Understanding valve replacement surgery.pptx

Analyzing valve replacement procedures and their implications on cardiopulmonary rehabilitation

1. Valve Replacements Presented by- Divya Sharma Guided by- Dr. Poonam Ma’am

2. In this presentation Introduction Valves of the heart Valvular heart disease- an overview Valve replacement surgery – indications, contraindications, types Pre operative requisites Overview of the procedure Post operative period Medical Management Physiotherapy management

3. Introduction Circulation  dynamic system Unidirectional flow of blood is important to ensure optimal functioning Any change in the fluid dynamics  impairments in function

4. Valves of the heart Highly organised connective tissue structures Composed of collages, elastin, proteoglycans and well differentiated cells + an endothelial cell layer Ensure unidirectional flow of blood during the cardiac cycle Smooth transitioning between different phases of the cardiac cycle

5. Valvular apparatus of the heart

6. Mechanism

7. Valvular heart disease

8. Normal heart valve Diseased heart valve

9. Rheumatic Fever & Rheumatic Heart Disease An acute, immunologically mediated multisystem inflammatory disease Classically occurs a few weeks after a streptococcal pharyngitis/ streptococcal skin infections May proceed over time to develop into chronic RHD Chronic RHD -  valvular abnormalities. *RHD = main cause of mitral stenosis.* Leaflet thickening, commissural fusion and shortening, thickening and fusion of chordae tendinae

10. Treatment- Surgical repair/ prosthetic valve replacement

11. Infective Endocarditis Microbial infection of the heart valves and the associated endocardium Leads to the formation of vegetations on the valve tissue and is accompanied by destruction of cardiac tissues Mostly bacterial May be acute/ subacute

12. Malformed heart valves Congenitally bicuspid aortic valves

13. Valvular incompetence due to cardiac dysfunction Increased distance between the valve leaflets leads to improper flow of blood Regurgitation Increased turbulence Effects of increased backflow of blood

14. Surgical Options Balloon Valvotomy SAVR (Surgical Aortic Valve Replacement) TAVR (Transcatheter Aortic Valve Replacement) Minimally invasive SAVR

15. Pre-operative assessments & requisites Detailed history and pre-anaesthetic evaluation Signs and symptoms Comorbidities Previous medical and surgical history Ongoing pharmacotherapy Investigations- Chest Xray, ECG, 2D-Echo, blood work, LFT, RFT, electrolytes, D-dimer, lipid profile PT-INR Nutritional work up

16. Pre-operative assessments & requisites Cardiac risk stratification CAG Smoking cessation Alcohol cessation

17. PT-INR International normalized ratio (INR) is the preferred test of choice for patients taking vitamin K antagonists (VKA).  used to assess the risk of bleeding / the coagulation status of the patients. PT (Prothrombin time)--- time taken to form a clot in the presence of sufficient concentration of calcium and tissue thromboplastin by activating coagulation via the extrinsic pathway. INR = Patient PT ÷ Control PT

18. PT-INR ratio LOW PT-INR IDEAL RANGE HIGHER PT-INR For normal patients who are not on anticoagulation, the INR is usually 1.0 regardless For patients who are on anticoagulant therapy, the therapeutic INR ranges between 2.0 to 3.0. INR levels above 4.9 are considered critical values and increase the risk of bleeding. The therapeutic INR range differs in a patient with prosthetic valve.

19. Balloon Valvotomy/ Balloon Valvuloplasty A cardiac intervention to open up stenotic or stiffed heart valves Done by inserting a catheter into the blood vessel from groin percutaneously Balloon valvuloplasty is a less invasive than open-heart valve replacement, but it is not an alternative to valve replacements. In many cases, the risks outweigh the potential benefits

20. Valve Replacement INDICATIONS Severe symptomatic stenosis Severe regurgitation Asymptomatic but severe stenosis Moderate AS but undergoing other cardiac surgery Previously failed replacements CONTRAINDICATIONS Life expectancy < 1 year due to non cardiac cause LVEF < 20% MI within the previous month ESRD Stroke ? TIA within last 6 months Cardiac tumours Severe PAH with RVD Structurally small annulus

21. SURGICAL AORTIC VALVE REPLACEMENT

22. TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

23. Biological valves Tissue valves Do not need life-long anticoagulation (unless other indications exist) Can be- Bovine/porcine tissue valves Own healthy valve (Ross procedure) Cadaveric heart valves

24. Tissue heart valve

25. Mechanical valves Can be- Ball valves Disc valves Bi-leaflet valves Made of titanium + blended carbon fibre Lifelong anti-coagulants are needed

26. Mechanical valve (Bi-leaflet)- lowest risk of thromboembolism

27. Disc valve

28. HOW TO IDENTIFY

29. Post Operative management Strict monitoring of hemodynamics Monitoring of lines, drains, tubes Intake-output charting Anticoagulation Nutrition Prevention of early post operative complications Early mobilisation Patient and caregiver education

30. Anticoagulation Compulsory for those with mechanical valves For patients with bioprosthetic valves & no complications= First 3 months post-op, with close monitoring Bioprosthetic valves + complications (e.g. A.Fib) = lifelong anticoagulation Ideal PT-INR is calculated for each patient based on risk factors and type of valve

31. Physiotherapy Management A multidisciplinary rehabilitation programme should be available for all patients undergoing valve surgery 2D Echo should be performed on all patients post-operatively and at completion of rehabilitation programme to allow comparison of long term effects on cardiac function

32. Physiotherapy Management Good patient education Patients should undergo a submaximal exercise testing at 2 weeks post surgery A tailor-made exercise program should be designed for each patient based on the exercise test A blend of aerobic exercises + strength training is recommended

33. Physiotherapy management Inpatient Cardiac Rehabilitation after Transcatheter Aortic Valve Replacement Is Associated with Improved Clinical Performance and Quality of Life Journal of Clinical Medicine, 2021 Use of a tailor-made approach for each patient based on their individual cardiopulmonary testing results Incorporating functional training along with aerobic exercises and strength training

34. Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up Randomised Controlled Trial-2021 Early initiation of inspiratory muscle training is recommended in the post operative period to offset the pulmonary complications associated with mitral valve replacement

35. Cardiac rehabilitation programme after transcatheter aortic valve implantation versus surgical aortic valve replacement Systematic review and meta-analysis - 2017 Equal benefit was observed when SAVR and TAVR groups were compared.