■

CARDIOVASCULAR
■ CENTER
■

HEART
VALVE
SURGERY
A Guide for Patients

75 Francis Street
Boston, MA 02115
Main Phone Line: (617) 732-5500

Weekday referral hotline (8:30am-5pm)

(617) 732-7678 Fax (617) 732-6559

Visit our web site at

www.brighamandwomens.org/cardiacsurgery

■
TEACHING AFFILIATE

(2/2004)
 ■
■
TABLE OF CONTENTS
■ ■
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
■ ■
Your Heart/Heart Valves . . . . . . . . . . . . . . . . . . . . . . 2
Heart Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . . 3
Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Conventional Heart Valve Surgery . . . . . . . . . . . . . . . 5
"Minimally Invasive" Heart Valve Surgery . . . . . . . . . . 7
Preparing for Surgery . . . . . . . . . . . . . . . . . . . . . . . . 8
The Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . 10
Postoperative Recovery . . . . . . . . . . . . . . . . . . . . . . 12
Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
(Prevention of Blood Clotting)
Prevention of Infections . . . . . . . . . . . . . . . . . . . . . . 16
Discharge Planning/Follow-up . . . . . . . . . . . . . . . . . 17
Notes/Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
This guide was written by Donna Rosborough, MS, RN, CCRN and
Lawrence Cohn, MD. It is not to be reproduced without permission
from the authors. February, 2004.
HEART VALVE SURGERY
AT BRIGHAM AND WOMEN’S HOSPITAL
If you are scheduled for surgery at Brigham and Women’s
Hospital to repair or replace a valve in your heart, you
can expect to receive the highest quality of skill and care
available anywhere.
Every year, our cardiac surgeons perform more than
600 heart valve operations, including “minimally invasive”
procedures that require only 3-inch incisions. In addition
to experienced surgeons at Brigham and Women’s
Hospital, you will be well cared for by a collaborative
team of nurses, physician assistants, physical therapists
and social workers.
It’s no wonder that, for the eleventh year in a row, U.S.
News & World Report® has included Brigham and Women’s
Hospital on its Honor Roll of America’s “Best Hospitals.”
We hope this brochure helps you and your family understand
what to expect with your heart valve surgery – from pread-
mission to discharge. If, after reading it, you have any
questions, please ask a member of the cardiac surgery team.
We are available to you at the hospital seven days a week.
BRIGHAM AND WOMEN’S HOSPITAL
DIVISION OF CARDIAC SURGERY
Lawrence H. Cohn, M.D., Chief
Sary F. Aranki, M.D.
John G. Byrne, M.D.
Gregory S. Couper, M.D.
Tomislav Mihaljevic, M.D.
Office Number: (617) 732-7678 Fax Number: (617) 732-6559
1
■
YOUR HEART/HEART VALVES
■ ■
Your heart is a pumping muscle responsible for circulating
■ ■
oxygen-rich blood throughout your body. There are four
chambers inside your heart: the two upper chambers are called
atria and the two lower chambers are called ventricles. The
heart muscle squeezes blood from chamber to chamber.
Your heart contains four valves, which open to allow blood
to move forward through the heart and close to prevent
blood from flowing backward.
— The mitral valve allows blood to move from the left
atrium into the left ventricle.
— The aortic valve allows blood to move out of the
left ventricle.
— The tricuspid valve allows blood to move from the
right atrium into the right ventricle.
— The pulmonary valve allows blood to move from the
right ventricle to the lungs.
■ HEART VALVE DISEASE
Heart valves can be abnormally formed as birth defects or
damaged by rheumatic fever, bacterial infection, and calcific
degeneration. Valves also can degenerate with the normal
aging process.
Two common types of valve disease are:
— Stenosis, which occurs when a valve does not open completely,
causing blood to flow through a narrower opening.
— Regurgitation, which results when a valve does not close
completely, allowing blood to flow backward through the valve.
To compensate for these disorders, your heart
pumps harder, which can result in inadequate
blood circulation to the rest of your body.
In addition, this excess work can weaken the
heart, causing it to enlarge and produce the
following symptoms:
• Increased shortness of breath
• Chest pain
• Swelling of the ankles and legs

pulmonary mitral • Increased fatigue

valve ATRIUM valve
• Dizziness

aortic • Fainting
ATRIUM VENTRICLE valve

tricuspid SEP
TU
valve VENTRICLE M

2 3
■ DIAGNOSTIC TESTS
■ ■
To diagnose and determine treatment for your particular valve
■ ■
disease, your doctor will obtain a complete medical history,
perform a thorough physical exam and order any or all of the
following special diagnostic tests:
■ Chest x-ray – X-rays can provide doctors information
about the size of your heart and its four chambers, as well
as information about your lungs.
■ Electrocardiogram (EKG) – This test records the changes
of electrical activity occurring during your heartbeat. It
helps to diagnose any irregularities in your heart's rate and
rhythm, as well as in heart muscle enlargement or damage.
■ Echocardiogram (echo) – This test uses ultrasound to
examine and measure the structure of your heart. An echo
demonstrates performance of the heart valves and provides
information on heart muscle function.
■ CONVENTIONAL HEART VALVE SURGERY
Heart valve disease initially may be treated medically but, in
most cases, surgery is necessary to repair or replace the damaged
valve or valves. Your surgeon will determine which procedure
is best for you, taking into consideration your age,
medical history, the nature of your heart disease,
your lifestyle and your ability to take anticoagulants
(medications that prevent your blood from clotting).
There are three main classifications of artificial valves:
— Bioprosthetic valves are from animals (for example,
Bioprosthetic Valve
the Hancock and Carpentier-Edwards valves)
specially treated with chemicals to avoid rejection.
— Mechanical valves are made of
metal, carbon and/or synthetics
(for example, the St. Jude valve).
Anticoagulation is required to
Bioprosthetic Valve
prevent blood clots.

■ Cardiac catheterization (coronary arteriogram) – This test
allows visualization of your blood vessels and measurement of
pressures inside your heart chambers following injection of a
contrast dye. An angiogram evaluates heart pumping function
and any obstruction of the coronary arteries that supply blood
to your heart muscle. If your coronary arteries have significant
Homograft Valve
blockages, your cardiac surgeon will perform coronary artery
bypass surgery at the time of your valve surgery.
— Biologic valves are human heart Mechanical Valve
valves obtained from donors after
death and frozen for later use (homograft). In the
Ross procedure, the patient’s own pulmonary valve
replaces the diseased aortic valve
and in turn is replaced by a
homograft valve.
Some valves can be surgically repaired to
help them open or close more efficiently.
Two common surgical repair procedures are:
— Ring Annuloplasty, which is a proce-
dure in which the annulus, or ringlike
part of the valve, is tightened by placing
a ring of metal, cloth or tissue around
the valve (for example, the Cosgrove and
Carpentier-Edwards Ring).
— Valve Repair, which is a procedure to
reconstruct the leaflets, chordae, and/or
Valve Repair/
papillary muscles of the valve. Ring Annuloplasty

4 5
 The average time required for heart valve surgery is four
hours. Your heart valve surgery will be performed by a
specialized team:
— Your cardiac surgeon will perform the surgery
— Surgical assistants will assist with the surgical procedure
— Nurses will provide surgical instruments and supplies to
the team
— Anesthesiologists will provide you freedom from pain and
a deep sleep that prevents any memory of surgery
— A perfusionist will operate the heart-lung machine that
keeps your blood circulating with oxygen
Heart valve surgery can be performed
by three surgical approaches:
— Sternotomy: an incision is made
down the middle of your chest
separating your breastbone and
muscle. The breastbone is closed
with stainless steel wires at the
conclusion of surgery.
— Thoracotomy: an incision is Sternotomy
made in your rib cage similar to
lung surgery.
— Minimally invasive surgery:
3-inch incisions are made in or
to the right of the sternum.
This surgery is now the most
common approach for isolated
heart value surgery.
Thoracotomy
6 7
■ MINIMALLY INVASIVE HEART
■
VALVE SURGERY
■
For patients without coronary disease,
heart valve replacement/repair can now
be performed through very small incisions
(3 inches) compared with those used in
conventional surgery.
Minimally invasive valve replacement
surgery is performed in two different ways:
— Aortic valve replacement incisions Upper-Mini-Sternotomy
are performed through an upper
mini-sternotomy, in which an Sternal Incision
incision is made from the sternal
notch to the third intercostal space.
— Mitral valve replacement/repair
incisions are performed through a
lower mini-sternotomy, in which
a 6-8 cm incision is made at the Skin Incision
lower end of the sternum upward
Lower-Mini-Sternotomy
to the second intercostal space
and extending into the interspace on the right.
Minimally invasive valve surgery, while maintaining
the quality of the operative procedure may result in:
• Less trauma
• Less blood loss
• Improved cosmesis, particularly with
mitral valve surgery
• Less incision pain
• Shorter hospital stay
■ Anticoagulants
PREPARING FOR SURGERY
■
Once heart valve surgery has been recommended and scheduled
■ by your cardiac surgeon, you will be admitted the day of or day
before your surgery. Patients
scheduled to be admitted on
the day of surgery will have an
appointment scheduled in the
preadmitting test center
(PATC) within the preceding
two weeks. All patients will
be given diagnostic tests, a
physical examination, and will
be seen by members of the
cardiac surgery and anesthesia
teams. A nurse will discuss
the Intensive Care Unit (ICU), postoperative recovery and
discharge planning procedures with you and your family.
Smoking
If you smoke, you should stop. Smoking constricts the
coronary arteries, produces excess secretions in the lungs, raises
blood pressure and increases the heart rate. The potential for
complications increases after surgery if you continue to smoke.
Dental Clearance
To prevent a delay in your surgery, ask your dentist to FAX
your dental clearance information to the cardiac surgery office.
This information is critical because if you have any oral bacterial
infections, they can cause infections of your heart valves. You
should have received this request for dental clearance within the
past six months in a letter from your cardiac surgeon's office.
Living Wills
If you have completed a living will or named a proxy, bring
copies with you for your medical file. We encourage you to
discuss any important personal values and/or medical care
preferences with your primary care physician, cardiologist or
cardiac surgeon prior to admission. If you have not yet
completed a proxy or living will document, forms are available
through the Brigham and Women's Hospital admitting office.
8 9
If you are taking Warfarin (brand name Coumadin®) or medications
containing aspirin, you will be instructed to discontinue them prior
to your surgery. The cardiac surgeon’s secretary will include this
information in your pre-admission letter.
Banking Blood
In advance of your surgery, you may be able to set aside blood in the
Brigham and Women's Hospital blood bank so that it is available to
you during and after your surgery. Your cardiac surgeon will determine
the amount required and whether your medical condition will allow
you to donate blood for yourself. Family members and friends may
also donate blood for you if they meet eligibility criteria. Blood may
be donated at the Brigham and Women’s Hospital blood bank or at a
local center and then shipped to the hospital.
Diet Restrictions
Until midnight the day before your surgery, you may eat and drink as
usual. After midnight, however, do not eat or drink anything. This helps
decrease any nausea and vomiting associated with anesthesia. If you have
prescribed medications, use only a small amount of water.
Pre-operative Preparation
Patients will be transported to the pre-operative area outside the operating
room a few hours prior to surgery. Here, the anesthesia team will insert
an intravenous line (IV) to sedate you. Once the operating room team
is prepared for your surgery, the anesthesiologist will take you to the
operating room. You will be anesthetized; an endotracheal tube (breathing
tube) will be inserted; and other tubes and lines will be placed to monitor
your heart, blood pressure, respirations and other bodily functions.
If you are interested in listening to music during surgery, please bring a
walkman, batteries, and your favorite selection of music to help you relax.
Waiting Room
While you are undergoing cardiac surgery, your family may wait in the
hospital or at home. The Family Liaison Service within the Robert
and Ronnie Bretholtz Center, located behind the Schuster Lobby, is a
resource area dedicated to families and friends waiting for patients
undergoing surgery. Following the operation, your cardiac surgeon will
personally talk with your family. After speaking with the surgeon, your
family must wait one hour before visiting you in the ICU, in order to
give the nursing staff sufficient time to assess your condition.
■ Once you recover from anesthesia...
THE INTENSIVE CARE UNIT You will be encouraged to take deep breaths and cough to help
■
Immediately after surgery, you will be taken to the cardiac sur- eliminate anesthesia and secretions from your lungs.
■
gery intensive care unit (ICU) where a team of specially trained It is also important to exercise your legs to help improve blood
physicians and nurses will take constant care of you and monitor flow and prevent blood clots. You will be instructed to wiggle
your vital signs and other vital bodily functions as you recover your toes and flex your feet hourly.
from the effects of anesthesia. The special intravenous catheters,
tubes and drains placed in the operating room will remain in Pain medication will be available to you intravenously on the day
place: of surgery. The day after surgery, when the endotracheal tube is
removed and you are able to take liquids, you will take your pain
— You will be connected by an endotracheal tube to a venti- medications by mouth. It is important to take pain medication for
lator (breathing machine) until you are awake enough to the first couple of days to enable you to cough, to breathe deeply,
breathe on your own. You will not be able to talk while and to increase your ability to walk with assistance.
this tube is in place because it is positioned between
your vocal cords. However, most patients are able to
have the tube removed on the day of surgery. Once the
tube is removed you will wear an oxygen mask for
additional oxygen and humidity.
— Your heart function will be monitored. An EKG will
continue to monitor your heart rate and rhythm; a special
intravenous catheter (arterial line) will measure your
blood pressure and allow the nurse to draw blood samples;
a probe on your finger (pulse oximeter) will measure your
oxygenation; and sometimes a special intravenous catheter
will have been inserted to measure pressures inside your
heart (pulmonary artery catheter).
— A urinary catheter in your bladder will drain urine into
a bag.
— Chest tubes will drain blood and fluid from your chest
incision into a special container to prevent a collection Visitors
from forming around your heart. Immediate family and close friends are allowed in the ICU
— Temporary pacemaker wires may be placed in your heart; 24 hours a day. However, prior to each visit, all visitors must call
if your heart rate becomes too slow following surgery, you from one of the family rooms on the floor. The ICU is a busy
may require a pacemaker temporarily. place and the nursing staff may be busy with your family member
or other patients. Please respect patients’ privacy at all times.

10 11
■ POSTOPERATIVE RECOVERY Nutritional Needs
■ Good nutrition is important for healing. It is very important
Once the cardiac surgery team determines that you no longer that you:
■
need to be in the ICU, you will be transferred to a unit where
your heart can continue to be monitored as needed. Most — Keep your weight within the normal range for your age
patients are able to be transferred out of the ICU the day after and body frame.
surgery. Then you will become an active participant in your — Reduce your salt intake to prevent fluid retention
recovery. that may overload your heart and cause it to work
inefficiently.
Exercise
To increase blood flow and improve your muscle strength, it is To monitor fluid retention, weigh yourself daily until your
important to gradually increase your level of activity. Walking is follow-up appointments with your physicians. If you gain
one of the simplest ways to help yourself recover. The nursing 3 pounds or more in one day, tell your doctor. A dietitian
staff will assist you in walking initially and encourage you to will be available to meet with you and your family to review
increase the distance and frequency daily. Your primary care nutritional guidelines recommended after heart valve surgery.
physician or cardiologist may recommend an outpatient cardiac
rehabilitation program, which can help you resume a healthy,
active lifestyle through exercise and education. The rate of
recovery will depend upon your age, general health and your
heart function.

Care of Your Incision

Once all of the tubes, lines and wires are discontinued, you will
be encouraged to shower daily with warm water and a mild soap
to keep your incision from becoming infected. If your incision
was made in your breastbone, do not lift anything over 10
pounds for 3 months after surgery. Your breastbone needs time
to heal properly.

Medications
During your hospitalization medications will be prescribed
and carefully adjusted for you. Common medications include
fluid pills, potassium, blood thinners, and medications to con-
trol a rapid/irregular heartbeat. Your nurse will review with you
your medications, including the correct dosage, frequency and
side effects.

12 13
 Food
■ ANTICOAGULATION You should avoid drastic changes in your dietary habits and
■
Warfarin foods high in vitamin K, which increases the blood’s tendency
■ to clot, such as:
Patients receiving a mechanical heart valve require a blood
thinner, warfarin, (brand name, Coumadin®) to prevent blood
clots. Other conditions associated with valve disease such as an — Mayonnaise — Kale (raw)
irregular heartbeat (atrial fibrillation) and an enlarged heart may
also be treated with warfarin. — Oils (canola, salad, soybean) — Lettuce

Warfarin works by prolonging the time it takes for your blood

— Broccoli — Mustard Greens (raw)
to clot. The drug must be carefully monitored by taking a blood
test (INR). Your physician (cardiologist or primary care physi-
— Brussel Sprouts — Parsley
cian) will prescribe a dose to keep the INR within certain
parameters. In order to control the level in your body, it is
important to take warfarin at the same time each day and to
— Green Cabbage (raw) — Spinach (raw)
avoid alcohol consumption, which affects the action of warfarin.
It is recommended that you ask your physician before you take — Collard Greens — Turnip Greens (raw)
any over-the-counter medications, including aspirin, cold
remedies, antibiotics, vitamins, and sleeping pills. — Cucumber Peel (raw) — Watercress (raw)

— Endive (raw) — Green Scallion (raw).

Other Procedures
Always inform your dentist and physicians that you are on
warfarin. Because warfarin limits your body’s normal ability
to stop bleeding, they may need to adjust your dosage prior
to any procedure to prevent excessive bleeding.

Physical Activity
Avoid any activity or sport that may result in a traumatic injury.

14 15

Consult your physician
It is extremely important that you consult your physician if any
of the following occurs:
— A serious fall or if you hit your head
— Excessive bruising on your skin
— Excessive bleeding, (i.e. nosebleeds, bleeding gums)
— Blood in your urine or stool
— A fever or other illness including vomiting, diarrhea,
or infection
— You become pregnant or are planning to become pregnant
Medical Alert Bracelet
You may want to wear a medical alert bracelet or carry a patient
identification card to alert hospital personnel in an emergency
that you are taking warfarin. If you are interested in obtaining
emergency identification, ask a member of the cardiac surgery
nursing staff for further information.
■ a follow-up appointment with the cardiac surgeon.)
PREVENTION OF INFECTIONS
■
All heart valve surgery patients must take antibiotics before
■
certain dental or surgical procedures to help prevent infection
of valves, which can occur when bacteria is released into the
bloodstream as a result of the procedure. Consult with your
physician before any dental and surgical procedures.
16
■
DISCHARGE PLANNING/FOLLOW-UP
■
■
Home Care
Generally, most patients can leave the hospital 5-6 days
following surgery. It is important to have family members or
friends available to assist you in your first week home. The
nursing staff will contact a home care agency near your home to
arrange a home nursing assessment the day after your discharge.
Additional services available through the home care agencies for
patients who meet criteria include physical therapy, occupational
therapy, and the services of a home health aide or social worker.
Cardiologist
It is important to make an appointment with your cardiologist
within two weeks of discharge. Your cardiologist will monitor
your progress over time and adjust your medications.
Cardiac Surgeon
Patients will also need to make an appointment with their
cardiac surgeon four to six weeks after discharge. The cardiac
surgeon’s secretary will send you a letter confirming the date,
time and location of your appointment. (Patients who live a
great distance from the hospital are not required to return for
Primary Care Physician (PCP)
Patients who have managed care insurance plans, such as
Harvard Pilgrim Health Care and Tufts Health Plan, will also
need to make an appointment with their primary care physician
within two weeks of discharge. Your PCP coordinates your plan
of care with your cardiologist and cardiac surgeon.
17
■
Extended Care Facility
■ NOTES/QUESTIONS
■ If you require physical and occupational therapy or other close ■

■ medical management, we will refer you to extended care facili- ■

ties. A team of nurses and social workers will meet with you to
discuss available facilities and will make a recommendation based
on the clinical care offered at the facility, its location, and your
insurance coverage.

Following your discharge from the hospital, a nurse from the

cardiac surgery office will call you at home to check on how you
are progressing. She will ask about your incision, activity level,
and follow-up appointments. If you are transferred to an
extended care facility, the nurse will contact the facility for
progress reports.

18 19
■ DIRECTIONS TO BRIGHAM AND WOMEN’S HOSPITAL DIRECTIONS (continued)
— Or —
■ Continue east on Massachusetts Turnpike. Take Huntington
■ Avenue/Copley Square/Prudential Center exit. Take Huntington
Avenue west for three miles, take right onto Francis Street at
Brigham Circle.
From the South:
Head north on Route 3 (Southeast Expressway), take the Mass Ave-
Roxbury exit. At the end of the ramp, cross Massachusetts Avenue
onto Melnea Cass Boulevard. Take a left onto Tremont Street. Take
first right onto Ruggles Street. Turn left onto Huntington Avenue at
intersection of Ruggles Street and Huntington Avenue. At second set
of lights (Brigham Circle), turn right onto Francis Street.

From the North:

Head south on Route 93, then head west on Storrow Drive.
Take the Fenway outbound 1-S exit (on the left). At lights, bear
right onto Boylston Street. At third set of lights bear left onto
Brookline Avenue. At fifth set of lights, turn left onto Francis
Street.
From the West:
Head east on the Mass. Turnpike. Take Route 128 South for
approximately one mile. Take Route 9 East for six miles. Bear left
onto Brookline Avenue (Brook House apartments will be on
right). At third set of lights, turn right onto Francis Street.

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