Heart valve replacement. Indications and stages of surgery

The achievements of Israeli cardiac surgeons are known throughout the world. Innovative developments and high qualifications of cardiac surgeons at the medical center of the Ikhilov Hospital allow all seriously ill patients who are on the threshold of life and death to get a chance to return to normal life. The use of sophisticated modern technology and manual skill allow our specialists to perform heart surgeries of varying levels of complexity. In most cases, they perform operations using the endoscopic method. However, there are cases when minimally invasive surgery is not possible. In such cases, our specialists select the optimal operation option.

Most often, when treating valve diseases that threaten the patient's life, heart valve replacement surgery is used. Heart valve replacement in Israel is performed for functional disorders of the heart caused by narrowing of the valve or its rupture, scarring or hardening.

Surgery to replace heart valves is performed on an open heart. If there is even the slightest chance of saving the valve, our cardiac surgeons perform valve-sparing operations . If prosthetics is necessary, an operation is performed to replace the heart valve with artificial or biological ones.

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1.Heart valve replacement

Heart Valve Replacement

– currently this is a very effective procedure with a low risk of complications. It is indicated for patients with symptoms of aortic valve stenosis. For some patients, refusing this advanced surgical technology means a significant reduction in life expectancy or the risk of sudden death. If there are no obvious contraindications to surgery (for example, coronary heart disease, previous heart attack), then this operation is usually prescribed and recommended for all patients with a degree of stenosis above average. With severe symptoms (chest pain, fainting, breathing problems), the life expectancy of many patients without heart surgery does not exceed 5 years, since the disease progresses over time.

Heart valve replacement surgery can be performed using an open procedure.

or
minimally invasive.
Although this is a rather complex procedure, extensive experience with such surgical treatment has now significantly reduced the possible risks. All stages are worked out to the smallest detail. During valve replacement, the possibility of complications and emergency situations is taken into account, therefore the operating room and medical staff are prepared taking into account the different developments of the situation during the operation.

Heart valve replacement occurs in eight stages.

Before this, the patient undergoes
preparation for the operation
(outpatient or in a hospital), following certain instructions and taking a number of medications. In some cases, it is necessary, on the contrary, to discontinue regularly taken medications.

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General principles of nutrition after heart surgery

1. Moderation of nutrition - you need to eat exactly as much as is currently required for life. Do not overload the body, do not allow it to “put aside reserves.” Excess weight puts a serious strain on the heart.
2. Fractional meals - you need to eat 5-6 times a day in small portions. Light snacks of fresh vegetables, fruits and dried fruits are allowed. Long breaks between meals and overeating should be avoided.
3. The optimal time for breakfast is 30 minutes after waking up, but no later than 2 hours. The last meal should be 2 hours before bedtime.
4. Strict control over sugar and salt intake. Sweet pastries should be completely excluded from the diet; dried fruits can be eaten as sweets. Excessive salt consumption can lead to increased blood pressure. It is better to replace table salt with sea salt; it contains iodine, which is beneficial for the heart. Or control the amount of table salt - up to 6 grams per day.

2.Stages of operation

At the first stage

the patient is connected to cardiac monitors, the chest is processed, breathing tubes are inserted from an artificial respiration apparatus, which is connected only after the anesthesia begins to take effect (i.e., the only discomfort for the patient may be some soreness and soreness in the throat after the operation).

The anesthesiologist puts the patient under general anesthesia. From this moment on, the patient does not feel anything.

An ultrasound device is placed through the esophagus into the heart area, transmitting an image of the heart to a monitor throughout the operation.

Second phase

- This is the opening of the chest. After marking, the heart surgeon makes an incision on the chest from the top of the rib cage to the navel. With the minimally invasive method, the incision length is two-thirds shorter.

The purpose of the third stage

is connection to a machine that provides artificial blood circulation. During the operation, the blood is enriched with oxygen outside the lungs, then it returns to the aorta and moves through the systemic circulation.

At this stage, the surgeon stops the heart, washes it and places it in a special solution that maintains its viability outside the circulation.

Fourth and fifth stages

- This is actually replacing the valve. The aorta is cut and the diseased valve is removed. If part of the aorta is also affected, it is also removed and a graft is placed. The valve hole is measured to select a new valve of the required size. The new valve is sewn on, then it is necessary to check that there are no leaks through it.

Sixth stage

- this is a disconnection from the artificial blood circulation machine. The aorta is sutured, and the trapped air is removed from the heart cavity. The heart begins to beat under the current of its own blood. If an uneven rhythm is observed, an electric shock is applied, which restores an even pulse.

