• What are heart valves?
• What causes a leak?
• What happens to the heart with stenosis and leaks?
• What you may feel with stenosis or a leak?
• Will I be in a lot of pain after surgery?
• What you should and should NOT do in the first few weeks
• What you need to know about your condition and this operation

Your Heart

The goal of this operation is to repair or replace a bad heart valve. By having this procedure, life-threatening conditions can be prevented from developing later.

The heart

The heart is a muscle that pumps blood through your body. And it's divided into 4 chambers:

• The chambers on your right side are called the "right atrium" and the "right ventricle".
• The chambers on your left side are called the "left atrium" and the "left ventricle".

What are heart valves?

Valves are one-way gates in the heart that keep blood flowing between the chambers and in the same direction. There are 4 valves in the heart, and each one has strong flaps called "leaflets" that control blood flow.

Leaflets open to let blood move through the heart and out to the rest of the body. Then they close to keep blood from leaking back in the wrong direction.

The chambers and valves all work together to keep blood flowing in one direction. This is how blood travels through the heart:

• Blood fills the right atrium.
• Then it moves into the right ventricle.
• At this point, blood needs oxygen. So it moves from the right ventricle into the lungs where it picks some up.
• Oxygen-rich blood then returns from the lungs and fills the left atrium.
• From here, blood moves through the "mitral valve" and into the left ventricle.
• The left ventricle pumps blood through the "aortic valve" and into the "aorta," which is the main pipeline for blood leaving the heart.
• When oxygen-rich blood leaves the aorta, it goes out to feed the body with oxygen.
• After oxygen's been delivered, blood returns to the heart, and the whole process starts again.

The left side of the heart pumps blood to the entire body, so it has to work a lot harder than the right side. And because the mitral and aortic valves are on the heart's left side, it's usually these valves that have problems.

Your Condition

The 2 most common heart valve conditions are:

• Narrowing ("stenosis")
• Leakage ("insufficiency" or "regurgitation")

Narrowing (stenosis)

Stenosis happens most often in the aortic valve. When a healthy aortic valve is open, it's about as big as a half dollar (mitral valves are a little bigger). But sometimes a valve's opening becomes narrow. In many cases, this is caused by the natural wear and tear of aging.

As we get older, a little bit of calcium can form on the valve's leaflets. And as this builds up, the opening can become more narrow, and blood can't flow as easily through the valve.

Leakage (insufficiency or regurgitation)

Leaks happen more often in the mitral valve. When a valve leaks, the leaflets don't close completely, and some blood flows backward rather than in one direction.

In a healthy heart, blood flows from the left atrium, through the mitral valve, and into the left ventricle. But if there's a leak, some blood flows back into the left atrium instead of out to the rest of the body as it should. And your body doesn't get all the oxygen-rich blood that it needs.

What causes a leak?

Like stenosis, many leaks happen because the valve simply wears out as we get older. But other things like a defective valve at birth, or if you had rheumatic fever as a child, can also cause a leak.

What happens to the heart with stenosis and leaks?

Both valve stenosis and leaks make the heart work harder. With stenosis, it has to work harder to pump blood through a narrowed valve. And when a valve leaks, the heart has to strain so the body gets enough oxygen-rich blood.

All of this extra work can make the walls of the heart thicker, causing the chambers to become smaller. This thickening prevents blood from flowing as it should. And over time, it can lead to serious, or even life-threatening, problems.

What you may feel with stenosis or a leak?

You can have valve stenosis or leakage and not even know it or feel a thing. But if your condition becomes more severe, there are a few things you could feel. For instance, you may have:

• Shortness of breath
• Chest pain ("angina")
• Lightheadedness
• Fainting
• Fatigue
• Your doctor may hear a "whooshing" sound when he listens to your heart ("heart murmur")

You could feel a combination of these symptoms or you may not feel anything. It really just depends on your condition.

