Mitral valve surgery Brought to you in association with EIDO Healthcare and endorsed by the Royal College of Surgeons England. Discovery has made every effort to ensure that we obtained the information in this brochure from a reputable source. We have adapted the content to reflect the South African market or healthcare environment. You should not only depend on the information we have provided when you make any decisions about your treatment. The information is meant to act only as a guide to the treatment you are considering having. Please discuss any questions you may have about your treatment with your treating healthcare professional. Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider, administrator of medical schemes.
What is mitral valve disease? Your heart is a muscle that pumps oxygen-rich blood from your lungs around your body and oxygen-poor blood from your body to your lungs. Your mitral valve is a one-way valve that controls the flow of blood from the main collecting chamber (left atrium) into the main pumping chamber (left ventricle). The valve is made up of two leaflets (or doors) that are forced open as the atrium contracts (see figure 1). Figure 1 An open mitral valve The leaflets close, preventing blood from flowing back into the atrium, while the left ventricle contracts and pumps oxygen-rich blood through your blood system (see figure 2). Pulmonary valve Mitral valve Figure 2 The heart valves viewed from below Aorta Mitral valve leaflets Left ventricle Aortic valve Tricuspid valve Mitral valve disease is where the valve does not open properly, is narrowed (stenosis), or does not close properly (incompetence). Your cardiologist and surgeon have recommended mitral valve surgery. However, it is your decision to go ahead with the operation or not. We understand this can be a stressful time as you deal with different emotions and sometimes have questions after seeing your surgeon. This document will give you a basic understanding about your operation. We tell you about the things you can do to help make the operation a success. It is also important to remember to tell your surgeon about any medicine you are on so he or she can manage this, if necessary. It will also tell you about what to expect after the operation while in hospital and in the long term. Your surgeon remains the best person to speak to about any questions or concerns you may have about the operation. How does mitral valve disease happen? The following are the main causes of mitral valve disease. The valve is abnormal from birth (congenital abnormality). For some people the condition gets worse and causes problems. Long-term effects of rheumatic fever, which may have happened many years before. Rupture or thickening of the valve. There is usually no specific cause. Infection of the lining of your heart (endocarditis), which is more likely in an abnormal valve. Your surgeon will tell you the cause of your mitral valve disease. A valve that does not open properly or is narrowed prevents the atrium from pushing enough blood into the ventricle. This causes the atrium to stretch and you can get palpitations (your heart beating a few extra times). Over time your heart will struggle to cope and you may get dizzy or breathless. A valve that does not close properly allows blood to leak back into the atrium and your heart becomes too full of blood. This puts pressure on your lungs and you can get palpitations and feel breathless. What are the benefits of surgery? You should get improved breathing, less chest pain and more energy. You should live longer with surgery. Copyright 2016 Page 1 of 4
Are there any alternatives to surgery? Medicine is the main alternative to surgery. Diuretics (water tablets that reduce extra fluid) to lessen the strain on your heart. ACE-inhibitors to make your heartbeat stronger. Digoxin to stabilise your heart rhythm. What will happen if I decide not to have the operation? You will continue to be given medicine to try to control your symptoms but your symptoms may get worse. Your heart will need to work harder to pump blood around your body, leading to damage and heart failure. What does the operation involve? The healthcare team will carry out a number of checks to make sure you have the operation you came in for. You can help by confirming to your surgeon and the healthcare team your name and the operation you are having. The operation is performed under a general anaesthetic and usually takes three to four hours. You may be given antibiotics during the operation to reduce the risk of infection. Your surgeon will usually make a cut down the front of your chest, through your breastbone (sternum). This cut is called a median sternotomy. Sometimes your surgeon may perform the operation through a small cut on the right side of your chest. Your surgeon will discuss this with you. You will be connected to a heart-lung machine, which allows your heart to be still while your surgeon replaces or repairs the valve. If the valve is not too damaged, your surgeon may be able to repair it. This can involve tightening the valve or closing a hole in a leaflet. There are two main types of replacement valve. Mechanical valves These do not wear out but blood can stick to them so you will need to take blood-thinning medicine for life. Tissue valves These gradually wear out and are therefore less suitable for younger people. However, you will not need to take blood-thinning medicine. When your surgeon has replaced or repaired the valve, you will be disconnected from the heart-lung machine and your own heart will take over again. Your surgeon will insert drains (tubes) in your chest to drain away air or fluid that can sometimes collect. Your surgeon will close your sternum with wires and stitches. The healthcare team will place a small tube in a vein in your arm (drip) and in your neck (called a central line). They will also place a catheter (tube) in your bladder to help you to pass urine. They may also place a tube (nasogastric or NG tube) into your nostrils and down into your stomach to keep your stomach empty. What should I do about my medicine? Let your doctor know about all the medicine you take and follow their advice. This includes all blood-thinning medicine as well as herbal and complementary remedies, dietary supplements, and medicine you can buy over the counter. What can I do to help make the operation a success? Bad teeth and gums can cause infection of the lining of your heart. Keep your teeth and gums as healthy as possible, and go to your dentist regularly for a check-up. You should not have the operation if you have poor dental hygiene or a dental infection. If you smoke, stopping smoking several