Seventh stage

- chest closure. The bones and tissues are stitched together, and the sternum is closed with a suture that remains visible for life.

The entire operation usually lasts from 2 to 5 hours.

is important for the outcome of treatment .

It starts in the intensive care ward. Discharge from the hospital occurs 5-9 days after surgery. Postoperative rehabilitation continues on an outpatient basis.

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A case of successful aortic and pulmonary valve replacement

To the Telemedicine Department of the Scientific Center for Cardiovascular Surgery named after. A.N. Bakulev received a discharge from a 43-year-old patient from Smolensk with a diagnosis of:

Subacute infective endocarditis with damage to the aortic valve and pulmonary valve, caused by Enterococcus faecalis. Arterial hypertension stage 3, risk 4. NC PA, 3 FC. Moderate pulmonary hypertension. Early recovery period of ischemic stroke in the territory of the left middle cerebral artery (cardioembolic variant). Partial motor aphasia, mild right-sided hemiparesis, moderate cognitive impairment. Bilateral segmental pneumonia, resolution stage.

Survey at the place of residence

The patient was admitted to the clinic at his place of residence as an emergency. Upon examination, he complained of severe general weakness, increased body temperature to 39.0°C, and shortness of breath when walking.

Considers himself sick for one week when his body temperature rises to 39.0°C. He was hospitalized in a hospital with a diagnosis of left-sided pneumonia and received treatment. Five days after hospitalization, an acute cerebrovascular accident (ACVA) was detected, and therefore the patient was transferred to the neurological department. Where echocardiography revealed damage to the aortic and pulmonary valves. The diagnosis was made: infective endocarditis. A bacteriological examination of the blood revealed the growth of Enterococcocus faecalis. After antibiotic therapy with improvement, the patient was discharged home.

Three months later, the patient’s condition worsened again: body temperature increased to 39.5-40.0°C, and shortness of breath increased. Hospitalized in the cardiology department of the Special Clinical Hospital. A bacteriological examination of the blood revealed the growth of Enterococcocus faecalis. Antibacterial therapy was carried out for 20 days. At the time of contacting the National Center for Cardiovascular Surgery, the body temperature had returned to normal. Receiving treatment.

The medical history materials were transferred to the TMC for teleconsultation with the Scientific Center for Cardiovascular Surgery named after. Bakulev and solving the issue of surgical treatment.

Research results

Inspection:

The general condition is moderate. Height 176 cm, weight 100 kg. Hypersthenic physique. The skin is pale. There is no swelling. Breathing through the nose is free, respiratory rate is 17 per minute. The chest is normosthenic in shape. Both halves of the chest participate in breathing evenly. Percussion above the lungs - pulmonary sound. The boundaries of the lungs are not displaced. Breathing is vesicular, no wheezing. Heart sounds are sonorous, rhythmic, rough diastolic murmur at all points of auscultation. Heart rate 80/min. Blood pressure is 130/40 mmHg, pulse is correct 80/min. The abdomen is soft and painless. The lower edge of the liver is not palpable, the percussion border is 10*9*8 cm. Pasternatsky's sign is negative on both sides. Urination is free and painless. Consciousness is clear. Correctly oriented in space, time and self.

Research

ECG:

sinus rhythm, heart rate 85/min, normal position of the electrical axis of the heart, decreased recovery processes in the myocardium of the left ventricle.

Echocardiography (EchoCG):

signs of infective endocarditis localized to the aortic valve and pulmonary valve. Dilatation of the left atrium and right chambers of the heart. Monophasic diastolic flow. Moderate mitral, tricuspid, aortic, pulmonary regurgitation. Moderate pulmonary hypertension, Average pressure gradient on the pulmonary artery - 45 mmHg. A small amount of fluid in the pericardium, up to 100 ml.

Ultrasound examination (ultrasound)

abdominal organs: ultrasound signs of moderate hepatomegaly, moderate diffuse changes in the liver. Diffuse changes in the pancreas. Moderate splenomegaly.

Spiral computed tomography (SCT)

abdominal cavity: CT scan - signs of a bilateral segmental inflammatory process (resolution stage).

Consultation with a neurologist: Early recovery period of ischemic stroke in the LSMA basin (cardioembolic variant). Partial motor aphasia, mild right-sided hemiparesis, moderate cognitive impairment.

The documents were sent to the Scientific Center for Agricultural Sciences named after. A. N. Bakulev to resolve the issue of surgical treatment.

Telemedicine consultation at the Bakulev Center

Based on the results of a consultation in the telemedicine department of the National Center for Cardiovascular Surgery, surgical correction of valve pathology under artificial circulation was recommended for emergency indications.

