A case report on open heart valve replacement

Muthuselvi1, J. Sheetal2

1Senior Staff Nurse, Kauvery hospital, Thirunelveli, Tamil Nadu

2Nursing Supervisor, Kauvery hospital, Thirunelveli, Tamil Nadu

Abstract

Heart valve replacement surgery is a procedure performed to treat heart valve disease, a condition characterized by damage or dysfunction of one or more of the heart’s four valves: the aortic valve, mitral valve, tricuspid valve, and pulmonary valve. When a valve becomes diseased, it can cause symptoms such as shortness of breath, chest pain, fatigue, and fainting spells. Severe valve disease can lead to heart failure and other serious complications.

Open-heart valve repair/replacement is widely used to treat various valvular pathologies. The development of percutaneous valve replacement technology may pave the way for less invasive treatment options. This study characterized the epidemiology of valvular repair and replacement procedures in the U.S. The Nationwide Inpatient Sample (NIS) was used to identify closed and open heart valvotomy, heart valve replacement, annuloplasty, and percutaneous valvotomy procedures between 1993 and 2007. NIS is an annual survey of ∼1,000 hospitals and contains 20% of the U.S. inpatient hospitalizations. The prevalence of these procedures was calculate as a function of age, gender, race, census region, and type of hospital.

Introduction

Rheumatic multivalvular disease is typically associated with annular narrowing, especially of the aortic valve, and even more so when it is accompanying by mitral valve involvement. Here is everything you need to know about heart valve replacement surgery. Including the types of replacements:

Types of Heart Valve Replacement Surgery

Aortic Valve Replacement (AVR)

The aortic valve controls blood flow from the heart has left ventricle to the aorta, the main artery that carries oxygen-rich blood to the body.

AVR is performed to replace a damaged or diseased aortic valve with a mechanical valve or a bio prosthetic valve (tissue valve).

Mechanical valves are made of durable materials such as metal or carbon and typically, last a lifetime but require lifelong anticoagulant medication to prevent blood clots.

Bio prosthetic valves are made from animal tissue (such as porcine or bovine) or human tissue (from cadavers). They do not require lifelong anticoagulant therapy but may need replacement after 10-15 years.

Mitral Valve Replacement (MVR)

The mitral valve regulates Aortic and mitral valve surgery

 

Treatment

Heart valve disease treatment depends on

  • The symptoms.
  • The severity of the disease.
  • If the heart valve problem is getting worse.

Treatment may include

  • Regular health check-ups.
  • Lifestyle and diet changes.
  • Surgery to repair or replace the valve.

Medication

Some people with heart valve disease need medicines to treat their symptoms. Blood thinners may be given to help prevent blood clots.

Surgery of other Procedures

  • A diseased or damaged heart valve might eventually need to be repaired or replaced, even if you do not have symptoms.
  • If you need surgery for another heart condition, a surgeon might do valve repair or replacement at the same time.
  • Methods to repair or replace heart valves include open-heart surgery or minimally invasive heart surgery. Surgeons at some medical centers may do robot-assisted heart valve surgery. The type of heart valve surgery done depends on many things, including age, overall health, and the type and severity of heart valve disease.

Heart Valve Repair

If you have heart valve disease, your health care team might suggest surgery to repair and save your heart valve. During heart valve repair, the surgeon might:

  • Patch holes in a valve.
  • Separate valve flaps that have connected.
  • Repair the structure of the valve by replacing torn or ruptured cords that support it.
  • Remove excess valve tissue so that the valve can close tightly.
  • Reduce the outer size of the valve so the flaps can better contact each other.

Heart valve repair procedures include

Annuloplasty:  A surgeon tightens or reinforces the outer ring around the valve. This surgery may be done with other treatments to repair a heart valve.

Valvuloplasty: This surgery is used to repair the flaps of the valve. It is often done to repair mitral valve prolapse. The surgeon inserts a flexible tube with a balloon on the tip into an artery in the arm or groin area. The surgeon guides the tube to the affected heart valve. The balloon is inflated. This widens the valve opening. The balloon is deflated, and the tube and balloon are removed. Sometimes clips or plugs are passed through the tube to repair the heart valve.

Case Presentation

A 58yrs old Female, Admitted with Complaints of Dyspnoea while walking On the Stairs, DVR [Double Valve Replacement] surgery. Patient Echo and ECG taken. Patient Known Case off CAD on 2 Weeks before Present.MV and AV Thickened. Mild MS, moderate MR, moderate AS, moderate AR, RA, LV dilated, normal lv systolic function, mild LVH. Then patient diagnosed then plan for double valve replacement.

On Clinical Assessment

  • BP: 100/50 mm/hg,
  • HR: 78b/mts,
  • Resp: 18b/ mts,
  • Tem: 98.60F
  • SPo2: 99%

Pre-Operative Investigation

Lab Investigation

HB 9.4
PCV27.8
WBC16130
Platelet201000
PT [Prothrombin Time]-16.0
Potassium4.5
Sodium132.4
Urea25.19
Creatinine– 1.18
Blood grouping typingB* Positive
Triple hNegative
Bleeding time3min
Clotting time4min

ECG

After informed consent. Pre medications given. Pre investigation enclosed. anesthetist fitness was obtained and patient underwent DVR- MVR with 17mm mitral valve/AVR with 18 mm miltonia valve replacement was done.

