valve disease and repair and replacement.docx

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Elham Ali Ahmed Ali
Holds a Bachelor's degree
In Nursing,
Ain Shams University,
Holds a diploma in therapeutic nutrition
Approved by the Arab Studies Center
And
Holds a diploma in a medical quality
Approved by the Arab Studies Center
And
Holds a diploma in an infection control
Approved by the Arab Studies Center and accredited by the
foreign consulate
And
Holds a Mini master’s in Medical administration
Approved by the Arab Studies Center and accredited by the
foreign consulate.
Out line
subject page

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 Introduction
 Heart valve disease
 Classification of heart valve disease
 Types of heart valve disease
 Etiology
 Symptoms
 Diagnosis
 Treatment
 Medication
 Surgeries and procedure
 Valve repaired
 Valve replacement
 Valvulopasty
 Annuloplasty
 Percutaneous or balloon
Valvulopasty/valvotomy
 Percutaneous mitral valve repair
 Commissurotomy
 Trans catheter aortic valve
implantation or replacement
 Open heart surgery
 Minimally invasive valve surgery
 Port access valve surgery
 Robot-assistedsurgery
 Preparation
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 Procedure
 Complication
 Management
 Nursingmanagement
 Nurse care plan
 Follow up
 Rehabilitation
 Life style
 reference
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Introduction
The heart
Has four chambers.
The two upper chambersare called the left and right atrium, and the
two lower chambers are called the left and right ventricle.
The four valves at the exit of each chamber maintain one-way
continuousflow of blood through the heart to the lungs and the rest
of the body.
Blood is pumped through your heart in only one direction.
Heart valves play a key role in this one-way blood flow, opening
and closing with each heartbeat.
Pressure changes on either side of the valves cause them to open
their flap-like “doors” (called cuspsor leaflets) at just the right time,
then close tightly to prevent a backflow of blood.
There are 4 valves in the heart:
Tricuspid, pulmonary, mitral, and aortic.
Location and functions of valves

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The tricuspid valve
 Lies betweenthe right atriumand the right ventricle.
 It opens so blood can be pumped to the right ventricle.
 Oxygen-poor blood coming into your heart from the body flows
into the right atrium.
The pulmonary valve
 Lies betweenthe right ventricle and the lungs.

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 It opens to let the heart pumpsblood out of the ventriclesintothe
pulmonary artery toward the lungsso it can pick up oxygen.
 The oxygen-rich blood flows back from the lungs into the left
atrium.
The mitral valve
 Lies betweenthe left atrium and the left ventricle.
 It opens so the oxygen-rich blood from the left atrium canbe
pumped intothe left ventricle.
The aortic valve
 Lies betweenthe left ventricle and the aorta
 Controls blood flow from the left ventricle intothe aorta
 Whenthisvalve opens, the oxygen-rich blood ispumped to the
aorta and thenout to fuel the rest of the body.
In between each step,
The valve closes to prevent blood from flowing backwards
And mixing oxygen-poor blood with oxygen-rich blood.
The one-way continuous flow of blood delivers oxygen throughout
the body.
Heart valve disease
Heart valve disease occurs when one or more of the heart valves
do not open or close properly.
When it affects more than one heart valve,

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It is called multiple valvular heart disease.
Stenosis
 When the valve opening becomesnarrow and restrictsblood
flow.
Prolapse
 When a valve slips out of place or the valve flaps (leaflets) do not
close properly.
Regurgitation
 When blood leaks backward througha valve, sometimesdue to
prolapse.
Classification of heart valve disease
 Mild
 Moderate
 Severe.
It can lead to an enlarged heart or heart failure.

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Types of Valvular heart disease
 Valvular stenosis (narrowing)
 Valvular prolapse (slipping out of place)
 Regurgitation (leaking)

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Valvular stenosis (narrowing)
The stiffening of heart valves can narrow the size of the valve
opening and restrict blood flow.
The narrowing is called valve stenosis.
It keeps the valve from opening fully and reduces the amount of
blood that can flow through.
In severe cases, the valve opening can become so narrow that the
rest of the body may not receive adequate blood flow.
Tricuspid valve stenosis (Tricuspid valve narrows)
 Blood is not able to fully move from the right atrium tothe right
ventricle.
 Thiscan cause the atrium to enlarge,
 Affecting pressure and blood flow in the surrounding chambers
and veins.

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 It can also cause the right ventricle to become smaller, so less
blood circulatestothe lungs to pick up oxygen.
Pulmonary valve stenosis (Pulmonary valve narrows)
 The flow of oxygen-poor blood from the right ventricle through
the pulmonary arteriestothe lungs is restricted.
 This affects the blood’s ability topick up oxygenand deliver
oxygen-richblood to the rest of the body.
 With pulmonary valve stenosis,
 The right ventricle hasto work harder topump blood through the
narrowed pulmonary valve and the pressure in the heart is often
increased.
Mitral valve stenosis (When the mitral valve narrows)
 Blood flow from the left atrium to the left ventricle is reduced.
 Thiscan cause fatigue and shortnessof breath becausethe
volume of blood carrying oxygenfrom the lungsis reduced.
 Pressure from the blood that hasstayed in the left atrium lungs.
Aortic valve stenosis (When the aortic valve narrows)

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 Blood flow from the heart to the aorta (the main artery tothe
body) and onwardsto the rest of the body is restricted.
 As a result, the left ventricle has to contract harder totry push
blood acrossthe aortic valve.
 Thiscan often lead to thickening ofthe left ventricle (left
vernacular hypertrophy) which eventually makesthe heart less
efficient.
Valvular prolapse (slipping out of place)
Prolapse is a condition when the valve flaps (leaflets) slip out of
place or form a bulge.
This can lead to improper or uneven closure of the heart valve.
As a result of the prolapsed valve, blood may leak backwards
through the valve and one-way blood flow may be disrupted.
Mitral valve prolapse

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 Mitralvalve prolapse is also called click-murmur syndrome,
Barlow’s syndrome or floppy valve syndrome
 In mitralvalve prolapse, the valve fails to close evenly.
 Part or all of the mitralvalve bulges upward intothe atrium
whenthe two ventriclescontracts.
 Thiscan allow a small amount of blood to leak backward through
the valve (regurgitation).
Tricuspid, pulmonary and aortic valve prolapse
 These prolapses are less common thanmitralvalve prolapse.
 Similar tomitralvalve prolapse, the leaflets of the valve do not
close completely and fail to form a tight seal.
Regurgitation (leaking)
Regurgitation can happen when the valve doesn’t close properly
and allows blood to flow backwards.
This disruption of the one-way blood flow in the heart puts a
strain on the heart,
Reduces its pumping efficiency and
Limits its ability to supply the body with oxygen-rich blood.
Tricuspid valve regurgitation
 Whenthe tricuspid valve does not close properly,

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 blood that is being pumped forward from the right ventricle to
the lungs can leak backwardintothe right atrium,
 And the atrium may become enlarged.
Pulmonary valve regurgitation
 Thisresults whenthe pulmonary valve doesn’t close properly.
 The right ventricle pushesblood through the pulmonary artery
into the lungs for blood to pick up oxygen.
 Whenthe pulmonary valve does not close completely, blood can
leak back from the lungs into the heart.
 Thisbackward blood flow mixes oxygen-poor and oxygen-rich
blood, and reduces the availability ofoxygen-richblood to fuel the
rest of the body.
Mitral valve regurgitation
 In mitralvalve regurgitation, some blood leaks backward intothe
left atrium through the mitralvalve from the lower chamber asit
contracts.
 This reduces the amount of blood that flows to the rest of the
body.
 As a result of regurgitation, the blood volume and pressure are
increased inthe left atrium.
 In severe cases, the increase in volume and pressure may lead to
enlargement of the atrium and build-up of fluid (congestion) in
the lungs.

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Aortic valve regurgitation
 Thisresults whenoxygen-richblood leaks backward from the
aorta into the left ventricle with each heartbeat.
 The body does not get enough blood and the heart hasto work
harder to make up for it.
 Over time the walls of the ventricle may thicken (hypertrophy).
 Thiscan increase risk of heart failure.
Etiology
Congenital causes
Developbefore or at birth
Such as
 Congenitalvalvular heart disease (defect in size or shape or valve
flaps (leaflets) not being properly attached)

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 Bicuspid aortic valve disease (hasonly twoleaflets rather than
the third leaflet)
 Marfansyndrome (may develop mitralvalve prolapse and aortic
valve regurgitation)
Acquired causes
Normal valves may become damaged during one’s lifetime
Such as
 Rheumatic fever
 Infective (bacterial) endocarditis
 Radiationtherapy
 Age age-related changes, such as calcium deposits
Defects can cause to valvular disease
 Coronary artery disease
 Heart attack
 Cardiomyopathy
 High blood cholesterol
 Certainmedications
 lupus
 syphilis
 hypertension
 aortic aneurysm
 Myxomatous degeneration

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Congenital causes
Congenital valvular heart disease
 Thisis a birth defect that may involve a heart valve being the
defect size and shape, or itsvalve flaps (leaflets) not being
properly attached tothe heart.
Bicuspid aortic valve disease
 A congenitaldefect that affectsthe aortic valve.
 Instead of the normalthree leaflets,
 The bicuspid aortic valve has only twoleaflets.
 Without the third leaflet, the valve is unable to open or close
properly, is more prone to aortic valve stenosis, and may lead to
regurgitation.

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Marfan syndrome
 Thisis a genetic disorder that affectsthe body’sconnective tissue.
 Connective tissue holds all the body’scells, organsand tissues
together, including inthe heart.
 People with Marfansyndrome may develop mitralvalve prolapse
and aortic valve regurgitation.
Acquired causes
Rheumaticfever
 Thisis an inflammatory disease that canaffect the heart valves if
it isn’t treated properly.
 Rheumatic fever usually startsas strep throat or an infection
involving strep (streptococcalbacteria).
 Heart valves may be damaged or scarred as the body fightsthe
strep infection.
Infective (bacterial) endocarditis
 Commongerms can travel through the bloodstream tothe heart
and infect the surface of the heart, including the heart valves.
 People with valvular heart disease are at a higher risk of
developing infective endocarditis.
Radiation therapy

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 People whohad radiationtherapy tothe chest due to cancer are
more likely to develop valvular heart disease.
Age
 Heart valve problemsmay result from degenerative changes, or
normal “wear and tear” of aging.
 age-related changes, such as calcium deposits
Defects can cause to valvular disease
 Coronary artery disease
 Stenosis, or a narrowing of the blood vessels, causesa less-
than-normalamount of blood to flow to the heart.
 Thiscausesthe muscle to work harder
 Damage to the heart muscle from a heart attack
 Other diseasesof the heart muscle (cardiomyopathy)
 which involvesdegenerative changesinthe heart muscle
 Metabolic disorderssuch as high blood cholesterol
 Tumor in the heart
 lupus,
 a chronic autoimmune disorder leading toinflammationin
heart
 syphilis,
 a relatively rare sexually transmitted infection
 Leading to aortitis, aortic valve insufficiency, coronary
artery stenosisor obstruction, Aortic aneurysmand

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mucinousmyocarditis due toinfectionleading to thickening
of the aortic wall and inflammationinwall of heart and
aorta.
 hypertension, or high blood pressure
 People whohave long-term raised blood pressure have an
increased risk of aortic valve disease (AVD)
 a 41% higher risk of aortic stenosis(AS) and
 a 38% higher risk of aortic regurgitation(AR) later in life.
 AS is a conditioninwhich the valve that opens and closes
whenblood is pumped out of the left ventricle becomes
narrowed and stiff due to calcium building up.
 Whenthishappens, the valve fails to work effectively,
making it harder for the heart to pump blood to the rest of
the body.
 AR occurswhenthe valve doesn’t close properly, allowing
some blood to leak back intothe left ventricle
 aortic aneurysm,
 an abnormalswelling or bulging of the aorta
 Myxomatous degeneration,
 a weakening of connective tissue in the mitralvalve.

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Symptoms
 Chest discomfort, pressure or tightness (angina)
 Palpitations (arrhythmia)
 Shortnessof breath
 Fatigue
 weakness
 Light-headedness,
 dizziness
 near fainting
 Swelling
 Chest discomfort, pressure or tightness (angina)
 Palpitations
(irregular or rapid heartbeatscaused by problems
with the heart'selectricalsystem)
Can sometimesbe a symptom of valvular heart
disease.
The heart may be working harder.
That cancause the heart to enlarge and affect normal
heart rhythm, leading to arrhythmia.
 Shortness of breath

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Valvular heart disease reducesthe amount of oxygen
available to fuel the body and that causes
breathlessness.
 Fatigue or weakness
May find it harder to do routine activitiessuch as
walking or housework.
 Light-headedness,dizziness ornear fainting
Most commonwith aortic stenosis.
 Swelling
can occur whenvalve problemscause blood to back up
in other partsof the body,
Leading to fluid buildup and swollen abdomen, feet and
ankles.

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Diagnosis
 Symptoms
Find some symptomsrefer to valvular disease
 Stethoscope hearinga heart murmur
 Echocardiogram:- usessound wavesto create a picture of the
heart valves and chambers.
 Angiogram:- isanother test used to diagnose valve disorders.
Thistest uses a thintube or catheter witha camera totake
picturesof the heart and blood vessels.
Thiscan help the doctor determine the type and severity of
your valve disorder.
 Chest X-ray :- may be ordered to take a picture ofthe heart.
Thiscan tell the doctor if the heart is enlarged.
 Electrocardiogram(ECG):-is a test that showsthe electrical
activity ofthe heart.
Thistest is used to check for abnormalheart rhythms.
 Stresstest:- can be used to determine how the symptomsare
affected by exertion.
The informationfrom the stress test can inform the doctor how
severe the conditionis.
 Heart MRI: - may provide a more detailed picture ofthe heart.
Thiscan help confirm a diagnosisand allow the doctor to
determine how tobest treat the valve disorder.
Treatment

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 Treatment dependsonthe severity of the valvular heart disease.
 If the heart valve problem is very minor
 May need to medications.
 Regular check-ups to see if conditiongetsany worse.
 Medicationcanbe prescribedifthe heart valve problem is
causing symptoms.
 If the conditionis more serious,
 May need more intensive treatment.
 Optionsinclude valve repair or replacement incombination
with medication.
Medication

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 Diuretics (water pills) to reduce swelling and fluid buildup in
the body.
 Blood thinnerstoprevent blood clots and reduce the risk of
other cardiac problems.
 Antiarrhythmic toprevent irregular or rapid heartbeats
(arrhythmias).
 beta-blockers and calcium channelblockers, whichhelp
controlheart rate and blood flow
 vasodilators, which are drugsthat open or dilate blood vessels
 May be prescribed medicationstoreduce the workload on
the heart and relieve the symptoms.
Surgeries and other procedures
Heart valve surgery torepair or replace the heart valves may be
necessary toprevent lasting damage to the heart

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Valve repair
 Repair of structuralsupport replacesor shortensthe cords
that give the valves support (these cords are called the
chordae tendineae and the papillary muscles). Whenthe
cordsare the right length, the valve can close properly.
 Patching holesor tears, coversholes or tearsin the leaflets with a
tissue patch.

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 Reshaping the valve, done when the surgeoncuts out a
sectionof a leaflet. Once the leaflet is sewn back together,
the valve canclose properly
 Separating valve leaflets
 trims, shapes, or rebuilds one or more of the leaflets of
the valve
 Reconnectingvalve flaps (leaflets or cusps)
 Removing excess valve tissue so that the leaflets or
cusps canclose tightly

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 Replacing cords that support the valve to repair the
structuralsupport
 Tighteningor reinforcingthe ring around the valve
(annulus)

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 Decalcification removescalcium buildup from the leaflets.
Once the calcium isremoved, the leaflets canclose properly.
Valve replacement
 Heart valve surgery isa procedure totreat heart valve
disease.
 If a faulty heart valve cannot be repaired,
 It is removed and replaced with a mechanicalvalve or a
biologicalvalve.
Valve replacement

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1. reach your heart by making an incisiondownthe middle of
your breastbone
2. use a heart-lung machine tocirculate blood around your body
during the operation
3. open up your heart toreach the affected valve, and
4. Perform the repair or replacement.
The main types of new valves are:
 Mechanical
 Biologicalalso called bioprosthetic

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Mechanical valves
Pros and cons
 Mechanical valves are made from durable metals, carbon,
ceramics, stainlesssteelor titanium or polyester materialsand
plastics that the humanbody tolerateswell.
 Artificial components that have the same purpose as a
naturalheart valve.

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 Make a slight clicking sound that patientsmay hear — although
some do not hear it at all.
 Their designmimicsthe leafletsof a naturalvalve.
 They are the type that surgeonsmost often implant in young
 They can last between 20 and 30 years without requiring
additionalsurgeries.
 The best for those who:
 Are younger than age 65 who want to avoid a second
surgery whenthey are older.
 Have overactive parathyroid glands(affecting blood
calcium levels).
 However, one of the risksassociated with mechanicalvalves is
blood clots.
 Will be need to take blood thinners for the rest of the life to
reduce the risk of stroke which increasesthe risk of bleeding.
 Newer, carbon-basedmechanicalvalves may reduce the need for
a daily blood thinner.

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Biologic valves
Pros and cons
 Are created from humanor animal tissue.
 A bioprosthetic doesn’t last as long as a mechanicalvalve and
may require replacementat a future date.
 Biologicalvalves are not as durable as mechanicalvalves.
 Doctorsuse humandonor valves only rarely.
 Typically, biologicalvalveslast between10 and 15 years, so
you may require another replacement surgeryat some point.
 They don’t come with a higher risk of blood clots, so you most
likely won’t need to take a blood thinner.

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Biological valves are best, for those who:
 Are over age 65.
 Have kidney disease.
 Are pregnant.
 Cannot take Coumadin® coagulationmedicine.
 Have a job or recreationalsport or hobby that increasesthe
risk for bleeding or injury.
There are three types of biologic heart valves:
 An Allograft or homograft ismade of tissue takenfrom a
human donor’s heart.
Thisis the least commonreplacement valve.
It is generally reserved for patientswhohave a disease
that affectstheir valve, such as infective endocarditis.
Human valve replacementsare associated withsevere
calcificationof the donor aortic wallover time, which
increasesthe potentialneed for subsequent surgery.
 A porcine valve is made from pig tissue.
Thisvalve canbe implanted with or without a frame
called a stent.

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They’re also treated toavoid rejectionfrom your body.
They perform similarly tocow valves, but they are less
likely to calcify but are more likely to tear over time.
 A bovine valve is made from cow tissue.
It connectsto your heart with silicone rubber.
The tissue is strong and flexible, and treating it prior to
surgery preparesit so that your body can accept it
without any negative immune response.
Cow valves can develop calcificationthatcannarrow the
valve opening and decrease blood flow over time.

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Several different techniques are used:
 Percutaneous surgery (through the skin)
 Valvulopasty
 Annuloplasty
 Percutaneous or balloon
Valvulopasty/valvotomy
 Percutaneous mitral valve repair
 Commissurotomy
 Transcatheteraortic valve implantation or
replacement
 Surgery
 Open heart surgery
 Minimally invasive valve surgery
 Robot-assistedsurgery

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Percutaneous surgery (through the skin)
 Valvulopasty
 strengthens the leafletsto provide more support and to let the
valve close tightly. Thissupport comesfrom a ring-like device
that surgeonsattach around the outside of the valve opening.
 Inserting a thincatheter with a balloon at the tip through a
blood vessel to the narrowed valve.
 The balloon is theninflated to widenthe valve opening.

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Annuloplasty
 A technique torepair anenlarged annulus (a ring of fibrous
issue at the base of the heart valve).
 There isa ring of fibrous tissue at the base of the heart valve
called the annulus
 To repair an enlarged annulus,
 Suturesare sewn around the ring to make the opening smaller.
 Or, a ring-like device is attached around the outside of the
valve opening to support the valve so it canclose more tightly

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Percutaneous or balloon valvulopasty/valvotomy
 Used for stiffened or narrowed (stenosis) pulmonary, mitralor
aortic valves.
 A balloon tip on the end of the catheterispositioned in the
narrowed valve and inflated to enlarge the opening.
Percutaneous mitral valve repair
 Methods - such as edge-to-edge repair - canfix a leaky mitral
valve in a patient whois considered high risk for surgery.
 A catheter holding a clip is inserted intothe groin and up into
the left side of the heart.
 The open clip is positioned beyond the leaky valve and then
pulled back so it catchesthe flaps (leaflets) of the mitralvalve.
 Once closed, the clip holds the leaflets together and stops the
valve from leaking.

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Commissurotomy
 used for narrowed valves, where the leaflets are thickened and
perhapsstuck together. The surgeonopens the valve by cutting
the points where the leaflets meet.
 A treatment for a tight valve.
 The valve flaps (leaflets) are cut to loosen the valve slightly,
allowing blood to pass easily.

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(TAVI or TAVR)
 Transcatheter aorticvalve implantation(TAVI) isalso called
transcatheter aorticvalve replacement (TAVR).

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 Open-heart surgery toreplace a malfunctioning aorticvalve is a
less invasive procedure
 A replacement valve is inserted through a catheter that isguided
to your heart with the ultrasound and chest x-rays.
 TAVIis a minimally invasive surgicalvalve replacement
procedure that isused to treat symptomaticaortic valve stenosis,
with twokey differencesfrom traditionalvalve replacement
surgery.
 Rather thanopening up the chest, TAVIis done through small
incisionsin the groin or chest.
 Instead of repairing, or removing and replacing the damaged
aortic valve, a new aortic valve is implanted directlyontop of the
damaged one.
 The surgeon insertsa catheter containing a new, collapsible
aortic valve through smallincisionsin the groin or chest.
 Using ultrasound and chest x-rays, the catheter isguided tothe
correct positioninthe heart and the new valve is implanted and
expanded.
 Once the new valve is in place, it startsto control blood flow
immediately.
 People whoundergoTAVI tend to recover faster and have shorter
hospitalstays(average three to five days) than people whohave
open-heart valve surgery.

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 TAVIis usually considered for people whoare at high risk for
complicationsfrom open-heart surgery.
 Your healthcare team willassess your symptomsand overall
health to determine ifTAVIis an option for you.
Open heart surgery

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Minimally invasive valve surgery
 The minimally invasive AVR and MVR proceduresare
minimally invasive direct accessapproachesfor the Aortic and
Mitralvalves.
 These proceduresare performed under direct visionthrough
right-sided mini thoracotomiesand achieved by creating a 5
cm incisionin the 2nd or 3rd intercostalspace (AVR) or the 4th
or 5th intercostalspace (MVR).
 In addition, these incisionsallow for double valve procedures
(AVR/MVRand MVR/TVR), congenitalheart defects(ASD),
atrialmyxoma resection, and concomitant atrialfibrillation
ablation
Applications for MICSValve procedures

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 Aortic Valve Disease
 AVR + CABG (RCA)
 MitralValve Disease
 Tricuspid Valve Disease
 Double Valve (AVR/MVRand MVR/TVR)
 ASD (Secundum or Primum)
 AtrialMyxoma
 Concomitant AtrialFibrillation(MVR+Maze)
Potential benefits of MICSValve procedures
 Reduced trauma and pain
 Decreased blood loss
 Decreased wound infection
 Reduced recovery time
 Better cosmetic resultsand improved patient satisfaction
 No differencesin morbidity and mortality
 Facilitatesredosurgery
 Avoidssternal wound complications

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 This procedure is done through small incisions
(ports) made in the chest.
 Valve is repaired or replacement.
 A heart-lung bypass machine is used during
this procedure
Robot-assisted technique

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 Thistype of procedure allows for even smaller, keyhole-sized
incisions.
 A small video camera isinserted in one incision toshow the
heart,
 Whilethe surgeon uses remote-controlled surgicalinstruments
to do the surgery.
 A heart-lung bypassmachine issometimesused during this
procedure.
Preparation

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 The healthcare provider willexplainthe procedure and you
can ask questions.
 The Pt will be asked to sign a consent form that gives the
permissiontodo the surgery.
 Read the form carefully and ask questionsif anything is
unclear.
 Along with a complete medicalhistory, the healthcareprovider
may do a complete physicalexam tomake sure this are in
otherwise good health before surgery.
 The Pt may need blood testsor other diagnostic tests.
 The Pt will be asked to fast (not eat or drink)for 8 hoursbefore
the procedure, generally after midnight.
 If the Pt are pregnant could be, tell the healthcare provider.
 The Pt must be Tell to healthcare provider ifhe are sensitive to
or are allergic to any medicines, iodine, latex, tape, or
anesthetic agents(localand general).
 Be sure the healthcareprovider knowsabout all medicines
(prescriptionand over-the-counter), vitamins, herbs, and
supplementsthat Pt are taking.
 The Pt must be Tell to healthcare provider if have a history of
bleeding disordersor if are taking any anticoagulant (blood-
thinning) medicine, aspirin, or other medicinesthataffect
blood clotting.

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 The doctors may be told to stop some of these medicinesbefore
surgery.
 The healthcare provider may doa blood test before surgery to
see how long it takesthe blood to clot.
 Tell to healthcareprovider if have a pacemaker or any other
implanted cardiac devices.
 If smoke, stop smoking as soon as possible.
 Thisimprovesthe chancesfor a successful recovery from
surgery and benefits overall health status.
 Based on the medicalcondition, the healthcare provider may
request other specific preparation.
Procedure
Heart valve repair or replacement surgeryrequiresa stay in a
hospital.
Proceduresmay vary depending onthe conditionand the healthcare
providerspractice.

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Generally,open-heart valve repair or replacement follows
this process:
 Ask to remove any jewelry or other objectsthat may interfere
with the procedure.
 Wear a hospitalgown and empty the bladder.
 The surgicalteam will positionthe Pt on the operating table,
lying on the back.
 A healthcare professionalwillstart an intravenous(IV) line in the
arm or hand for injectionof medicine and to give IV fluids.
 More catheterswillbe put in blood vessels the neck and wrist to
monitor the statusof the heart and blood pressure, and to take
blood samples.
 The anesthesiologist willcontinuously monitor the heart rate,
blood pressure, breathing, and blood oxygenlevel during the
surgery.
 The doctor will put a breathing tube through a mouth intolungs
and connect to a ventilator, a machine that willbreathe during
the surgery.

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 The doctor will place a transesophagealechocardiogram(TEE)
probe into esophagus(swallowing tube) so he or she canmonitor
the functionof the valves.
 A soft, flexible tube (called a Foley catheter) willbe put into the
bladder to drainurine.
 A tube will be put through a mouth or nose intothe stomach to
drainstomach fluids.
 Someone on the surgicalteam will cleanthe skin over chest with
an antiseptic solution.
 If there is a lot of hair at the surgicalsite, it may be shaved off.
 If having an open-heart surgery, the healthcare provider will
make an incision(cut) downthe center of the chest from just
below the Adam'sapple to just above the navel.
 If having a less invasive procedure it may require smaller
incisions.
 The sternum (breastbone) willbe cut in half lengthwise.
 The healthcare provider willseparatesthe halvesof the
breastbone and spread them apart toexpose the heart.

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 To do the valve repair or replacement, the doctor must stop the
heart.
 He or she will put tubesinto the heart so that the blood can be
pumped through a body by a heart-lung bypassmachinewhile a
heart is stopped.
 Once the blood hasbeen completely diverted intothe bypass
machine for pumping, the doctor will stop the heart by injecting it
with a cold solution.
 Whenthe heart has stopped, the doctor will remove the diseased
valve and put in the artificialvalve, 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 example, your doctor may separate
fused valve leaflets, repair tornleaflets, or reshape valve parts to
ensure better function.
 Once the surgery isdone, the doctor will shock the heart with
small paddles to restart the heartbeat.

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 Next, he or she will allow blood circulatingthroughthe bypass
machine tore-enter your heart and remove the tubesto the
machine.
 Once the heart isbeating again, your doctor will watch it to see
how well the heart and valves are working and be sure that there
are no leaks from the surgery.
 The doctor may put wiresfor pacing intoheart.
 He or she canattach these wirestoa pacemaker outside the body
for a short time and heart can be paced, if needed, during the
initialrecovery period.
 The doctor will rejointhe sternum sewing it together with small
wires(like those sometimesused to repair a brokenbone).
 The doctor will put tubesintochest to drainblood and other fluids
from around the heart.
 The doctor will sew the skin over the sternum back together and
close the incisionwith suturesor surgicalstaples.
 A member of the surgicalteam will apply a sterile bandage or
dressing.

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Complication of valve replacement
 Bleeding during or after the surgery
 Blood clots that cancause heart attack,stroke,or lung
problems
 Infection
 Pneumonia
 Pancreatitis
 Breathing problems

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 Arrhythmias(abnormalheart rhythms)
 The repaired or replaced valve doesn't work correctly
 Death
Management
 After surgery, the pt will typically spend 1 or 2 days in an
intensive care unit (ICU).
 Assess heart rate, blood pressure, and oxygenlevels will be
checked regularly during thistime.
 An intravenousline (IV) will likely be inserted intoa vein in
arm.
 Through the IV line, may get medicinesto
 controlblood circulationand blood pressure and

60 | P a g e
 manage pain
 And lower cholesterol
 and medicationtoreduce the risk of blood clots
forming
 and medicationmanage diabetes;
 Or treat depression.
 Also will likely have a tube in the bladder to drainurine and a
tube to drainfluid from the chest.
 May receive oxygentherapy (oxygengiventhroughnasal
prongs or a mask or connect with ventilation) and a
temporary pacemaker while inthe ICU.
(A pacemaker isa small device that'splaced in the chest ).
 The initialmanagement ofpatientsfollowing cardiac surgery
focuses on ensuring adequate analgesia and ventilationand
managing bleeding and hypothermia.
 Maintaining cardiacoutput isimportant because it affects
meanarterialpressure and tissue perfusion.
 Reduced tissue perfusioncan lead to organ failure.

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 Low cardiac output following cardiac surgeryismanaged by
giving intravenousfluid therapy toincrease and optimize
preload, which increasesthe volume of each stroke and hence
output.
 Inotropes, givenby a centralvenous catheter, may be started
whenfluid therapy failsto provide an adequate effect.
 Typically mechanicalventilationwillbe reduced and ended
within24 hoursfollowing surgery.
 Chest tubes, which are inserted during cardiac operationsto
drainfluid from the chest cavity, are removed when drainage
volume is minimal(for example, severalconsecutive zero
readings);thisusually occursthe day after the operation.
 Centralvenous catheters, arteriallinesand urinary catheters
inserted during surgery are also removed during the initial
recovery period.
 Patientsare givena course of antibioticsasprophylaxisfor the
first 24 hoursafter surgery.
 Thisis typically a combinationofintravenousflucloxacillin
and gentamicintocover both Gram-positive and Gram-
negative organisms[2].
 The choice and dose regimenof antibioticscanvary
considerably betweencardiaccentres.

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NURSINGMANAGEMENT OF valve replacement PATIENT
NURSINGMANAGEMENT
 Preoperative Nursing Management.
 Intraoperative NursingManagement.
 Postoperative NursingManagement
PREOPERATIVE NURSINGMANAGEMENT
 The preoperative nursing management
 Usually beginsbefore hospitalization.
 Patientswith non-acute heartdisease
 may be admitted tohospitalthe day

63 | P a g e
 Before or the day of their surgery.
PREOPERATIVE ASSESSMENT
 History Physicalexamination
 Radiographicexamination
 Electrocardiogram
 Laboratory analysis
 Typing and cross-matching ofblood.
 Assessing patient’sfunctionallevel
 Psychosocialassessment.
 Family support system
PHYSICAL EXAMINATION
 Generalappearance and behavior
 Vitalsigns
 Nutritionaland fluid status, weight and Height
 Inspectionand palpationof heart
 Auscultationofheart

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 JVP
 Peripheralpulses.
 Peripheraledema.
PSYCHOSOCIAL ASSESSMENT
 Meaning of surgery to patient
 Coping mechanismsbeing used.
 Anticipated changesinlifestyle
 Support system ineffect
 Fear regarding present & future
 Knowledge & understanding ofsurgicalprocedure
INTRAOPERATIVE NURSINGMANAGEMENT
 Assisting in surgicalprocedure

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 Continuousmonitoring
 Monitoring for complications:dysrhythmias, hemorrhage,
MI, CVA, embolizationetc.
POST OPERATIVE NURSINGMANAGEMENT
ASSESSMENT:
 Neurologicalstatus
 Cardiac status
 Respiratory status
 Peripheralvascular status
 Renal function
 Fluid & electrolyte status
 Pain
 Assessment of equipment and tubing
 Psychologicaland emotionalstatusas patient regains
consciousness
 Assessing for complications.

66 | P a g e
Nurse care plan
NURSINGDIAGNOSIS
 Fear related to surgicalprocedure, itsuncertainoutcome, and
the threat of well-being.
Goal:
 To reduce fear.
INTERVENTIONS
 Allowing patient and family to expresstheir fears.
 Explainthe patient regarding surgeryand sensationsthat are
expected during and after the surgery.
 Reassuring the patient that fear of painis normal and explain
that some pain will be experienced but certainmeasureswill
help to relieve the pain.

67 | P a g e
COMMUNICATION
INTERVENTIONS
 Encourage the patient totalk about the fear of dying.
 Patient should be reassured and misconceptionsshould be
corrected.
NURSINGDIAGNOSIS
 Knowledge deficit regarding the surgicalprocedure and the
postoperative course.
Goal:
 To provide the knowledge regarding surgery
INTERVENTIONS
 Patient and family teaching about
 Hospitalization
 Surgery

68 | P a g e
 Length of surgery
 Expected painand discomfort
 Criticalcare phase
 Recovery phase
PATIENT TEACHING
INTERVENTIONS
 Physicalpreparationbefore surgery
 Medicationsbefore surgery
 Informationregarding equipment, tubesthatwillbe present
postoperatively
 Teaching the postoperative exercises.
 Outcome of the surgery
NURSINGDIAGNOSIS
 Potentialfor complicationsrelated tothe stress of impending
surgery (Angina, Severe anxiety, Cardiacarrest)
Goal:
 To monitor and manage the complications
INTERVENTIONS

69 | P a g e
 Assess for complicationsAngina:oxygentherapyand
nitroglycerinetherapy.
 Severe anxiety:emotionalsupport
 Cardiac arrest:cardiaclife support
NURSINGDIAGNOSIS
 Decreased cardiac output related toblood loss and
compromised myocardialfunction
Goal:
 To restore cardiac output
INTEREVENTIONS
 Monitor cardiovascularstatus
 Assess arterialpressure every 15 min. untilstable
 Auscultate for heart sounds and rhythms
 Assess all peripheralpulses
 Hemodynamic monitoring
 ECG monitoring
 Assess cardiac enzymes
 Monitor urinary output
 Observe for persistent bleeding

70 | P a g e
 Observe for cardiac temponade
 Observe for cardiac failure
 Observe for myocardialinfarction.
NURSINGDIAGNOSIS
 Risk for impaired gasexchange related totrauma of
extensive chest surgery
Goal:
 To maintainadequategasexchange
INTERVENTIONS
 Maintainproper ventilation
 Monitor arterialblood gases, tidalvolumes, peek inspiratory
pressuresand extubationparameters
 Auscultate chest for breath sounds
 Provide chest physiotherapyasprescribed
 Promote deep breathing coughing and turning, use of
incentive spirometer.
 Teach incisionalsplinting with a cough pillow to decrease
discomfort during deep breathingand coughing
 Suctiontracheobronchialsecretionsasneeded, using aseptic
technique

71 | P a g e
EARLY AMBULATION
NURSINGDIAGNOSIS
 Risk for alterationin fluid volume and electrolyte balance
related to alterationinblood volume
Goal:
 To maintainfluid and electrolyte balance
INTERVENTIONS
 Maintainintake and output chart
 Assess the following parameters:LAP, BP, CVP, PAWP,
weight, electrolyte levels, hematocrit, JVP, tissue turgor,
breath sounds, urinary output etc.
 Measure post operative chest drainage
 Be alert to serum electrolyte levels
NURSINGDIAGNOSIS
 Painrelated to operative trauma and pleuralirritation
caused by chest tubes
Goal:

72 | P a g e
 To relieve pain
INTERVENTION
 Record nature, type, locationand duration
 Providing comfortable position
 Assist patient to differentiatebetweensurgicaland angina
pain Administerprescribed painmedication
 Encourage relaxationtechniques
PAIN MEDICATION
NURSINGDIAGNOSIS
 Risk for alterationin renal perfusionrelated to decreased
cardiac output, hemolysis, or vasopressor therapy
Goal:
 To maintainadequaterenalperfusion
INTERVENTION
 Measure urine output strictly
 Monitor renal functiontests
 Report to physicianifurine output less
 Administer medicationsasprescribed

73 | P a g e
NURSINGDIAGNOSIS
 Risk for hypothermia/hyperthermiarelated to
cardiopulmonarybypasssurgery, infectionsetc.
Goal:
 To maintainnormalbody temperature
INTERVENTIONS
 Warm the patient gradually with warmair or warm
blanketsor heat lamps
 Assess for dysrhythmiasdue tohypothermia
 Assess for elevated body temperature
 Assess for infection( lungs, urinary tract, incisionsand
intravascular catheter
 Use the aseptic technique while dressing and other
procedure
 Using proper hand washing technique Meticulouscare tobe
takento prevent contaminationat the sitesof catheterand
tube insertion

74 | P a g e
INCISION CARE
 Incisioncare is extremely important.
 Keep the incision site warm and dry, and wash hands before
and after touching it.
 If the incisionis healing properly and there is no drainage, can
take a shower.
 The shower shouldn’t be more than 10 minuteswith warm (not
hot) water.
 Should ensure that the incisionsite isn’t hit directly by the
water.
It’s also important to regularly inspect the incision sites for
signs of infection, which include:
 increased drainage, oozing, or opening from the incisionsite
 redness around the incision
 warmth along the incisionline
 fever

