HEART SURGERY and TRANSPLANTATION

Valve damage has many possible causes. Stenotic valves are often a natural result of aging. An infection can scar or rupture a valve. A heart attack can create a leaking valve. And congenital defects can cause any of the above. Depending on the extent and location of the damage, valves can either be repaired or replaced.

Aortic valves are the most frequently replaced valve. The aortic valve controls the flow of blood from the left ventricle of the heart to the aorta (the main artery of the body). Mitral valves are both repaired and replaced, depending on the extent of damage. The mitral valve controls the flow of blood from the left atrium to the left ventricle.

Two types of valves are used for replacement.

Tissue valves are valves that come from an animal donor. The most common sources of a tissue valves are the valve leaflets of pigs. Human organ-donor valves (homografts) can be used, but are uncommon. The advantage of tissue valves is that they do not require blood thinners. (Blood thinners, or anti-coagulation drugs, are medicines that help prevent the blood clotting caused by the presence of artificial material in the bloodstream.)

CONGENITAL HEART DISEASE TREATMENTS

Many children with congenital heart and blood vessel defects may need medical treatment such as diuretics, digoxin or other drugs. Diuretics promote the excretion of water and salts by increasing the rate that urine forms. Digoxin makes the contraction of the heart muscle stronger, slows the rate of heartbeats and helps remove extra fluid from body tissues. Some children may need surgery.

· Arterial switch — A surgical procedure in which the major arteries are switched in babies with transposition of the great arteries. The aorta is connected to the left ventricle, which pumps oxygen-rich (red) blood to the body. The pulmonary artery is connected to the right ventricle , which pumps venous (bluish) blood to the lungs. This arterial switch procedure may be done in the first few weeks after birth or, depending on various factors, slightly later. If there's a large ventricular septal defect or other defects related to the transposition, the repair gets more complicated. Then other surgical procedures may be needed.

· Balloon atrial septostomy — A special procedure used during heart catheterization to improve the body’s oxygen supply in babies with transposition of the great arteries. It enlarges the atrial opening and helps the baby by reducing the cyanosis (blueness).

· Balloon valvuloplasty — A procedure in which a special catheter (a tube introduced into a blood vessel and threaded to the heart) containing a deflated balloon is inserted into the opening of a narrowed heart valve. When the balloon is inflated, the valve is stretched open; then the balloon is removed. The procedure is used with favorable results to improve blood flow in pulmonary stenosis . It is also used in some cases of aortic stenosis, where the long-term results are still being studied.

· Damus-Kaye-Stansel procedure — A surgical technique used to repair a congenital transposition of the great arteries of the heart by dividing (cutting) the pulmonary artery in two, and attaching the closest (proximal) section to the ascending aorta and connecting the farthest (distal) section to the right ventricle .

· Fontan procedure or operation — A surgical procedure in which the right atrium is connected to the pulmonary artery either directly or with a conduit. This allows blood to bypass an incomplete or underdeveloped right ventricle , as in tricuspid atresia and pulmonary atresia . The atrial defect is also closed to relieve cyanosis (blueness).

· Pulmonary artery banding — A procedure in which a surgeon places a band around the pulmonary artery to narrow it and reduce the blood flow and high pressure in the lungs. This is done to relieve such defects as ventricular septal defect, atrioventricular canal defect, and tricuspid atresia
. When the child is older, doctors can remove the band and fix the defect with open heart surgery.

· Ross procedure — A procedure in which a person’s diseased or abnormal aortic valve is replaced with the patient’s own pulmonary valve (pulmonary autograft). A homograft valve (valve from a human donor) is then placed where the pulmonary valve was.

· Shunt or shunting procedure — The operation of forming a passage between blood vessels to divert blood from one part of the body to another. It is used to reduce the cyanosis (blueness) in infants with severe tetralogy of Fallot and those with tricuspid atresia or pulmonary atresia .

· Venous switch or intra-atrial baffle — A procedure that creates a tunnel inside the atria to help correct transposition of the great arteries. It redirects oxygen-rich (red) blood to the right ventricle and aorta , and redirects venous (bluish) blood to the left ventricle and pulmonary artery . In the Mustard procedure, the intra-atrial baffle is made of tissue from the pericardium . In the Senning procedure, the intra-atrial baffle is made of flaps from the atrial wall.

HEART TRANSPLANTS

When does a person need a heart transplant?

