8.Can medication replace surgery?
Many patients feel significantly relieved after medication during hospitalization, which leads to the question, “Is it possible to do without surgery? For most valve diseases, drug therapy is necessary because it can improve the patient’s heart function and relieve the patient’s symptoms to a certain extent. However, medication cannot stop the development of heart disease. Therefore, if the heart disease caused by valve lesions has reached a certain level, i.e., if the criteria for surgery are met, the patient should receive surgery.
9.What preparations are needed before surgery?
After admission, first of all, routine blood tests, echocardiogram, chest X-ray, electrocardiogram, respiratory function and other tests should be performed. If the patient is judged to be in the rheumatic activity stage, it is necessary to delay the operation, carry out certain anti-inflammatory treatment, and wait for more than 3 months for the rheumatic activity to stop before the operation (except for the condition requiring emergency operation).
Those who are older than 50 years old, or those who are younger than 50 years old but have high-risk factors for coronary heart disease (such as obesity, high blood pressure, hypertension, diabetes, etc.) or have symptoms of chest pain need to undergo coronary angiography to diagnose the combination of coronary heart disease. If the combination of coronary stenosis is clear by coronary angiography and reaches a certain level, coronary artery bypass grafting is also required at the same time as valve replacement surgery.
Patients themselves also need to make some preparations: 1. respiratory function exercises (practice blowing up balloons or simple lung function trainers for respiratory function exercises, practice slow deep breathing, breath-holding movements, practice correct coughing methods). 2. for patients with smoking habits, it is recommended that they must completely quit smoking for more than 2 weeks. 3. proper control of water intake, small meals, and proper nutrition. 4. rest is the mainstay, avoid straining, and prevent respiratory infections. Prevent respiratory tract infections. If your condition allows, get out of bed and move appropriately every day, but do not leave the ward without permission.5. Pay attention to oral hygiene, brush your teeth every day, especially on the day of surgery, and make sure to brush your teeth to maintain oral hygiene to reduce the risk of postoperative infection.
There are also several other issues that we feel are very important, that is, if you have chronic inflammatory conditions before surgery, such as periodontitis, otitis media, sinusitis, skin infections, etc., be sure to tell the doctor in charge! These chronic inflammatory conditions may cause infections after flap replacement surgery and must not be concealed in the rush to operate.
10.How to choose the timing of surgery?
I often hear patients say, “Doctor, I came here to have surgery, why did the ones who came later than me have surgery and I haven’t done it yet?” Other patients want to ask the doctor to schedule surgery according to the time their children take off from work. These are inappropriate, and we preach that the timing of surgery requires comprehensive consideration and is one of the important factors in the success of surgery. We often say to patients and families, “which end do you think is cost-effective, to stay an extra week before surgery to adjust the medication and then operate, and to recover quickly after surgery, and to come to the surgery in a hurry before adjusting well, and to recover badly after surgery?” The reasoning behind this will be understood by everyone.
Some patients with valve disease, when they come to hospital, already have cardiac insufficiency or even heart failure, and after hospitalization, they need to make adequate drug adjustments before surgery to improve heart function and increase the reserve capacity of the heart, so that the heart is in the best condition to meet the surgery, thus improving the safety of the surgery, and this adjustment takes a certain amount of time. Some patients with valve disease, on the other hand, have good heart function and do not need too much preoperative medication adjustment, and can be scheduled for surgery after perfecting the admission examination with no abnormalities. The surgeon will choose the most reasonable time to perform the surgery according to the patient’s condition and hopes that the patient will be patient and actively cooperate.
11.What kinds of prosthetic valves are there? What type of valve should I choose?
Many patients do not have a thorough understanding of the characteristics of the different types of prosthetic valves before surgery, or they hesitate, or they simply say to the surgeon, “Doctor, give me the best valve.” In fact, there are different types of prosthetic valves with different characteristics, each with its own advantages and disadvantages, and there is no such thing as the absolute best, nor is the expensive one the right one. Therefore, we generally take a longer time to go into detail. Here we will talk to you in more detail about those things related to valve selection.
There are two types of prosthetic valves: mechanical and biological.
(1) The advantages of mechanical valves: mechanical valves are designed to last longer than biological valves, and a single flap change can basically last a lifetime. Disadvantages: A. Mechanical valves installed into the body, will grow thrombus, in order to prevent thrombosis, you need to take anticoagulants (warfarin) for life. At the same time, in order to adjust the dose of warfarin, it is necessary to regularly visit the hospital to take blood tests to monitor the anticoagulation index. This may affect the patient’s quality of life after surgery. b. Overdose of warfarin can lead to bleeding, and underdose of warfarin can lead to thrombosis. c. In a quiet environment Sometimes you may hear a “tick-tock” sound in the chest, which is normal for mechanical valves, but if you are very sensitive to noise and have insomnia, you should consider this when choosing a valve. Of course, the vast majority of patients can accept and adapt to this sound.D. Taking warfarin during pregnancy may lead to fetal malformations, and during pregnancy and delivery may lead to fetal, placental, and maternal hemorrhage, thus endangering the life of mother and child, so women of childbearing age who are ready to replace their valves should consider this carefully, whereas men do not have this problem, which will be described in detail later.
