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Expert Speak

Heart Valve Problems and Repair

Dr S Mukundan

“Patient education is an important aspect of heart valve replacement,” says Dr S Mukundan, Consultant Cardiovascular and Thoracic Surgeon.

  • When is Valve Replacement Surgery Required?
  • Causes of Valve Problems
  • Common Symptoms Patients Experience
  • Treatment Options
  • Diagnostic Tests that confirm the Necessity for Surgery
  • What happens During Surgery
  • ICU Stay
  • Minor Complications Patient may Experience
  • Long Term Care
  • Some Recent Advances

    When is Valve Replacement Surgery Required?

    There are four valves in the heart namely Aortic, Mitral, Tricuspid and Pulmonary valve. These valves are unidirectional valves which allow blood to flow only in one direction. The mitral valve is situated in between the left atrium and left ventricle and aortic valve between the left ventricle and aorta. The tricuspid valve is between the right atrium and right ventricle and pulmonary valve between the right ventricle and pulmonary artery.

    To simplify the diseases of these valves, valves either become very narrow (stenotic) and they obstruct the forward flow of blood or they leak back (regurgitate) and become inefficient. In such conditions valve replacement surgery is required.

    What causes these conditions?

    The common diseases affecting the heart valves are :

    1) Rheumatic Fever This is the common cause in India. Classically rheumatic fever occurs in teenage, but the effect of the fever on the heart occurs much later. Rheumatic fever classically “Licks the joints and bites the Heart” meaning the effect on the joints is minimal but the effect on the heart valve is serious. Rheumatic fever destroys the heart valves and makes them either stenotic (narrow) or regurgitant (leaky).

    2) Degenerative valve disease. This is more common in the Western World but it is increasing in India also due to increased longevity. This mainly affects the mitral and aortic valves.

    3) Congenital Problems Some people are born with defective heart valves eg : bicuspid aortic valve meaning the aortic valve has only two leaflets instead of three.

    4) Other Conditions: Rarer condition like collagen disease, infective endocarditis etc., can also affect the heart valves.

    What are the most common symptoms that patients are able to notice?

    The following are some of the symptoms that are noticeable:

    Palpitation: This is an increased awareness of one’s heart beat and it can make the person quite uncomfortable.

    Breathlessness: This is difficulty in breathing, especially on effort such as going uphill or climbing stairs.

    Paroxysmal nocturnal dyspnoea (PND): In this case the patient wakes up in the middle of the night or early morning with a sudden bout of breathing difficulty.

    Black outs: This is a serious symptom seen with narrowing of aortic valve and often signifies severe reduction in forward blood flow from the heart.

    There are some other rare symptoms pertaining to infection of heart valves namely very high spiking temperature seen with infective endocarditis (infection of the heart valves) or angina seen with severe narrowing of aortic valve (aortic stenosis).

    What are the treatment options before a person with heart valve problems?

    The different options available for treatment are

    1) Medication. In early stages the cardiologist tries to manage the problem with medicines. Diuretics may be prescribed.

    2) Repair. If the valve is not damaged much, valve repair is suggested. The patient’s own valve is repaired using special techniques and rings . However this can be used only for the mitral and tricuspid valves and does not work well on the aortic valve.

    3) Replacement. If the valve is diseased beyond a point valve replacement is performed. This is often the only resort available in most patients. There are predominantly two types of heart valves which can be used, 1) Mechanical heart valve made out of pyrolitic carbon and titanium 2) Tissue valves which are made from porcine (pig’s) aortic valve or from bovine (cow’s) pericardium

    How is a diagnosis made?

    The patient is assessed using echo cardiography and angiography. Echocardiography is the mainstay of assessment for heart valves. The heart function also can be assessed accurately using echocardiography. However most patients over the age of 35-40 will need coronary angiography to assess whether there is any additional coronary artery disease or not.

    Echo Cardiography is an ultrasound test that makes use of sound waves to examine the heart's structure and movements. This test is safe and painless. When a device is moved over the patient’s chest silent sound waves that bounce off the heart, create images of its chambers and valves. The echo can tell the doctor how thick the heart muscle is and how well the heart pumps.

    Coronary angiography is an X-ray examination of the blood vessels or chambers of the heart. A very small tube (catheter) is inserted into a blood vessel. A special fluid (called a contrast medium or dye) is injected. This fluid is visible by X-ray, and the doctor is able to view if there are blocks or valve problems. This test procedure has some risk for some patients and the cardiologist decides if the patient can undergo this test.

