What is Rheumatic Disease of the Heart Valves?
Rheumatic Heart Disease is a common heart disease in children that damages the valves of the heart. This heart condition starts because of a ‘Sore Throat’ by a particular type of bacteria (Streptococcus). In about 30% children that are infected with this germ- Fever will appear after 2-3 weeks (Rheumatic Fever) and with this fever there may be -pain in joints and damage to the heart muscles and valves.
The risk of damage to the heart and its valves is more if this sore throat happens frequently.
There are four valves in the heart: two on the left side-Mitral Valve and Aortic Valve and two on the right side- Tricuspid valve and Pulmonary Valve. The ones on the left side are damaged most frequently by this rheumatic fever and once damaged- they either start to leak or with time become narrow. This effects the functioning of the heart adversely and when the narrowing or leak in these valves is ‘Severe’- Open Heart surgery to replace these valves is recommended.
Children that have narrowing or leak in his or her heart valves may have:
- Shortness of breath (breathing difficulty).
- Fatigue.
- Chest pain.
- Dizziness.
- Swelling of the ankles and feet.
- Fainting.
- Irregular heartbeat.
Why do the surgery?
If this heart condition is not treated, the narrowing or leak in the valves will put strain on the heart and with time the heart becomes weaker and there is a very high risk that it may fail and cause death.
Timely treatment will prevent this damage to the heart and will improve the quality of life and life expectancy of the child.
The surgical procedure
The surgeon makes an incision down the front of the chest (called a median sternotomy) and divides the breastbone (sternum) in half to get access to the heart. The heart is placed on cardiopulmonary bypass, meaning that a machine takes over the heart’s work of pumping of the blood so the surgeon can enter the heart to change the valves that have been damaged by Rheumatic fever.
This will consist of the following steps:
- Removing the damaged valve
- Replacing it with an implant (usually a mechanical valve)
To put the breastbone back together, stainless steel wires are usually wrapped around the bone to fix it. The surgery will take an average of five to six hours from start to finish.
Risks and benefits of the surgery
The benefit of the surgery is for the child to have a better functioning heart valves and this will improve the efficiency of the heart and decrease in symptoms of heart failure
Risks of any heart surgery include bleeding, infection, stroke, organ damage, requirement for a temporary or permanent pacemaker, or possibly death. However, the risk of these occurring is usually 2 to 4% or less.
Usually there are two types of heart valves available: Mechanical Valve and Tissue Valve and both have their advantages and disadvantages:
- Mechanical Valves: These are metal valves and so are expected to work for a very long time (for a lifetime) but as our blood clots when it comes in contact with anything that does not belong inside the body- it will also clot on these valves unless a blood thinner is given. And so, when this valve is used, lifelong anticoagulation with Warfarin is a must. Most side effects of these valves come from this need for a blood thinner- there is a risk of bleeding if the blood gets too thin OR there is a risk of clot forming on the valve if the blood is not thin enough.
To give the child the right amount of blood thinner, a blood test is needed (PT/INR). Early after surgery this test is more frequent (about once a week or two) to understand the correct dose, later this test becomes a little less frequent (once in a few weeks to once in a few months). - Tissue Valves: these valves are made from tissue from animals (pig, cow, cattle etc). The advantage of these valves is that there is usually no need to give blood thinners and the frequent blood tests that are done with blood thinners, are also not needed.
BUT, the greatest disadvantage with this valve is that blood will slowly deposit calcium (stone like substance) on these valve and these valves will fail over time and will have to be replaced. In older patients this happens in approximately 10- 15 years but in children this happens much faster and can happen in just a few years.
And so, whenever a child needs a heart valve replacement a detailed discussion between the family members and the surgeon is needed to understand what is best for the child and what the family needs to do in the future.
What to expect during the hospital stay
The length of the hospital stay usually varies from seven to 14 days, depending on how quickly the heart recovers. The child may need to be in the hospital for longer if they experience any of the following:
- A fast heartbeat (supraventricular tachycardia or SVT), requiring medications to slow down the heart
- Low heart function
- Fluid in the chest (pleural effusions), requiring a chest tube that is put in place at the end of surgery to stay in longer or additional chest tubes to be added
- Needing longer than usual help from a machine (ventilator) to breathe.
These challenges are part of the normal recovery after surgery in a child after open heart surgery.
For a few days after surgery, the child will be on heart medications to improve heart function and will be on in sedation and on a ventilator- to help the heart get stronger.
After the ventilator is removed and the child is breathing on its own- he/she will be sleepy while recovering from and will be under the influence of strong pain medications. It is normal for a child to be confused, thirsty, and irritable. The child will have many tubes and wires attached, including a chest tube
Going home
The hospital will supply specific discharge instructions, and all instructions from the hospital, cardiac surgeon, and cardiologist should be strictly followed. The child should get back to his or her normal routine upon arrival at home.
For the first week, the child may wish to take more frequent naps or wake up occasionally at night. The child should be seen by his or her cardiac surgeon/ cardiologist within the first 3-5 days after discharge from the hospital. The incision should be kept clean and dry until it is healed.
It should also be protected from the sun for a full year. The child should not be picked up under the arms for four weeks following surgery. Any of the following symptoms should be reported immediately to the cardiologist:
- fever greater than 101,
- redness, puffiness, discharge from the incision, or
- unusual nausea or flu-like symptoms.
If a mechanical valve has been used, the doctor will tell you about the range in which the child’s INR is supposed to be. This blood test will be done a little frequently after discharge and once the correct dose has been reached, the testing will become less frequent. Please always have a detailed discussion with your surgeon about the Do’s and Don’ts if your child is on a blood thinner.
