Tokushukai Medical Group

Treatment of disorder

medical treatment

Cardiac Valvular Disease

This is an adults heart disease followed by Angina Pectoris and Cardiac Infarct. There are various one from minor to severe life-threatening diseases. Early-stage diagnosis and treatment of the disease improves almost all patients.

Cardiac Valve to regulate blood flow to one direction

Heart is a pump which eject blood out, and the valve which makes blood flow to one direction effectively. For example, left ventricle is the strongest pump having an entrance and an exit. When heart constricts, exit open and entrance close. When heart expands largely, exit is closed and entrance open. Heart is repeating this cycle 100,000 times a day. The valve is an opening and closing apparatus located at entrance and exit. Valve located at the exit of left ventricle is aortic valve, and valve at the entrance is a mitral valve. And the valve at the exit of right ventricle is pulmonary valve, and valve at the entrance is tricuspid valve. With using these valves, the heart is effectively circulating blood to entire body.

Mitral Valve is the most important valve in left ventricle

Mitral Valve is the most important valve located at the entrance of left ventricle. It is positioned at the entrance flowing from left atrial to left ventricle. Valve consists of round cap shaped anterior leaflet and curtain like posterior leaflet, and prevent from adverse flow of blood supported with pillar like papillary muscle and tendinous cord. Lung oxygenated red blood flows into left atrial through blood vessel (lung vein). After that, flows into left ventricle through this mitral valve. Mitral Valve repeats open and close.

Incompetence of the mitral valve leading to adverse blood flow

Incompetence of the Mitral Valve means that the blood flew into Left Ventricle adversely flow because at the time when blood flows out from aortic valve as an exit, mitral valve must close, but it cannot close. Reverse flow of blood further flows back to left ventricle, thus too much blood flows in to left ventricle. The heart becomes barely keeping itself afloat. Blood is congested in left atrial so that the function of left atrial also becomes compounded. With these sequence, heart efficiency turns to bad. There are several types in adverse blood flow.

Mitral Prolapse
Mitral Prolapse means that the papillary muscle or tendinous cord, which are the pole to prevent adverse flow of mitral valve, is cut or extended so that the valve comes out from left ventricle. The cause is the papillary muscle or tendinous cord is getting weaker, but there is a case where the cause is in cardiac infarction. There are many cases that the disease is suddenly developed, or hospitalized with cardiac arrest.
Mitral Annular Ring Ectasia
Mitral Annular Ring Ectasia means the disease, annular ring, where the mitral valve is attached, becomes broader so that the mitral valve flows adversely. The cause of the expansion of annular ring can be considered as the expansion of left ventricles.

What is the arctation of mitral valve?

Mitral valve opens in full when blood flows in. But Mitral Valve Stenosis means that the mitral valve is getting hard to open. It is a state that mitral valve is getting stiff, then the entrance becomes narrower. Since getting too stiff, mitral valve is getting hard to close, resulted adverse blood flow occur. Since the blood becomes hard to flow in to left ventricle, blood is getting hard to permeate. At last, volume of blood pumped to entire body is decreased. Also, because blood does not flow in from left atrial to left ventricle, blood is accumulated in left atrial. With this sequence, blood is stopped at left atrial , and also make stasis in lung.

Aortic valve which three lids open/close

Aortic valve locate at the exit of left ventricle which pumps blood out to entire body. It opens when blood goes out, and close when all blood goes out. Three lid like thing open/close.

Incompetence of the aortic valve: blood flows backward

Incompetence of the aortic valve means that blood flows backward with the valve does not close at the time when it must close. It must pump out much more blood in addition to cover adversely flew volume to entire body. Much blood flow in to left ventricle, resulted burden to heart.

Critical condition of aortic stenosis

Aortic Stenosis is the disease that the valve does not completely open at the time when it must open, so that the blood is getting hard to go out from the heart. Left ventricle cannot flow blood out to entire body unless it has an additional pressure. Too much pressure to left ventricle becomes too much burden to it.

