The Cardiac / Heart Valves are delicate, flexible structures that consist of fibrous tissue covered by Endothelium.

They permit only unidirectional blood flow through the heart. The valves open and close passively, determined by pressure gradients between the cardiac chambers. Leaky valves that do not seal when closed are called regurgitant or insufficient. Stiff valves that cannot open completely are called stenotic.

Tricuspid Valve

is on the right dorsal side of the mammalian heart, between the right atrium and the right ventricle. The normal tricuspid valve usually has three leaflets and three papillary muscles. are connected to the papillary muscles by the chordae tendineae, which lie in the right ventricle. will not always consist of three leaflets and may also occur with two or four leaflets; the number may change during life.

 Pulmonary sometimes

Valve

referred to as the pulmonic

valve. is the semilunar valve of the heart that lies between the right ventricle and the pulmonary artery and has three cusps. opens in ventricular systole, when the pressure in the right ventricle rises above the pressure in the pulmonary artery.

 Mitral also

Valve

known as the bicuspid valve or left atrioventricular valve. a dual-flap valve in the heart that lies between the left atrium and the left ventricle. known collectively as the atrioventricular valves because they lie between the atria and the ventricles of the heart and control the flow of blood.

Aortic Valve

is normally tricuspid (with three leaflets), although in 1% of the population it is found to be congenitally bicuspid (two leaflets). lies between the left ventricle and the aorta. During ventricular systole, pressure rises in the left ventricle. When the pressure in the left ventricle rises above the pressure in the aorta, the aortic valve opens, allowing blood to exit the left ventricle into the aorta. When ventricular systole ends, pressure in the left ventricle rapidly drops. When the pressure in the left ventricle decreases, the aortic pressure forces the aortic valve to close. The closure of the aortic valve contributes the A2 component of the second heart sound.

Regurgitation is also called as insufficiency or incompetence which occurs when a valve doesnt close properly and blood leaks backward instead of continuing in the proper onedirectional flow. If too much blood flows backward, only a small amount can travel forward to the bodys organs. The heart tries to make up for this by working harder, but eventually the heart will become enlarged (dilated) and less able to pump blood through the body.

 Stenosis occurs

when the leaflets do not open wide enough, reducing the amount of blood that can flow through the valve. Stenosis results from the leaflets thickening, stiffening, or fusing together. Because of the narrowed valve, the heart must work harder to maintain circulation.

Myxomatous degeneration, which is a weakening of the valve tissue caused by metabolic changes in the body. This occurs most often in the elderly and commonly affects the mitral valve. Calcific degeneration, which causes a buildup of calcium on the aortic or mitral valves, causing the valves to thicken. Congenital (inherited) defects, such as an irregularly shaped aortic valve or a narrowed mitral valve. Infective endocarditis, which is an infection in the lining of the hearts walls and valves (the endocardium). Coronary artery disease. Heart attack

 Symptoms

will vary from patient to patient and depend on the type and severity of valve disease. Some patients have no symptoms at all. In other cases, valve disease may take its toll over many years. Eventually, congestive heart failure may occur. In addition, valve disease also may lead to heart muscle disease, arrhythmia (irregular heartbeat), and blood clots

Initial diagnosis is made by listening to the heart with a stethoscope. Valve disease tends to be associated with distinct clicking sounds or murmurs. A more definitive diagnosis requires the use of imaging techniques. A chest X-ray can show if the heart is enlarged, which may occur if the valve isnt functioning properly.

Doppler ultrasound can be used to determine whether blood is flowing properly through the valves by recording the Swishing noise (turbulence) of the blood flow.
Echocardiography can produce a picture of the thickness of the hearts walls, the valves shape and action, and the size of valve openings. Doppler echocardiography can be used to diagnose and determine the severity of either stenosis (narrowing) or backflow of blood.

Electrocardiography (EKG or ECG) can be used to determine if the ventricles or the atria are enlarged. ECG can also determine if arrhythmia (irregular heartbeat) is present. Coronary angiography, as part of cardiac catheterization, allows physicians to see the heart as it is pumping to identify a narrowed valve or any backflow of blood. This test also helps physicians decide if surgery is needed, and, if so, what type. Likewise, any associated coronary artery disease may be identified. Chest magnetic resonance imaging (MRI) can provide an accurate 3dimensional picture of the heart and valves without having to inject a dye.

The tricuspid valve is often considered in the workup of heart failure only after more prominent cardiac pathologies such as aortic, mitral, and coronary atherosclerotic disease have been discussed, and as such it has been referred to as the forgotten valve. The sequel of significant tricuspid regurgitation can be significant however and include as cites, hepatosplenomegaly, pleural effusions, and peripheral edema. Tricuspid regurgitation is usually secondary to leftsided valvular pathology (commonly the mitral valve) causing elevated pulmonary pressures with subsequent dilation of the tricuspid annulus. Rheumatic disease, Ebstein's anomaly, and endocarditis are other important causes of tricuspid incompetence. When significant tricuspid incompetence exists that we do not feel will resolve after left-sided reparative procedures, our preference is to repair the valve with a formal ring annuloplasty. If valve repair is not possible, then valve replacement is necessary.

standard anesthetic for cardiac procedures is utilized. A pulmonary artery catheter placed via the right internal jugular vein is essential to assess pulmonary pressures pre- and postrepair. This catheter is temporarily withdrawn during valve replacement, and then replaced by the surgeon. Transesophageal echocardiography is used in all cases to evaluate the cardiac pathology, identify patent foramen ovale and assess the adequacy of repair.

Aortic and bi- caval cannulation is accomplished with direct cannulation of the superior vena cava (SVC) and inferior vena cava (IVC). We routinely utilize vacuum assistance up to 40 mmHg as it allows for smaller cannula. Drainage is generally adequate using a 24fr wire wrapped right angle cannula in the SVC and a 26fr wire wrapped right angle cannula in the IVC. If there is no patent foramen ovale, we perform tricuspid procedures with the heart beating and perfused after all other aspects of the case requiring aortic cross clamping have been performed. Caval tapes are snared around the IVC and SVC to achieve right heart isolation. A caval clamp can be used alternatively in the setting of significant adhesions. An oblique right atriotomy is performed down to the IVC cannula, incorporating any existing retrograde catheter site. The foramen ovale is examined to ensure it is closed. A self retaining retractor is used. Occasionally pledgeted traction sutures are placed on the edges of the atriotomy to enhance exposure. A flexible weighted vent is placed in the coronary sinus.

The tricuspid valve is inspected and an assessment of repair versus replacement is made. When repair is not feasible, our preference is to use a bioprosthetic bovine pericardial valve. The leaflets are left in place to preserve the sub- valvularapparatus. When prolapsing leaflets are large and bulky, they are fenestrated along a radial axis, which allows them to foldout of the way while preserving the tissue. Everting 2-0 pledgeted Ticron sutures are placed along the circumference of the annulus from the atrial to the ventricular side of the valve, starting at the anterior leaflet and working clockwise. Great care is taken when suturing near the AV node along the septal leaflet. Standard valve sizes allow proper sizing of the chosen valve. The tricuspid annulus generally allows for large valve sizes and gradients across the valve are clinically insignificant with 27 mm or greater sizes. The valve must be oriented properly to avoid obstruction of the RVOT by the stent posts of the bioprosthetic valve. From the surgeons view, the posts should lie at the 12, 4 and 8 o'clock positions. A dental mirror is used to confirm that the RVOT is left unobstructed. The valve is seated and the sutures are secured starting at the septal leaflet.

The pulmonary artery catheter is replaced through the valve and confirmed in position in the pulmonary artery by palpation. The atriotomy is closed with 4-0 polypropylene sutures in two layers after de-airing maneuvers. The caval tapes are released and the patient is weaned from cardiopulmonary bypass. It is our practice to place permanent epicardial pacing wires on all patients receiving a tricuspid valve replacement and leave them buried in a pocket on the left chest wall in case the need for subsequent permanent pacing arises. This avoids the issue of transvenous pacing leads injuring the prosthetic valve leaflets and causing recurrent tricuspid regurgitation. Temporary epicardial pacing wires are also placed in all patients given the higher incidence of transient conduction disturbances in the post-operative period following tricuspid procedures.

Pulmonary valve replacement can be performed electively with little risk and may improve symptoms of right ventricular failure and provides excellent mid-term survival. The surgical procedure has a peri-operative mortality of 14% and a 10-year survival of 86 95%.Previous echocardiographic evaluation of right ventricular dimensions in children and adolescents showed a decrease in end-diastolic volume and endsystolic volume after pulmonary valve replacement. However, in adults, radionuclide angiography measurements showed no effects of pulmonary valve replacement on right ventricular volumes and ejection fraction.

If you have no symptoms and tests reveal mild or moderate disease, your doctor may recommend regular checkups to monitor for any changes in your pulmonary heart valve. You may also need to take antibiotics prior to any dental or surgical procedures in order to avoid contracting bacterial endocarditis, a serious infection of the heart and its valves. Catheter-based Therapy During cardiac catheterization, doctors thread a tube through a vein in your leg and up to your heart. Then, they insert instruments through the tube to perform procedures on the heart. Mayo Clinic doctors offer procedures such as balloon valvuloplasty or percutaneous pulmonary valve therapy to repair the pulmonary valve. These procedures are available to select patients who fit the criteria for this type of treatment.

Heart valve repair can involve separating fused valve cusps, sewing torn cusps or reshaping parts of the valve to allow it to close tightly. More commonly, surgeons replace the pulmonary valve with an artificial valve, which may need to be replaced again after a number of years. Ross procedure (or pulmonary autograft) is a cardiac surgery operation where a diseased aortic valve is replaced with the person's own pulmonary valve. A pulmonary allograft (valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. Pulmonary autograft replacement of the aortic valve is the operation of choice in infants and children, but its use in adults remains controversial.

a cardiac surgery procedure in which a patients mitral valve is replaced by a different valve. Mitral valve replacement is typically performed robotically or manually, when the valve becomes too tight (mitral valve stenosis) for blood to flow into the left ventricle, or too loose (mitral valve regurgitation) in which case blood can leak into the left atrium and back up into the lung.
performed to treat severe cases of mitral valve prolapsed, heart valve stenosis, or other valvular diseases. Since a mitral valve replacement is an open heart surgical procedure, it requires placing the patient on cardiopulmonary bypass to stop blood flow through the heart when it is opened up.

performed under general anesthesia, which will keep the patient asleep during the whole surgery. The preferred method is to first make an incision under the left breast rather than through the breastbone in the front of the chest, to get to the heart. After the heart is exposed, blood must be rerouted to a heart-lung machine(cardiopulmonary bypass). An incision is made in the left atrium to expose the mitral valve. The valve is then replaced with either a biological or mechanical valve. Then after the functioning of the new valve is tested and confirmed, the heart is then closed with sutures. The patient is then taken off the cardiopulmonary bypass and blood is allowed to flow into the coronary arteries. If the heart does not beat on its own, an electric shock is used to start it. Then the chest is closed up.

there are risks such as bleeding, infection, or a complicated reaction to anesthesia. Each risk is determined best with each patients own cardiologist and cardiothoracic surgeon. They will better know each individuals medical history and conditions. Risks depend on a patients age, general condition, specific medical conditions, and heart function.

common postoperative complication with mitral valve surgery in a study involving 99 patients who had surgery for mitral regurgitation from January 1990 to June 1996 is atrial fibrillation. This occurred in 32% of patients. A common pulmonary complication is congestion necessitating prolonged use of oxygen. Other patients required prolonged ventilation of longer than 24 hours for conditions like pulmonary edema, ARDS, and pulmonary thromboemboli. Nine patients had renal failure with six of them dying within 30 days after their operation. Five patients had permanent strokes, and nine patients were readmitted to the hospital within 30 days of their discharge

After the surgery the patient is taken to a post-operative intensive care unit for monitoring. A respirator may be required for the first few hours or days after surgery. After a day, the patient should be able to sit up in bed. After two days, the patient may be taken out of the intensive care unit. Patients are usually discharged after about seven to ten days. If the mitral valve replacement is successful, patients can expect to return to their regular condition or even better. Patients who have biological valve are prescribed blood thinners (Anticoagulation) with warfarin for 6 weeks to 3 months postoperative, while patients with mechanical valves are prescribed blood thinners for the rest of their lives. These blood thinners are taken to prevent blood clots that can move to other parts of your body and cause serious medical problems, such as a heart attack. Blood thinners will not dissolve a blood clot but they prevent other clots from forming or prevent clots from becoming larger.

Once the patients wounds are healed they should have few, if any, restrictions from daily activities. Patients are advised to walk or undertake other physical activities gradually to regain strength. Patients who have physically demanding jobs will have to wait a little longer than those who dont. Patients are also restricted from driving a car for six weeks after the surgery. Once a person has a mitral valve procedure, they are required to have prophylactic antibiotics as a preventative measure against infection whenever they have dental work done. Depending on the method of surgery, some scarring will occur. If the breastbone is divided, the patient will have a long scar along the breast bone. If the heart is accessed from under the left breast there will be a smaller scar in the spot.

Aortic valve replacement means that a patient's aortic valve is replaced by a different valve. The aortic valve can be affected by a range of diseases and require aortic valve replacement. The valve can become either leaky (regurgitant or insufficient) or stuck partially shut (stenotic). Aortic valve replacement currently requires open heart surgery. Research is being done now to develop valves that can be implanted using a catheter without open heart surgery. There are two basic types of artificial heart valve, mechanical valves and tissue valves.

Mechanical valves Mechanical valves are designed to outlast the patient, and have typically been stress-tested to last several hundred years. Although mechanical valves are long-lasting and generally only one surgery is needed, there is an increased risk of blood clots forming with mechanical valves. As a result, mechanical valve recipients must generally take anticoagulant (blood thinning) drugs such as warfarin for the rest of their lives, which makes the patient more prone to bleeding. Recent advances in mechanical valve materials (pyrolytic carbon) have the promise of reducing and possibly eliminating the need for anti-coagulants. One such valve is the On-X. The material used resists the formation of blood clots. Research is on-going. Warfarin is the traditional drug used as an anticoagulant. There is a study underway into the use of Plavix instead of Warfarin which will significantly simplify blood clotting control.

Tissue valves Tissue heart valves are usually made from animal tissues, either animal heart valve tissue or animal pericardial tissue. The tissue is treated to prevent rejection and calcification. There are alternatives to animal tissue valves. In some cases a homograft (a human aortic valve) can be implanted. Homograft valves are donated by patients and harvested after the patient dies. The durability of homograft valves is comparable to porcine and bovine tissue valves. Another procedure for aortic valve replacement is the Ross procedure (or pulmonary autograft). In a Ross procedure, the aortic valve is removed and replaced with the patient's own pulmonary valve. A pulmonary homograft (pulmonary valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. This procedure was first used in 1967 and is used primarily in children, because the procedure allows the patient's own pulmonary valve (now in the aortic position) to grow with the child

 Aortic

valve replacement is most frequently done through a median sternotomy, meaning the incision is made by cutting through the sternum. Once the pericardium has been opened, the patient is put on a cardiopulmonary bypass machine, also known as the heart-lung machine. This machine takes over the task of breathing for the patient and pumping their blood around while the surgeon replaces the heart valve.

Once the patient is on bypass, a cut is made in the aorta and a crossclamp applied. The surgeon then removes the patient's diseased aortic valve and a mechanical or tissue valve is put in its place. Once the valve is in place and the aorta has been closed, the patient is taken off the heart-lung machine. Transesophageal echocardiogram (TEE, an ultra-sound of the heart done through the esophagus) can be used to verify that the new valve is functioning properly. Pacing wires are usually put in place, so that the heart can be manually paced should any complications arise after surgery. Drainage tubes are also inserted to drain fluids from the chest and pericardium following surgery. These are usually removed within 36 hours while the pacing wires are generally left in place until right before the patient is discharged from the hospital.

 The

risk of death or serious complications from aortic valve replacement is typically quoted as being between 1-3%, depending on the health and age of the patient, as well as the skill of the surgeon. Older patients, as well as more fragile ones, are sometimes ineligible for surgery because of elevated risks.