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Heart valve surgery

Published by Bupa's health information team, July 2006.

This factsheet is for people who are considering having heart valve surgery.

Heart valve surgery is "open heart" surgery to treat heart valve disease. It can repair or replace a diseased or abnormal heart valve. For more information about heart valve disease, please see the separate Bupa factsheet, Heart valve disease.

Heart valve replacement animation

Why have heart valve surgery?

If one or more valves in the heart are not working fully, blood does not flow through the heart as it should. This can put an extra strain on the heart and cause symptoms such as breathlessness and swollen ankles. Severe heart valve disease can cause the heart to pump less efficiently.

Surgery can treat heart valve disease by replacing or repairing a diseased or abnormal valve. Whether you have the valve replaced or repaired will depend on what is wrong with the valve and how serious the problem is. Your doctor will advise you which treatment is best for you.

Heart valve surgery can eliminate, or improve your symptoms and may prevent permanent damage to your heart.

What are the alternatives?

Alternative treatments for heart valve disease include:

• if you have mild heart valve disease, drug treatments to relieve symptoms (such as diuretics, ACE-inhibitors, and digoxin)
• balloon valve surgery which can widen a narrowed valve (stenosis)

For more information on alternative treatments, please see the separate Bupa factsheet, Heart valve disease. Your doctor will advise you which treatment is best for you.

What happens before surgery?

Your surgeon will discuss how to prepare for heart valve surgery.

For example if you smoke, you may be advised to give up as smoking increases the risk of chest infection and slows the healing of wounds as well as increasing the risk of blood clots in the legs. For help and advice on quitting smoking, please see the separate Bupa factsheet, Giving up smoking.

What should I expect in hospital?

Heart valve surgery usually requires around five to seven days in hospital.

The operation will be performed under general anaesthetic so you will be asked to follow fasting instructions. Typically, you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

Before surgery you will talk to your surgeon about the operation and you will be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead. This is a good time to ask any unanswered questions about the operation.

The operation

The length of your operation will depend on whether your valve is to be repaired or replaced and how many valves are going to be treated - your surgeon will advise you how long the operation will take.

Heart valve surgery is carried out under a general anaesthetic, which means that you will be asleep throughout the procedure and will feel no pain.

The surgeon will make a cut, about 25cm (10") long, down the middle of your breastbone (sternum) and will open your ribcage to reach your heart.

Medication is used to temporarily stop your heart. Your blood will be re-routed to a heart-lung (bypass) machine. This will take over from your heart and lungs, and will add oxygen to your blood and maintain your circulation.

The diseased valve will then be replaced or repaired.

The types of heart valve replacement

Valve replacement

Your surgeon will remove your diseased valve and sew in a replacement prosthetic (artificial) valve. There are two types.

• Mechanical valves are artificial manufactured valves. They are made of carbon fibre which is a hard material. Sometimes they make a clicking sound but most people soon get used to this. Mechanical valves have the advantage of lasting a long time - usually a lifetime. However there is a risk that a blood clot can form on the valve so you will need to take blood thinning drugs (anticoagulants), such as warfarin, for the rest of your life to avoid this. Your doctor will give you more advice about these drugs.
• Biological valves are made from human or animal tissue (usually pig). You will probably not need to take anticoagulants for the rest of your life but your surgeon may recommend them for the few weeks after the operation while the valve settles in. You may need further surgery every 10-15 years because biological valves can wear out faster than mechanical valves. Biological valves are not suitable for everybody - your doctor will advise you whether they are the best choice for you.

Valve repair

Valve repair is most commonly used to repair mitral valves that are not seriously damaged. The mitral valve is on the left side of the heart and separates the atrium from the ventricle.

There are a number of techniques for repairing the valve depending on what is wrong with the valve. Ask your surgeon for more information.

After the valve(s) have been replaced or repaired your surgeon will restart your heart and blood will flow back through your heart again. Your sternum will be rejoined using wires and the skin on your chest will be closed with dissolvable stitches. Tubes will be put into small holes in your chest to drain blood and fluid that collects as part of the normal healing process.

Minimally invasive surgery

Less commonly "minimally invasive" or "key hole" surgery is used.

Instead of making a cut down the sternum, the operation is performed through small incisions. Special instruments are passed through the small incisions and the surgeon uses a video monitor to see the inside of your chest. These methods are not suitable for all patients - your surgeon will advise you if they are suitable for you.

After the operation

After heart valve surgery, you will be taken to the intensive treatment unit (ITU) of the hospital and will be closely monitored for a day or two before you go back to your ward.

