When one or more heart valves don’t function perfectly well, then two basic types of heart valve disease might occur: Stenosis and Regurgitation.
Narrowing that obstructs blood flow. This will force the heart to work harder to pump blood through the narrowing. It also increases pressure in the heart before the narrow valve.
It is also called insufficiency or incompetence, essentially a leaky valve. Blood can now also travel backward. The heart’s pumping action becomes inefficient since part of the blood energized by the heart flows backward. Secondly, to maintain adequate forward blood flow in the face of inefficiency, the heart has to work harder.
Combinations of the two types of Heart valve disease (HVD), i.e., stenosis and regurgitation, are very common and are called mixed heart valve disease. Whether the valvular disease is a result of infection, inflammation, degeneration, scarring, or fragility: valve repair or replacement might be necessary.
- Breathing difficulty
- Chest pain
- Fatigue, tiredness
- Dizziness or lightheadedness
- Irregular heartbeat
When a doctor sees a patient with these complaints, further tests are done to define the cause, nature, and extent of heart valve disease.
Key learning for patients:
- Firstly, you can expect to live a long, active and healthy life.
- Secondly, a detailed ECHOCARDIOGRAM (an ultrasound of the heart) can figure out the heart valve problem, its severity, and effects on the heart. It’s important that patient symptoms, valve disease, and the effects on the heart must correlate and explain each other before a plan is made regarding treatment. Many patients do not require surgical intervention for some years, and some young ladies can be encouraged to plan families during this time.
- Some patients with mild or moderate HVD could be monitored with a regular physical check, echocardiogram, and some other tests. Often these checks are required once every 1–2 years, with the provision that the patient can be seen earlier if needed.
- Commonly prescribed medications can slow down the disease progress, relieve symptoms and improve quality of life. Operating becomes necessary when patient symptoms aren’t well controlled despite medical treatment, and the echo or other tests predict worsening or risk of worsening in the near future.
Surgery for Heart Valve disease:
With appropriate preparation and assessment, most HVD patients can undergo safe heart valve surgery. In general, most patients can expect a risk of less than 2% for such operations. I look at many important factors, including the patient’s age, heart valve disease type, heart function, back-pressure effects on the lungs or other chambers of heart, the health of other organ systems, general fitness, steroid use, etc., before advising a heart valve operation
Mitral valve repair is commonly performed, and there are well-established techniques for this type of surgery. Aortic valve repair is becoming popular over the last five years. The chief advantage of heart valve repair surgery is that a large portion of natural tissues are maintained, keeping the basic architecture of the heart intact.
Natural surfaces also mean that the patient does not need to take blood thinner medicines for a long time after repair. Patients have improved longevity after mitral valve repair.
Most patients with heart valve disease undergo heart valve replacement. For a replacement, the surgeon generally removes the entire heart valve and positions either a mechanical heart valve or a biological valve (bioprosthesis). This is the rule for aortic valve replacements.
Some aortic valve disease patients have a very narrow space for a good size artificial heart valve, and we need to resort to the Aortic Root Enlargement procedure for the same.
For mitral valve replacements, one must make attempts to preserve all/ most/ some heart valve structures called chordae. We know from experience as well as research that preserving mitral valve structures is of great importance for the future.
For patients with aortic and mitral valve disease, we perform Double valve repair or replacement. Many patients with Tricuspid valve disease, in addition, would be treated by a triple valve procedure mostly involving double valve replacement and a tricuspid repair.
For patients undergoing heart valve surgery, sometimes we have additional important disease in the coronary arteries, and that’s treated with 1-4 bypass grafts at the same time.
Heart valve replacement procedure:
A heart valve replacement is performed under full general anesthesia. Surgeries are carried out either by full sternal division with a cut in the middle of the chest or by minimally invasive techniques. There are some clear benefits of minimally invasive cardiac surgery, provided your surgeon feels it’s a safe option for you.
For a safe heart valve surgery, it is vital that the body is kept well supplied by blood, oxygen, and nutrients by a machine (heart-lung machine) while the surgeon works on a still heart. Through an appropriate incision in the relevant part of the heat, the surgeon will approach the diseased valve, remove it and replace it with an appropriate sized and type valve. The cardiac structures are repaired, and the heart is allowed to commence function towards the end of surgery. Once a patient’s heart regains its function, the heart-lung machine is separated from the patient. The chest is closed, and the patient returns to recovery/ intensive care.
What patients frequently want to know?
- RISK of SURGERY
Over the past 3 decades, heart valve surgery has become very efficient and pain-free. Today we have better instruments, better valves and repair materials, better surgery and anesthesia techniques, better control of risk factors, and more efficient drugs. Most patients continue to enjoy great results even 15-20 years after surgery.
Most centers in India are operating with over 95% success rate, and better hospitals are witnessing 97-98% early survival. It’s a relatively safe operation.
- PAIN after SURGERY
All patients suffer pain after the surgery. This is well known for all types of operations. The truth is that chest surgery causes slightly less pain than a belly operation. Pain will make a patient eat less, walk less, talk less, exercise less, sleepless, and in short, one can also become depressed. And I know this very well by closely observed in patients over 35 years of age.
I insist that my patient should not suffer pain after surgery. A pain-free patient (or nearly pain-free patient) is more active from early after surgery and able to enjoy life fully. Since most of my patients start to perform exercise normally very soon after the recovery phase and after they don’t suffer complications of inactivity.
- RECOVERY & REHABILITATION AFTER SURGERY
These follow a normal recovery pattern as after any open chest procedure, and most patients are discharged within 4-6 days after surgery.
- First 2 days
All patients are cared for in an intensive care unit for the first two days after surgery. A dedicated specialist cardiac surgery postop care nurse is with the patient 24×7. Monitoring each and every vital parameter and we look after Pulse, BP, variety of pressures from within the heart chambers, lung function whether the patient is breathing by a machine or by themselves. Kidney, liver, brain functions, need for blood transfusion and intravenous fluids, etc., are also monitored.
There is a dedicated Cardiac Surgery and a Cardiac Anaesthesia Doctor in the hospital only for Cardiac Surgery patients to supervise the nurses. I am also available round the clock for any issues for which doctors or nurses might seek advice.
- Next 3-5 days
Most patients start to walk to the bathroom before this stage, food progressively becomes more interesting, and they are shifted to the SICU or ward depending upon many clinical factors. While nurses and doctors are always around, this time is spent making patients more and more independent for their daily needs.
- Blood thinners
All patients are commenced on blood thinners within the first couple of days after surgery.
Blood must be adequately thin before the patient is discharged. We monitor the thinness of blood by a test called INR, and a ratio of 2-3.5 is adequate for most patients. Depending upon the type of heart valve and some patient variables, a different ratio is often prescribed for the patient.
- Day of discharge
A patient and a relative are educated in a rehabilitation class by a rehabilitation expert. All patients learn to get in and out of bed unsupported. Patients are expected to travel home by car, sitting in the front seat with a towel between the chest and seat belt. All patients are asked to climb stairs and not be carried in chairs as it can cause makeshift palanquin.
Bathing is almost always allowed, as suggested by doctors and nurses onwards. Exercises as per embedded video .
- First review after a week
Some blood tests, an ECG, and CXR are required at this clinic attendance. Most patients can start short walks in the local parks and increase exercise.
- A month after surgery
Most self-employed people who can control their timings are back to work by this time; people in employment need about 2 months to regain strength.