weeks or more before the operation may reduce your risk of developing complications and will improve your long-term health. Try to maintain a healthy weight. You have a higher risk of developing complications if you are overweight. Regular exercise should help to prepare you for the operation, help you to recover and improve your long-term health. Before you start exercising, ask the healthcare team or your GP for advice. You can reduce your risk of infection in a surgical wound. In the week before the operation, do not shave or wax the area where a cut is likely to be made. Try to have a bath or shower either the day before or on the day of the operation. Keep warm around the time of the operation. Let the healthcare team know if you feel cold. What complications can happen? The healthcare team will try to make the operation as safe as possible but complications can happen. Some of these can be serious. You should ask your doctor if there is anything you do not understand. Copyright 2016 Page 2 of 4
Your doctor may be able to tell you what the risk of a complication for you is. 1 Complications of anaesthesia Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic. 2 General complications of any operation Pain. The healthcare team will give you medicine to control the pain and it is important that you take it as you are told so you can breathe deeply, cough and move about as advised. Infection of the surgical site (wound) (risk: 2 in 100). It is usually safe to shower after two days but you should check with the healthcare team. Let the healthcare team know if you get a high temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics but you may need another operation. Bleeding during or after the operation. You may need a blood transfusion and another operation to identify and control the bleeding points (risk: 6 in 100). Unsightly scarring of your skin, although a midline chest wound usually heals neatly. Blood clot in your leg (deep-vein thrombosis DVT). This can cause pain, swelling or redness in your leg, or the veins near the surface of your leg to appear larger than normal. Blood clots are uncommon after cardiac surgery. The healthcare team will assess your risk. They will encourage you to get out of bed soon after the operation and may give you injections, medicine, or special stockings to wear. Let the healthcare team know straightaway if you think you might have a DVT. Blood clot in your lung (pulmonary embolus), if a blood clot moves through your bloodstream to your lungs (risk: less than 1 in 100). Let the healthcare team know straightaway if you become short of breath, feel pain in your chest or upper back, or if you cough up blood. If you are at home, call an ambulance or go immediately to your nearest casualty unit. 3 Specific complications of this operation Heart attack (where part of the heart muscle dies) (risk: on average less than 2 in 100). Stroke (loss of brain function resulting from an interruption of the blood supply to your brain) (risk: on average less than 3 in 100). The risk depends on your age and if you have a history of stroke. Your surgeon will be able to give a more accurate risk for you. Infection of the replacement valve (risk: less than 1 in 100). An infection can happen soon after the operation or later. The risk is higher if you have another infection such as a urinary tract or dental infection. You will need antibiotics and you may need another operation. Death (risk: on average 6 in 100). The risk of dying is related to different risk factors and your surgeon will be able to give a more accurate risk for you. How soon will I recover? In hospital After the operation you will be transferred to the cardiac intensive care unit or high care unit for a few days, so the healthcare team can monitor you more closely. You will then go to the ward. The healthcare team will help you with deep breathing, coughing and moving about, usually from the second day after the operation. You will be given fluid through the drip. The healthcare team will use the central line to monitor the pressure of blood returning to your heart. This will help your doctor to know how much fluid to give you. When you are ready to drink, the NG tube will be removed and you can drink small amounts of water. Over a few days you should be able to drink and then eat normally. You may need to take laxatives if you get constipated. The drains, drips and catheter will usually be removed after 2 to 5 days. You will be given strong painkillers to treat any chest discomfort and this should gradually lessen. Drink plenty of fluid and increase the amount of fibre in your diet to avoid constipation. You should be able to go home after 7 to 10 days. However, your doctor may recommend that you stay a little longer. If you are worried about anything, in hospital or at home, contact the healthcare team. They should be able to reassure you or identify and treat any complications. Copyright 2016 Page 3 of 4
Returning to normal activities To reduce the risk of a blood clot, make sure you follow carefully the instructions of the healthcare team if you have been given medicine or need to wear special stockings. The healthcare team will tell you when you can return to normal activities. Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your GP for advice. Do not drive for at least 8 weeks. You should be confident about controlling your vehicle and always check with your doctor. The future Most people make a good recovery, with no more shortness of breath or chest pain. You may have more energy after you recover. You may need to continue with some medicine. If you take blood-thinning medicine, you will need to be monitored regularly. If you have any surgical or dental procedures in the future, you will always need antibiotics to prevent infection of the replaced or repaired valve. Summary Mitral valve disease can cause pain, shortness of breath and eventually death. Mitral valve surgery can relieve your pain, improve your energy levels and may help you to live longer. Surgery is usually safe and effective but complications can happen. You need to know about them to help you to make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early. Keep this information leaflet. Use it to help you if you need to talk to the healthcare team. Acknowledgements Author: Prof. Julian Smith MBMS MSurgEd FRACS FACS FCSANZ FAICD Illustrations: Medical Illustration Copyright Medical-Artist.com This document is intended for information purposes only and should not replace advice that your relevant healthcare professional would give you. You can access references online at www.aboutmyhealth.org. Use reference CT03. Copyright 2016 Page 4 of 4