care of patients undergoing valvular heart surgerry

8/11/2019 Care of Patients Undergoing Valvular Heart Surgerry

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CARE OF PATIENTS

UNDERGOINGVALVULAR HEART

SURGERRY

PRESENTED BY:

MS.ANU SARANNYA

M.SC(N) II YEAR

ACON


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INTRODUCTION

When heart valves fail to open and closeproperly, the implications for the heart can

be serious, possibly hampering the heart's

ability to pump blood adequately through

the body.


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TERMINOLOGIES

COAPTATION:


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ANATOMY AND PHYSIOLOGY OF

VALVES

Valves are actually flaps (leaflets) that actas one-way inlets for blood coming into a

ventricle and one-way outlets for blood

leaving a ventricle.

Normal valves have three flaps (leaflets),

except the mitral valve, which only has two

flaps


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VALVES OF THE HEART

Tricuspid valve.This valve is locatedbetween the right atrium and the rightventricle.

Pulmonary valve. The pulmonary valve is

located between the right ventricle and thepulmonary artery.

Mitral valve.This valve is located betweenthe left atrium and the left ventricle.

Aortic valve.The aortic valve is locatedbetween the left ventricle and the aorta.


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ATRIO VENTRICULAR VALVES

Mitral valve Tricuspid valve


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SEMILUNAR VALVES

Aortic valve Pulmonary valve


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ATRIOVENTRICULAR VALVE

These are the mitral and tricuspid valvessituated between the atria and the ventricles thatprevent backflow from the ventricles into theatria during systole.

They are anchored to the walls of the ventricles

by chordae tendineae, which prevent the valvesfrom inverting.


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The chordae tendineae are attached topapillary muscles that cause tension tobetter hold the valve.

Together, the papillary muscles and the

chordae tendineae are known as thesubvalvular apparatus

opening and closure of the valves ISentirely by the pressure gradient across

the valve


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The mitral valve is also called the bicuspidvalve because it contains two leaflets or

cusps.

The mitral valve gets its name from theresemblance to a bishop's mitre (a type of

hat).

It is on the left side of the heart and allows

the blood to flow from the left atrium into

the left ventricle.


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The closure of the AV valves is heard aslub, the first heart sound (S1). The closure

of the SL valves is heard as dub, the

second heart sound (S2).


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SEMILUNAR VALVES

The semilunar valves, the aortic and thepulmonary valves, are located at the base

of the aorta and the pulmonary trunk or

artery, and the aorta.

These two arteries receive blood from the

ventricles and their semilunar valves

permit blood to be forced into the arteries,

and prevent backflow from the arteries into

the ventricles


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SEMILUNAR VALVES

The valve opens in ventricular systole,when the pressure in the ventricle

rises above the pressure in the

artery. At the end of ventricularsystole, when the pressure in the

ventricle falls rapidly, the pressure in

the artery will close the pulmonaryvalve.


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SEMILUNAR VALVES

The closure of the aortic valve contributesthe A2 component of the second heart

sound (S2).

The closure of the pulmonary valvecontributes the P2 component of the

second heart sound (S2)


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HEART VALVE DISEASE

Valvular heart disease is any disease processinvolving one or more of the four valves of the

heart (the aortic and mitral valves on the left and

the pulmonary and tricuspid valves on the right).

Collectively and anatomically, the valves are partof the dense connective tissue makeup of the

heart known as the cardiac skeleton.

Valve problems may be congenital (inborn) or

acquired (due to another cause later in life).


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REGURGITATION

This means the valve doesn't closecompletely, causing the blood to flow

backward through the valve.

This results in leakage of blood back intothe atria from the ventricles (in the case of

the mitral and tricuspid valves) or leakage

of blood back into the ventricles (in the

case of the aortic and pulmonary valves).


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STENOSIS

The valve opening is narrowed and thevalve doesn't open properly, inhibiting the

ability of the heart to pump blood across

the narrowed valve due to the increased

force required to pump blood through the

stiff (stenotic) valve(s).


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ATRESIA

This means the valve opening doesn'tdevelop at all, preventing blood from

passing from an atria to a ventricle, or

from a ventricle to the pulmonary artery or

aorta. Blood must find an alternate route,

usually through another existing congenital

(present at birth) defect, such as an atrial

septal defect or a ventricular septal defect.


