seminar valve reconstruction and replacement
TRANSCRIPT
SEMINAR ON
VALVE RECONSTRUCTION
AND REPLACEMENT
PRESENTED BY,UMADEVI.K
IIND YEAR MSC NURSINGTHE OXFORD COLLEGE OF NURSING
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INTRODUCTION Valve reconstruction has proved to be an
effective, reproducible and durable treatment for life-threatening Cardiac diseases.In the United States, surgeons perform about 99,000 heart valve operations each year. Nearly all of these operations are done to repair or replace the mitral or aortic valves. These valves are on the left side of the heart, which works harder than the right. They control the flow of oxygen-rich blood from the lungs to the rest of the body.If valve damage is mild, doctors may be able to treat it with medicines. If damage to the valve is severe, surgery to repair or replace the valve may be needed.
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HEART VALVES
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HEART VALVE REPAIR
Heart valve repair is a surgical technique used to fix defects in heart valves in valvular heart diseases, and provides an alternative to valve replacement.
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GENERAL TECHNIQUES TO REPAIR VALVES
COMMISSUROTOMY For narrowed valves, where the
leaflets are thickened and perhaps stuck together. The surgeon opens the valve by cutting the points where the leaflets meet.
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COMMISURE
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VALVULOPLASTY
Valvuloplasty is the widening of a
stenotic valve using a balloon
catheter
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RING ANNULOPLASTY
When a valve loses its shape and
strength, it's unable to close tightly.
An annuloplasty gives the leaflets
support through ring-like devices
that your surgeon attaches around
the outside of the valve opening.
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RESHAPING The surgeon cuts out a section of a
leaflet. Once the leaflet is sewn back together, the valve can close properly.
DECALCIFICATION Decalcification removes calcium buildup
from the leaflets. Once the calcium is removed, the leaflets can close properly.
REPAIR OF STRUCTURAL SUPPORT which replaces or shortens the cords
that give the valves support (these cords are called the chordae tendineae and the papillary muscles). When the cords are the right length, the valve can close properly.
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PATCHING The surgeon covers holes or tears in
the leaflets with a tissue patch.
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TYPES
Mitral valve repair
Aortic valve repair
Tricuspid valve repair
Pulmonary valve repair
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MITRAL VALVE REPAIR
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Mitral valve repair is a cardiac
surgery procedure performed by
cardiac surgeons to treat stenosis
(narrowing) or regurgitation
(leakage) of the mitral valve. The
mitral valve is the "inflow valve" for
the left side of the heart.
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HISTORY
In 1923 Dr. Elliott Cutler of the Peter Bent
Brigham Hospital performed the world’s
first successful heart valve surgery - a
mitral valve repair. The patient was a 12-
year-old girl with rheumatic mitral
stenosis.
Replacement of the mitral valve with an
artificial valve in the 1960s
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TECHNIQUES
ANNULOPLASTY Inserting a cloth-covered ring
around the valve to bring the leaflets into contact with each other
QUADRANGULAR RESECTION removal of redundant/loose
segments of the leaflets
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QUADRANGULAR RESECTION
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RE-SUSPENSION of the leaflets with
artificial (Gore-Tex) cords.
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INDICATIONS Bacterial endocarditis
Mitral regurgitation may also occur as a
result of ischemic heart disease (coronary
artery disease) or non-ischemic heart
disease (dilated cardiomyopathy).
Surgery for MR is recommended when
Patient have symptoms of heart failure, or
when ejection fraction drops below 55%
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MITRAL VALVE DAMAGE Examples of serious damage or complicated
conditions that might lead to mitral valve replacement include:
Extensive ballooning of the mitral valve (rather than a single flap that puffs up).
Severe hardening (calcification) of the valve.
Prolapse (bulging) of the valve at an unusual location.
Damage to the valve from infection (endocarditis)
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CARIOMYAPATHY AND REGURGITATION
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PROCEDURE During valve surgery, patient is given
general anesthesia.
Surgeon makes a large incision in patient chest.
Patient placed on a heart-lung machine during the surgery.
Blood is circulated outside of the body and oxygen is added to it using a heart-lung (cardiopulmonary bypass) machine.
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LEFT VENTRICULAR VENT
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TO PROTECT THE HEART MUSCLE FROM DAMAGE DURING
SURGERY TO REPLACE THE HEART VALVE, THE HEART MAY
BE COOLED.
IN ADDITION, A CARDIOPLEGIA SOLUTION (WHICH IS A
FLUID WITH HIGH CONCENTRATIONS OF POTASSIUM AND
MAGNESIUM) IS INTRODUCED TO STOP THE HEART
COMPLETELY.THE DAMAGED MITRAL VALVE IS EITHER
REPAIRED OR REMOVED AND REPLACED WITH AN ARTIFICIAL
(PROSTHETIC) HEART VALVE.
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AORTIC VALVE REPAIR
Aortic valve repair is a surgical
procedure used to correct some
aortic valve disorders as an
alternative to aortic valve
replacement.
