heart valve replacement

DR SHYAM PRASAD SHETTYCon Cardiothoracic Surgeo FRCS ( CT) FRCS ( ENG) FRCS (EDIN) : 

DR SHYAM PRASAD SHETTYCon Cardiothoracic Surgeo FRCS ( CT) FRCS ( ENG) FRCS (EDIN) APOLLO BGS HOSPITAL, MYSORE

Slide 2: 

30 yrs Male Civil contractor C/O -SOB on minimal exertion since 6 months and Palpitations No history of rheumatic fever , had bilateral elbow joint pains which was not treated NO diabetes , NO BP, NO Smoking, NO Dyslipidemia,

Slide 3: 

Haemodynamically stable Pulse 110 SR , BP 130/70 Jvp-elevated, bilateral pedal edema Chest bilateral basal rales

Slide 4: 

Presented with cardiac failure Pulse 110 SR, BP 110/70 JVP - ↑ Bilateral pedal edema Chest had bilateral basal rales

INVESTIGATIONS : 

Hb 13.7 Blood group A positive WC 11,700 Diff count – N Anti HCV –N Anti HIV1 &2 –N HbSag – N ABG –N INVESTIGATIONS

INVESTIGATIONS : 

ASLO Titre – Neg ESR – 10 TC- 11,700 TFT – N LFT –N ROUTINE BLOODS – N COAGULATION SCREEN - N INVESTIGATIONS

ECHO : 

Rheumatic heart disease Mitral valve is thick and fibrotic Moderate sub-valvular fusion seen. Sever MR /no MS Sever AR / no AS Moderate tricuspid regurgitation Mod pulmonary arterial hypertension Left atrium dilated Left ventricle mildly dilated Good LV /RV function Mild pericardial effusion ECHO

OPERATIVE PROCEDURE : 

Membrane oxygenator Moderate systemic hypothermia St Thomas hospital cardioplegia given every 20- 25 min Topical ice slush Mitral valve was replaced first Mitral valve size 31 St Jude mechanical valve Aortic valve size 23 St Jude mechanical valve OPERATIVE PROCEDURE

POST OP MANAGEMENT : 

Low mol wt dextran Ventilated for 24 hours Warfarin started soon after extubation Low mol wt heparin started INR 2.5 – 3.5 POST OP MANAGEMENT

HISTOLOGY : 

HISTOLOGY

POST OP CXR : 

POST OP CXR

POST OP ECG : 

POST OP ECG

POST OP ECHO : 

POST OP ECHO

POST OP ECHO : 

POST OP ECHO

POST OP ECHO : 

POST OP ECHO

FOLLOW UP : 

Instilling insight into the problems of chemoprophylaxis In preventing recurrent attacks of rheumatic fever ( penicillin inj once in every 3 weeks remains necessary until the age of 40 years ) Advice regarding prevention of bacterial endocarditis , particularly in relation to dental problems . Education and counseling regarding anticoagulation. FOLLOW UP

Slide 30: 

30 days Hospital mortality 9.2% cardiac output refractory arrhythmias endocarditis anticoagulant related bleeding air embolism sepsis respiratory insufficiency

Slide 31: 

Late deaths 10.1% CCF Arrhythmias Acute MI Valve thrombosis Anticoagulation related hemorrhage Prosthetic valve thrombosis Paravalvular leak Renal failure pneumonia

Slide 32: 

30 day hospital death rate was 9.2% Late death occurred in 10.1% Actuarial survival- at 5, 10 ,20 and 24 years was 90.4%, 85.6%,84.4%,82.45 per year respectively All the cause of valvular dis was rheumatic 4.6% - calcific MS, 82.7% - severe MR 24.7% - calcific AS, 84.6% - severe AR Stanley john,CMC Vellore, ATS 2000,69:1167-1172

Slide 33: 

15 year follow up after DVR Late survival 5 ,10 and 15 yrs, 92%,78%, 45% Mean survival 154 months Panda,CMC Vellore,J of Heart Valve Dis,March 2009

Slide 34: 

Rheumatic multivalvular disease unless aggressive and timely intervention in the form of replacement /repair is pursued the condition progresses rapidly to disability and death . Combined mitral and aortic replacement represents a major technical challenge and carries high early and late mortality rates .