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Valve involved Stenotic disease Insufficiency/regurgitation

disease

Aortic valve Aortic valve stenosis Aortic

insufficiency/regurgitation

Mitral valve Mitral valve stenosis Mitral


Tricuspid valve Tricuspid valve

stenosis

Tricuspid


Pulmonary valve Pulmonary valvestenosis

Pulmonaryinsufficiency/regurgitation


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Aortic and mitral valve disorders,Theseare termed left heart diseases.

Pulmonary and tricuspid valve disorders

are right heart diseases. Pulmonary valvediseases are the least common heart

valve disease in adults.


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DYSPLASIA

Heart valve dysplasia is an error in thedevelopment of any of the heart valves,and a common cause of congenital heartdefects in humans as well as animals;

tetralogy of Fallot is a congenital heartdefect with four abnormalities, one ofwhich is stenosis of the pulmonary valve.Ebstein's anomaly is an abnormality of the

tricuspid valve


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RHEUMATIC HEART DISEASE

Valvular heart disease resulting fromrheumatic fever is referred to as

"rheumatic heart disease".


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SURGICALMANAGEMENT

MITRAL VALVE ANNULOPLASTY


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MITRAL VALVE ANNULOPLASTY

Mitral regurgitation is the most commonform of mitral valve dysfunction. Todaymore than 2.5 million Americans areestimated to be affected by mitral

regurgitation. This number is expected to double by the

year 2030. Every year, 300,000 peopleworldwide undergo open heart surgery formitral valve repair, 44,000 people in theUS alone


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GOAL The goal of mitral valve annuloplasty is to

regain mitral valve competence by restoring

the physiological form and function of the

normal mitral valve apparatus.


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SEMI RIGID RINGS


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The goal of semi-rigid rings is to maintaincoaptation and valve integrity during

systole, while allowing for good

hemodynamics during diastole. Rigid rings

are designed to provide rigid support in

large dilation and under high-pressure.


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Annuloplasty devices are classified by theU.S. Food and Drug Administration (FDA)as class II medical device. According tothe FDA following issues need to beaddressed before annuloplasty rings can

be approved for marketing: Biocompatibility testing

Computational structural analysis

Tensile testing


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Suture pull-out testing

Sterilization validation

Biological testing including bioburden and

pyrogen testing

Shelf-life validation

MINIMALLY INVASIVE


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MINIMALLY INVASIVE

ANNULOPLASTY

New technologies that allow for minimallyinvasive surgery have also begun to

change mitral valve surgery. A number of

devices and techniques have been

developed that do not necessitate open-

heart surgery for the repair of the mitral

valve


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BALLOON MITRAL VALVOTOMY

Balloon valvotomy

successfully opens

the narrowed valve

and improves the

overall function of theheart


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INDICATIONS

select patients who have mitral valvestenosis with symptoms

older patients who have aortic valve

stenosis, but are not able to undergo

surgery

some patients with pulmonic valve

stenosis


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PROCEDURE

Long, slender tubes called catheters arefirst placed into blood vessels in the groin

and guided into the chambers of the heart

The catheter is positioned so the balloon

tip is directly inside the narrowed valve

When the opening of the valve has been

widened enough, the balloon is deflated

and removed.


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COMMISUROTOMY

Fused valve leaflets, or flaps, areseparated to widen the valve opening.

A median sternotomy is generally used,

but a right antero-lateral thoracotomy

through a submammary incision is an

excellent optional approach for mitral

commissurotomy and may be preferred for

cosmetic reasons


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If there is localised calcification

of the commissures,debridement with a rongeur is

carefully performed first,

avoiding injury of the leaflets

Often, the commissural

chordae are thickened andshortened and the papillary

muscle may even come right to

the leaflet. When this happens,

the head of the muscle is

incised longitudinally to permita wide separation of the

leaflets


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One of the advantages of the opencommissurotomy is the possibility of

immediate assessment of the valve

anatomy and function. This is usually done

by pressurising the left ventricle with salineinjected through the mitral valve with a

bulb syringe


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Method of testing by

pumping saline

through an apical LV

vent cannula. Air is

allowed to escapethrough an aortic root

vent.


