Surgical repair and replacement of diseased valves ppt.

1. BPT 4TH YEAR
402 PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS
Submitted By:- Stuti Sah
Submitted To :- Dr. Jamal Ali Moiz
Centre Of Physiotherapy And Rehabilitation Sciences,
Jamia Millia Islamia, New Delhi

2. Heart Valves-
• Blood is pumped through the heart in only one direction. Heart valves play a key
role in this one-way blood flow, opening and closing with each heartbeat.
• Heart valves separate the atria from ventricles, or the ventricles from a blood vessel.
• A normal heartbeat makes two sounds like "lub-dup“ when the heart valves
opens and closes. And a heart valve that's not working correctly typically causes
the murmur sound.
• The introduction of valve replacement surgery in the early 1960s has dramatically
improved the outcome of patients with valvular heart disease.
• Valvular heart disease are clinical conditions involving heart valves leading to
different patterns of dysfunction like hemodynamic instability.
• There are 4 valves in the heart: tricuspid, pulmonary, mitral, and aortic
• The heart also has a coronary sinus valve and an inferior vanacaval valve.
• The aortic and semilunar valves is the most common valve to be replaced. The
mitral valve is the most common valve to be repaired.
• In the United States, surgeons perform about 106,000 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.

3. • 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.
• Parts of heart valve- Annulus ,Commissure, Cordae tendineae, Papillary muscles
Types of heart valves
Parts of a heart valve

4. Valvular Heart Disease-
• Valve stenosis (mitral, aortic, tricuspid
and pulmonary).
• Valve regurgitation (mitral, aortic, tricuspid
and pulmonary).
• Both
Causes of Valvular Disorders-
• Congenital heart disease
• Rheumatic heart disease
• Infections- bacterial endocarditis
• Heart attack- damage to the heart muscle, papillary muscles
• Weakening of supporting structures of the heart

5. Valve Replacement/Repair Surgery-
• Valve repair involves a surgical procedure during which the surgeon may need to
trim, reshape or rebuild the diseased valves. Whereas valve replacement surgery is
the replacement of one or more of the heart valves with either an artificial heart
valve or a bioprosthesis.
• Valve replacement is preferred over valve repair where feasible.
Valve surgery Indications-
• Symptomatic severe valvular disease
• Asymptomatic severe valvular disease with left ventricle systolic dysfunction
pulmonary hypertension, atrial fibrillation
• Valvular regurgitations caused due to tear, shortening or elongation of valve
leaflets, chordae tendinae, annulus, papillary muscles and disecting aneurysm of the
aorta
• Stenosis caused due to congenital leaflet malformations and rheumatic endocarditis.

6. Valve surgery Contraindiacations-
• Presence of severe pulmonary hypertension
• Dilated right heart with right heart failure
• Major annular calcification
• Severe aorto-iliac atherosclerosis
• Co-morbidity imposing an elevated surgical risk
Limitations of surgery related to technical factors-
• The risk of damage to the grafts and issues related with cardioplegia especially with
arterial grafts in redo surgery with patent coronary artery bypass grafts
• Severe calcification of annulus also makes valve repair difficult and valve
replacement hazardous from risk of atrioventricular rupture.
Possible risk of heart valve repair or replacement
surgery include-
• Bleeding during and after the surgery
• Blood clots that can cause heart attack and stroke or lung problems
• Infection , Pneumonia, Pancreatitis, Breathing problems
• Arrhythmias, the repaired or replaced valve doesn’t work correctly

7. Valve repair surgery-
1. Commissurotomy is used 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.
• Patient is put on a heart lung bypass machine
• Calcium deposits and other scar tissue from the valve leaflets are removed
• It is used for people where balloon valvulotomy is contraindicated
• Mediastinal incision is made. A small hole is cut into heart, surgeon’s finger or
dilator is used to break or open the commissure.
Commissurotomy

8. 2.Balloon valvuloplasty (also called valvulotomy or valvotomy) is a procedure that
widens a heart valve that is narrowed. The cause of this narrowing in the aortic
valve is valve stenosis. During this procedure, the surgeon puts a thin, flexible tube
called a catheter into a blood vessel through the lower extremity (groin).
3.Reshaping is done when the surgeon cuts out a section of a leaflet. Once the leaflet is
sewn back together, the valve can close properly. For elongated leaflets -
• leaflet plication
• leaflet resection
4.Decalcification removes calcium buildup from the leaflets. Once the calcium is
removed, the leaflets can close properly.
5.Repair of structural support- It replaces or shortens the cords that give the valves
support (these cords are called the chordae tendineae and the papillary muscles).
And short leaflets are also most often replaced by chondroplasty.
6.Patching covers holes or tears in the leaflets with a tissue patch. If there are holes in
the leaflets pericardial patch repair is done.
(Chondroplasty-Repair of the chordae tendinae. It is mostly used for mitral valve.
Gore-Tex can be used to create chordae tendinae)

9. Reshaping Patching
Balloon Valvuloplasty Chondroplasty

10. Valve Replacement-
• Performed when valvuloplasty is not suitable.
• Approached through a median sternotomy or right thoracotomy incision.
Two kinds of valves can be used for replacement:
• Mechanical valves are usually made from materials such as plastic, carbon, or
metal. Mechanical valves are strong, and they last a long time. Because blood tends
to stick to mechanical valves and create blood clots, patients with these valves will
need to take blood-thinning medicines (called anticoagulants) for the rest of their
lives. Example- cage ball valve leaflet, tilting disc valve, bileaflet valve.
• Biological valves 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)- Ross
procedure. Patients with biological valves usually do not need to take blood-
thinning medicines. These valves are not as strong as mechanical valves, though,
and they may need to be replaced every 10 years or so. Biological valves break
down even faster in children and young adults, so these valves are used most often
in elderly patients.

11. Cagedball valve leaflet Tilting disc valve Bileaflet valve
Xenograft

12. • 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.
• Before surgery an electrocardiogram (ECG or EKG), blood tests, urine tests, and a
chest x-ray is done to give the surgeon the latest information about the patient’s
health.
• If the patient smokes, the doctor ask the patient to stop smokng at least 2 weeks
before the surgery. Smoking before surgery can lead to problems with blood
clotting and breathing.
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.
• 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

13. Transcatheter Aortic Valve Implantation (TAVI) -
• Also called transcatheter aortic valve replacement (TAVR)
• 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.
Ross procedure-
• The diseased aortic valve and a portion of the aortic artery are removed.
• The pulmonic valve and a portion of the pulmonic artery are excised and placed in
the aortic position. The left and right main coronary arteries are attached to the
pulmonary artery.
• A homograft(allograft) pulmonary valve and portion of artery are placed in the
pulmonary position.

14. Physiotherapy Management-
There are 3 main areas of physiotherapy involvement:
1.Chest care
2.General mobility
3. Cardiac Rehabilation
1.Chest Care:
Chest problems do occur after cardiac surgery even if the patient have no history of
chest problem or smoking.
Reasons for chest problems after the operation include:
• The anaesthetic gases- Increase the amount of phlegm produced , make the phlegm
sticky and difficult to cough up , make the patient sleepy after operation , make the
patient to take small rather than big breaths , make the cough les effective
• Previous chest problems or history of smoking – can lead to increased amounts of
phlegm being produced after the operation.
• The incision – the discomfort from the wound may mean the patient is reluctant to
take deep breaths or cough effectively.

15. • Posture- if sitting or lying in a slumped position in the bed or chair, the patient will
be unable to take a fully deep breath. So, ask the patient to always sit in a upright
position, not slumped
• Decreased activity – in the early stages after the operation the patient spend more
time in bed than usual, and do not take such deep breaths as they would when
walking, so phlegm can accumulate.
• Therefore to speed the recovery and prevent chest infections, it is vital that the
patient practice the breathing exercises and coughing
• Ask the patient to complete 3 sets of 4 deep breath every 30 minutes
• Cough and clear the chest as necessary- Effective coughing is extremely important
to clear any phlegm present on the chest.
• When coughing, ensure that the patient is sitting upright and that he/she support the
wound with the cough pillow provided
• Ask the patient to take a deep breathe in and cough strongly from the abdomen not
throat.
• Afterwards ask the patient to do some relaxed breathing.

