Nursing care of young patient with aortic valve replacement for bicuspid aortic valve and aortic valve stenosis

Jayamenon1, Umarani2, Jasmine3

1Nursing Superintendent, Kauvery Heart city, Trichy, India

2Assistant Nursing Superintendent, Kauvery Heart city, Trichy, India.

3Nursing Supervisor, Kauvery Heart city, Trichy, India.

Abstract

Bicuspid Aortic Valve:

A bicuspid aortic valve is a congenital heart defect where the aortic valve has two leaflets instead of the normal three, which can lead to complications like aortic stenosis (narrowing), aortic regurgitation (leaking), or an enlarged aorta. This condition is present at birth and is the most common congenital heart defect. . It can be hereditary and passed down through families. It affects approximately 1% to 2% of the population3.

Individuals with a bicuspid aortic valve may also have other heart defects or conditions like Marfan syndrome.

Bicuspid Valve

Aortic Valve Stenosis

Aortic valve stenosis (AS) is the narrowing of the aortic valve, which restricts blood flow from the left ventricle of the heart to the aorta. This forces the heart to work harder to pump blood, which can lead to damage over time. The condition typically worsens with age and can cause major health problems, including heart failure and death, if left untreated1.

Symptoms

  • Chest discomfort or pain
  • Shortness of breath, especially during exercise
  • Fatigue
  • Feeling dizzy, lightheaded, or fainting
  • Heart palpitations (a fast, fluttering heartbeat)
  • Ankle or foot swelling

Causes for Aortic Valve Stenosis

  • Aortic valve calcification
  • Congenital heart defects
  • Rheumatic fever

Medical history of the patient

A 29-year-old female, married, was admitted for Aortic Valve Replacement. She married in 2018 and has two daughters. Two female children were born by cesarean section. She is the youngest child in her family. She experienced her first episode of breathing difficulty 8 months into her first pregnancy and visited a nearby hospital where she was referred to a Cardiology Specialty Hospital.

They evaluated her and performed an ECHO, diagnosing her with a Bicuspid Aortic Valve with stenosis. She was recommended to continue medication and avoid additional pregnancies. She didn’t have consistent follow-up with any specialties and had her second daughter, undergoing a tubectomy at 26 years old. She came to Kauvery Hospital Heart City, and she was seen and evaluated by the doctor and he advised for Aortic Valve Replacement.

Diagnostic Evaluation

  • ECG
  • ECHO
  • Trans Esophageal Echo Cardiogram
  • Cardiac MRI
  • CT Aortogram

Pre OP ECHO

  • Normal chambers dimension
  • No RWMA
  • Good LV function (EF -60%)
  • E/e -7
  • Aortic valve
    • Bicuspid aortic valve
    • Severe aortic stenosis
    • Aortic valve gradient – 60/40 mmhg
    • Mild AR
    • Aortic annulus -19mm
  • Mild TR/mild PAH
  • RVSP – 26 (+) rap
  • Septae intact
  • No pericardial effusion / clot

Impression

  • Bicuspid aortic valve
  • Mild AR
  • Good LV function
  • Mild / mild PAH

ECG: Left Ventricular Hypertrophy by voltage criteria

Chest X-Ray

Operation notes

Diagnosis: Severe Aorta stenosis / bicuspid aorta vale EF 60%

Operation done: Aortic valve replacement (- 17 mm TTK Chitra Mechanical valve)

Findings

1) Narrow aortic annulus

2) Calcified, stenotic, bicuspid aortic valve seen

Procedure

Chest opened by a median sternotomy. Aortic and RA cannulation done. Antegrade del Nido plegia given Cooled to 32°C.

Aorta opened by a transverse aortotomy. Valve excised. A 17 MM TTK Chitra mechanical aortic valve replaced using interrupted 2-0 Esterlus pledgeted sutures (pledgeted on LV side).

Aorta closed in two layers with continuous 5-0 prolene sutures. Rewarming done, hot shot given. Weaned off CPB in sinus rhythm. Decannulation done. Sites reinforced. One ventricular pacing wire placed. Pericardium closed over the aorta.

Dense right pleural adhesion and right pleural cavity partially opened. Chest closed with no -6 steel wires after placing one right pleural and one mediastinal chest tubes. The patient was shifted to ICU with stable vitals with moderate inotropic supports.

Post OP ECHO

  • Tachycardia during study
  • Normal chambers dimension
  • No RWMA
  • Good lv function (EF -60%)
  • Trivial MR
  • Aortic valve: s/p AVR
  • Normally functioning aortic valve prosthesis
  • Aortic valve gradient – 37/20 mmHg
  • No paravalvular leak
  • Trivial TR / no PAH
  • Septae intact
  • Mild pericardial effusion (+)
  • No clot

Impression

  • S /p AVR
  • Normally functioning aortic valve prosthesis
  • Good LV function
  • Mild pericardial effusion (+

Nursing Management Pre – Operative

  1. Routine blood investigation like – CBC, RFT, etc., done for surgery
  2. Informed consents are obtained after counselling the patient and attender
  3. Blood was arranged for surgery
  4. IPSG goals assessed
  5. WHO surgical safety checklist was done
  6. Patients were hemodynamically monitored
  7. Skin preparation was done, and povidone bath was given.
  8. NPO explained and maintained

Post – Operative

Patient got stabilized and transferred to the post-operative ward and connected to the mechanical ventilator

Bi lateral air entry level checked.

  1. Transferred to specialized cost with sterile equipment & clothes
  2. Monitored vital signs hourly and recorded.
  3. Monitored ICD drainage level and check for inside operation site drains are clotted or bleeding.
  4. Bundles care rendered properly.
  5. Placed under warmer for thermoregulation, according to patient demand at least for initial four hours.
  6. Chest X – ray was taken to obtain the baseline lung assessment.
  7. Vitals are stable, BP maintained.  Patient was extubated after being conscious & oriented.

Patient Health Education

  • Personal Hygiene
  • Wound care
  • Active and passive exercise
  • Breathing exercise
  • Avoid strenuous activity
  • Watch for Intake and urine output.
  • Diet advice –Acitrom diet, High fiber, High protein, Rich in Vitamin C
  • Avoid strain during defecation
  • Regular follow up and medication

Outcome

Patient condition improved and was discharged in a stable condition, on anticoagulants, with INR within optimal range. Patient and attenders were highly satisfied with our management treatment and nursing care.

Reference

  • Libby P, et al., eds. Aortic valve stenosis. In: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Aug. 17, 2024.
  • Aortic valve stenosis (AVS) and congenital defects. American Heart Association. https://www.heart.org/en/health-topics/congenital-heart-defects/about-congenital-heart-defects/aortic-valve-stenosis-avs. Accessed Aug. 16, 2024.
  • Braverman AC. Clinical manifestations and diagnosis of bicuspid aortic valve in adults. https://www.uptodate.com/contents/search. Accessed Aug. 16, 2024.
  • Braverman AC. Bicuspid aortic valve: General management in adults. https://www.uptodate.com/contents/search. Accessed Aug. 16, 2024.

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment