Valvuloplasty

(Balloon Valvuloplasty)

Procedure Overview

What is valvuloplasty?

Valvuloplasty is performed, in certain circumstances, to open a stenotic (stiff) heart valve. In valvuloplasty, a very small, narrow, hollow tube, or catheter, is advanced from a blood vessel in the groin through the aorta into the heart. Once the catheter is placed in the valve to be opened, a large balloon at the tip of the catheter is inflated until the leaflets (flaps) of the valve are opened. Once the valve has been opened, the balloon is deflated and the catheter is removed.

Other related procedures that may be used to assess and treat the heart include resting and exercise electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest x-ray, computed tomography (CT scan) of the chest, coronary artery bypass graft surgery, valve repair/replacement surgery, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and ultrafast CT scan. Please see these procedures for additional information.

Valves of the heart:

Click Image to Enlarge

To better understand how valvular heart disease affects the heart, a review of basic heart anatomy and valve function follows.

The heart is a pump made of muscle tissue. The heart has four pumping chambers: two upper chambers, called atria, and two lower chambers, called ventricles. The right atrium pumps blood into the right ventricle, which then pumps the blood into the lungs where wastes such as carbon dioxide are given off and oxygen and other nutrients are taken into the blood.

From the lungs, the blood flows back into the left atrium, is pumped into the left ventricle, and then is pumped through the aorta out to the rest of the body and the coronary arteries. When the atria are pumping, the ventricles are relaxed in order to receive the blood from the atria. Once the atria have pumped their entire blood load into the ventricles, they relax while the ventricles pump the blood out to the lungs and to the rest of the body.

In order to keep the blood flowing forward during its journey through the heart, there are valves between each of the heart's pumping chambers:

• tricuspid valve - located between the right atrium and the right ventricle
• pulmonary (or pulmonic) valve - located between the right ventricle and the pulmonary artery
• mitral valve - located between the left atrium and the left ventricle
• aortic valve - located between the left ventricle and the aorta

If the heart valves become damaged or diseased, they may not function properly. Conditions that may cause dysfunction of heart valves are valvular stenosis and valvular insufficiency (regurgitation). When one (or more) valve(s) becomes stenotic (stiff), the heart muscle must work harder to pump the blood through the valve. Some reasons why heart valves become stenotic include infection (such as rheumatic fever or staphylococcus infections) and aging. If one or more valves become insufficient (leaky), blood leaks backwards, which means that less blood is pumped in the proper direction.

Valvular heart disease may cause the following symptoms:

• dizziness
• chest pain
• breathing difficulties
• palpitations
• edema (swelling) of the feet, ankles, or abdomen
• rapid weight gain due to fluid retention

Reasons for the Procedure

Valvuloplasty is performed in certain situations in order to open a heart valve that has become stiff as a result of disease or the aging process. Not all conditions in which a heart valve becomes stiff are treatable with valvuloplasty.

There may be other reasons for your physician to recommend a valvuloplasty.

Risks of the Procedure

Possible risks associated with valvuloplasty include, but are not limited to, the following:

• bleeding at the catheter insertion site
• blood clot or damage to the blood vessel at the insertion site
• infection at the catheter insertion site
• cardiac dysrhythmias/arrhythmias (abnormal heart rhythms)
• stroke
• rupture of the valve, requiring open-heart surgery

The amount of radiation used during a valvuloplasty procedure is considered minimal; therefore, the risk for radiation exposure is very low.

If you are pregnant or suspect that you may be pregnant, you should notify your physician due to risk of injury to the fetus from a valvuloplasty. Radiation exposure during pregnancy may lead to birth defects. If you are lactating, or breastfeeding, you should notify your physician.

There is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dyes, iodine, shellfish, or latex should notify their physician. Also, patients with kidney failure or other kidney problems should notify their physician.

For some patients, having to lie still on the procedure table for the length of the procedure may cause some discomfort or pain.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
• Notify your physician if you have ever had a reaction to any contrast dye, or if you are allergic to iodine or seafood.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, or anesthetic agents (local and general).
• You will need to fast for a certain period of time prior to the procedure. Your physician will notify you how long to fast, usually overnight.
• If you are pregnant or suspect that you may be pregnant, you should notify your physician.
• Notify your physician if you have any body piercings on your chest and/or abdomen.
• Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have heart valve disease, as you may need to receive an antibiotic prior to the procedure.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure.
• Your physician may request a blood test prior to the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well.
• Notify your physician if you have a pacemaker.
• You may receive a sedative prior to the procedure to help you relax.
• The area around the catheter insertion (groin area) may be shaved.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

A valvuloplasty may be performed as part of your stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, a valvuloplasty follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aids if you use either of these.
2. You will be asked to remove clothing and will be given a gown to wear.
3. You will be asked to empty your bladder prior to the procedure.
4. An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
5. You will be placed in a supine (on your back) position on the procedure table.
6. You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.
7. There will be several monitor screens in the room, showing your vital signs, the images of the catheter being moved through the body into the heart, and the structures of the heart as the dye is injected.
8. You will receive a sedative medication in your IV before the procedure to help you relax. However, you will likely remain awake during the procedure
9. Your pulses below the injection site will be checked and marked so that the circulation to the limb below the site can be checked after the procedure.
10. A local anesthetic will be injected into the skin at the insertion site. You may feel some stinging at the site for a few seconds after the local anesthetic is injected.
11. Once the local anesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart.
12. The valvuloplasty catheter will be inserted through the sheath into the blood vessel. The physician will advance the catheter through the aorta into the heart valve. Fluoroscopy (a special type of x-ray that will be displayed on a TV monitor) may be used to assist in advancing the catheter to the heart.
13. Once the catheter is in place, contrast dye will be injected through the catheter into the valve in order to look at the area. You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, or a brief headache. These effects usually last for a few moments.
14. You should notify the physician if you feel any breathing difficulties, sweating, numbness, itching, chills, nausea and/or vomiting, or heart palpitations.
15. The physician will watch the contrast dye injection on a monitor. The physician may ask you to take a deep breath and hold it for a few seconds.
16. Once the balloon is in place and has been inflated, you may notice some dizziness or even brief chest discomfort. This should subside when the balloon is deflated. However, if you notice any severe discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing difficulty, tell your physician.
17. The balloon may be inflated and deflated several times in order open the valve.
18. Once it has been determined that the valve is opened sufficiently, the catheter will be removed. The catheter insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your physician will determine which method is appropriate for your condition.
19. If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the physician (or an assistant) will hold pressure on the insertion site so that a clot will form. Once the bleeding has stopped, a very tight bandage will be placed on the site. A small sandbag or other type of weight may be placed on top of the bandage for additional pressure on the site, especially if the site is in the groin.
20. Your physician may decide not to remove the sheath, or introducer, from the insertion site for approximately four to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off. You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give you medication to make you more comfortable.
21. You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area. NOTE: If the insertion was in the groin, you will not be allowed to bend your leg for several hours. To help you remember to keep your leg straight, the knee of the affected leg may be covered with a sheet and the ends tucked under the mattress on both sides of the bed to form a type of loose restraint.

After the Procedure

In the hospital:

After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. You will remain flat in bed for several hours after the procedure. A nurse will monitor your vital signs, the insertion site, and circulation/sensation in the affected leg or arm.

You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm.

Bedrest may vary from two to six hours depending on your specific condition. If your physician placed a closure device, your bedrest may be of shorter duration.

In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bedrest will be prolonged until the sheath is removed. After the sheath is removed, you may be given a light meal.

You may be given pain medication for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period.

You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.

You may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. You will need to use a bedpan or urinal while on bedrest so that your affected leg or arm will not be bent.

You may resume your usual diet after the procedure, unless your physician decides otherwise.

After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. You should move slowly when getting up from the bed to avoid any dizziness from the long period of bedrest.

You will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge and recovery period.

At home:

Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the injection site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your physician.

If your physician used a closure device for your insertion site, you will be given specific information regarding the type of closure device that was used and how to take care of the insertion site. There will be a small knot, or lump, under the skin at the injection site. This is normal. The knot should gradually disappear over a few weeks.

It will be important to keep the insertion site clean and dry. Your physician will give you specific bathing instructions.

You may be advised not to participate in any strenuous activities. Your physician will instruct you about when you can return to work and resume normal activities.

Notify your physician to report any of the following:

• fever and/or chills
• increased pain, redness, swelling, or bleeding or other drainage from the insertion site
• coolness, numbness and/or tingling, or other changes in the affected extremity
• chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

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