1. VALVULAR CARDIAC SURGERY

2. Outline Heart and Heart Valve A & P Valvular Pathology
Valvular Diagnostics
Open Heart Patient Preparation
Supplies, Instrumentation, and Equipment
Valve Surgery (aortic, mitral, tricuspid)
Ventricular Aneurysmectomy

3. A & P
Your Heart’s Valves

4. Normal Circulation
Blood comes back to heart for reoxygenation via the superior and inferior vena cava entering into the right atrium
Passes through the tricuspid valve into the right ventricle, then through the pulmonic valve into the pulmonary artery
Blood is reoxygenated in the lungs and returns via the pulmonic veins into the left atrium
There it goes through the mitral valve into the left ventricle through the aortic valve pushing oxygenated blood into the coronary ostia as it passes them and throughout the rest of the body where oxygen is needed by all the organs and tissues

5. CARDIAC VALVES
Tricuspid valve lies between the right atrium and right ventricle
Blood returns to the heart through the superior and inferior vena cavae into the right atrium where it passes through the tricuspid valve into the right ventricle where it is pumped through the pulmonic valve into the pulmonary artery to be taken to the lungs for re-oxygenation

6. CARDIAC VALVES
Mitral Valve lies between the left atrium and the left ventricle
Blood returns via the pulmonary veins (after re-oxygenation) into the left atrium, passes through the mitral valve and into the left ventricle, where it is pumped through the aortic valve

7. CARDIAC VALVES
Aortic valve lies between the aorta and the left ventricle
Blood is pumped from the left ventricle through the aorta to the coronary ostia, head vessels, upper and lower extremities, and the abdominal organs, via the aorta

8. Clarification
The aortic and pulmonic are often referred to as semi-lunar, meaning they have three half moon shaped cusps
The mitral and tricuspid are often referred to as atrioventricular valves, as they separate the atria and ventricles
The tricuspid valve is “three-cusped”
The mitral valve is “two-cusped” or bicuspid

9. Mitral Valve
Has two cusps (a posterior and anterior leaflet)
Often referred to as the bicuspid valve
Leaflets are attached and anchored to the endocardial papillary muscles by cords called cordae tendineae
Cordae tendinae keep the valve from prolapsing

10. Cardiac Conduction Coordinates cardiac conduction
SA Node (sinoatrial) “the pacemaker”
AV Node (atrioventricular)
Bundle of HIS or AV Bundle
Down R/L insulated branched bundles in ventricular septum
Purkinge Fibers non-insulated and feed into R/L ventricles

11. Cardiac Conduction
SA node initiates impulse > atria contract (blood forced into ventricles)> stimulus picked up by AV node > AV Bundle (signal slightly delayed) > brnached bundles > purkinge fibers > ventricles stimulated and contract (blood forces atrioventricular valves to close and semilunar valves to open)
These valves should go one-way

12. Pathology of Valves
Obstruction of the valves is usually caused by stenosis or fusion of the leaflets causing diminished blood flow resulting in poor oxygenation or backup of blood into the respective ventricles
Backup of blood damages the ventricular endocardium and myocardium over time, which can cause ventricular aneurysm (thinning and enlargement of the ventricle)
Can be regurgitant or insufficient due to leaflet damage (may not necessarily be stenosed)
In the case of the mitral valve, damage can be to the cordae tendineae, causing elongation, rupture, or shortening

13. Aortic Stenosis Calcification of the aortic valve cusps
LV hypertrophy develops as result of restricted blood flow into the aorta
Sx: fatigue, DOE, palpitations, dizziness, fainting, angina (chest pain)

14. Pulmonic Stenosis Calcification of pulmonic valve cusps
Restricts flow into PA
RV hypertrophy

15. Mitral Regurgitation
Blood flows back (regurgitates) into the LA through the incompetent mitral valve
LV hypertrophy
Sx: fatigue, palpitations, orthopnea (need to sit up to breath), PND (paroxysmal nocturnal dyspnea, after sleeping wakes up needing air)

16. Mitral Stenosis Calcified mitral valve Impedes flow of blood into LV
LA hypertrophy or enlargement
Sx: fatigue, palpitations, DOE, orthopnea, PND, pulmonary edema

17. Tricuspid Regurgitation
Blood flows back (regurgitates) into RA due to incompetent tricuspid valve
Sx: engorged pulsating neck veins, liver enlargement, RV hypertrophy, thrill at left sternum

18. Tricuspid Stenosis Calcification of tricuspid valve
Impedes blood flow into RV
Sx: diminished arterial pulse, jugular venous prominence

19. Valvular Disease Causes: CAD and MI Degenerative disease due to age
Rheumatic heart disease (a complication of bacterial strep)
Congenital disease
Obstruction results in left ventricular myocardial overload due to backflow of blood, which stresses the myocardium over time
IV Drug Abuse
Dental Infections
Lupus
Marfan’s Syndrome
Scleroderma

20. Symptoms of Valvular Disease
Fatigue
Weakness
Dyspnea with or without exertion, stress, or pregnancy
Pulmonary edema
1° cause rheumatic fever
May go from mild to total disability in years
May be asymptomatic years after initial damage to valve

21. Diagnosis NONINVASIVE H & P ECG/EKG Exercise EKG (stress test)
Echocardiogram (echocardiography is the Gold Standard for diagnosing valvular disease)
Chest x-ray

22. Diagnosis
INVASIVE
Cardiac catheterization ( may be in conjunction with echocardiogram)
Trans-esophageal echocardiogram (usually done preoperatively in the OR suite in conjunction with valve surgery)

23. Anesthesia
General

24. Medications Warm saline with antibiotic solution
Topical hemostatic agents of choice: surgicel, gelfoam and thrombin, gelfoam/thrombin/antibiotic rolled into balls for sternal bone application, bone wax for sternum with raytex underneath to prevent surgeon from ripping gloves on rough edges
Extra NS for valve rinsing if is a xenograft
Will rinse x 3 in 250cc NS each rinse for 2 minutes each or per manufacturer’s recommendations
Some surgeons may want antibiotic added to 2nd or 3rd rinse

25. Patient Positioning Supine position Arms padded and tucked
May want a shoulder roll to elevate the sternum (optional)
Headrest
Pillow under knees (preferable)
Heel pads (preferable)

26. Prep
Begin at anterior thorax prepping outward in a circular motion to the bedline, prep to top of thighs/ bilateral groins, then pubis
With a separate sponge prep both legs to knees to the bedline
Use betadine soap, then paint
May use gel or spray
Should do minimum of two coats of paint

27. PREP
For a CABG and valve replacement, will prep sternum to neck, bedline to bedline, groins, pubis, then each leg circumferentially to ankles or feet (institutional policy)

28. Equipment Two large tables (back table and Mayfield)
Mayo stand (for saw)
Double ring
Prep tables x 2
Slush machine/warmer
ECU x 2
Cell saver
CPB machine
Off-table suction
External Pacing box

29. Instumentation Open heart Trays Valve Tray Suture Guide Holder
Sternal retractor (Ankinney for aortic valve) and (Cosgrove or Korous for mitral or tricuspid)
Finochetti
Sternal saw
Internal defibrillator paddles
Doctor’s specials
Micro instruments needed if CABG done with valve surgery

30. Supplies Valve Custom Pack (Coronary pack for CABG/Valve)
CV Drape Pack
Gloves
Chest tubes
Suture guide inserts
Valve Sizers for appropriate valve
Appropriate valves of surgeon request in the room
Misc. suture: pericardial suture, cannulation suture, aortic retraction suture (for aortic valve only), valve repair or replacement suture, suture to close aorta or atrium, pacing wires, suture to sew in pacing wires, cutting needles to sew in chest tubes and pacing wires, sternal wires, fascia suture, subcutaneous, subcuticular
Coronary ostia perfusion catheters (auto-inflating, gummy tip, or spencers (for aortic only)