Arrhythmia

The heart has its own electrical system, and electrical signals typically fire in rhythm to give the heart a steady beat. An "arrhythmia" is anything that changes this steady beat and makes the heart feel like it's fluttering or skipping a beat. And one of the most common arrhythmias is "atrial fibrillation."

Atrial fibrillation

With this, the electrical signals in the atria "short circuit." And the heart's upper chambers pump in a fast or irregular way. So in addition to fixing or replacing a valve, your surgeon may treat atrial fibrillation during this operation as well.

Before Your Surgery

If you're having a valve replaced, a number of factors need to be considered before deciding if you'll get a "mechanical valve" or a "tissue valve." These factors include:

• Your age
• Personal preference
• Other medical conditions

So you and your surgeon will talk about these things to decide which kind of heart valve is right for you.

Mechanical valve

Like a normal valve, mechanical valves have flaps that open and close. And they're made of a strong, carbon-based material and a cloth ring.

Mechanical valves are designed to last forever. But the downside is that blood clots can sometimes form on them. And if a clot breaks off, it can enter the bloodstream and block an artery. And this can be very serious.

Tissue valve

Tissue valves are often made from a cloth ring and the thin layer of tissue that's around a cow's heart. And because tissue valves aren't as strong as mechanical valves, they tend to wear out over time. How long before a tissue valve wears out varies. But they typically last about 15 years. And when a valve finally wears out, another open-heart operation to replace the valve may be needed.

Blood-thinning medication (mechanical valve vs. tissue valve)

If you get a mechanical valve, to prevent blood clots, you'll have to take at least one pill of blood-thinning medication every day. And you'll have to do this for the rest of your life. You'll also need to have your blood tested regularly to make sure your medication levels are right.

Blood-thinning medication (mechanical valve vs. tissue valve)

If you get a mechanical valve, to prevent blood clots, you'll have to take at least one pill of blood-thinning medication every day. And you'll have to do this for the rest of your life. You'll also need to have your blood tested regularly to make sure your medication levels are right.

Blood clots are NOT as common in tissue valves. So with tissue valves, you most likely will NOT have to take blood thinners for the rest of your life. You may have to take them for several months after the operation (just until your heart gets used to its new valve).

Think of yourself as a key member of your healthcare team

Even though you're having surgery on your heart, your surgeon needs to learn about your overall health and your health history. So it's up to you to fill him in. When you give your doctor the information he needs, you increase your chance for success. So let him know if:

• You have any other health conditions
• You're allergic to anything like penicillin or latex
• You, or anyone in your family, has ever had a bad reaction to anesthesia

Also, for your safety, it's important to make a list of everything you take. You may need to get some medications out of your system in the weeks before surgery. This includes:

• Aspirin
• Anti-inflammatory drugs (like Advil™ or Motrin®)
• Blood-thinners like (Coumadin® or Plavix®)
• Injections
• All prescription and over-the-counter drugs
• Herbal supplements (like Ginkgo biloba)
• Vitamins
• Recreational drugs

For a complete list of what to stop taking and when, ask your doctor.

Smoking

To help prevent problems during and after the operation, you may need to stop smoking before surgery.

Comfort and support

It's a good idea to ask a family member or a friend to be there with you for comfort and support. Think of this person as your partner in care.

Doctors and nurses like to have one "go to" person for all communication. He or she should be able to speak up for you, ask questions, and give information about your health. Be sure to introduce this person to your doctors and your nurses so they know it's OK to share your health information with them.

Visit the dentist before surgery

If you haven't gone to the dentist in a while, do it BEFORE the operation. Why? When you have work done on your teeth and gums, bacteria can enter the bloodstream. And if bacteria settles around the new valve, it can cause an infection.

After the operation, you'll most likely have to take antibiotics before you visit the dentist or have a medical procedure like a colonoscopy. And you may have to do this for the rest of your life.

Night before surgery

You may go into the hospital the night before your operation. But if you don't go in until the morning of the procedure, do NOT eat or drink anything after midnight the night before.

Why? Food in your stomach can be very dangerous if you throw up during surgery. So make sure your stomach is EMPTY, or your surgery may need to be rescheduled. That said, if your doctor says it's OK to take a pill, just take it with a sip of water.