Sometimes the heart is irreversibly damaged by long-lasting heart disease or viral infection of the heart. Adults with long-term heart failure that doesn't respond to all available treatment may be candidates for heart (cardiac) transplants. People with various forms of cardiomyopathy (acute or chronic disease of the heart muscle) are also possible heart transplant candidates.

When the heart can no longer work adequately and a person is at risk of dying, a heart transplant may be indicated. Heart transplantation is the removal of a diseased heart and its replacement with a healthy human heart.

How many people need and receive heart transplants?

• There were 2,361 heart transplants performed in the United States in 1995 and 2,345 in 1996.
• Each year about 16,000 Americans age 55 or younger could benefit from a heart transplant. This figure rises to about 40,000 at age 65 or below.
• In the United States, 76.5 percent of heart transplant patients are male; 85 percent are white; 52 percent are age 50–64 and 22 percent are age 35–49.
• The one-year survival rate is 83 percent; the two-year survival rate is 78.9 percent; the three-year survival rate is 75.4; and the four-year survival rate is 71.7.

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BATISTA HEART FAILURE PROCEDURE

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What is the Batista heart failure procedure?

The Batista heart failure procedure is a potential alternative to a heart transplant. It was developed by Brazilian surgeon Dr. Randas J. V. Batista, primarily as a treatment for heart failure. Today a small number of surgeons in the United States and Europe as well as here at St Vincent's are performing it and evaluating its effectiveness. It must be emphasized that this is still an experimental procedure.

When is it used?

The Batista procedure is used for patients whose heart muscles have been stretched or weakened by disease, such as infection or inflammation which have led to congestive heart failure. (Weakened heart muscle that results from heart attack does not seem to respond as well.) Because of their weakened condition, these hearts can’t pump enough blood to sustain themselves and the body.

In the Batista procedure a triangular or elliptical piece of living heart tissue about the size of a golf ball is sliced from the left ventricle . Then the heart is stitched back together. By removing part of the left ventricle (the heart’s main pumping chamber), the heart’s chamber is made smaller and it can contract more effectively to pump more blood.

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LEFT VENTRICULAR ASSIST DEVICE

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What is a left ventricular assist device (LVAD)?

Left ventricular assist device (L.V.A.D.) is a mechanical pump-type device that is surgically implanted. It helps maintain the pumping ability of a heart that is unable to effectively function on its own. This device is sometimes referred to as a "bridge to transplant." People awaiting a heart transplant often have to wait for a long time before a suitable heart becomes available. During this wait, the patient's already weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can assist the weakened heart and "buy time" for the patient.

How does an LVAD work?

A typical type of LVAD will have a tube going into the left ventricle that pulls blood from the ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively "bypasses" the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the wall of the abdomen to the outside of the body and attached to the control system for the pump. LVADs are typically used for weeks to months.

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POSTOPERATIVE CARE

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It is normal in the CCA (Critical Care) that your nurse frequently checks your vital signs and your condition including measuring your urine output, helping remove secretions from your mouth with a suction catheter, helping you turn, cough, breathe deeply, or draw blood samples.

Communication 
 While the breathing tube is in your mouth you will be unable to speak. The staff and your family should communicate with you by asking "yes" and "no" questions so it will be easier for you to answer.

Pain Management  Your doctor will order pain control for you after surgery. Your pain medication will be given to you through your IV the first few days after surgery, then will be given to you in pill form after that. It is normal to feel sleepy the first 24 hours after surgery.

Activity   You will be helped to sit on the side of your bed the first day after surgery, and will sit in the chair on either the first or second day after your surgery. Your activity will be gradually increased every day.

Coughing and Deep Breathing Exercises   Once the breathing tube is removed from your mouth, it is important to perform coughing and deep breathing exercises to expand your lungs and prevent pneumonia. You will be instructed on these exercises prior to surgery. Your nurses will assist you while you are in the CCA to perform these exercises. You should do ten deep breaths every hour you are awake. You do not need to do all the breaths consecutively. Take several deep breaths, then rest. You should continue these exercises when you are transferred to the telemetry floor (Cameron Wing 16 or Level 7).

Going Back Upstairs After Surgery   Usually one to two days after surgery your IV lines and tubes have been removed and you are ready to be transferred to a telemetry unit where you will be able to increase your activity while still being monitored. We will advance your activity with the help of the physiotherapist and have you go up and down a flight of stairs prior to going home.

It is vital to keep your lungs well expanded after surgery. You may help to do this by using your Incentive Spirometer and by doing coughing and deep breathing exercises every hour, five to ten times.