16. 2.General mobility-
• It is important to become active as soon as possible
• The physiotherapist will, if possible, help the patient sit out in a chair on the first
day after the operation and start walking on the second day, despite any drips or
drains the patient may have. When moving in bed or rising from a chair it is
important not to push down through the arms. This would put too much of a strain
through the wound.
• The exercise prescription and training of valvular heart disease patients following
the valve replacement are similar to those for CABG patients
• However the physical activity for some VHD patients may have been restricted for
an extended period because of symptoms before valve repair or replacement
resulting in low functional capacity requires these patients to start and to progress
slowly during the early stages of an exercise training program
• Cardiac rehabilitation professionals should do standard exercise prescription
methodology for these patients but should take care to avoid upper extremity
exercise including resistance training involving the upper extremities until the
sternum is stable and there is no issues
• Exercise training intensity should be kept under the threshold, that precipitates the
onset of symptoms because the symptoms indicate the cardiac output is not meeting
the demands of the exercise

17. 3.Cardiac Rehabilitation-
Comprehensive cardiac rehabilitation program should contain specific core
components. These components should optimize cardiovascular risk reduction,
reduce disability, encourage active and healthy lifestyle changes, and help the
patient to maintain those healthy habits after rehabilitation is complete. Cardiac
rehabilitation programs should focus on-
• Patient assessment
• Nutritional counselling
• Weight management
• B.P management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counselling
• Exercise training
Phase 1: Inpatient phase-
Invloves immediate inpatient exercise rehabilitation that emphsizes-
a) Patient education
b) Counselling.

18. Exercise therapy
a)Musculoskeletal ROM activities.
b) ADLs (sitting, standing, and walking).
Purpose-
a) Counter the deconditioning effects of prolonged bed rest,
b) Prepare patient for a return to normal daily activities.
EXERCISE PRESCRIPTION FOR PHASE I
1. ROM Exercises-
• Enhances blood flow to damaged areas, accelerate tissue repair, increasing
muscular strength and flexibility.
• Shoulder flexion, abduction and internal & external rotation (once the sternum is
stable)
• Elbow flexion
2.Ambulation -
• Ambulatory activities in phase 1 should be low in intensity (approx. 1.5-3 METS)
and initially include self care activities (eating, sitting), which are gradually
progressed to slow walking, ROM exercises and activities of daily living.
• Later stair climbing can also be introduced.

19. EXERCISE INTENSITY- Exercise performed in phase 1 typically do not exceed 2-3
METS.
• The use of Borg Rating of Perceived Exertion Scale in encouraged after first few
days in the hospital.
Phase II: Outpatient cardiac rehabilitation-
• Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation
may begin.
• Phase II typically lasts three to six weeks though some may last up to twelve weeks.
• Initially, patients have an assessment with a focus on identifying limitations in
physical function, restrictions of participation secondary to comorbidities, and
limitation to activities.
• A more rigorous patient-centered therapy plan is designed, comprising three
modalities- information/advice, tailored program, and a relaxation program. The
treatment phase intends to promote independence and lifestyle changes to prepare
patients to return to their lives.
Exercises include-
• Breathing exercises- During the first two weeks after the patient is discharged
home, it is important to continue with the breathing exercises
• Shoulder exercises- Shoulder shrugs

20. • Trunk exercises-
a) Alternate side bending in standing
b) Thoracic rotation
• Leg exercises-
a)Alternate knee bends
b)Half squats
c)Step ups
Phase III: Post-cardiac rehab, Maintenance-
• This phase involves more independence and self-monitoring. Phase III centers on
increasing flexibility, strengthening, and aerobic conditioning.
• Goal: facilitate long term maintenance of lifestyle changes, monitoring risk factor
change and secondary prevention.
• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes
• Exercise program organised by qualified phase IV gym instructor
• Ongoing involvement of partners/spouses/family at home.

21. References-
 Heart valve repair or replacement, Texas Heart Institute
 Mitral valve disease, European Society of Cardiology
 Limits to surgery in mitral valve disease European Society of Cardiology
 Heart valve repair or replacement surgery, Johns Hopkins Medicine
 Physiopedia
 Physiotherapy following cardiac surgery, NHS.