Reoperations for Valvular Heart Diseases

Re-operations are technically more difficult than primary operations, because the heart gets stuck to the breastbone after a prior surgery and there is a risk of damage to the heart during repeat Sternotomy.

The number of patients undergoing re-operation for valvular heart diseases is increasing and will continue to rise due to the increasing age of the general population. Re-operations are technically more difficult than primary operations, because the heart gets stuck to the breastbone after a prior surgery and there is a risk of damage to the heart during repeat Sternotomy. Patients with advanced heart disease along with  associated or underlying conditions such as increased pressure in the lungs, kidney dysfunction, chronic diabetes, history of stroke, increased age may tolerate the complications poorly. As a result, re-operative valve surgery has presented considerably higher operative mortality than primary valve surgery. However, with alternative surgical approaches and advanced perioperative care, there has been significant improvement in patient outcomes.

Re-operative surgery in India is considered a difficult proposition.The cost is high since the duration of hospitalisation is more than usual, including the recovery period. Not many can afford surgery at big centres, and patients instead compromise and get operated at centres not equipped to handle such cases, which most often leads to poor outcomes. Unlike countries like the UK, New Zealand, Canada, where patients are either funded by the government or have insurance, Indian patients have to pay from their own pocket in India while generating funds which are considerably more than the first surgery; as the cost for equipment required for the usage of  a heart lung machine increases.

Native valves can be replaced using either a Mechanical Heart valve or a Tissue (Bioprosthetic) Heart Valve. The Bioprosthetic valves are obtained from leaflets of the valves of a pig (Porcine) or the pericardium caving the cows heart (Bovine). The advantage of Tissue valve is that the patient does not have to take blood thinners. Mechanical prostheses usually are preferred for younger recipients because of their proven durability over time. However, due to medication such as blood thinners or anticoagulants which are administered to keep the mechanical valve in function,  there is  risk of  bleeding into the brain. Hence, many patients opt for a quality of life by selecting Biological valves. Yet, these valves deteriorate with time requiring a repeat surgery.

Factors responsible for delayed recovery in patients undergoing repeat valve surgery

Many patients who undergo redo valve surgery are very critical and hence the outcomes may not be good. Post op recovery can be complicated by Stroke, Kidney failure  postoperative neurological dysfunction, pneumonia and liver dysfunction.

Dr. Sameer Bhate, recalls the story of a young farmer whom he operated in 2014 for the 4th time, a very rare event in India. The farmer had been operated on 3 times before in other Hospitals. As an adolescent, he had a valve repair. About 10 years later, he underwent a Mechanical heart valve replacement. After 2 years he was admitted with a clotted heart valve. He required emergency surgery but this time he opted for a Tissue valve. He was willing to take the risk of a repeat surgery to have a good quality of life. Over time the valve degenerated and Dr. Sameer Bhate operated on him for the 4th time to re-replace the existing tissue valve with a new tissue valve. The patient has been doing well since then.”

Recently in 2021, Dr. Bhate also operated on a 48-year old Baker who needed to get his valve replaced for the 3rd time. It is incredible as this was the first time such a repeat surgery was performed amidst the COVID-19 pandemic.

Living with valvular heart disease 

If a patient has heart valve disease and or the valve is repaired or replaced, lifelong precautions are recommended. Heart valve disease often progresses over time and develops rapidly with serious consequences. It is very important that an individual with valvular heart disease take care of themselves. The patient should undergo regular physical exams to rule out heart murmurs or abnormal heart rhythms, chest x-rays, CT or MRI scans to view the heart and lungs for any abnormalities. Regular electrocardiograms can help detect stiffness of the heart muscle, changes in heart rate. Additional procedures such as echocardiograms or cardiac catheterization (coronary angiography) to check for changes in valve structure, heart muscle strength (ejection fraction), or function.

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