Adverse flow (incompetence) of tricuspid valve rarely occur by itself

Adverse flow (incompetence) of tricuspid valve alone may rarely happen. In case mitral valve stenosis and closure insufficiency become advanced, right ventricle has a stress caused by lung high blood pressure, then incompetence of tricuspid valve arises. Also, arctation of tricuspid valve does not develop after being matured. It is a congenital disease.

What is a symptom of cardiac valvular disease?

The symptom of these cardiac valvular disease is altered depend on, type of diseased valve, degree of pathological abnormality, and personality. Since medical check and ultrasonography diagnostic has been progressed these days, the case is decreased that the disease will not diagnosed until getting too bad. But, in any valvular disease if heart function becomes compounded, it turns into cardiac arrest. Firstly, symptom of Cardiac Arrest is explained.

Symptom of Cardiac Arrest
Symptoms are: Breath shortness is getting worse when exercised. Breath shortness happen even at rest. Having a palpitation. Likely happen a breathing difficulty. Coughing does not stop. Breath wheezing. Being told as asthma. Feet are swollen. Swollen belly. Getting less urination. Weight increased. Adversely, weight decreased. Looked as low in nutrition. It does not mean directly that person has Cardiac Arrest when having above symptoms, but it is recommended to consult with doctor.

Below listed are the specific symptoms of each valvular diseases.

Mitral Valve Stenosis
Breath shortness, cough, cough is getting worse when lay down at night. Heart palpitates. Body weight decrease, etc.
Incompetence of the mitral valve
Breath shortness. Cough. Cough is getting worse when lay down at night. Heart palpitates, etc.
Aortic Stenosis
Chest Pain, Faint, Breathing Difficulty
Incompetence of the Aortic valve
Chest Pain, Breathing Difficulty

Able to diagnose by auscultation

If there is certain symptom and it continues for longer time, it is better to consult with doctor. And, in case if cardiac murmur is recognized at medical check, or found an abnormality in cardiac electrogram, it is also recommended.

Almost all cardiac valvular disease can be found if specialty doctor auscultates the heart. Also, more detailed diagnose is possible with cardiac ultrasonography test. Below are the list stating what kind of thing can identified in each test.

Cardiac Electrogram
Abnormality may come up in electrogram when heart is enlarged or become hypertrophied by the stress burden which valvular disease. Or, abnormal cardiac rhythm, especially atrial fibrillation may be raised by cardiac valvular disease. Degree of myocardial hypertrophy caused by valvular disease or degree of abnormal cardiac rhythm can be found with cardiac electrogram.
Chest X-Ray
It can judge, at certain level, the provability of cardiac valvular disease as the size and shape of heart can be discriminated by Chest X-Ray. How much strain is applied to heart, or any strain is applied to lung can be found. But the accurate judgment is impossible by this test.
Cardiac Ultrasonography
This test clearly identify which valve is how badly compounded. At the same time, it will identify how much strain applied to heart or degree of myocardial hypertrophy. This test is the definitive diagnosis for cardiac valvular disease.
Blood Test
Cardiac valvular disease will never be judged by blood test. Recently, so called BNP test becomes available. This is the test to assume the degree of cardiac arrest.
Cardiac Catheter Test
This test is not indispensable for the diagnosis of cardiac valvular disease, but it may help at below cases. For example, judge the degree of stenosis with measuring the pressure in aortic stenosis, evaluate the degree of cardiac arrest further in detail with measuring pulmonary pressure and beat volume. Or, in case angina pectoris or cardiac infarct is possibly associated, or in case where cardiac infarct possibly generate the cardiac valvular disease, coronary arteriographic check is necessary.

Cure is necessary even if no symptom is appeared

When having a symptom, it is inevitable to have medical treatment. When no symptom or symptom is minor so that it can bear off, there may be necessary to have medical treatment. In case heart function is found compounded with cardiac ultrasonography, having a medical cure before it gets too worse can make the thing better. There are variety of cases.

Burdens to the heart continue if left with no care

If left with no cure, daily life may be suffered by the symptom of cardiac arrest. As the burden continuously applied to heart with cardiac valvular disease, there is a risk of the function of heart becomes compounded. Or, there is a case where function of the breathing is compounded due to lung blood stasis. If this is a case, heart or lung function may not be restored back even if medicine treatment or valve replacement surgery is performed. Furthermore, as special case, in case if severe valvular disease is associated, blood clot is generated in the heart, or valve or heart is compounded further dur to the developed bacteria on the valve.

There are two treatment methods available. The one is a medicine treatment. The other is surgical treatment. As a special case, there is a catheter treatment is also available.

Medicine treatment subject to mild case and end-stage patients

Medicine Treatment is the method to dose the medicine to improve the symptom. This treatment is applied for the case of not serious condition where surgery is not necessary, or for the end-stage case where no surgery is possible. There is a medicine which relieve the heart burden (like diuretic, blood pressure drug), and which prevent valvular disorder associated disease (example; abnormal cardiac rhythm, intracardiac thrombus). Regrettably, there is no medicine which make heart itself to improve or restore damaged valve back to original state.

Consider Catheter Treatment in case of arctation

For the Mitral Valve Stenosis, a treatment of narrowed mitral valve broaden by balloon is also available. This treatment has a merit of not cutting breast, but it is comparatively lessor in assuredness. Also, recidivation exists. It is judged by the degree of valve arctation. Another treatment of broadening the arctation by blowing the balloon is also available for aortic stenosis. This surgery is performed for aged and surgery is difficult person. But for the most cases, it is recidivated in shorter period.

What is transcatheter aortic valve implantation (TAVI)?

TAVI is the cutting-edge new treatment. It is to indwell an artificial valve at the compounded aortas with using catheter. Insert catheter from the vessel of groin and indwells folded artificial valve on the aortic valve area. The surgery is performed for older-old person and the person having many associated diseases so that perform surgery is difficult. Because this method has a merit of less invasion, prognosis is extremely good. However, depend on the condition of aortas, aortic valve or coronary artery, there is a case where this surgery cannot be used. Also, using this method has a provable risk of, breaking aortas, artificial valve is shifted or blood flow adversely, generating brain infarct with the fraction of aortic valve flows into the brain. When surgery is possible, assured surgery is strongly recommended at this moment of time.

Surgery as a fundamental Cure has a certain risk.

The cause of cardiac valvular disease is the abnormality on its shape. Therefore, the fundamental cure is either to restore abnormal valve or replace with new valve. Surgery opens one’s breast, and make the heart stopped, and it’s not a simple and easy one, so that there should exist certain risks. Candidates for surgery are listed as below:

Artificial heart lung apparatus is inevitable for surgery

Conduct dissection, about 15cm length vertically, at the center of chest, the cut the breast bone vertically. Then operation is made to the valves of the heart. Human life cannot be maintained if the heart stops working. But to perform surgery to valves of heart, heart must stop beating. Therefore, artificial heart lung apparatus is used instead of heart. While heart lung apparatus is used, surgery to inside with heart stopped becomes possible.

Recently as MICS surgery, it is possible to perform cardiac operation using right subcostal small incision method. This operation is performed as less-invasive surgery when patient desires small cut, but this operation does use heart lung apparatus with heart stopped.

Mechanical Valve and Biological Valve used at artificial valve replacement

Artificial Valve Replacement is the surgery to replace un-restorable valve with artificial valve. Remove valve and then implant the artificial valve. It is well-established operation method and relatively safe operation. There are two kinds of artificial valve. They are mechanical valve and biological valve. Patients worry about whether this artificial valve is to;

Characteristics of mechanical valve and biological valve are as follows;

Made by Performance Durability Easy to make thrombus Warfarin treatment Size
Mechanical valve Metal
Easy to build up

Inevitable

Small size available
Biological Valve Membrane covering Cow’s heart
10~15years

Hard to build up

Unnecessary

Relatively large

Mechanical Valve where the dosage of Warfarin is necessary.