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VALVE REPLACEMENT

Mechanical -- made of man-madematerials, such as titanium and carbon.These valves last the longest. You willneed to take blood-thinning medicine,

such as warfarin (Coumadin) or aspirin, forthe rest of your life.

Biological -- made of human or animaltissue. These valves last 10 - 12 years, butyou may not need to take blood thinnersfor life


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BIOPROSTHETICVALVE

MECHANICALVALVE


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VALVE REPLACEMENT SURGERY

Valve replacement surgery is thereplacement of one or more of the heart

valves with either an artificial heart valve

or a bioprosthesis (homograft from human

tissue or xenograft e.g. from pig). It is analternative to valve repair


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AORTIC VALVE REPLACEMENT


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AORTIC VALVE REPLACEMENT

Aortic valve replacement is a procedure inwhich a patient's failing aortic valve is

replaced with an artificial heart valve. The

aortic valve can be affected by a range of

diseases; the valve can either becomeleaky (aortic insufficiency / regurgitation)

or partially blocked (aortic stenosis).


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Current aortic valve replacementapproaches include

open heart surgery,

minimally invasive cardiac surgery (MICS)

minimally invasive, catheter-based

(percutaneous) aortic valve replacement.

TISSUE VALVES


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TISSUE VALVES

Tissue heart valves are usually made fromanimal tissue, either animal heart valve

tissue or animal pericardial tissue. The

tissue is treated to prevent rejection and

calcification

homograft - a human aortic valvecan be

implanted.


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Another procedure for aortic valve replacement

is the Ross procedure(or pulmonary autograft).

In a Ross procedure, the aortic valve is removed

and replaced with the patient's own pulmonary

valve. A pulmonary homograft (pulmonary valvetaken from a cadaver) is then used to replace

the patient's own pulmonary valve. This

procedure was first used in 1967 and is used

primarily in children, as the procedure allows thepatient's own pulmonary valve (now in the aortic

position) to grow with the child.

ROSS PROCEDURE


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ROSS PROCEDURE

The Ross Procedure is a type ofspecialized aortic valve surgery where thepatient's diseased aortic valve is replacedwith his or her own pulmonary valve. The

pulmonary valve is then replaced withcryopreserved cadaveric pulmonary valve.In children and young adults, or olderparticularly active patients, this procedure

offers several advantages over traditionalaortic valve replacement withmanufactured prostheses


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The pulmonary valve and a segment of the pulmonary

artery are excised. This pulmonary segment will later be

placed in the aortic position replacing the diseased aortic

valve.


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The diseased aortic valve and proximal tissue is

removed, leaving the right and left coronary arteries

with only a button of tissue.


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The pulmonary autograft is placed in the aortic position and the

buttons of tissue on both the right and left coronary arteries are

then sewn into that pulmonary segment and closed. A cadaveric

pulmonary valve and artery homograft is then replaced in the

pulmonary position to replace the excised pulmonary segment.

PROCEDURE


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PROCEDURE

Aortic valve replacement is most frequently done

through a median sternotomy, meaning theincision is made by cutting through the sternum.

Once the pericardium has been opened, thepatient is put on a cardiopulmonary bypass

machine, also known as the heart-lung machine.This machine takes over the task of breathing forthe patient and pumping their blood aroundwhile the surgeon replaces the heart valve.

Once the patient is on bypass, a cut is made in

the aorta and a crossclamp applied.


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The surgeon then removes the patient's diseased aortic

valve and a mechanical or tissue valve is put in its place. Once the valve is in place and the aorta has been

closed, the patient is taken off the heart-lung machine.

Transesophageal echocardiogram (TEE, an ultra-soundof the heart done through the esophagus) can be used to

verify that the new valve is functioning properly. Pacing wires are usually put in place, so that the heart

can be manually paced should any complications ariseafter surgery.