31. Supplies continued Aortic cannula
Venous cannula (need two for bicaval cannulation-need for mitral valve surgery)
Antegrade cannula (may just use retrograde and place this after aorta closed for aortic valve surgery/is placed for mitral valve surgery)
Retrograde cannula
Medusa
Cardiac insulation pad
Myocardial temperature probe
Extra saline
Three cytals for washing valve if using a xenograft (porcine or bovine)

32. Valve Replacement Options
Mechanical
Biological
Diseased valve excised and replaced

33. Valve Replacement Options (Aortic and Mitral)
1. Mechanical:
St. Jude or Starr-Edwards
valve only
conduit/valve available for aortic
Durable
Used primarily in young patients
Patient requires long-term anticoagulant therapy (not for elderly)
Complications: emboli and bleeding from other injury due to anticoagulant therapy

35. Valve Replacement Options (Aortic or Mitral)
2. Heterograft/Xenograft
Biologic
May be bovine or porcine
Bovine pericardium is the new rage
Old porcine has a duration of 15 years
Bovine pericardial are thought to last longer/research inconclusive due to recent development
No anticoagulant therapy needed

37. Valve Replacement Option (Aortic)
3. Aortic Stentless
Biologic
Porcine
Durability good over age of 60
No anticoagulant therapy needed

39. Valve Replacement Options (Aortic, Mitral, Pulmonic)
4. Allograft/Homograft
Biologic
Cadaver from organ donor
Will measure annulus size with TEE
Will choose graft before incision made or as opening chest
Time will be required for proper thawing procedure to be implemented to prevent damage to the graft
Long term
Limited availability

40. Valve Replacement Option (Aortic)
5. Autograft (ROSS Procedure)
Requires expert valve surgeon
Excision of patient’s pulmonic valve to be used as the patient’s new aortic valve
A pulmonic allograft will be used to replace excised pulmonic valve
Long term
Limited availability of pulmonic allograft

42. Valve Repair Options Annuloplasty rings Mitral annuloplasty rings
Tricuspid annuloplasty rings

43. Replacement verses Repair
Aortic and Mitral are replaced
Tricuspid in extreme situations can be replaced with a mitral valve
Mitral and tricuspid usually repaired with annuloplasty rings
Mitral may have to be replaced if attempted repair is unsuccessful

44. Annuloplasty Rings
Used for repairing of the mitral or tricuspid valves
Mitral rings are a near to complete circle
Tricuspid rings are an incomplete circle or half-circle
Sizers are half moon shaped and have T or M on them (will come with a malleable handle-bend it slightly for ease of sizing)
Are differentiated between by T or M on the tag (remove the Minnie-Pearl tag before passing it to the surgeon)
Provide reduction of the dilated annulus
Often the tricuspid function will return to normal with the repair of the mitral

47. Valve Repair/Replacement Procedure
Incision with #10 blade
Cautery
May use curved mayo scissors to ream under the xiphoid to loosen the fascia from the sternum
Sternal saw
Bone wax or gelfoam powder mixed with saline or thrombin to make soft balls to spread on sternum
Wet laps folded in half (should have been soaked in antibiotic NS and wrung out)
Sternal retractor
Cautery and debakeys to open/dissect the pericardium
Pericardial sutures (may use pop-off silk or neurolon)

48. Valve Repair/Replacement Procedure
Dissect aorta from pulmonary artery to provide room to place aortic cross-clamp
Purse-string cannulation stitches for aortic cannula (x2), venous cannula, and retrograde cannula, each is rommeled
Heparin is administered by anesthesia at surgeon prompt
Cannulas are placed, aortic first, stab blade (#11), aortic cannula, heavy tie or umbilical tape, tube clamp, bowl and scissors to cut aortic pump line, hook to CPB tubing, make sew cannula to patient/drape or clamp with non-penetrating towel clip
Venous cannula placed, metz, cannula (some surgeons may use a satinsky to clamp the atrial appendage before incising it), heavy tie or umbilical tape, tube clamp or not and hook to venous line from CPB machine
Surgeon will say to perfusion, “Go on bypass”