Mechanical valve is made by metal. Its performance is very good. There is no galling because of metal so that it can be used semi-permanently. But it’s demerit is to generate blood clots in the contact with blood. It is therefore dosing the warfarin, which prevent from generating the blood clot, is necessary to control. Warfarin is a powerful medicine but if it works too well, becomes easy to bleed, and if it does not work well, easy to generate blood clots. Therefore, it is necessary to constantly take adequate dose every day. It does not fit to the person who has a difficulty on dosing warfarin. Although it is a very rare case but there is the case where blood clots is stuck on artificial valve so that movement of the valve becomes worse, or artificial valve generates communicable disease, resulted repeat surgery.

The merit of using biological valve is that it is hard to produce blood clots.

Biological valve is an artificial valve made from the membrane covering cow’s heart. Another one made from pig’s cardiac valve processed. Performance is the same as mechanical one so that its excellent. Regarding its life duration, it is less superior in comparison of mechanical valve, there are many reports available, but they say, it lasts 10 to 15 years in average. However, it also says that the valve is hard to deplete when implanted to aged person. The merit is that it is hard to generate blood clots in contacting with blood, and the permanent dosage of warfarin is not necessary.

Mechanical valve or biological valve?

Selection of either mechanical valve or biological valve is requested to consider each merit and demerit then select best adequate valve for each individual. Generally speaking, mechanical valve is adequate for younger person, and biological one for aged person. Even for younger person, if person is thinking about having baby in the future, or if doing the aggressive physical exercise, the use of biological valve is recommended in consideration of the side effect by warfarin dosage. As the recent tendency, the use of biological valve is getting bigger.

Valve Restoration Surgery mainly performed for incompetence of mitral valve.

Valve Restoration Surgery is to only restore abnormal part of valve without replacing own valve with artificial one. This surgery is performed mainly for incompetence of the mitral valve. The cut method for mitral valve stenosis is seldom performed. Recently, restoration surgery is performed for aortic valve, or incompetence of tricuspid valve associated with other surgery for another valve.

For incompetence of the mitral valve, in case blood flow adversary due to the cut of valve supporting tendinous cord, it is possible to take the method of cutting the portion off and seams them. But this method can take only for posterior leaflet amongst two mitral valves. In case when tendinous cord at anterior leaflet is cut or loosened so that blood flows adversely, there is a method to back up tendinous cord, but in many cases it does not restore in better finish. Further, in case if the valve itself is extending due to adverse flow, surrounding the valve is backed up with ring.

As valve restoration surgery use its own valve, there are several merit in comparison with foreign objects artificial valve. The one is the dosage of warfarin is not necessary because it hard to produce blood clots. Another merit is to last longer period since it is a living valve. Regarding the demerit, perfect restoration is impossible so that there is a case where a little adverse flow still remains after the surgery, and there is a risk for the recurrence of adverse flow in the future. Forced restoration rather generate the risk of recurrence.

Better to have early-stage surgery for the heart function recovery

Does the heart return to normal with performing these surgery operations? Reverse flow of the valve and stenosis may back to normal with these operations. But the heart or lung which were under the burden for long time may not return to normal so easily. But, as they will not have any burden after the surgery, they will certainly get better gradually. Therefore, it is better to have surgery before cardiac function goes into end-stage condition. Recovery of heart is also expected.

Safeness at surgery increase, but…….?