    Valve replacement, if done early has good results. However if valve replacement is delayed the ventricle can progressively dilate if the valve is regurgitant or get hypertrophied if the valve is stenotic. Very severe stage of dilatation can make surgery hazardous. Thus the risk of operation goes up if surgery is delayed.

    What really happens during surgery?

    After shifting the patient into the operating room he is anaesthetized and several monitoring lines are put to continuously record blood pressure, central venous pressure, heart rate etc. The chest is opened and the patient is put on to a “heart lung” machine which does the work of the heart and the lungs for the duration of the operation. The heart is stopped with a special solution rich in potassium and the diseased heart valves are cut out and replaced with the new valves using special stitches. After removing all air from the heart slowly blood is reintroduced into the heart and once the heart is beating adequately and effectively the patient is detached from the heart lung machine.

    ICU Stay

    Here the patient is continuously monitored for all vital parameters including BP, Heart rate, central venous pressure, urine output, blood oxygenation etc.,. Between four and twelve hours after surgery, if he is breathing well, the patient is removed from the ventilator. ( The Ventilator is the machine that helps the patient breathe).

    The usual stay in the ICU is 48 hrs after which the patient is shifted to the ward.

    Are there any complications that patients face in the post operative stage?

    Some of the minor problems that the patient can have after surgery are fluid retention, wound infection, irregular heart rhythm, pain, memory disturbances etc., Most of the problems are minor and can be managed easily with medication. In rare cases a patient with aortic valve replacement may develop a complete heart block and would need a pacemaker.

    What about long term care?

    Patient education is an important aspect of heart valve replacement. Most of our patients are young, and affected by rheumatic heart disease and often from poorer socio-economic strata. They have to be counseled about the care of mechanical heart valves, especially regarding life long anti coagulation to prevent thrombosis (choking) of the heart valve, as clot formation is a possibility. Regular testing for blood coagulation is essential and can be life saving. If not cared for properly the heart valve replacement operation carries great risk mainly when mechanical heart valves are used. Tissue valves however are more forgiving and do not have much complications for the first 12 to 15 years. However these valves start degenerating after that and may have to be replaced again. Hence in general we tend to use tissue valves in older patients and reserve mechanical valves for younger patients.

    Have you adopted any new techniques/met challenges in this sphere?

    We have a very strong, dedicated and highly efficient team to manage all sorts of complex heart valve operations. Some of the newer procedures we do are:

    Stentless aortic valve replacement This is a new type of heart valve procedure which is being done by only two teams in the country in significant numbers. This is a good option for the elderly patients with isolated aortic valve disease with or without coronary artery disease. This valve lasts much longer than other tissue valves, but is more difficult to implant and requires lot of training and expertise.
    Heart Valve replacement or repair with MAZE Procedure Several patients with mitral valve disease suffer from a condition called atrial fibrillation. This is an irregular heart beating which leads to complications like clot formation, stroke, palpitation etc., There is a new procedure called the MAZE operation where a special device delivering radio frequency current is used to set right the irregular electrical activity inside the heart.
    We have performed heart valve replacement in patients with advanced disease and associated co morbid conditions.
    Let me tell you of one case we operated on : The patient we operated on recently had enough problems to serve as a was a walking medical encyclopedia. He had aortic and mitral valve disease, liver cirrhosis, duodenal ulcer, renal impairment, left ventricular dysfunction presenting in NYHA class III to IV with frequent episodes of paroxysmal nocturnal dyspnea. He was often breathless even at rest. Normally this procedure with so many associated problems carries high risk and most surgeons would not be willing to tackle this problem. However we managed to get a successful result in this patient realizing that medical line of management had a zero percent chance of succeeding.

    Dr S Mukundan, is an MS in General Surgery, M Ch and DNB in Cardiovascular and Thoracic Surgery. Academically brilliant, he has been the winner of gold medals. He has international work experience and has worked in New Zealand and UK. Having served as the Chief of Cardiovascular Surgery at the prestigious Railway Hospital, Perambur, he has been the Chief of Cardiovascular Surgery at the Mallya Hospital, Trinity Hospital and Bhagwan Mahaveer Jain Heart Centre, Bangalore since 2002.

    He has performed nearly 6000 Open Heart Surgeries, including beating Heart Surgeries which he pioneered in Tamil Nadu. His area of specialization are procedures such as stentless aortic valve replacement and ventricular reconstruction (DOR). He is keen on water sports.

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