49. Valve Repair/Replacement Procedure
Hypothermia will begin by perfusion who can cool the blood he is circulating
Cross Clamp will be placed across the aorta
Cardiac insulation pad may be placed
Myocardial temp probe may be placed near the apex of the left ventricle
Ice may be applied to the heart as well

50. Aortic Valve Replacement
Once temperature is where surgeon wants it, he will take a metz and cut the aorta open above the aortic valve and below the aortic cross clamp
He may want stay sutures or retraction sutures
He may continue to perfuse the heart with cardioplegia fluid directly into the coronary ostia via the medusa and coronary perfusion cannula that is attached (his/her preference)

51. Aortic Valve Replacement
He/She will begin to excise the valve using metz, a pituitary ronguer, knife (#15c or #11)
Be prepared to wipe ronguer , metz, and forceps frequently with a moist lap
Retraction may be provided by the assistant with a hand-held aortic retractor
Off-table suction will be used to “vacuum” (tonsil suction without tip) as plaque is removed
Care is taken NOT to get debris into the ventricle as it could cause stroke later
Cold NS Irrigation provides thorough cleaning using an asepto

52. Mitral Valve Repair/Replacement
Caval tapes will be used with a ligature passer or right angle and long dacron or polyester tapes and rommeled to provide a tight seal around the cavae and their cannuli to prevent blood from coming into the field around the cannuli
Heart is turned over and left atrium is exposed
Surgeon will take an #11 or #15 blade to open the atrium, long metz to widen the incision
Mitral retraction will be achieved with a hand-held mitral/atrial retractor or placement of the arm attachments for the cosgrove or korous retractor
Two long, blunt nerve hooks will be passed to the surgeon for him to manipulate the valve leaflets and determine location/extent of damage
Will repair by removing a leaflet, repairing the cordae tendineae with gortex (PTFE) or prolene suture (have knife, metz, and nerve hooks available)
One of the leaflets may be left to maintain ventricular configuration (if one passed to you, ask if it is the anterior or posterior for proper specimen labeling)

53. Mitral Valve Repair/Replacement
Once the annulus is cleaned or the cordae are repaired, the annulus will be sized using mitral sizers for the appropriate valve being used
Clarify the valve before obtaining it from the circulator
Valve sutures will be placed (double load pledgeted valve sutures)
Once valve sutures are in hand up three NH as you will assist with loading the valve sutures in order to place through the annuloplasty ring or valve
Be sure you keep up with how many sutures are used

54. Valve Repair/Replacement Procedure
Once valve annulus is clean, annulus is sized with appropriate sizer
Valve is passed to field after being verified by the circulator, scrub, and surgeon
Bovine and porcine valves require a rinsing process (2 minutes in a minimum of 250ml NS times three)
Baxter-Edwards only require one minute x 3
Sutures for valve are placed (pledgeted 2-0 RB-1 ethibond or CV-316 Ticron
Pledgeted sutures are used for valve replacement/Non-pledgeted for Repair
Sutures will be passed double loaded as all pledgeted sutures should
Once sutures are in, if valve is ready, three short NH will be passed up and the assistant, scrub, PA, and surgeon will work their way around the suture guide loading each needle in sequence for the surgeon to pass through the valve
The sutures should have been counted before valve is up so the surgeon knows how far apart to place the sutures in the cuff of the valve

55. Valve Repair/Replacement Procedure
After sutures are in surgeon will ask for 2 kellys and you or he will cut the needles
He will pass them to you attached to the other kelly
He will work the valve into the annulus of the excised valve (you should moisten the strings with NS as he seats the valve)
He may take a knife at that point to release the insert holding the valve to the handle
He will work his way around, tying in the interrupted sutures
When done, he will take long tenotomy scissors and cut the strands just above the knots
He will test the valve leaflets with NS on an asepto (may use several)
May want a short piece of a red-rubber catheter attached to asepto for visibility as he is squirting the NS to test the leaflets
If mechanical may use rubber shodded debakey forceps or long cotton-tip applicator to test leaflets

56. Valve Repair/Replacement Procedure
Will close aorta with 2 prolene sutures usually pledgeted with a corresponding on a 3-0 or 4-0 tapered RB-1 or SH needle
Will close atrium with a 4-0 or 3-0 prolene on a tapered SH or MH needle (usually non-pledgeted)
Air is vented via antegrade placement (if was not in-aortic)
May need a 14 jelco on a 60 cc syringe to stab the apex/ventricle of the heart to remove air within before discontinuing bypass

57. Valve Repair/Replacement Procedure
Topical hemostatic may be used (gelfoam pad strips with NS or thrombin)
Patient may need to be defibrillated (have ready when closing aorta or atrium)
CPB will be discontinued when patient is re-warmed (metz, tube clamps, metz)
Pacing wires will be placed (atrial and ventricular)
Chest tubes will be placed (1 mediastinal and 1 substernal)
Sternal wires placed twisted and cut with wire cutter, irrigation of NS with Antibx, fascial layer, subcutaneous, hook up pleurevac after suctioning out the chest tubes, subcuticular
Dressing, steri-strips, telfa, 4x4s, primapore
Fluffs or 4x4s to chest tubes and tape

58. Ventricular Aneurysm Repair or Ventricular Aneurysmectomy
Result of myocardial damage after an MI causing myocardial replacement with scar tissue
Scar stretches with pressure resulting in aneurysm formation
Is the excision of the portion of the ventricle that has become aneurysmic and re-enforcing it with a patch of synthetic graft material (may be PTFE or hemashield)
Often a tube graft is used and a circular patch is cut with it

59. Ventricular Aneurysm Repair or Ventricular Aneurysmectomy
May require CPB
Prep/Set up is as described for any Open Heart surgery with exception of if being done alone, you would not need a lot of the previously described items
Most frequently done in conjuction with CABG or Valve surgery
May hear referred to as the DOR Procedure

60. Ventricular Aneurysm Repair or Ventricular Aneurysmectomy
Procedure:
Incision made into the ventricle with a #15 or #11 blade extended with a metz
Will require retraction by the assistant with two allises or babcocks (are usually part of a valve tray of instruments)
Surgeon may remove or excise a part of the scar tissue
A neck will be created in the rim of the scarring with a prolene suture (2-0 or 3-0 on an SH, to pull the tissue back together)

61. Ventricular Aneurysm Repair or Ventricular Aneurysmectomy
Interrupted pledgeted ticron or ethibond sutures will be placed (2-0 RB-1 or CV-316, SH or CV-305)
Patch will be passed up with 2 NH to place sutures through the patch
Patch will be eased down to cover the created neck
Myocardium will be closed with another 3-0 prolene SH
Epicardium will be closed with two thinly cut strips of teflon felt and two running 3-0 or 2-0 Prolene sutures on an SH or MH tapered needle

62. Ventricular Aneurysm Repair or Ventricular Aneurysmectomy
Surgery proceeds with patient rewarming if was cooled and discontinuation of CPB
Routine open heart surgery closure

63. Complications Hypothermia Infection Myocardial contusion Bleeding
Cardiac tamponade
Embolus
Valve malfunction

64. Summary Heart and Heart Valve A & P Valvular Pathology
Valvular Diagnostics
Open Heart Patient Preparation
Supplies, Instrumentation, and Equipment
Valve Surgery (aortic, mitral, tricuspid)
Ventricular Aneurysmectomy