia and improve your circulation.

Drainage tubes in the chest are removed in one to two days. You are discharged from hospital when your surgeon is satisfied with your progress. Most people need about three months to recover completely. Those who work in non-physical jobs may be able to return to work in 6 to 12 weeks.

To help your recovery, gradually increase your activity. Most patients are encouraged to join a rehabilitation exercise program. Do not lift heavy weights (including small children) or drive until approved by your doctor.

After heart valve surgery, patients report a variety of problems that usually resolve, such as tiredness, blurred vision, nausea, poor appetite, poor concentration, memory loss, constipation or sleep disturbances.

There have been significant advances in pain relief after heart valve surgery in recent years and a variety of methods are available. Discuss this with your anaesthetist. After the first few days, tablets (such as paracetamol and codeine) are usually sufficient.

To improve your health and well being, eat healthy foods, lose excess weight, exercise regularly (under your doctor’s supervision) and do not smoke.

Anticoagulant or “blood Thinning” Drugs

Anticoagulant drugs reduce the risk of blood clots forming on the surface of a mechanical or tissue valve and prevent a mechanical valve from sticking or jamming. The most commonly used anticoagulant is warfarin (Coumadin), which is taken orally once a day. Initially, the dose is adjusted every second day based on the result of a blood test to measure clotting time (called the INR). Once the correct dose is established, the test is done weekly and finally monthly.

The dose varies from person to person and may vary in the same person, often depending on diet. Patients with a mechanical valve have to take warfarin permanently. Those with a tissue valve may be able to stop taking warfarin in six to 12 weeks. The main side effect of warfarin is bleeding, which can be life threatening. This is unlikely to occur if the correct dose is taken. However, notify your doctor immediately if you have any of these symptoms:

  • Bleeding from a cut or wound that does not stop by itself
  • Nosebleeds
  • Bleeding gums from brushing
  • Red or black, tarry stools
  • Blood-stained urine
  • Any unusual symptoms such as pain, swelling or discomfort.

You should wear a medical alert bracelet stating that you are taking anticoagulant medication. To determine a patient’s level of anticoagulation (or INR), testing kits are available. They must be used under close medical supervision and are not suitable for everyone.

Types of Artificial Valve

If a diseased heart valve cannot be repaired, your surgeon can replace it with an artificial valve that is either mechanical or bioprosthetic. Discuss with your surgeon the attributes of each and which device best suits your needs.

  • Mechanical valves: These are made of durable synthetic materials and can last a lifetime. However, life-long anticoagulation with warfarin is needed to reduce the risk of blood clots. These valves are associated with a slight ticking noise related to valve closure. It is usually only noticeable in a quiet room, and in many patients it is not noticeable at all.
  • Bileaflet Mechanical Valve Tilting disc mechanical valve Bioprosthetic or tissue valves: These are heart valves taken from animals or humans. The tissue has been treated to reduce the risk of rejection. Bioprosthetic valves have a limited lifespan that is dependent on age and other factors. Warfarin anticoagulation may not be necessary.

Possible Complications of Heart Valve Surgery

As with all surgical procedures, heart valve surgery does have risks, despite the highest standards of surgical practice. While your surgeon makes every attempt to minimize risks, complications can occur, and some may have permanent effects.

It is not feasible for a surgeon to outline every possible or rare complication of the operation. However, it is important you have enough information to fully weigh up the benefits and risks of surgery. As complications are unusual, most patients will not have a complication, but if you have concerns about possible side effects, discuss them with your surgeon.

The surgical risks of death and serious complications increase with age, other significant illnesses, heart damage, urgency of operation, the need for other heart surgery (such as coronary artery bypass grafting) and recurrent surgery. The following possible complications are listed for your information. There may be others that are not listed. You may wish to discuss the frequency and consequences of these complications with your surgeon.

Early Risks after Surgery

Mortality: For an otherwise healthy person under 70 years of age, the risk of dying during or after heart valve surgery is about one to two in every 100 procedures. However, in the case of a badly malfunctioning valve, a decision to NOT have the surgery will carry a much higher risk of serious debility and consequent early death.

Stroke: Although stroke is uncommon, the risk increases with age and disease of the aorta. The effects of stroke may be temporary and resolve over a few days or may be permanent and include:

  • Loss of feeling in a part of the body. Paralysis of one side of the body or an arm or leg (the paralysis may be complete or partial)
  • Speech difficulty
  • Visual disturbances. Cognitive dysfunction: About one patient in three may have some difficulty with concentration or blurred vision after valve surgery. This may last for three to four weeks. A permanent effect on concentration or vision is unlikely.