Your Procedure

Your surgeon will go over his specific plan for your procedure and recovery. But this will give you a general sense of how surgery will go. The operation can take anywhere from 3 to 5 hours.

Before surgery begins

You'll be connected to monitors that measure your blood pressure, heart rate, and oxygen in your blood. You may also have support hose or compression boots to help lower the risk of blood clots in your legs.

• An intravenous line (IV) will be placed in your hand or your arm. This is so you can receive antibiotics, medication, and fluids.
• Then they'll start the anesthesia. This surgery is done under general anesthesia, which puts you into a deep sleep.
• First, the anesthesiologist will place an oxygen mask over your mouth and nose and ask you to take deep breaths.
• Then you'll get the anesthesia through your IV. The medication may sting or burn a little bit when it goes in, but that’s normal.
• Very quickly, you'll fall asleep. After this, you really won't remember anything about the procedure.
• Once you’re asleep, a tube is placed in the back of your throat or down your windpipe to help you breathe.
• And another IV that measures the pressure in your heart may be placed through a vein in your neck.
• A soft tube may also be placed in your bladder to drain urine.
• Your surgeon will start by making a cut over the breastbone.
• Then the skin and muscle are pulled back, and the breastbone is separated.
• Next, he'll open this thin layer of tissue that surrounds the heart.
• To do this operation, your surgeon will need to temporarily stop your heart. So you'll be connected to something called a "heart-lung machine." The machine will do the heart's job during the operation and keep oxygen-rich blood flowing through your body.

What your surgeon does next really depends on your condition.

Mitral valve repair

• If the mitral valve is causing problems, your surgeon will open the heart so he can see the valve.
• Then he'll examine the mitral valve to see how much damage there is.
• If he thinks the valve can be fixed, your surgeon may repair it so the leaflets open and close normally.
• Or he may sew a ring around the valve's rim to improve its shape and size.
• Many times, a damaged mitral valve can be repaired. But if your surgeon finds that a valve has too much damage, he'll need to replace it.

Aortic valve replacement

• First, your surgeon will make a cut in the aorta so he can see the valve.
• Next, he'll remove the damaged valve.
• Then he'll measure the opening so he'll know how big the replacement valve should be.
• To attach the new valve, he'll put stitches in the aorta's rim.
• Then the new valve is fitted and stitched to the aorta.
• After he's done placing the new valve, your surgeon will stitch the aorta closed.

If any other heart problems need to be treated, your surgeon may fix those as well. For instance, if you have atrial fibrillation (when electrical signals in your heart go a little haywire), your surgeon may treat it with the "Maze procedure."

Maze procedure

The Maze procedure treats atrial fibrillation by making thin cuts or burn lines in either of the heart's upper chambers. And scar tissue forms on the lines.

Because electrical signals can't travel across scar tissue, the signals are re-routed so they move between the scar lines. This way, the signals move normally between the heart's upper and lower chambers.

When he's done repairing your heart:

• Your surgeon will allow your heart to beat on its own again.
• Then he'll remove the heart-lung machine.
• To help your heart beat normally, "pacing wires" may be placed alongside your heart.
• Your surgeon will also place tubes in your chest to drain fluid.
• Then he'll reconnect the breastbone with wire.
• And close the skin with dissolvable stitches.

After Your Surgery

In recovery

After surgery, expect to feel groggy and a little out of it. If you feel queasy or have the chills, just ask your nurse to help you get comfortable.

You'll be hooked up to some monitors and your IV line for medication and fluids. And you may also see the tubes and pacing wires in your chest. But these will be removed in a day or so.

Breathing tube

One thing that can be a little scary is if you wake up to find that your breathing tube is still in and you can't speak. Many people don't remember the tube coming out. But if it is still in when you wake up, don't fight it. It will be removed soon, so just let it continue to breathe for you.

Will I be in a lot of pain after surgery?

Many people say they're surprised by how well they feel. You can of course expect your chest to be a little sore. But to help with any pain and soreness, your nurse will give you medication.

Pain pump

You may also have a button that's attached to a pain pump. This lets you give yourself pain medication when you need it. This button is only for YOU to use. So make sure that anyone who visits you in the hospital knows they should NOT push it for you.

Your hospital stay

After a night or so in the intensive care unit (ICU), you'll move to your hospital room. Most people stay in the hospital for 5 to 7 days.

As soon as you're ready, a nurse will help you get up and walk. Moving around can help prevent blood clots from forming in your legs and helps you regain strength.

Lung strength

Your lungs may be a little weak after surgery as well, so it's important to get them back in shape. To do this, you may be asked to:

• Take deep breaths
• Cough a lot
• Use an "incentive spirometer"

An incentive spirometer looks kind of like a small plastic toy. As you breathe in, a little ball flies up to show you how deeply you're breathing. This keeps your lungs clear and helps prevent lung infections as you recover.

Going home

Once your doctor thinks you're ready, you can go home (again, it usually take about a week). Just make sure you have someone to drive you home and stay with you. In fact, your doctor may tell you not to drive for a while. Just ask your doctor what his instructions are for you.

First few weeks

After you go home, you'll have follow-up appointments in the first few weeks with your surgeon. You may have to see your cardiologist as well. This is so they can see how you're recovering and how well your new valve is working.

What you should and should NOT do in the first few weeks:

• Try to walk as much as comfort allows (it's great way to regain strength and help prevent blood clots in your legs).
• Do NOT lift anything heavy. If you need to pick up something that's even a little heavy (like a gallon of milk), ask someone to get it for you.
• You can resume sex as soon as you feel ready. Just don't overdo it.

About bathing

To help prevent an infection, you'll want to keep your cuts as dry as possible for a while.

• Your doctor may tell you NOT to soak in any water
• Showering will most likely be fine
• Just don't go swimming or take baths until he says it’s OK

Clicking sound

If you get a mechanical valve, you may notice a soft clicking sound when it's quiet or when you're falling asleep. This is just the sound of your new valve doing its job. Not all valves click. But if you hear something in there, it's nothing to worry about.

Blood thinners

Many people who have valve surgery take blood thinners soon after their operation. These help prevent blood clots from forming around your new valve.

But your healthcare team will need to figure out how much blood-thinning medication is right for your system. So they'll need to test the levels in your blood.

Testing your blood thinner levels

While you're still in the hospital, your levels will be tested every day. But then it will have to be done every 3 to 5 days for about a month after leaving the hospital. To have your blood tested after you've gone home, you may have to:

• Visit the hospital or your doctor's office
• A nurse may come to your home
• You may be able to use a home-testing kit so you can test the levels on your own (more common if you have a mechanical valve)

If you have any questions about having your blood-thinner levels tested, ask your surgeon.

Blood-thinning medication (mechanical valve vs. tissue valve)

If you get a tissue valve, some doctors will have you take blood-thinning medication for the first 6 to 12 weeks after surgery.

But if you have a mechanical valve, you'll take blood-thinning medication and test your levels regularly for the rest of your life. And if this is the case, there's a lot you need to know.

What can throw off the balanced blood-thinner levels in my system?

• Foods high in vitamin K like spinach
• Medications like aspirin
• Changing what you eat or drink, or what medications you take

Be consistent about what you eat and the medications you take

Even though you'll be able to eat and drink whatever you want, it's VERY important that you're consistent about what you eat and the medications you take.

If your blood-thinner levels are too high it can cause bleeding. And if they're too low, blood clots may form. So if you change what you eat or start taking a new medication, you may need to take higher or lower doses of your medicine.

Avoid sports or activities that can get rough and cause bleeding.

Also, because your blood won't clot as well, avoid sports or activities that can get a little rough and cause bleeding. But many activities like golf, jogging, and tennis are fine.

These are just a few of the things you should know about taking blood thinners regularly. There's more you'll need to learn, so talk with your doctor about everything that's going to change.