Operational Notes

  1. Median sternotomy pericardium opened.
  2. Heparinised opened. Heparinised CPB estabilize by aorta bicaval cannulation LV vented via RSPV .AXC  heart arrested by ostial delnido CP.
  3. Heart cooled to 29-degeree celcius.transverse aortotomy done.
  4. Aortic Valve excised SVC and IVC and IVC snugged RA .Opened.
  5. IAS opened mitral valve excised replaced with 27mm mitonia valve with 2.0 ethibound interrupted pledgetted mattress sutures.
  6. Aortic valve replacement done using 18mm miltonia valve with 2.0 ethibound interrupted pledgetted mattress suture.Aortotomy closure done rewarmining started.IAS closed heart deaired AXC released. Heart picked up in controlled AF rhythm. RA closed.
  7. On full rewarming came off CPB protamine given. Heart decannulated haemostasis secured.
  8. Routine closure done with drain tube and pacing wire insitu.
  9. TEE done showed normally functioning aortic and mitral valve prosthesis.

Aortic Valve Surgery: Ross Procedure (Auto transplant of pulmonic valve to the aortic position)

  • Re-implantation of the coronary arteries
  • Homograft valve in the pulmonic position
  • Indications
    1. Younger patients
    2. No anticoagulation
    3. Requires similar sized aortic and pulmonic roots

Post procedure uneventful. Patient was shifted to CT ICU with ventilator.

CT – ICU Care

  1. After surgery, patient was taken to the intensive care unit and monitored.
  2. Cardiac monitors – to monitor vital signs
  3. Patient with Mechanical ventilator support.
  4. Infusion pumps – e g. Inj. NTG, Inj. Dobutamine, Inj. Nor adrenaline to regulate the Heart rate and BP.
  5. ICD tube connected with negative pressure suction.
  6. Pain medication given as appropriate.
  7. Inotropes slowly tapered and stopped.
  8. ICD Tube removed after 2 days.
  9. Patient hemodynamically stable and patient shifted to ward.

Treatment

  1. Tab. Acitrom 2mg OD
  2. Inj. Pitaz 4.5g IV TDS
  3. Tab.Ecospirin 75mg OD
  4. Inj. Pan 40 MG od
  5. T. dytor 5 mg BD
  6. T. Conco 2.5 mg OD
  7. T. Dolo 650 mg TDS
  8. Neb Duolin TDS
  9. Neb Budecort TDS

Nursing Management

  1. Counselling given to the attenders related to post op care.
  2. Healthy dietary habit advised, then explained avoid green leaf vegetables.
  3. Wound kept clean and healthy
  4. Chest physiotherapy given
  5. Encouraged spirometry exercises
  6. I/O chart maintained. Early ambulation is done Educated the patient to avoid weight lifting.
  7. After 1 week INR to be checked in lab.
  8. Early ambulation is done Educated the patient to avoid weight lifting.

Post OP Chest X-ray

S/P MVR AND AVR: Mitral & aortic prosthetic valve in situ functioning normally, mild LV Systolic dysfunction, atrial fibrillation during the study. LA dilated. LVH (mild) pericardial effusion behind RA, RV, LV,Left side pleural effusion present.

Dietary advice

During the post-operative period clear liquid was given, followed by liquid diet is started. After that semi solid diet was given to patient, which was tolerated and after that advised to take potassium rich diet and avoid green leafy vegetables.

Condition at Discharge:

General condition was good

Vitals stable

Discharge Advice

S.noDrug nameStrengthFrequencyRouteRelationship with mealDays
MAN
1T. Abphylline101oralafter food1 week
2T. Warfarin¾ mg01(6pm)0oralafter foodalternative day
3T. Ecosprin75 mg011oralafter food1 week
4T. Dytor plus10mg01/20oralafter food1 week
5T. Ultracetoralafter foodsos
6T. Cardarone50 mg100OralAfter food1 week
7T. Digoxin0.25mg100OralAfter foodAlternative day
8T. vibact100oralafter food1 week
9T. becosule100oralafter food1 week
10T. ceftas200mg101oralafter food1 week
11T. clonotril0.25mg001oralafter food1 week
12T. Prolomet xl12.5mg100oralafter food1 week
13T. Pan DSR40mg100oralbefore food1 week

Follow Up

Review after 1 week with ECG, ECHO, and urea. creatinine, sodium, potassium, PT INR, In case of any breathlessness, bleeding, pain, swelling around the surgical site.

Conclusion

DVR can be a life-changing procedure for individuals with severe heart valve disease, offering a chance for improved health and quality of life.

Reference

  • Ravi Kumar, S.V. and S. Siva Nagaraju, 2007. Power quality improvement using d-statcom and DVR. Int. J. Elect. Power Eng., 1
  • John Newman, , D. Grahame Holmes, J. Godsk Nielsen and F. Blaabjerg, 2003. A Dynamic Voltage Restorer (DVR) with selective harmonic compensation at medium voltage level
  • Moreno-Munoz, A., D. Oterino, M. González and F.A. Olivencia, 2006. Study of Sag Compensation with DVR: Benalmádena (Málaga), Spain. IEEE MELECON May, pp: 16-19.
  • Stump, M.D., G.J. Kaene and F.K.S. Leong, 1998. Role of custom power products in enhancing power quality at industrial facilities. In: Conf. Rec. IEEE/EMPD, pp: 507-517.
  • Li, B.H., S.S. Choi and D.M. Vilathgamuwa, 2001. Design considerations on the line-side filter used in the dynamic voltage restorer: IEE Proc. Generat. Transmission Distribut., 148: 1-7.

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