Care after a heart valve operation is determined by both the operative intervention and the pathophysiological status of the patient, with particular regard to ventricular function and the presence of pulmonary hypertension. In adults, operations on the aortic or mitral valve form the vast majority of such cases. This chapter deals primarily with the anatomical and physiological issues specific to surgery for heart valve disease.

Aortic valve surgery

Anatomical concerns

The leading cause of aortic stenosis in the elderly is a calcific degenerative process that often extends beyond the annulus into the wall of the aorta with calcified, atheromatous plaques. Aortic cannulation, aortotomy, excision of the valve and annular decalcification are all potential sources of particulate debris that increase the risk of perioperative stroke in this group. Cardiac structures that lie close to the aortic annulus are at risk during removal of the native valve, decalcification of the annulus or valve suture placement. The atrioventricular node lies near the base of the right coronary cusp and may be injured to produce complete heart block; if persistent, a permanent pacemaker may be needed. The anterior leaflet of the mitral valve may also be accidentally hitched up, producing new mitral regurgitation. The ostia of the coronary arteries are very close to the aortic annulus and may be compromised by the valve sutures or by an implanted valve that is too large or badly seated.