75 | P a g e
NURSINGDIAGNOSIS
 Risk for sensory- perceptualalterationsrelated tosensory
overload
Goal:
 to prevent postcardiotomysyndrome
INTERVENTIONS
 Explainall proceduresto patient
 Plan nursing care to provide for periodsof uninterrupted
sleep with day-night pattern
 Decrease sleep preventing environmentalstimuli asmuch
as possible
 Promote continuityofcare from nurse to nurse
 Orient the patient totime, place and person.
 Encourage the family to visit at regular times
 Teach relaxationand divisionaltechniques
 Observe for signs of pericardiotomy syndrome

76 | P a g e
NURSINGDIAGNOSIS
 Knowledge deficit about self-care activities
Goal:
 to help the patient in the performance of self-care activities
INTERVENTIONS
 Develop teaching planfor patient and family specifically
about:
 Diet
 Activity progression
 Exercise
 Deep breathing, coughing exercises
 Medicationregimenand Follow up
NursingDiagnosis

77 | P a g e
 Risk for Impaired Gas Exchange
Risk Factors
 Alveolar-capillary membrane changes, e.g., fluid
collection/shiftsintointerstitialspace/alveoli
DesiredOutcomes
 Demonstrate adequate ventilationand oxygenationof tissues
by ABGs/oximetrywithinpatient’snormalrangesand free of
symptomsof respiratory distress.
 Participate intreatment regimenwithinlevel of
ability/situation.
NursingAssessment and Rationales
 Auscultate breathsounds, noting crackles, wheezes.
Reveals presence of pulmonary congestionand collectionof
secretions, indicatingthe need for further intervention.
 Instruct patient ineffective coughing, deep breathing.
Clears airwaysand facilitatesoxygendelivery.
NursingInterventions and Rationales

78 | P a g e
 Encourage frequent positionchanges.
Helps prevent atelectasisand pneumonia.
 Maintainchair or bed rest, with head of bed elevated 20–30
degrees, semi-Fowler’sposition. Support armswith pillows.
Reducesoxygendemands and promotesmaximallung
inflation.
 Place the patient in Fowler’s positionand give supplemental
oxygen.
To help the patient breathe more easily and promote
maximum chestexpansion.
 Graph graph serialABGs, pulse oximetry.
Hypoxemia canbe severe during pulmonary edema.
Compensatory changesare usually present in chronic
Administer supplementaloxygenasindicated.
Increasesalveolar oxygenconcentration, which may reduce
tissue hypoxemia.
Administermedications as indicated:
 Diuretics: furosemide (Lasix)
Reducesalveolar congestion, enhancing gasexchange.
 Bronchodilators:aminophylline
Increasesoxygendelivery by dilating small airwaysand
exertsmild diuretic effect toaid in reducing pulmonary
congestion.
Follow up

79 | P a g e
 Care after surgery may include periodic checkupswith doctors.
 During these visits, testsmay be done to see how the heart is
working.
 Testsmay include ECG (electrocardiogram), stresstesting,
echocardiography, and cardiacCT.
 Must be maintaintake the medicationafter surgery.
 The pt and the doctor may develop a treatmentplanthat includes
lifestyle changesto help the pt stay healthy and reduce the chance
of CHD getting worse.
 Lifestyle changesmay include making changesto the diet,
quitting smoking, doing physicalactivityregularly, and lowering
and managing stress.
 The doctor also may refer you to cardiac rehabilitation(rehab).
Rehabilitation

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(Cardiac rehab isa medically supervised program that helps
improve the health and well-being of people who have heart
problem)
 Rehab programsinclude exercise training, educationonheart
healthy living, and counseling to reduce stressand help you
returnto an active life.
 Doctorssupervise these programs, which may be offered in
hospitalsand other community facilities.
 Talk to your doctor about whether cardiac rehabmightbenefit
you.
 Taking medicinesasprescribed alsois an important part of care
after surgery.
 The doctor may prescribe medicinestomanage painduring
recovery;
 lower cholesteroland blood pressure;reduce the risk of blood
clots forming;
 Manage diabetes;or treat depression.
Lifestyle

81 | P a g e
You canlower your risk of developing other heart diseasesand
stroke by knowing and controlling your blood pressure, diabetes
and blood cholesterol. It’s also important tolead a healthy lifestyle.
 Be smoke-free.
 Be more active.
 Aim for a healthy weight.
 Eat a healthy balanced diet – there are some specific diets you
can follow that have beenproven to reduce the risk of heart
disease.
 Drink less alcohol.
 Manage stress.
Talk to your doctor about the lifestyle changesthat willbenefit you
the most.
Reference

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https://www.healthline.com/health/heart-disease/valve-
replacement-surgery#surgerytypes
https://medlineplus.gov/ency/article/002954.htm
https://www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/heart-valve-repair-or-replacement-surgery
https://www.revespcardiol.org/en-valvular-heart-disease-in-
women-articulo-13092251
https://health.clevelandclinic.org/heart-valve-replacement-which-
type-is-best-for-you/
https://www.texasheart.org/heart-health/heart-information-
center/topics/valve-repair-or-replacement/
https://www.mayoclinic.org/tests-procedures/heart-valve-
surgery/about/pac-20384901
https://nurseslabs.com/heart-failure-nursing-care-plans/
https://www.myamericannurse.com/caring-patients-
transcatheter-aortic-valve-replacement/
https://www.nhs.uk/conditions/aortic-valve-
replacement/recovery/
https://www.bhf.org.uk/informationsupport/treatments/valve-
heart-surgery

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