Bleeding: About three patients in 100 may require further surgery to control excessive bleeding. In most cases, this results in no adverse effects.

Arrhythmia (irregular heartbeats):

he most common arrhythmia in the first postoperative week is atrial fibrillation, which can affect up to one in three patients. It is usually treated with medication. Occasional extra beats are common and not a cause for concern. Uncommonly, a serious irregular rhythm can occur and may require an electrical shock to correct it.

In rare cases, a permanent pacemaker may have to be implanted to control the heart rate. If you feel palpitations after you go home, speak with your cardiologist. If the palpitations do not subside after a few minutes or if you are feeling unwell or dizzy, call an ambulance.

Non-healing of the breastbone: Uncommonly, the bone may not heal normally. This is more likely following protracted coughing after surgery. In some cases, the wire sutures may pull out. Surgery to repair the bone may be necessary. This complication can also be caused by infection of the breastbone.

Infection of the breastbone

Treatment of infection of the breastbone usually requires rehospitalisation, prolonged administration of antibiotics and often surgery.

Scarring: Most incisions heal well, but a few people develop raised or widened scars. Infection in the wound or areas of movement increases the risk of adverse scarring.

Blood clots: A clot may form in a deep vein, most often in the leg or thigh (deep venous thrombosis, or DVT). DVT requires immediate treatment and can be life threatening in some cases.

Areas of collapsed lung: These typically respond to physiotherapy.

Chest wall pain: This usually resolves by four to six weeks after the surgery.

Kidney failure: In those patients with previously normal kidney function, this is a rare complication.

Mood swings: It is common for patients to have some anxiety and loss of confidence related to their heart and general health, but this usually improves during the weeks following surgery.

Other Risks: Although uncommon, numerous other risks of heart valve surgery exist, including:

  • Respiratory failure and the need for a tracheostomy
  • Blood infection
  • Accumulation of fluid around the heart and in lung cavities that may require further drainage
  • Accumulation of air in the chest (pneumothorax) requiring temporary tube drainage

Late Risks after Surgery Bacterial endocarditis: The heart chambers and valves are covered with a membrane called the endocardium. As mentioned on page 3, patients with a diseased heart valve or an artificial valve are at risk of an infection developing on the valve. This is called infective endocarditis and is a very serious condition.

Therefore, to reduce the likelihood of it happening, it is important that, for the rest of your life, you take prophylactic antibiotics before all dental or surgical procedures, no matter how minor, including endoscopy or removal of a skin lesion. If you have an artificial valve, always tell your dentist and other doctors so they can take appropriate precautions.

Valve failure: Rarely, a mechanical valve malfunctions, requiring urgent surgery to replace it. If a tissue valve fails, it does so more slowly and progressively.

Peri-valvular leak: Rarely, a small leak can develop between the valve prosthesis and where the valve has been sewn in. In some cases, further surgery may be needed to correct the problem.

Haemolysis: This rare problem causes anaemia and occasionally mild jaundice. It is more likely to occur if the complication of peri-valvular leak develops late after heart valve surgery.

Symptoms to Beware of Contact your surgeon or cardiologist at once if you develop any of the following:

  • Fever (more than 38°C) or chills
  • Night sweats
  • Loss of appetite
  • Joint pains
  • Bleeding from the surgical area
  • Blood in urine, dark or black stools
  • A wound that drains for more than a day
  • Increasing pain or redness of a wound
  • Severe headache
  • Sudden breathlessnes
  • Persistent or frequent palpitations
  • Dizziness or blackouts
  • Eye symptoms, such as loss of vision or spots in front of your eyes
  • Weakness in any part of your body or slurring of speech
  • Any other concerns you may have about the surgery.

Asian Institute of Medical Sciences (AIMS) is a state-of-the-art 350 bedded super specialty hospital and cancer centre, located at Sector-21A, Faridabad. The Institute, truly futuristic in its services and technology, brings together some of the most talented medical professionals. The Institute provides preventive, diagnostic, therapeutic, rehabilitative, palliative and support services under one roof and is designed to meet patient care and research requirements of the new millennium.

Last updated on: August 16, 2017

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