Heart Valve Repair or Replacement Surgery

What is heart valve repair or replacement surgery?

The heart is a pump made of muscle tissue. It has 4 pumping chambers: 2 upper chambers, called atria, and 2 lower chambers, called ventricles. Valves between each of the heart's pumping chambers keep blood flowing forward through the heart.

• Tricuspid valve. Located between the right atrium and the right ventricle

• Pulmonary valve. Located between the right ventricle and the pulmonary artery

• Mitral valve. Located between the left atrium and the left ventricle

• Aortic valve. Located between the left ventricle and the aorta

When valves are damaged or diseased and don't work the way they should, they may need to be repaired or replaced. Conditions that may cause heart valve dysfunction are valve stiffness (stenosis) and a leaky valve (regurgitation).

When one or more valves become stiff (stenotic), the heart has to work harder to pump the blood through the valve. Valves can become narrow and stiff from infections, such as rheumatic fever or staphylococcus, and aging. If 1 or more valves become leaky, blood leaks backward. This means less blood is pumped in the right direction. Based on your symptoms and the overall condition of your heart, your healthcare provider may decide that the diseased valve or valves need to be surgically repaired or replaced.

Traditionally, open heart surgery is used to repair or replace heart valves. A large incision is made in the chest and the heart is stopped for a time so that the surgeon can repair or replace the valves. Newer, less invasive techniques have been developed to replace or repair heart valves. Minimally invasive procedures use smaller incisions. Generally, you have less pain afterward and a shorter hospital stay.

The diseased valve may be repaired using a ring to support the damaged valve. The other option is to remove the entire valve and replace it with an artificial valve. Artificial valves may be made of carbon-coated plastic or tissue made from animal valves or human valves taken from donors. You and your healthcare provider will talk about the pros and cons of each type and what might be best for you.

Why might I need heart valve repair or replacement surgery?

Valve repair or replacement surgery is done to correct the problems caused by 1 or more diseased heart valves.

If your heart valve becomes damaged or diseased, you may have the following symptoms:

• Dizziness

• Chest pain

• Breathing problems

• Palpitations

• Swelling (edema) of the feet, ankles, or belly (abdomen)

• Rapid weight gain due to fluid retention

There may be other reasons for your healthcare provider to advise heart valve repair or replacement surgery.

What are the risks of heart valve repair or replacement surgery?

Possible risks of heart valve repair or replacement surgery include:

• Bleeding during or after the surgery

• Blood clots that can cause heart attack, stroke, valve dysfunction, or lung problems

• Infection

• Pneumonia

• Pancreatitis

• Breathing problems

• Arrhythmias (abnormal heart rhythms), sometimes requiring a pacemaker

• Problems with the function of the repaired or replaced valve

• Death

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for heart valve repair or replacement surgery?

• Your healthcare provider will explain the procedure. Be sure to ask any questions that you may have.

• You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if anything is unclear.

• Along with a complete health history, your provider may do a complete physical exam to make sure that you are in otherwise good health before surgery. You may need blood tests or other diagnostic tests.

• Follow any directions you're given for not eating or drinking before the surgery.

• If you're pregnant or think you could be, you should tell your provider right away.

• Tell your provider:

  • If you are sensitive or allergic to any medicines, iodine, latex, tape, or anesthetic agents (local and general)

  • About all medicines (prescription and over-the-counter), vitamins, herbs, and supplements that you're taking. You may be told to stop some of these medicines before surgery.

  • If you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medicine, aspirin, or other medicines that affect blood clotting. Your provider may do a blood test before surgery to see how long it takes your blood to clot.

  • If you have a pacemaker or any other implanted cardiac devices

• If you smoke, you should stop smoking as soon as possible. This improves your chances for a successful recovery from surgery. It also benefits your overall health.

Based on your medical condition, your healthcare provider may request other specific preparation.

What happens during heart valve repair or replacement surgery?

Heart valve repair or replacement surgery usually requires a stay in a hospital. Procedures may vary depending on your condition and your healthcare provider's practice.

Generally, open-heart valve repair or replacement follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2. You will change into a hospital gown and empty your bladder.

3. The surgical team will position you on the operating table, lying on your back.

4. An IV (intravenous) line will be placed in your arm or hand for injection of medicine and to give IV fluids. More catheters may be put in blood vessels in your neck and wrist to monitor the status of your heart and blood pressure, and to take blood samples.

5. The anesthesiologist will give you medicine to relax you and put you to sleep. They will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

6. Once you are sedated, a breathing tube will be inserted through your throat and into your lungs. You will be connected to a ventilator, a machine that will breathe for you during the surgery.

