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Heart Valve Replacement Surgery


Topic Overview

Valve replacement surgery is generally performed as an open-heart procedure in the operating room of a hospital. It may also be done as a minimally invasive surgery.

Although valve surgery is an intricate procedure, it is also common. In the majority of cases, valve replacement surgery is a straightforward procedure with a high rate of success and a low risk of complications. A cardiac surgeon, who specializes in heart surgery and has had years of training, will do the surgery. A team of nurses, an anesthesiologist, and possibly a surgical resident will assist the surgeon.

In rare cases, a more complex operation is done. The aortic valve may be replaced with one of the person's other heart valves (usually the pulmonary valve between the lower right heart chamber and the opening to the artery that goes to the lungs). Since the pulmonary valve is used in the heart to replace the aortic valve, an artificial valve is implanted to replace the pulmonary valve. This type of valve surgery may be used in people younger than 25 years of age who are more likely to benefit the most from this difficult surgery. The pulmonary valve is more durable, grows with the person, and has a lower risk of infection.

Prepare for surgery

Preparing for valve replacement surgery is similar to preparing for other major surgeries. You will be asked to not eat before surgery to prevent the risk of vomiting while you are under anesthesia. Your doctor may also have you stop taking certain medicines temporarily.

When you are in the operating room, a nurse will attach a number of monitoring devices, such as an EKG, to monitor the function of your heart and other vital signs during surgery. The nurse also will insert an intravenous (IV) line into your arm to deliver fluids and any necessary medicine. Finally, the nurse will place sterile drapes over your body, shave your chest if needed, and sterilize the area.

To help you breathe during surgery, you will be placed on a respirator, which involves placing a tube down your throat and into your lungs. This tube may be uncomfortable, but you will not be awake for most of the time that the tube is in your throat.

An anesthesiologist will place you under general anesthesia so that you do not see or feel anything during surgery. After you are unconscious, a transesophageal echocardiogram, which is a type of ultrasound device, will be inserted into your esophagus to display images of your heart during surgery.

Open the chest

The surgeon will use a marker to outline the incision on your chest before making it. To gain access to the heart, the surgeon will typically cut straight down the middle of your chest, from the top of your rib cage to just above your belly button. The incision goes through your sternum, or breastbone. Some surgeons are currently doing a new type of procedure called minimally invasive surgery, which uses an incision that is about one-third the size of a normal incision.

Establish heart-lung bypass

When your heart is visible, the surgeon will place you on a heart-lung machine, which will take over the function of your heart and lungs for the remainder of the operation by circulating oxygen-rich blood throughout your body. To attach you to the heart-lung machine, the surgeon will insert a tube into your right atrium, which receives oxygen-depleted blood from your body. Instead of going to your lungs to receive oxygen, the blood travels to the heart-lung machine to exchange carbon dioxide for oxygen. The blood then travels through a tube back to your aorta, which supplies blood to your entire body.

During bypass, your aorta is clamped near your valve to prevent blood from interfering with the surgery. To stop your heart temporarily, the surgeon will flush it with cold salt water or with a medicine. The surgeon will then bathe the heart in a solution that allows it to survive being deprived of blood for a short time.

This bypass is needed because it is difficult to work on your heart while it is beating. The bypass allows the surgeon to stop your heart temporarily without interfering with the circulation of oxygen-rich blood to your body. Bypass also reduces the risk of serious bleeding (hemorrhage).

Remove the old valve

After blood flow is diverted to the heart-lung machine, the surgeon will make an incision in the aorta to expose the aortic valve. The surgeon will inspect the aorta and the valve to evaluate the extent of disease. If only your valve is diseased, the surgeon will cut out the valve leaflets. If the aorta is also diseased, the surgeon may also cut out a portion of the aorta and replace it with a graft, which may be part of the replacement valve.

Attach the new valve

After the old valve is removed, the surgeon will use a device to measure the size of the valve opening to select the proper size for the replacement valve. In general, the surgeon will choose the largest possible valve to ensure the best possible blood flow through the valve. The surgeon may then place the valve in the opening to make sure it fits correctly. After properly aligning the valve, the surgeon will sew it in place.

The surgeon will then check the placement to make sure there is no room for leaks. The stitches are then tied off and trimmed.

Remove heart-lung bypass

When the new valve is in place, the surgeon will allow some blood to flow through the valve to check for leaks. The surgeon will sew up the aorta, remove air bubbles from your heart, and restore blood flow. When blood flows through your heart, it will typically start beating again. Sometimes, though, the heart begins to beat erratically (fibrillate), and the surgeon will give it an electrical shock to induce normal beating patterns.

Close the chest

When your heart is beating normally, your surgeon will close your rib cage using heavy-gauge steel wire to sew the breastbone (sternum) together. The surgeon then will use stitches to close the incision in your chest. In most cases, you will have a visible scar on your chest.

Recover in the hospital

In the ICU

When you first wake up after your operation, you will be in an intensive care unit (ICU) so that your doctor can monitor your heart function to make sure that there are no complications. You will also find many wires and tubes inserted into different body parts. Most of these wires and tubes were inserted while you were in surgery. But they were kept in place to help your body perform vital functions and to provide you intravenously with medicine (primarily painkillers) and nutrients.

The purposes of the wires and tubes include checking your heart and blood pressure, getting blood samples, draining fluid from your chest, and draining urine from your bladder.

At first, you will feel drowsy and disoriented while the anesthesia wears off. You may also experience some pain, though you will be given painkillers. For the first few hours after surgery, you will be kept on a respirator or ventilating machine to help you breathe. The breathing tube usually will be removed from your lungs soon after you wake up.

In your hospital room

When your condition stabilizes and you have been moved to a regular hospital room, you will continue to rest and recuperate while your doctor monitors your recovery. Your care will also include physical and respiratory therapy, emphasizing breathing exercises and simple exercise such as walking. You will also receive counseling about a heart-healthy diet and exercises that you should maintain after you leave the hospital.

You will likely be able to eat solid foods within 24 hours after surgery and will be able to get up and walk around within 48 hours after surgery. Your chest will, of course, be sore for some time.

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