Polyclinic NCSS named after Bakulev

Six days after the telemedicine consultation, an examination was carried out in the clinic of the National Center for Cardiovascular Surgery, the results of which established the diagnosis:

“Secondary infective endocarditis with damage to the aortic valve and pulmonary valve, active phase, subacute course. Aortic valve insufficiency.

Pulmonary valve insufficiency. Arterial hypertension 3 degrees. Condition after acute ischemic cerebrovascular accident. NK 2a degree.”

A decision was made to hospitalize him.

Hospitalization at the Bakulev Center

The patient was hospitalized in the department of emergency surgery of acquired heart defects at the age of 43 years.

Upon inspection:

moderate condition. The severity of the condition is due to heart failure. Consciousness is clear. Activity is somewhat reduced. Hypersthenic. Height 176 cm, weight 94 kg.

The body structure is correct. There is no swelling. The skin is pale, the mucous membranes are pale pink. The tongue is moist and clean.

The chest is of the correct shape. Breathing is harsh, weakened on the left in the lower parts, no wheezing, respiratory rate (RR) 18/min. Heart sounds are muffled, rhythmic, heart rate (HR) 80 beats/min. Diastolic murmur is on the pulmonary artery, systolic-diastolic murmur is on the aorta. Blood pressure 120/80 mmHg. The liver is located on the right, not enlarged. The spleen is not palpable. Physiological functions are normal. Pasternatsky's symptom is negative on both sides.

Examination in the department

ECG:

sinus rhythm, normal position of the electrical axis of the heart. Heart rate 75 beats per minute.

EchoCG:

LA - left atrium, LV - left ventricle, ESV - end-systolic volume, EDV - end-diastolic volume, EF - ejection fraction, AK - aortic valve, FC - annulus fibrosus, MK - mitral valve, TC - tricuspid valve, PMS - anterior mitral valve.

X-ray:

in the lower lobe on the left there is an infiltration measuring 4.5*2.5 cm, in the pleural cavity on the left there is a minimal amount of fluid, the pulmonary pattern is enhanced. TTI = 51%.

On the fourth day of hospitalization, surgery was performed:

aortic valve replacement with a mechanical prosthesis MIX No. 25 with sanitation of the fibrous ring; pulmonary valve replacement using a mechanical prosthesis MICS No. 25 with sanitation of the fibrous ring; suturing of the oval window, under IR, hypothermia and FHKP.

Postoperative period and discharge

The postoperative period proceeded without complications. Enterococcus faecalis was isolated from cultures of intraoperative material.

EchoCG:

PV = 60%.

Aortic valve prosthesis: leaflet movement is normal, peak gradient on the prosthesis is 19 mmHg;

Pulmonary valve: peak gradient on the prosthesis is 13 mm Hg. There is no free fluid in the pericardial cavity.

ECG:

sinus rhythm. There are no rhythm or conduction disturbances.

Analyzes

blood and urine without pathology.

X-ray:

in dynamics there is less enhancement of the pulmonary pattern; on the right there is a rough “heaviness” in the area of ​​the apex of the heart. There is no fluid in the pleural cavities.

The patient was transferred from intensive care on the second day after surgery in satisfactory condition.

Doesn't have a fever. The skin is clean. The breathing in the lungs is harsh, there is no wheezing. Heart sounds are rhythmic, the melody of the prosthesis, heart rate = 80 beats/min. Blood pressure = 120/75 mm Hg. The liver is not enlarged. Physiological functions are normal. Postoperative wound without signs of inflammation.

On the eighth day after surgery, in satisfactory condition, the patient is discharged home with recommendations: observation by a cardiologist at the place of residence; limiting physical activity; continue taking prescribed medications; EchoCG monitoring after one week for separation; limiting fluid intake to 1.5 liters per day for a month; control of prothrombin index; a general blood and urine test once a week and control at the clinic of the Scientific Center for Cardiovascular Surgery every year. Rehabilitation in a cardiological sanatorium.

Description prepared by:

Makarenko Maria Vladimirovna

4. Lifespan of heart valves

Today, two types of heart valve implants are used in heart surgery: artificial and biological.

The first ones are durable, but their installation is associated with lifelong use of a number of drugs to eliminate the risk of blood clots. Biological valves are closest to living tissues, but wear out faster. Cardiologists are constantly working to develop and introduce into medical practice new types of valves that combine the best properties of both types - durability and maximum acceptability for the body. The service life of artificial valves is 10-15 years. Newer materials are still being studied. Widespread practice of their use in the near future will provide cardiologists with more accurate information about their service life.