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INDICATIONS
Aortic valve repair is most commonly
performed in patients with aortic
regurgitation caused by;
a dilated aortic annulus
conjoined cusp prolapse in bicuspid aortic
valves (BAV)
single cusp prolapse in tricuspid aortic
valves, and
aortic valve cusp perforation from
endocarditis
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DILATED AORTIC ANNULUS
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BICUSPID AORTIC VALVE
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TECHNIQUES
There are two surgical techniques of aortic-valve repair:
The Reimplantation-Technique (David-
Procedure)
The Remodeling-Technique (Yacoub-
Procedure)
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PROCEDURE A complete median sternotomy is performed.
In patients requiring only aortic valve repair, a complete median sternotomy is performed through a limited 8 cm skin incision
After establishing cardiopulmonary bypass, a transverse aortotomy is performed 2 cm above the sinotubular junction.
For better visualization, the aorta can be completely transected and suspended with stay sutures positioned above the commissures to better visualize the anatomy.
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SINOTUBULAR JUNCTION
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SPECIFIC APPROACHES
1.annular dialatation
This type of AR is caused by a dilated
aortic annulus resulting in a sagging of the
belly of the cusp resulting in lack of central
cusp apposition. Reduction annuloplasty
corrects the problem by increasing the
surface area of cusp coaptation.
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ILLUSTRATION DEMONSTRATING PLEDGETED COMMISSUROPLASTY
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Intraoperative photograph prior to repair. Note: loss of cusp coaptation. The pledgeted sutures are stay sutures for improved exposure.
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Intraoperative photograph following pledgeted commissuroplasty
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2. BICUSPID AORTIC VALVE
This type of AR results from the
prolapse of the conjoint cusp. The
usual conjoint cusp is a fusion of the
right and left coronary cusps. The
goal of the correction is to shorten
the redundant conjoint cusp thus
elevating the free margin of the cusp
to coapt with the other non-
prolapsing cusp.
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ILLUSTRATION DEMONSTRATING BICUSPID VALVE WITH CONJOINT CUSP
PROLAPSE AND SUBSEQUENT SHORTENING
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Intraoperative photograph after
resection of a central triangle of
redundant prolapsing conjoint cusp.
The first interrupted suture
reapproximating the cut edges of
the cusp is being placed.
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CUSP PROLAPSE IN TRICUSPID VALVE
This type of AR is caused by the
prolapse of one or more cusps. The
free margin is elongated. This can
occur by rupture of a small
fenestration. The goal of this repair
is to shorten the free margin to meet
the other cusps.
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Intraoperative photograph demonstrating
completed repair of cusp prolapse in
tricuspid valve. Repair was performed by
plicating prolapsed cusp and pledgeted
commissuroplasty.
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CUSP PERFORATION
This type of AR is caused by infective
endocarditis or iatrogenic perforation.
The goal of this repair is to patch the
defect in the cusp.
An autologous pericardial patch is
prepared and used to cover the defect
with either running or interrupted 6-0
polypropylene suture
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PLICATION SUTURE
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Illustration demonstrating cusp
perforation and subsequent patch
repair.
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Intraoperative photograph
demonstrating cusp perforation prior
to repair.
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Intraoperative photograph following
patch repair of cusp perforation with
non-fixed autologous pericardium.
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TRICUSPID VALVE REPAIR Depending on the extent of valve disease,
Patient need to have the valve repaired or replaced.
To repair the valve, surgeon may perform a commissurotomy or implant a valve ring.
A commissurotomy is performed for a tight
valve (stenosis). The valve leaflets are cut to loosen the valve slightly, allowing blood to pass easily.
Another type of valve repair is a valve ring annuloplasty, which is sewn in place when the valve is leaking (regurgitant or insufficient). The valve leaflets are tucked in place with the ring.
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HEART VALVE REPLACEMENT
Heart valve replacement surgery
involves the removal of the badly
damaged valve. The valve is
replaced with a plastic or metal
mechanical valve, or a bioprosthetic
valve, which is usually made from
pig tissue. The damaged valve is cut
out, and the new valve is sewn into
place
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KINDS OF VALVES USED FOR VALVE REPLACEMENT:
Mechanical valves, which are usually made
from materials such as plastic, carbon, or
metal. Mechanical valves are strong, and
they last a long time
Biological valves : which are made from
animal tissue (called a xenograft) or taken
from the human tissue of a donated heart
(called an allograft or homograft).
Sometimes, a patient's own tissue can be used
for valve replacement (called an autograft)
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INDICATIONS
Surgery to repair or replace the mitral valve
is often required in MR. Surgery is generally
done for mitral valve prolapse (MVP) only
when MR is present.
Conditions that are most likely to require
surgery include:
Sudden (acute) MR.
MR with symptoms of heart failure.
MR with mild-to-moderate left ventricular
dysfunction (ejection fraction less than 55%)
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CONDITIONS THAT MAY REQUIRE SURGERY INCLUDE:
MR with an irregular heartbeat (atrial fibrillation) but no symptoms and no signs of functional damage to the left ventricle.
MR with elevated blood pressure in the lungs (pulmonary hypertension) but no symptoms and no signs of functional damage to the left ventricle.