Drainage tubes are also inserted to drain fluids from the

chest and pericardium following surgery. These areusually removed within 36 hours while the pacing wiresare generally left in place until right before the patient isdischarged from the hospital

MITRAL VALVE REPLACEMENT


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MITRAL VALVE REPLACEMENT

Mitral valve replacement is a cardiac surgical

procedure in which a patients diseased mitralvalve is replaced by either a mechanical orbioprosthetic valve. Mitral valve replacement isperformed when the valve becomes too tight

(mitral valve stenosis) for blood to flow into theleft ventricle, or too loose (mitral valveregurgitation) in which case blood can leak backinto the left atrium and thereby back into the

lung. Mitral valve disease can occur frominfection, calcification, inherited collagendisease, or other causes

SURGICAL PROCEDURE


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SURGICAL PROCEDURE

Patients having mitral valve surgery receive general

anesthesia. Incision can be made somewhat horizontally under the

left breast, or vertically through the sternum.

After the heart is exposed, canulae are placed to reroutblood to a heart-lung machine for cardiopulmonary

bypass. An incision is made in the left atrium to expose the mitral

valve.

The valve is then replaced with either a biological ormechanical valve. The left artium is then closed, and the

patient weaned from cardiopulmonary bypass. Aftersurgery patients are typically taken to an intensive careunit (ICU).

TRICUSPID VALVE REPLACEMENT


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TRICUSPID VALVE REPLACEMENT

The tricuspid valve is often considered in the workup of

heart failure only after more prominent cardiacpathologies such as aortic, mitral, and coronaryatherosclerotic disease have been discussed, and assuch it has been referred to as the forgotten valve.

The sequelae of significant tricuspid regurgitation can be

significant however and include ascites,hepatosplenomegaly, pleural effusions, and peripheraledema.

Tricuspid regurgitation is usually secondary to left-sidedvalvular pathology (commonly the mitral valve) causingelevated pulmonary pressures with subsequent dilationof the tricuspid annulus.

Rheumatic disease, Ebstein's anomaly, and endocarditisare other important causes of tricuspid incompetence

SURGICAL PROCEDURE


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SURGICAL PROCEDURE

Aortic and bi-caval cannulation is

accomplished with direct cannulation ofthe superior vena cava (SVC) and inferiorvena cava (IVC).

Caval tapes are snared around the IVCand SVC to achieve right heart isolation

A caval clamp can be used alternatively inthe setting of significant adhesions. Anoblique right atriotomy is performed downto the IVC cannula, incorporating anyexisiting retrograde catheter site


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A self retaining retractor is used.

Occasionally pledgeted traction suturesare placed on the edges of the atriotomyto enhance exposure

The tricuspid valve is inspected and anassessment of repair versus replacementis made.

When repair is not feasible, our preferenceis to use a bioprosthetic bovine pericardialvalve.

The leaflets are left in place to preservethe sub-valvular apparatus.


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When prolapsing leaflets are large and

bulky, they are fenestrated along a radialaxis, which allows them to fold out of theway while preserving the tissue.

Everting 2-0 pledgeted Ticron sutures areplaced along the circumference of theannulus from the atrial to the ventricularside of the valve, starting at the anteriorleaflet and working clockwise. Great care

is taken when suturing near the AV nodealong the septal leaflet


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The AV node lies in the triangle of Koch

bordered by the tendon of Todaro, the

septal leaflet of the tricuspid valve and the

orifice of the coronary sinus. Careful

suture placement in this region ismandatory to avoid injury to the

conduction system


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The pulmonary artery catheter is replaced

through the valve and confirmed in

position in the pulmonary artery by

palpation.

The atriotomy is closed with 4-0

polypropylene sutures in two layers after

de-airing maneuvers. The caval tapes are

released and the patient is weaned fromcardiopulmonary bypass.

CHORDAL TRANSFER FOR REPAIR OF


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ANTERIOR LEAFLET PROLAPSE

Chordal transfer is a reliable technique for

correction of anterior leaflet prolapse. In mostcases, normal chordae and a strip of leaflettissue are transferred from the posterior leaflet tothe free edge of unsupported anterior leaflet; theposterior leaflet is repaired as after aquadrangular resection with either a slidingrepair or a standard repair.

Occasionally, secondary anterior leaflet chordaemay be transferred from the undersurface of the

anterior leaflet to its unsupported free edge,effecting a rapid and effective repair. Afterchordal transfer, annuloplasty completes themitral valve repair.

care of patients undergoing valvular heart surgerry

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