Table of Contents Clinical examinationIndications for surgeryDetail about valve types ProcedureQuestionsTry some OSCE stations 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 (2nd 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 Thoracic scars Questions Please list some complications of valve replacements? Oops! This section is restricted to members. Which bacteria commonly cause infective endocarditis? Oops! This section is restricted to members. What is a TAVI and when may this be indicated? Oops! This section is restricted to members. Try some OSCE stations Metallic aortic valve Metallic mitral valve More stations can be found here!