When you wake up from the anaesthesia, you will be connected to machines that record the activity of your heart, lungs and other body systems. These might include a ventilator machine to help you breathe. You may also have between two and four wires, called pacing wires, inserted near the chest drains. These are used to control your heart rate if necessary after the operation. These will be removed three or four days after your operation.

You will be given painkillers to help relieve any pain and discomfort as the anaesthetic wears off.

A physiotherapist will usually visit you every day to help you do exercises designed to help your recovery.

Before discharge, your nurse will give you advice about caring for your wounds, diet and exercise, and will give you medicines to take home with you. You should tell your GP when you are discharged from hospital so he or she can provide the care you need.

Recovering from heart valve surgery

At home, take painkillers if needed, as advised by your surgeon or nurse.

If you have questions about what you can and can't do, ask your surgeon or nurse for guidance.

The wires holding your sternum together are usually permanent, but the stitches closing the wound will gradually dissolve. The sternum takes about six weeks to heal.

You shouldn't drive until you can perform an emergency stop without discomfort. If you have a licence to drive a large vehicle such as a minibus or truck, you should tell the DVLA as you will need to be tested to get your licence back.

When you see your surgeon for a follow-up appointment, he or she will advise you about when you can resume other activities such as returning to work. A full recovery can take two to three months.

Deciding to have heart valve surgery

For most people, the benefits of having heart valve surgery are greater than any disadvantages. However, in order to make a well-informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications.

Side-effects are the unwanted but mostly temporary effects of a successful procedure. For heart valve surgery, side-effects include:

• discomfort around the operation site for a few weeks
• a scar down the length of your sternum - the scar will be red at first but should fade over time

Complications are unexpected problems that can occur during or after the procedure. Most people are not affected. The main complications of any operation are bleeding during or soon after the procedure, infection and an abnormal reaction to the anaesthetic.

Specific complications of heart valve surgery are rare but can include the following.

• Blood clots may form, particularly if you have had a mechanical valve fitted. These clots can break off and block an artery (blood vessel) which can lead to a heart attack or stroke. Anticoagulant medicines will help to prevent this happening.
• The valve may wear out or be damaged, particularly tissue valves in young, more active people.
• It's possible that you may have an irregular heart beat (arrhythmia), which can be treated with drugs and is usually temporary.
• Your new valve can become infected and inflamed (endocarditis). This can damage your heart. You will be given antibiotics to help lower this risk.
• There is a small risk of death during or soon after this operation.

The chance of complications depends on the exact type of procedure you are having and factors such as your general health. Ask your surgeon to explain how these risks apply to you.

Further information

• The British Heart Foundation
  08450 70 80 70
  www.bhf.org.uk

Sources

• Valvular heart disease. British Heart Foundation. Heart Information Series Number 11. May 2005.
  www.bhf.org.uk
• Simon C, Everitt H, Birtwistle J, Stevenson B. Oxford Handbook of General Practice. Oxford: Oxford University Press, 2002:262-263.
• Mitral valve repair. The Society of Thoracic Surgeons.
  www.sts.org
  accessed 3 March 2006
• BNF British National Formulary 50, September 2005.
• Balloon valvuloplasty for aortic valve stenosis in adults and children. National Institute of Clinical Excellence (NICE). July 2004. Interventional procedure Guidance 78.
  www.nice.org.uk
• Balloon dilatation of pulmonary valve stenosis. National Institute of Clinical Excellence (NICE). June 2004. Interventional procedure Guidance 67.
  www.nice.org.uk
• Smoking and wound healing. Am J Med. 1992 Jul 15;93(1A):22S-24S.
• BHF factsheet on DVT,
  www.bhf.org.uk
  accessed 21/02/2005
• Having heart surgery. British Heart Foundation. Heart Information Series Number 12. January 2005.
  www.bhf.org.uk
• Aortic valve. The Society of Thoracic Surgeons.
  www.sts.org
  accessed 3 March 2006
• Longmore M, Wilkinson I, Torok E. Oxford Handbook of Clinical Medicine. Oxford: Oxford University Press, 2001 134-135.
• At a Glance. Guide to the current Medical Standards of Fitness to Drive. Driver and Vehicle Licensing Agency (DVLA). September 2005.
  www.dvla.gov.uk

Reviewed by Dr James Quekett, Bsc.MB Ch.B MRCGP DRCOG DFFP, partner/principal general practitioner at Rowcroft Medical Centre.

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