MR with mild to severe left ventricular dysfunction, no symptoms, and a high likelihood of preserving some of the related structures of the mitral valve.
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COMPLICATIONS
People who receive a mechanical heart valve
are more likely than those who receive a
bioprosthetic heart valve to develop blood
clots in the heart. The clots may break loose,
travel to the brain , and cause a stroke. So if
patient received a mechanical heart valve to
treat severe MR, patient need to take
medicine for the rest of your life to prevent
clots from forming (anticoagulant medicine).
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PREOPERATIVE CARE Most patients are admitted to the hospital the day
before surgery or, in some cases, on the morning
of surgery.
The night before surgery, patient should take
bathe to reduce the amount of germs on skin.
After admitted to the hospital, the area to be
operated on will be washed, scrubbed with
antiseptic, and, if needed, shaved.
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Patient is asked not to eat or drink after
midnight the night before surgery.
An electrocardiogram (ECG or EKG) ,
blood tests, urine tests, and a chest x-ray
should be done.
A (mild tranquilizer) is given before taken
into the operating room.
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PROCEDURE
During valve repair or replacement surgery, the breastbone is divided, the heart is stopped, and blood is sent through a heart-lung machine.
Because the heart or the aorta must be opened, heart valve surgery is open heart surgery. After hooked up to the heart-lung machine, heart is stopped and cooled.
Next, a cut is made into the heart or aorta, depending on which valve is being repaired or replaced.
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Once the surgeon has finished the repair or replacement, the heart is then started again, and are disconnected from the heart-lung machine.
The surgery can take anywhere from 2 to 4 hours or more, depending on the number of valves that need to be repaired or replaced.
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POST OPERATIVE CARE Recovery from heart valve surgery
usually involves a few days in an intensive care unit (ICU) of a hospital. Full recovery from heart valve surgery can take several months.
Recovery includes healing of the surgical incision, gradually building physical endurance, and exercising.
Patient should resume most of normal activities.
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Continue to monitor patient condition.
Watch out for symptoms of blood
clots and infections.
An artificial valve may need to be replaced after a period of time. Should be informed.
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RISKS Effects from the operation itself (such as
bleeding, infection, and risks associated with anesthesia). These risks are low.
Blood clotting caused by the new valve. Replacement with a mechanical valve requires lifelong treatment with medicine to prevent blood clots (anticoagulant).
Infection in the new valve. Infection is more common with valve replacement than with valve repair.
Failure of the new valve. Valve failure is more common with valve replacement than with valve repair. Bioprosthetic valves last for about 8 to 15 years.
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RECOVERY TIME
Patient has to stay in the hospital for
about a week, including at least 1 to 3 days
in the Intensive Care Unit (ICU).
Recovery after valve surgery may take a
long time, depending on how healthy
patient were before the operation. Patient
have to rest and limit your activities.
Patient have to begin an exercise program
or to join a cardiac rehabilitation program.
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OUTCOME AND FOLLOW UP Most valve repair and replacement operations are
successful. The outcome of mitral valve replacement depends on a person's overall health, including other health conditions.
In some rare cases, a valve repair may fail and another operation may be needed.
Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Mechanical valves may also fail, so patients should alert their doctor if they are having any symptoms of valve failure.
Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives. Because these medicines increase the risk of bleeding within the body, patient should always wear a medical alert bracelet and inform doctor or dentist about taking a blood-thinning medicine.
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Bacteria can enter the bloodstream during
these procedures. If bacteria get into a
repaired or artificial valve, it can lead to a
serious condition called bacterial endocarditis.
Antibiotics can prevent bacterial endocarditis.
Patients with mechanical valves say they
sometimes hear a quiet clicking sound in their
chest. This is just the sound of the new valve
opening and closing, In fact, it is a sign that
the new valve is working the way it should.
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MINIMALLY INVASIVE VALVE SURGERY
Minimally invasive heart valve
surgery is a technique that uses
smaller incisions to repair or replace
heart valves. This means there is
less pain. Minimally invasive surgery
also reduces the length of the
hospital stay and the recovery time
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INDICATIONS Minimally invasive valve surgery can only
be done in certain patients. This type of
surgery cannot be done in patients
With severe valve damage
Who need more than one valve repaired or
replaced
Who have clogged arteries (atherosclerosis)
Who are obese
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TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)
Transcatheter aortic valve implantation is
a minimally invasive procedure to repair a
damaged or diseased aortic valve. A
catheter is inserted into an artery in the
groin and threaded to the heart. A balloon
at the end of the catheter, with a
replacement valve folded around it,
delivers the new valve to take the place of
the old.
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CONCLUSION Heart valve repair or replacement surgery is
a treatment option for valvular heart
disease. When heart valves become damaged
or diseased, they may not function properly.
Conditions which may cause heart valve
dysfunction are valvular stenosis and
valvular insufficiency (regurgitation).When
one (or more) valve(s) becomes stenotic
(stiff), the heart muscle must work harder to
pump the blood through the valve.
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THANK UUUUUUUUUUUUUU…………….