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KEY HOLE AORTIC VALVE REPLACEMENT

WHAT ARE THE ADVANTAGE OF KEY HOLE AORTIC VALVE REPLACEMENT OVER CONVENTIONAL AORTIC VALVE REPLACEMENT?

  • Key hole aortic valve replacement need lesser hospital stay,
  • least pain,
  • minimum chance of infection and
  • least use of blood and blood products.

WHAT ARE THE DISADVANTAGES OF CONVENTIONAL AORTIC VALVE REPLACEMENT?

Conventional Aortic valve replacement involves cutting of entire length of breast bone which may recquire a cut of about 15 cm inthe front of chest which might lead to a non healig and sometimes infection. The bone after cut is joined back with steel wires and will take about one and half months to heal and till then activities like travelling,lifting weights,sex,driving ,etc are restricted. This cut on front of chest lead many times to psychological problems as well as certain wound discomforts.

Key hole aortic valve replacement excludes the need for this unnecessary large cut.

CAN ALL AORTIC VALVE REPLACEMENTS BE DONE THROUGH KEY HOLE?

90% of aortic valve replacements can be done through key hole. However it may not be the preferred option when the replacement is done as an emergency or when associated with concomitant CABG.

WHAT ARE CUTS USED FOR KEY HOLE AORTIC VALVE REPLACEMENT?

a.A vertical cut about 5 cm on the upper part of chest in the midline.

b. A 5cm horizontal ct on right side of chest.

Which incision to be chosen depends upon the anatomical position of aorta as assessed by CT scan.

WHEN CAN THE DUTIES RENEWED AFTER KEY HOLE AORTIC VALVE REPLACEMENT?

Key hole aortic valve repacement usually requires 2 days of ICU stay and another 3 days of ward stay. However in the old and sick stay may be longer ,but the discomfort will be much lesser.

After discharge from the hospital ,was asked to rest at home for another one week and are are asked to review . The progress is monitored and if found satisfactory ,will be asked to review activities in another week.

WHAT IS MEANT BY HIGH RISK AORTIC REPLACEMENT?

Patients of  advanced age, those associated with coronary artery disease especially after an acute heart attack, those with associated problems like kidney disease,lung disease or liver disease,those with deteriorated left ventricular function and enlarged heart and those with pathologically advanced calcific aortic stenosis and second operations,etc

HOW THE RISK OF AORTIC VALVE REPLACEMENT CALCULATED?

This is by following EUROSCORE pointing system where factors like age,sex,serum creatinine, associated diseases ,etc are given a score and the total score is calculated . The risk very well corelate with the total Euroscore.

CAN THE AORTIC VALVE BE RPAIRED?

Some aortic valve lesions like hole in the leaflets, prolapse of leaflets, mild calcifications, shrivelling ,etc can be repaired.

WHAT ARE THE VALVES USED FOR REPLACEMENT?

Mainly two types. Metal valves and Tissue valves. Metal or Mechanical valves are made from synthetic matereals and Tissue valves are taken from other animals. Metal valves are made by companies like ST.JUDE, MEDTRONIC,etc

Tissue valve are made from tissues of  Cow,Pork or Horse. The tissues taken may be from heart itself or designed from pericardial tissues. Examples of vales taken from pork heart are St.Jude valves and those made from bovine pericardium are Perimount and Magna valves by Starr Edward corporation.

WHAT ARE THE ADVATAGES AND DISADVANTAGES OF MECHANICAL VALVES?

Mechanical valves last longer perhaps lifetime ,unless structural damage take palace which is quite rare.It cost much less compaired to tissue valves.

The main disadvantage is the need to take anticoagulant medicine for the entire life. If anticoagulant medicine is not taken thrombus will form and will eventually block the valve with calamitous consequences. 

Anticoagulant is a dangerous medicine with lot of drug interaction and synergies. These medicines act by interfering with vitamin K which ia an essential component of blood clotting. The dose of this drug has to be finely adjusted by frequently checking the coagulation parameters . The coagulation parameters has to be maintained at a required range by adjusting the dose of medicine,usually in the range of 2 to 3.

A lot of foods like green leafy vegetables  and others which are rich in vitamin K interfere the actionof this  of this medicine. 

WHAT ARE THE COMPLICATIONS OF ORAL ANTICOAGULANTS?

Anticoagulant act by interfering with Vitamin k production in the liver. It is given to prevent clot formation on the artificial valves. If it is not taken it will form thrombus and block the mechanical valve.

If its dose exceeds the required level, cause bleeding in various places like gastro-intestinal track,oral cavities, joint cavities inside the cranium,etc

Silent bleeding in the upper gastro-intestinal track is evident by passing of black stools otherwise known as malena.

In the old age intra-cranial complications are common and can be serious.

Warfarin and acitrom are the two commonly used medicines.

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF TISSUE VALVES?

Thease type of valves are made from animal tissues and no need for life long anticoagulant therapy to make it working. Usually anticoagulant is used for three months and then discontinued.

The main disadvantage of this valve is that ,being dead xenographic tissue ,it get degenerated by calcification over a variable period of time and loose the required function ultimately needing re-replacement.

WHAT ARE THE PREPARATIONS FOR KEY HOLE HEART SURGERIES?

  1. Before the operation , the condition of all organs has to assessed by available means.
  2.  For these a hemogram,renal funtion tests,kidney funtion tests,diabetic status, etc are ascertained.
  3. an,ecg,chest xray,ultrasonogram of abdomen,carotid dopplar , lung function tests, peripheral dopplar ,etc are mandatory.
  4. A CT scan may be considered.
  5. Spirometric excercises are used to assess and improve the lung function.
  6. 5 units of blood are arranged as a precaution. Generally one or sometime none are used.
  7. If any of the biochemical or imaging tests show any abnormality , corresponding speciality experts are consulted and suitable action followed.
  8. If the person is found to be very anxious or depressed, psychological support arranged.
  9. Familiarisation of the team members, hospital facilities, intensive care unit  and operationtheatre arranged.
  10. On the day prior to surgery the whole body is shaved and washed twice with an antibiotic solution.
  11. On the night prior to the surgery,the anesthetist will give a visit again and will brief about the operative procedure, later stay in the ICU,etc.He might instruct you rgarding when to take your dinner,etc
  12. Usually your operation is scheduled in the first half you will be asked not to take any food after 10 pm, take a wash next day mornig and not to take any food but the necessary medicines with a sip of water.
  13. If the operation is in the second half ,you may asked to take a light breakfast,the morning medicines and nothing after that.

WHO ALL WILL BE THERE IN YOUR AFTER CARE ?

After the heart operation a heat surgeon and heart anesthetist will be always by your side looking after you. You will be in the post-operative ICU, looked after by specialised nurses,respiratory physiotherapists,general physiotherapists,dieticians,pain specialists,etc.All your neds will be taken care off. During the three days of ICU stay,staff will give you body wash daily, brush your teeth, feed you,help you with passing urine and motion. The specialised nurses in the ICU will look after you just like their father or mother.

WHO ALL WILL BE THERE IN YOUR OPERATION?

There will be two cardiac surgeons, two specialised cardiac anesthetists, a person called perfusionist who run the heart lung machine, nurses and technician staff.

HOW WILL THE DAY OF OPERATION BE LIKE ?

If your operation is on the first half, you will be asked to get up around six in the morning,will be given an antibiotic wash, the necessary medicines with a sip of water and will be shifted to the operation theatre by 8 am. It is bit natural to feel bit anxious, but feel relaxed,the opeartion is only going to relieve you, you will not be allowed to feel any pain.

The nursing staff from ward will escort you to the operation theatre and then the operation theatre staff will care you after that. Always there will be a staff with you. You will be escorted to the operation theatre where you will be given an injection to go to sleep. From there on wards you will not feel anything.

WHAT IS DONE IN THIS OPERATION?

After putting you to sleep the doctors will take necessary IV lines, one wire into the artery of your hand or leg to accurately see your blood pressure continously, a wide IV line into your nack vein, a catheter in to your urinary blabber to pass urine, and finally a tube in to your wind pipe to give your breaths.. You will know none of these.

Through a small cut in the front of chest or right side of chest surgeons will see your heart and locate the place on aorta where exactly the cut has to be made. Once this done you will be connected to a heart lung machine, in order to stop your heart. Once heart is stopped,your aorta will opened,the disease aortic valve will be removed,the new valve will be sutured in, heart will be made to beat again,your cut will be closed and will be shifted to ICU,means intensive care unit.

HOW WILL BE THE ICU STAY?

While in the ICU ,you will slowly coming out of your sleep. When you come out of the sleep,might feel little bit of pain and discomfort, tubes coming from,hands,leg,urine,throat,etc.But please be reassured,all these are for your safety and one by one everything will be removed.

You might feel fresh and re -assured. Before the operation if you had some breathing difficulty,you might feel that after the operation it is much better.

Because of slight pain you might stiffen your neck,legs,chest,shoulder,etc. Try to keep all your muscles relaxed, that will reduce pain if you have any. Most but dont feel any pain,only a little bit of difficulty because of sitting in one position and a slight discomfort from the tubes and lines.

WHEN WILL ALL THE TUBES AND WIRES WILL BE REMOVED?

All those tubes are placed for your safety and wil be removed at the earliest. Out of all the tubes,the one in to your windpipe will be most hurting. The discomfort will be much less if you keep relaxed , all your muscles light,breath slowly.  Once you have recovered well from anesthesia and breathing well ,this tube will be removed at the earliest.

You may be on certain medicines to keep up your blood pressure and heart rate,once all those are settled,the wire in to your aretery of the hand or leg will be removed. May be by the second day,you will be made to sit on the chair beside and the catheter in to your urinary bladder will be removed.

WHEN WILL YOU BE SHIFTED TO ROOM FROM ICU?

Once your condition is stabilised, all the wires and tubes removed,you no more require oxygen,you can walk in the ICU,you will be shifted to theward. So far you were under the care of nurses and doctors  for 24hours.  Now you have recovered reasonably well from the operation and the resposibility of caring is being handed over to your relatives assisted by the ward nurses. Ward nurses may not be as experienced as the ICU nurses. The ICU nurses will teach your relatives and you what all have to be cared for . You also have to read through patient iformation booklet handed over to you.

WHAT ALL HAVE TO BE CARED WHILE IN THE WARD?

Unlike the abdominal operation, heart operation patients  dont have to rest in the bed always. If lie down in the bed ,there is more chance phlegm accumulation in the lung and more chance of pneumonia. May be take rest only few hours in the day time. Try to become more active. Do the incentive spirometry excercises every hour for ten times either ways, walk for 15 minutes every hour. Keep all muscles of the body relaxed all the time. Do excercises of the neck,shoulder, legs,ankle ,etc .

Little bit of breathlesness,mild pain, swelling of legs,loss of appetite,lack of sleep , constipation,etc are common after the operation

PREPARING TO GO HOME?

Say about 5 th day ,if most of your discomforts are better,if you can walk from one end of the verandha to the other and can climb the steps,you are ready to go home. The day prior to the discharge your blood will be tested for hemoglobin, kidney function and liver function,ECG,chest xray and echocardiogram.

If all these tests are also fine,you are ready to go home.

WHAT ALL HAVE TO BE CARED AT HOME?

You need to rest for another one or two weeks. Though the external wound has healed,inside wound is yet to be healed. For the first week keep youself to indoor,backyards or front verandha.Avoid relatives and small children. Continue to do breathing excercises, hand shoulder excercises, relaxation techniques and mild walking.

If you feel any discomfort, you are free to come to hospital at any time or feel free to contact any member of our team.

WHEN ARE THE FOLLOW UP VISITS?

Usually after the first week, you will be asked for the first visit just to see how you are progressing. You may be asked to bring your temperature chart,BPchart,pulse chart or sugar chart to monitor your progress.

If in this first visit ,if you are progressing well you will be scheduled for another visit after 2 weeks,when all blood examinations,chest xrays,echocardiogram,etc will be done. If all these examinations are normal,you will be advised to resume your duties.

Then you will have a follow up visit by the end of six months and then every year.