(2) The advantage of a biologic valve, in contrast to a mechanical valve, is that it does not require a lifetime of anticoagulant medication, but only 3-6 months, during which time only, periodic blood tests are required, and if there is no atrial fibrillation, warfarin anticoagulation can be discontinued after 3-6 months, so the risk of thrombosis and bleeding associated with it is greatly reduced. The disadvantages are: poorer durability than mechanical valves, shorter service life than mechanical valves, and damage to the bioprosthetic valve over time. Therefore, if the bioprosthetic valve becomes damaged after several years of surgery, a second valve replacement surgery will be faced. In general, the younger the patient is, the faster the bioprosthetic valve will break down, the shorter the service life, and the greater the chance of a second surgery. How long does it last for each patient? It is impossible to give a definitive answer to this question because the life expectancy varies depending on the patient’s physical condition, metabolic status, exercise level, basal heart rate, blood pressure, etc. Therefore, when choosing a valve, you need to fully anticipate the possibility of a second surgery.
The choice between mechanical and biologic valves has its own advantages and disadvantages and is based on the patient’s age, general condition, co-morbidities, as well as his or her own life, work, physical strength, psychological factors, economic conditions, and other practical considerations to see which one is suitable for him or her.
To summarize: in general, biological flaps are suitable for the following cases.
(1) Women of childbearing age who wish to become pregnant. This is because there is a risk of fetal malformations, hemorrhage, and other problems for patients who are taking warfarin before and during pregnancy with a mechanical flap exchange. This problem can be avoided if the biological flap is replaced.
(2) In terms of age, a bioprosthetic valve can be preferred for mitral valve replacement over 65 years of age and aortic valve replacement over 60 years of age.
(3), Suffering from bleeding disorders or being a bleeding body themselves, they cannot take anticoagulants for a long time.
(4), in distant mountain villages where long-term anticoagulation monitoring cannot be performed.
(5) Those who do not want to use mechanical flaps, do not want to make frequent trips to the hospital for blood tests (even if it is once a month), and require a higher quality of life.
(6), general condition, poor physical condition of the patient (life expectancy is not long).
12 .How to solve the problem of anticoagulation after valve replacement in women of childbearing age.
First, to understand the effect of warfarin on pregnancy and childbirth.
1, warfarin can act on the fetus through the placenta, there is a certain degree of teratogenicity (about 6%, the appearance of fetal cleft lip, cleft palate, etc.), there are also studies that as long as the daily warfarin dosage is less than 5mg, this teratogenicity is relatively small. The national warfarin dosage is also mostly below 5mg, and through modern medical genetic testing, the amount of warfarin that may need to be taken to meet the anticoagulation standard after valve replacement can be predicted in advance.
2.Patients with warfarin anticoagulation may have placental hemorrhage leading to miscarriage, bleeding or postpartum hemorrhage, which endangers the life of pregnant women and fetuses in serious cases.
3.It may cause internal bleeding of the fetus. Therefore, it is better to deliver such patients by cesarean section to avoid the extrusion process of the fetus passing through the birth canal and to avoid the use of forceps; anesthesia should not be epidural, but preferably general anesthesia.
13.Is it impossible to get pregnant after the mechanical flap is replaced?
No! There are different anticoagulation methods recommended for pregnant women with mechanical flaps. Our recommended method is to use warfarin anticoagulation throughout the pregnancy, to keep the anticoagulation index as low as possible and as smooth as possible, and to use heparin replacement before delivery. Although there is some risk of teratogenicity, it reduces the risk of bleeding and maximizes the safety of the mother. Of course, only one approach is provided here and its implementation requires a detailed treatment plan together with your OB/GYN and cardiac surgery specialist.
The use of anticoagulants during pregnancy and childbirth is indeed a more problematic issue. Prior to cardiac surgery, we generally recommend the use of a biologic valve for women with childbearing requirements who require valve replacement. Although there is an age limit for the biologic valve and the need for a second procedure in younger patients, we believe that the risk of a second procedure is more manageable and acceptable to the patient than the risk of placental hemorrhage, intrauterine hemorrhage, and possible fetal malformations associated with warfarin administration during pregnancy and childbirth.
Patients with sinus rhythm using a bioprosthetic valve have no effect on later pregnancy or childbirth as long as they become pregnant after stopping warfarin 3-6 months after the procedure.
There is no effect on fertility in men taking warfarin.