Valve replacements

Vivas and Spotters > Cardiovascular

Clinical examination

Metallic valves
- Metallic mitral valve: S1 sounds metallic
- Metallic aortic valve: S2 sounds metallic
- There is often a click audible without a stethoscope
Tissue valves
- Relevant heart sounds may be normal, loud or quiet
Systolic flow murmurs are normal for aortic valve replacements
Assess for valve function (signs of regurgitation of replaced valve), cardiac decompensation (signs of heart failure), and signs of infective endocarditis
Also look for signs of over-anticoagulation (bruising) and anaemia (haemolysis)

Metallic mitral valve

Indications for surgery

Indications in left-sided valve dysfunction

Any valve: associated LVF, symptomatic

If regurgitation, also: acute onset, associated LV dilation

If mitral, also: presence of pulmonary hypertension

NB: for MR, valve repair is preferred when possible; for MS, balloon valvuloplasty is preferred unless contraindicated (i.e. coexistent MR, thrombus or calcified valve).

Indications in infective endocarditis

Associated heart failure

Uncontrolled infection (fistula, enlarging vegetation, false aneurysm, aortic root abscess, persistently positive blood cultures, fungal/multidrug-resistant organism)

High embolic risk (persistent large vegetation)

NB: If prosthetic valve, surgery also indicated if: <2 months post-op, valve dysfunction or Staphylococcus aureus infection.

Detail about valve types

Tissue valve

Usually porcine xenograft

Needs replacing after 10-15 years; sooner if patient is active

No need for warfarin

Recommended for older people, people with low life expectancy and females of child-bearing age

Mechanical valve

Longer lasting (older valves 20-30 years, newer valves >30 years)

Lifelong warfarin

Makes a quiet clicking noise

Recommended for younger people (<60 years) so they don’t need repeat surgeries (unless female and of child-bearing age because warfarin is teratogenic)

Procedure

Pre-operative: transthoracic ± transoesophageal echo, coronary angiography
May be performed by:
- Open surgery: via midline sternotomy
- Minimally invasive surgery
  - Aortic valve: via right anterior mini-thoracotomy (2^nd intercostal space) or mini-sternotomy
  - Mitral valve: via right lateral mini-thoracotomy (below nipple or in breast crease)
Patient is put on cardiopulmonary bypass while valve is replaced
If there is also coronary artery disease, CABG is usually performed concurrently – check the legs for a vein grafting scar

Questions

Please list some complications of valve replacements?

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Which bacteria commonly cause infective endocarditis?

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What is a TAVI and when may this be indicated?

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