ID card

If you had a valve replaced, you'll most likely get an ID card. It'll have your name, your doctor's name, and other information about your new heart valve.

The card is small enough to fit in your wallet or purse. And it's VERY important that you carry it with you at all times. If there's ever a medical emergency, the card has valuable information a hospital would need.

Your recovery period

After surgery, it's probably going to take 6 to 8 weeks before you can get back to your normal activities. But if you have any problems during recovery, please call your doctor.

Call right away if you have:

• A fever of 101° or higher
• Pain that does not get better with medication
• Sudden, severe shortness of breath or chest pain
• A fast or irregular heartbeat that does not go away
• Pain, redness, or swelling in one or both of your legs
• Nausea or you can't keep food down
• Drainage from your cut

Or if you experience anything unusual. If something just feels wrong, don't be afraid to call.

Risks and Benefits

Benefits

Heart valve surgery of course has many, many benefits. For starters, this operation should help relieve any pain, fatigue, or breathing problems you're having.

But even more importantly is that this procedure may also prevent heart failure. And this could help you live longer, or even save your life.

Risks

But like any operation, heart valve surgery has some risks. It's important for you to understand what's involved, so some of the risks related to this operation are described here.

If you have any questions about how these risks relate to you, please ask your surgeon. Also, there are some very unusual risks that will not be covered here. So please do not consider this list complete.

There is a risk of a stroke.

A stroke happens when blood flow to part of the brain is blocked. If you've already had a stroke, you may be at a higher risk for another one. It is possible to recover from a stroke and be perfectly fine. In other cases, the damage can be permanent.

There is a risk of injury to the heart during the operation or the recovery period. If this happens, you could have a heart attack during or after the operation.

Although your surgeon will do everything he can to protect the heart, your heart may not respond well to the stress of surgery. As a result, there is a risk that you could have a heart attack during or after the operation. If this happens, the heart muscle could become damaged, and you could lose some heart function. In some cases, heart function returns over time. But in other cases, the damage can be permanent.

There is a risk of bleeding both during and after the surgery. In some cases, a blood transfusion or more surgery may be needed to treat this.

With any surgery, there's a risk of bleeding. In most cases, your doctor will be able to control any bleeding. While it's very rare, if you lose too much blood, you may need a blood transfusion. All blood is checked to make sure it’s clean and free of disease. But there is still an extremely small chance you could get a virus or your body could reject the blood. And while it's very rare, you may have bleeding in the days after surgery and may need another operation.

There is a risk an infection could develop in your heart. In rare cases, special antibiotic treatments or more surgery may be needed to treat an infection.

If you have a heart valve replaced, your new valve won’t be able to fight off infections as well as the old one. As a result, there is a risk that your heart may become infected. This is called “endocarditis.” Signs of endocarditis include a fever, fast heart rate, joint pain, or blood in your urine. You may also sweat a lot or feel very tired. Endocarditis may also cause tiny red spots to appear on your skin or in the whites of your eyes. If you see or feel any of these things, call your doctor right away. You may need to be admitted to the hospital for special antibiotic treatments or more surgery.

There is a risk of infection around your wound or in other parts of your body. In rare cases, more surgery may be needed to treat an infection.

Although your doctor will take great care to prevent infections, you may still get an infection around your surgical area. Signs of a wound infection include redness, swelling, fluid drainage, or pain that gets worse. You may also get a high fever or chills. If you feel any of these things, please call your doctor right away. Infections can also form in other parts of your body, like in your lungs or bladder. Most of the time, antibiotics get rid of infections. But in some cases, you may need to be admitted to the hospital for special treatments or more surgery.

There is a risk that after surgery, your kidney function may be worse. In rare cases, a "dialysis" machine may be needed to do your kidneys' job.

Although it doesn't happen often, there's a risk that your kidneys may not work as well after this operation. This is especially true if your kidneys are weak or diseased before surgery. Weak kidney function is often temporary and gets stronger over time. But in rare cases, your kidneys may not recover. And if this happens, you may need a machine to do the work of your kidneys. This is called "dialysis." You may only need dialysis for a short time (just until your kidneys recover). But in very rare cases, you may need dialysis permanently.

There is a risk of bad or allergic reactions to the anesthesia or medications that are used. While it's very rare, you can die from one of these reactions.

An allergic reaction happens when your body tries to get rid of something it doesn't want. And it's your body's response that can be serious. Signs can include dizziness, vomiting, swelling, or trouble breathing. You should know that your healthcare team is trained and ready to respond to allergic reactions. But in rare cases, people can die. If you have ever had an allergic reaction, or know you are allergic to any drug or food or materials like latex, please let your doctors know. And let them know if you, or anyone in your family, has ever had a serious reaction to anesthesia.

There is a risk that surgery will cause your heart to beat irregularly.

As you know, a healthy heart beats at a steady and constant rate. But this operation can put a lot of stress on the heart and change its rhythm. This is called an "arrhythmia." One of the most common arrhythmias after heart valve surgery is "atrial fibrillation." This causes the heart to beat too fast. And even though a fast heartbeat can be scary, it's usually a temporary condition. But in rare cases, your heart may continue to beat too fast. If this happens, you may need to take daily medication to treat it.

There is a risk that the electrical system in the heart could be damaged during the operation. If this happens, a "heart block" may develop, causing your heart to beat more slowly.

To make the heart beat as it should, electrical signals move steadily between the heart’s upper and lower chambers. But in rare cases, this electrical system could be injured during the operation, causing your heart to beat more slowly. This is called a "heart block." Sometimes you can have a heart block and not have any symptoms or need to be treated at all. But in more severe cases, the electrical signals could be completely blocked. Signs of heart block include a slowed heart rate, lightheadedness, fatigue, dizziness, or shortness of breath. In very rare cases, a complete block could even result in death. If you feel any of these symptoms, call your doctor or get emergency help right away. If medication doesn't work to treat heart block, an operation to put a small, electrical device called a "pacemaker" in your chest may need to be done to return your heart to its normal speed.

There is a risk of blood clots that, in rare cases, can be life threatening.

Blood clots can form on a replacement heart valve. And even though it’s extremely rare, clots can also form during or after the procedure in other parts of the body (like your legs or lungs). If this happens, it can be very dangerous, and can even result in death. The key to preventing blood clots is to keep blood flowing. This is why it's so important to move around as much as you can after the operation, and to take your blood-thinning medication as directed. Signs of blood clots include sudden shortness of breath, chest pain, and painful swelling in one or both of your legs. If you have any of these signs, call your doctor or get emergency help right away.

There is a risk of death.

How your body handles surgery depends on what kind of condition your body is in. Some bodies are stronger and can handle surgery better than others. Age, illnesses, past strokes, and other things like being overweight may make it harder to perform surgery successfully. Although the risk of death is small, you may die during surgery or the recovery period from any of the risks I mentioned earlier, or for other reasons.

Alternatives

No surgery

The decision to have this surgery is of course up to you. You can choose not to have surgery and try to manage your symptoms with medication. And for mild valve conditions, this may be all you need. But your doctor most likely thinks that your heart condition is more severe.

Other ways surgery can be done to repair or replace a valve

Some techniques use smaller cuts and don’t have to open the breastbone to reach the heart. So there's less scarring and a shorter hospital stay than with open-heart procedures.

But this type of surgery isn't for everyone. And because these operations are more complicated, many surgeons prefer to do open-heart procedures.

What you need to know about your condition and this operation

Conditions like valve stenosis and leakage often get worse over time. And if the problem isn't treated, your heart may begin to fail. You could even die.

Also, if your condition gets worse, the risks of this operation increase. And your recovery may be less successful. So if your doctor thinks you should have this operation, it's best to do it sooner rather than later. It could save your life.

Health Information Forms

After you print this summary, you can fill out the following forms. Keep a copy at home and take a copy to your next doctor's appointment.