7. Your surgeon will place a transesophageal echocardiogram (TEE) probe into your esophagus (swallowing tube) to monitor the function of the valves.

8. A soft, flexible tube (called a Foley catheter) will be put into your bladder to drain urine.

9. A tube will be put through your mouth or nose into your stomach to drain stomach fluids.

10. Someone on the surgical team will clean the skin over your chest with an antiseptic solution. If there is a lot of hair at the surgical site, it may be clipped.

11. If you are having an open heart surgery, your surgeon will make an incision (cut) down the center of the chest from just below the Adam's apple to just above the navel. If you are having a less invasive procedure, smaller incisions will be used.

12. The sternum (breastbone) will be cut in half lengthwise. The surgeon will separate the halves of the breastbone and spread them apart to expose your heart.

13. To do the valve repair or replacement, your surgeon must stop your heart. They will put tubes into the heart so that the blood can be pumped through your body by a heart-lung bypass machine while your heart is stopped.

14. Once the blood has been completely diverted into the bypass machine for pumping, your surgeon will stop your heart by injecting it with a cold solution.

15. When the heart has stopped, your surgeon will remove the diseased valve and put in the artificial valve, in the case of a valve replacement. For a valve repair, the procedure done will depend on the type of valve problem you have. For instance, your surgeon may separate fused valve leaflets, repair torn leaflets, or reshape valve parts to ensure better function.

16. Once the surgery is done, your surgeon will shock your heart with small paddles to restart your heartbeat. Next, blood circulating through the bypass machine will be allowed to re-enter your heart. The tubes to the machine will be removed.

17. Once your heart is beating again, your surgeon will watch it to see how well the heart and valves are working. They'll also make sure there are no leaks from the surgery.

18. Your surgeon may put wires for pacing into your heart. These wires can be attached to a pacemaker outside your body for a short time and your heart can be paced, if needed, during the initial recovery period.

19. The sternum will be put back together.

20. Tubes may be put into your chest to drain blood and other fluids from around the heart.

21. Your surgeon will sew the skin over the sternum back together and close the incision with stitches or surgical staples.

22. A sterile bandage or dressing will be applied.

What happens after heart valve repair or replacement surgery?

In the hospital

After the surgery, a member of the surgical team will take you to a recovery room and, later, the intensive care unit (ICU) to be closely monitored for several days. Or you may be taken directly to the ICU. You will be connected to machines that will constantly display your electrocardiogram (ECG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. Open heart valve repair or replacement surgery generally requires an in-hospital stay of several days or longer.

You will most likely have a tube in your throat that's connected to a ventilator to help you breath until you are stable enough to breathe on your own. As you wake up from the anesthesia more and start to breathe by yourself, your healthcare provider can adjust the breathing machine to allow you to take over more of the breathing. When you are awake enough to breathe completely by yourself and are able to cough, your healthcare provider will remove the breathing tube. They may also remove the stomach tube at this time.

After the breathing tube is out, you will be encouraged to cough and take deep breaths every couple of hours. This will be uncomfortable due to soreness, but it is very important that you do this to keep mucus from collecting in your lungs and possibly causing pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

You will get pain medicine if you are hurting. Ask for the medicine before you become extremely uncomfortable.

You may get IV (intravenous) medicines to help your blood pressure and your heart and to control any problems with bleeding. As your condition stabilizes, your provider will gradually decrease then stop these medicines. Any pacing wires in your heart will also be removed. Once all the tubes have been removed and you are stable, you may start to drink liquids. You can start eating more solid foods as soon as you can tolerate them.

When your healthcare provider decides that you are ready, you will be moved from the ICU to a post-surgical unit or acute care unit. Your recovery will continue there. Your activity will be slowly increased as you get out of bed and walk around for longer periods. A member of your healthcare team will arrange for you to go home and schedule a follow-up visit with your provider.

At home

Once you're home, it will be important to keep the surgical area clean and dry. You will be given specific bathing instructions. Your healthcare provider will remove the stitches or surgical staples during a follow-up office visit, if they were not removed before leaving the hospital.

Don't drive until your healthcare provider tells you it's OK. Other activity restrictions may apply.

Tell your healthcare provider right away if you have any of these:

• Fever of 100.4°F (38°C) or as advised by your provider, or chills (these may be a sign of infection)

• Redness, swelling, bleeding, or drainage from the incision site or any of the catheter sites

• More pain around the incision site

• Trouble breathing

• More swelling in the legs or belly

• Easy bruising

• Lasting nausea or vomiting

• Fast or irregular pulse

• Weakness in the arms and legs

Your healthcare provider may give you other instructions after the procedure, depending on your situation.

Next steps

Before you agree to the test or the procedure, make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure