— Introduction to Heart Valve Surgery
— Your Heart/Heart Valves
— Heart Valve Disease
— Diagnostic Tests
— Conventional Heart Valve Surgery
— "Minimally Invasive" Heart Valve Surgery
— Preparing for Surgery
— The Intensive Care Unit
— Postoperative Recovery
— Anticoagulation (Prevention of Blood Clotting)
— Prevention of Infections
— Discharge Planning/Follow-up

Introduction To Heart Valve Surgery

If you are scheduled for heart valve repair or heart valve replacement surgery at Brigham and Women's Hospital, you can expect to receive the highest quality of skill and care available anywhere.

Every year, our cardiac surgeons perform more than 600 heart valve operations, including "minimally invasive" procedures that require only 3-inch incisions. In addition to experienced surgeons at Brigham and Women's Hospital, you will be well cared for by a collaborative team of nurses, physician assistants, physical therapists and social workers.

It's no wonder that U.S. News & World Report consistently includes Brigham and Women's Hospital on its Honor Roll of America's "Best Hospitals."

We hope this guide helps you and your family understand what to expect with your heart valve surgery — from preadmission to discharge. If, after reading it, you have any questions, please ask a member of the cardiac surgery team. We are available to you at the hospital seven days a week.

Brigham and Women's Hospital Division of Cardiac Surgery

• R. Morton Bolman, III. MD, Chief
• Sary F. Aranki, MD
• Frederick Y. Chen, MD, PhD
• Lawrence H. Cohn, MD
• Gregory S. Couper, MD
• Michael J. Davidson, MD
• Paul A. Pirundini, MD
• James D. Rawn, MD
• Robert J. Rizzo, MD
• Prem S. Shekar, MD

Your Heart/Heart Valves

Your heart is a pumping muscle responsible for circulating oxygen-rich blood throughout your body. There are four chambers inside your heart: the two upper chambers are called atria and the two lower chambers are called ventricles. The heart muscle squeezes blood from chamber to chamber.

Your heart contains four valves, which open to allow blood to move forward through the heart and close to prevent blood from flowing backward.

• The mitral valve allows blood to move from the left atrium into the left ventricle.
• The aortic valve allows blood to move out of the left ventricle.
• The tricuspid valve allows blood to move from the right atrium into the right ventricle.
• The pulmonary valve allows blood to move from the right ventricle to the lungs.

Heart Valve Disease

Heart valves can be abnormally formed as birth defects or damaged by rheumatic fever, bacterial infection, and calcific degeneration. Valves also can degenerate with the normal aging process.

Two common types of valve disease are:

• Stenosis, which occurs when a valve does not open completely,  causing blood to flow through a narrower opening.
• Regurgitation, which results when a valve does not close completely, allowing blood to flow backward through the valve.

To compensate for these disorders, your heart pumps harder, which can result in inadequate blood circulation to the rest of your body. 

In addition, this excess work can weaken the heart, causing it to enlarge and produce the following symptoms:

• Increased shortness of breath
• Chest pain
• Swelling of the ankles and legs
• Increased fatigue
• Dizziness
• Fainting

Diagnostic tests

To diagnose and determine treatment for your particular valve disease, your doctor will obtain a complete medical history, perform a thorough physical exam and order any or all of the following special diagnostic tests:

• Chest x-ray — X-rays can provide doctors information about the size of your heart and its four chambers, as well as information about your lungs.
• Electrocardiogram (EKG) — This test records the changes of electrical activity occurring during your heartbeat. It helps to diagnose any irregularities in your heart's rate and rhythm, as well as in heart muscle enlargement or damage.
• Echocardiogram (echo) — This test uses ultrasound to examine and measure the structure of your heart. An echo demonstrates performance of the heart valves and provides information on heart muscle function.
• Cardiac catheterization (coronary arteriogram) — This test allows visualization of your blood vessels and measurement of pressures inside your heart chambers following injection of a contrast dye. An angiogram evaluates heart pumping function and any obstruction of the coronary arteries that supply blood to your heart muscle. If your coronary arteries have significant blockages, your cardiac surgeon will perform coronary artery bypass surgery at the time of your valve surgery.

Conventional Heart Valve Surgery

Heart valve disease initially may be treated medically but, in most cases, surgery is necessary to repair or replace the damaged valve or valves. Your surgeon will determine which procedure is best for you, taking into consideration your age, medical history, the nature of your heart disease, your lifestyle and your ability to take anticoagulants (medications that prevent your blood from clotting).

There are three main classifications of artificial valves:

• Bioprosthetic valves are from animals (for example, the Hancock and Carpentier-Edwards valves) specially treated with chemicals to avoid rejection.
• Mechanical valves are made of metal, carbon and/or synthetics (for example, the St. Jude valve). Anticoagulation is required to prevent blood clots.
• Biologic valves are human heart valves obtained from donors after death and frozen for later use (homograft). In the Ross procedure, the patient's own pulmonary valve replaces the diseased aortic valve and in turn is replaced by a homograft valve.

Some valves can be surgically repaired to help them open or close more efficiently. Two common surgical repair procedures are:

• Ring Annuloplasty, which is a procedure in which the annulus, or ringlike part of the valve, is tightened by placing a ring of metal, cloth or tissue around the valve (for example, the Cosgrove and Carpentier-Edwards Ring).
• Valve Repair, which is a procedure to reconstruct the leaflets, chordae, and/or papillary muscles of the valve.

The average time required for heart valve surgery is four hours. Your heart valve surgery will be performed by a specialized team:

• Your cardiac surgeon will perform the surgery.
• Surgical assistants will assist with the surgical procedure.
• Nurses will provide surgical instruments and supplies to the team.
• Anesthesiologists will provide you freedom from pain and a deep sleep that prevents any memory of surgery.
• A perfusionist will operate the heart-lung machine that keeps your blood circulating with oxygen.

Heart valve surgery can be performed by three surgical approaches:  

• Sternotomy: an incision is made down the middle of your chest separating your breastbone and muscle. The breastbone is closed with stainless steel wires at the conclusion of surgery.
• Thoracotomy: an incision is made in your rib cage similar to lung surgery.
• Minimally invasive surgery: 3-inch incisions are made in or to the right of the sternum. This surgery is now the most common approach for isolated heart value surgery.

Minimally Invasive Heart Valve Surgery

For patients without coronary disease, heart valve replacement/repair can now be performed through very small incisions  (3 inches) compared with those used in conventional surgery.
Minimally invasive valve replacement surgery is performed in two different ways:

• Aortic valve replacement incisions are performed through an upper mini-sternotomy, in which an incision is made from the sternal notch to the third intercostal space.
• Mitral valve replacement/repair incisions are performed through a lower mini-sternotomy, in which a 6-8 cm incision is made at the lower end of the sternum upward to the second intercostal space and extending into the interspace on the right.

Minimally invasive valve surgery, while maintaining the quality of the operative procedure may result in:

• Less trauma
• Less blood loss
• Improved cosmesis, particularly with mitral valve surgery
• Less incision pain
• Shorter hospital stay

Preparing for Surgery

Once heart valve surgery has been recommended and scheduled by your cardiac surgeon, you will be admitted the day of or day before your surgery. Patients scheduled to be admitted on the day of surgery will have an appointment scheduled in the Center for Preoperative Evaluations (also known as the preadmitting test center or PATC) within the preceding two weeks. All patients will be given diagnostic tests, a physical examination, and will be seen by members of the cardiac surgery and anesthesia teams. A nurse will discuss the Intensive Care Unit (ICU), postoperative recovery and discharge planning procedures with you and your family.

Smoking

If you smoke, you should stop. Smoking constricts the coronary arteries, produces excess secretions in the lungs, raises blood pressure and increases the heart rate. The potential for complications increases after surgery if you continue to smoke.

Dental Clearance

To prevent a delay in your surgery, ask your dentist to FAX  your dental clearance information to the cardiac surgery office. This information is critical because if you have any oral bacterial infections, they can cause infections of your heart valves. You should have received this request for dental clearance within the past six months in a letter from your cardiac surgeon's office.

Living Wills

If you have completed a living will or named a proxy, bring copies with you for your medical file. We encourage you to discuss any important personal values and/or medical care preferences with your primary care physician, cardiologist or cardiac surgeon prior to admission. If you have not yet completed a proxy or living will document, forms are available through the Brigham and Women's Hospital admitting office.

Anticoagulants

If you are taking Warfarin (brand name Coumadin) or medications containing aspirin, you will be instructed to discontinue them prior to your surgery. The cardiac surgeon's secretary will include this information in your pre-admission letter.

Banking Blood

In advance of your surgery, you may be able to set aside blood in the Brigham and Women's Hospital blood bank so that it is available to you during and after your surgery. Your cardiac surgeon will determine the amount required and whether your medical condition will allow you to donate blood for yourself. Family members and friends may also donate blood for you if they meet eligibility criteria. Blood may be donated at the Brigham and Women's Hospital blood bank or at a local center and then shipped to the hospital.

Diet Restrictions

Until midnight the day before your surgery, you may eat and drink as usual. After midnight, however, do not eat or drink anything. This helps decrease any nausea and vomiting associated with anesthesia. If you have prescribed medications, use only a small amount of water.

Pre-operative Preparation

Patients will be transported to the pre-operative area outside the operating room a few hours prior to surgery. Here, the anesthesia team will insert an intravenous line (IV) to sedate you. Once the operating room team is prepared for your surgery, the anesthesiologist will take you to the operating room. You will be anesthetized; an endotracheal tube (breathing tube) will be inserted; and other tubes and lines will be placed to monitor your heart, blood pressure, respirations and other bodily functions.

If you are interested in listening to music during surgery, please bring a walkman, batteries, and your favorite selection of music to help you relax.

Waiting Room

While you are undergoing cardiac surgery, your family may wait in the hospital or at home. The Family Liaison Service within the Robert and Ronnie Bretholtz Center, located behind the Schuster Lobby, is a resource area dedicated to families and friends waiting for patients undergoing surgery. Following the operation, your cardiac surgeon will personally talk with your family. After speaking with the surgeon, your family must wait one hour before visiting you in the ICU, in order to give the nursing staff sufficient time to assess your condition.

The Intensive Care Unit

Immediately after surgery, you will be taken to the cardiac surgery intensive care unit (ICU) where a team of specially trained physicians and nurses will take constant care of you and monitor your vital signs and other vital bodily functions as you recover from the effects of anesthesia. The special intravenous catheters, tubes and drains placed in the operating room will remain in place:

• You will be connected by an endotracheal tube to a ventilator (breathing machine) until you are awake enough to breathe on your own. You will not be able to talk while this tube is in place because it is positioned between your vocal cords. However, most patients are able to have the tube removed on the day of surgery. Once the tube is removed you will wear an oxygen mask for additional oxygen and humidity.
• Your heart function will be monitored. An EKG will continue to monitor your heart rate and rhythm; a special intravenous catheter (arterial line) will measure your blood pressure and allow the nurse to draw blood samples; a probe on your finger (pulse oximeter) will measure your oxygenation; and sometimes a special intravenous catheter will have been inserted to measure pressures inside your heart (pulmonary artery catheter).
• A urinary catheter in your bladder will drain urine into a bag.
• Chest tubes will drain blood and fluid from your chest incision into a special container to prevent a collection from forming around your heart.
• Temporary pacemaker wires may be placed in your heart; if your heart rate becomes too slow following surgery, you may require a pacemaker temporarily.

Once you recover from anesthesia...

You will be encouraged to take deep breaths and cough to help eliminate anesthesia and secretions from your lungs. It is also important to exercise your legs to help improve blood flow and prevent blood clots. You will be instructed to wiggle your toes and flex your feet hourly.

Pain medication will be available to you intravenously on the day of surgery. The day after surgery, when the endotracheal tube is removed and you are able to take liquids, you will take your pain medications by mouth. It is important to take pain medication for the first couple of days to enable you to cough, to breathe deeply, and to increase your ability to walk with assistance.

Visitors

Immediate family and close friends are allowed in the ICU 24 hours a day. However, prior to each visit, all visitors must call from one of the family rooms on the floor. The ICU is a busy place and the nursing staff may be busy with your family member or other patients. Please respect patients' privacy at all times.

Postoperative Recovery

Once the cardiac surgery team determines that you no longer need to be in the ICU, you will be transferred to a unit where your heart can continue to be monitored as needed. Most patients are able to be transferred out of the ICU the day after surgery. Then you will become an active participant in your recovery.

Exercise

To increase blood flow and improve your muscle strength, it is important to gradually increase your level of activity. Walking is one of the simplest ways to help yourself recover. The nursing staff will assist you in walking initially and encourage you to increase the distance and frequency daily. Your primary care physician or cardiologist may recommend an outpatient cardiac rehabilitation program, which can help you resume a healthy, active lifestyle through exercise and education. The rate of recovery will depend upon your age, general health and your heart function.

Care of Your Incision

Once all of the tubes, lines and wires are discontinued, you will be encouraged to shower daily with warm water and a mild soap to keep your incision from becoming infected. If your incision was made in your breastbone, do not lift anything over 10 pounds for 3 months after surgery. Your breastbone needs time to heal properly.

Medications

During your hospitalization medications will be prescribed and carefully adjusted for you. Common medications include fluid pills, potassium, blood thinners, and medications to control a rapid/irregular heartbeat. Your nurse will review with you your medications, including the correct dosage, frequency and side effects.

Nutritional Needs

Good nutrition is important for healing. It is very important that you:

• Keep your weight within the normal range for your age and body frame.
• Reduce your salt intake to prevent fluid retention that may overload your heart and cause it to work inefficiently.

To monitor fluid retention, weigh yourself daily until your follow-up appointments with your physicians. If you gain 3 pounds or more in one day, tell your doctor. A dietitian will be available to meet with you and your family to review nutritional guidelines recommended after heart valve surgery.

Anticoagulation

Warfarin

Patients receiving a mechanical heart valve require a blood  thinner, warfarin, (brand name, Coumadin¨) to prevent blood clots. Other conditions associated with valve disease such as an irregular heartbeat (atrial fibrillation) and an enlarged heart may also be treated with warfarin.
Warfarin works by prolonging the time it takes for your blood to clot. The drug must be carefully monitored by taking a blood test (INR). Your physician (cardiologist or primary care physician) will prescribe a dose to keep the INR within certain parameters. In order to control the level in your body, it is important to take warfarin at the same time each day and to avoid alcohol consumption, which affects the action of warfarin. It is recommended that you ask your physician before you take any over-the-counter medications, including aspirin, cold remedies, antibiotics, vitamins, and sleeping pills.

Food

You should avoid drastic changes in your dietary habits and foods high in vitamin K, which increases the blood's tendency to clot, such as:

• Mayonnaise   
• Oils (canola, salad, soybean) 
• Broccoli 
• Brussel Sprouts
• Green Cabbage (raw)
• Collard Greens  
• Cucumber Peel (raw)
• Endive (raw)
• Kale (raw)
• Lettuce
• Mustard Greens (raw)
• Parsley
• Spinach (raw)
• Turnip Greens (raw)
• Watercress (raw)
• Green Scallion (raw)

Other Procedures

Always inform your dentist and physicians that you are on warfarin. Because warfarin limits your body's normal ability to stop bleeding, they may need to adjust your dosage prior to any procedure to prevent excessive bleeding.

Physical Activity

Avoid any activity or sport that may result in a traumatic injury.

Consult your physician

It is extremely important that you consult your physician if any of the following occurs:

• A serious fall or if you hit your head
• Excessive bruising on your skin
• Excessive bleeding, (i.e. nosebleeds, bleeding gums)
• Blood in your urine or stool
• A fever or other illness including vomiting, diarrhea, or infection
• You become pregnant or are planning to become pregnant

Medical Alert Bracelet

You may want to wear a medical alert bracelet or carry a patient identification card to alert hospital personnel in an emergency that you are taking warfarin. If you are interested in obtaining emergency identification, ask a member of the cardiac surgery nursing staff for further information.

Prevention of Infections

All heart valve surgery patients must take antibiotics before certain dental or surgical procedures to help prevent infection of valves, which can occur when bacteria is released into the bloodstream as a result of the procedure. Consult with your physician before any dental and surgical procedures.

Discharge Planning/Follow-up

Home Care

Generally, most patients can leave the hospital 5-6 days following surgery. It is important to have family members or friends available to assist you in your first week home. The nursing staff will contact a home care agency near your home to arrange a home nursing assessment the day after your discharge. Additional services available through the home care agencies for patients who meet criteria include physical therapy, occupational therapy, and the services of a home health aide or social worker.

Cardiologist

It is important to make an appointment with your cardiologist within two weeks of discharge. Your cardiologist will monitor your progress over time and adjust your medications.

Cardiac Surgeon

Patients will also need to make an appointment with their cardiac surgeon four to six weeks after discharge. The cardiac surgeon's secretary will send you a letter confirming the date, time and location of your appointment. (Patients who live a great distance from the hospital are not required to return for a follow-up appointment with the cardiac surgeon.)

Primary Care Physician (PCP)

Patients who have managed care insurance plans, such as Harvard Pilgrim Health Care and Tufts Health Plan, will also need to make an appointment with their primary care physician within two weeks of discharge. Your PCP coordinates your plan of care with your cardiologist and cardiac surgeon.

Extended Care Facility

If you require physical and occupational therapy or other close medical management, we will refer you to extended care facilities. A team of nurses and social workers will meet with you to discuss available facilities and will make a recommendation based on the clinical care offered at the facility, its location, and your insurance coverage.

Following your discharge from the hospital, a nurse from the cardiac surgery office will call you at home to check on how you are progressing. She will ask about your incision, activity level, and follow-up appointments. If you are transferred to an extended care facility, the nurse will contact the facility for progress reports.

This guide was written by Donna Rosborough, MS, RN, CCRN and Lawrence Cohn, MD. It is not to be reproduced without permission from the authors. February, 2004.