Surgery for cardiac valvular disease has gotten extremely safe, but the fatality risk is not yet 0 %. It is influenced by patient’s physical capacity, age and complicated diseases. It is better to listen carefully what doctor says to understand well before the surgery. Complicated disease to cardiac valvular disease are; bleeding after operation, cardiac arrest, abnormal cardiac rhythm, breathing disorder, brain infarct, and infection of a wound. Regarding the fatal rate, the report says the postsurgical death rate is about 4%.

Discharge from hospital will be in two weeks from surgery

In case there is no complicated disease, person can be discharged from hospital in two weeks from the surgery.

Even after discharge from hospital, in case there is no complicated disease, after discharge life will be as same as or be better than before. Person can spend ordinally life and do exercise. After two months from discharge, there is no limitation for work. But for a while after discharge, it is necessary to visit hospital once in a month or once in two months. For the mechanical valve, warfarin treatment is necessary so that continued visit to hospital is necessary. For Biological valve or restoration surgery person, outpatient care will be once in half year or once a year, provided function of heart is in goodness, thus no need for medicine dosage.

What is Warfarin: a medicine which mechanical valve patient must take.

In the nature of blood, they are thick liquid, but circulate through entire human body without clotting. But in case artificial valve or artificial vessel is implanted in the body, it becomes easy to generate clots when contacting foreign objects. To prevent this, drug named as warfarin may be used to make blood hard to generate clots. It is a difficult to use medicine so that please read below remarks carefully for better understanding.

How to take Warfarin
Easiness for blood clotting varies by person, so that with periodically check the blood clotting time (PT: Prothrombin Time) decide the adequate warfarin amount. It is important for warfarin dosage that promptly adhere to set amount, and do not miss or over-dose the medicine. Even when missed dosage, one or two times missing does not affect so much. Simply restart the set amount. But when you missed more than 2 days, please consult with doctor.
Adverse effect
For Warfarin, the best appropriate amount is dosed for the patient. But, it merely occurs that the body becomes easy to bleed as the warfarin effect strongly appeared. Warfarin itself is a safe medicine when taking the set amount correctly, but in case below listed diagnostics strongly, consult with doctor or take medical check.
  • Bleed Nose

  • Blood oozing from gums

  • Much bleed from cut

  • Bleed under the skin

  • Hypermenorrhea

  • Bloody Sputum

  • Red or Cola colored urine

  • Red or black colored slop

  • lightheadedness

  • Womble

  • Headache

  • Bleeding in the skin

Drugs needs an attention when taking warfarin together
There is a drug which require certain attention when taking Warfarin together.
Some will strengthen the effect of warfarin, some will weaken the effect. Drugs, needs an attention when taking Warfarin together, are antibiotic, cold medicine (Aspirin, lysozyme chloride, serrapeptase, etc.), medicine for pain (aspirin, etc.) may strengthen the effects, but drugs containing Vitamin K may weaken its effect.
When having medicine at hospital or buying medicine at local drug store, patient must tell to a doctor and have its direction.
Food better to refrain from eating
While warfarin is prescribed, it’s better not to change daily eating habit and to care for the balanced meal. But, in case if eat or drink below listed food/drink too much, the warfarin effect may change.

Food/drink which strengthen warfarin effect

Alcohol

Food/drink which weakened warfarin effect

Natto (There is no influence to the effect in eating Soy Bean, Tofu, Miso, and also food contains lactic acid bacteria, like yogurt), food containing vitamin K a lot (ex. Broccoli, spinach, tomato, asparagus, cabbage, lettuce, sea weed etc.). Especially Natto has a strong influence to strengthen warfarin effect so that it is better not to take any.

Precautions on daily life

Please take special attention for the followings while warfarin is prescribed.

  1. ・Avoid playing sports which expect bruise or bruising.
  2. ・Avoid driving motorcycle, because it may bruise one head in accident
  3. ・Be careful about bleeding when using edged tool (shaver etc.)
  4. ・To tell doctor the use of warfarin whenever having the other surgery like dental care.

The usage of Warfarin may influence to the pre-born child. Person expecting pregnancy must consult with doctor.

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