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VALVE SURGERIES

ANATOMY AND PHYSIOLOGY

A heart valve normally allows blood flow in only one direction through the heart. The four 

valves commonly represented in a mammalian heart determine the pathway of blood flow

through the heart. A heart valve opens or closes incumbent upon differential blood

 pressure on each side.

The four valves in the heart are:

  The two atrioventricular (AV) valves, which are between the atria and the ventricles, are

the mitral valve and the tricuspid valve. 

  The two semilunar (SL) valves, which are in the arteries leaving the heart, are the aortic

valve and the pulmonary valve. 

A form of heart disease occurs when a valve malfunctions and allows some blood to flow in

the wrong direction. This is called regurgitation.ATRIOVENTRICULAR VALVES

These are small valves that prevent backflow from the ventricles into

the atrium during systole. They are anchored to the wall of the ventricle by chordae

tendineae, which prevent the valve from inverting.

The chordae tendineae are attached to papillary muscles that cause tension to better hold the

valve. Together, the papillary muscles and the chordae tendineae are known as the

subvalvular apparatus. The function of the subvalvular apparatus is to keep the valves from

 prolapsing into the atria when they close. The subvalvular apparatus have no effect on the

opening and closure of the valves, however. This is caused entirely by the pressure gradient

across the valve. The peculiar insertion of chords on the leaflet free margin however providessystolic stress sharing between chords according to their different thickness.

The closure of the AV valves is heard as the first heart sound (S1).

MITRAL VALVE

Also known as the "bicuspid valve" because it contains two flaps, the mitral valve gets its

name from the resemblance to a bishop's mitre (a type of hat). It allows the blood to flow

from the left atrium into the left ventricle. It is on the left side of the heart and has two cusps.

A common complication of rheumatic fever is thickening and stenosis of the mitral valve.

TRICUSPID VALVEThe tricuspid valve is the three-flapped valve on the right side of the heart, between the right

atrium and the right ventricle which stops the backflow of blood between the two. It has three

cusps.

SEMILUNAR VALVES

These are located at the base of both the pulmonary trunk (pulmonary artery) and the aorta,

the two arteries taking blood out of the ventricles. These valves permit blood to be forced into

the arteries, but prevent backflow of blood from the arteries into the ventricles. These valves

do not have chordae tendineae, and are more similar to valves in veins than atrioventricular 

valves.

AORTIC VALVE

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The aortic valve lies between the left ventricle and the aorta. The aortic valve has three cusps.

During ventricular systole, pressure rises in the left ventricle. When the pressure in the left

ventricle rises above the pressure in the aorta, the aortic valve opens, allowing blood to exit

the left ventricle into the aorta. When ventricular systole ends, pressure in the left ventricle

rapidly drops. When the pressure in the left ventricle decreases, the aortic pressure forces the

aortic valve to close. The closure of the aortic valve contributes the A2 component of thesecond heart sound (S2).

The most common congenital abnormality of the heart is the bicuspid aortic valve. In this

condition, instead of three cusps, the aortic valve has two cusps. This condition is often

undiagnosed until the person develops calcific aorticstenosis. Aortic stenosis occurs in this

condition usually in patients in their 40s or 50s, an average of over 10 years earlier than in

 people with normal aortic valves.

PULMONARY VALVE

The pulmonary valve (sometimes referred to as the pulmonic valve) is the semilunar valve of 

the heart that lies between the right ventricle and the pulmonary artery, and has three cusps.

Similar to the aortic valve, the pulmonary valve opens in ventricular systole, when the

 pressure in the right ventricle rises above the pressure in the pulmonary artery. At the end of 

ventricular systole, when the pressure in the right ventricle falls rapidly, the pressure in the

 pulmonary artery will close the pulmonary valve.

The closure of the pulmonary valve contributes the P2 component of the second heart sound

(S2). The right heart is a low-pressure system, so the P2 component of the second heart sound

is usually softer than the A2 component of the second heart sound. However, it is

 physiologically normal in some young people to hear both components separated during

inhalation.

Heart valves can develop one or both of these problems:

  The valve opening becomes narrow (stenotic) – which limits the amount of blood pumped

to the rest of the body.

  The valve does not close completely (valve insufficiency or regurgitation) – which means

that blood can flow backward instead of only forward. Backward blood flow reduces your 

heart's ability to pump blood to the rest of your body. This also causes a buildup of back 

 pressure in your heart and lungs.

CAUSES

Heart valve disease can develop:   before birth (congenital),

   be acquired during your lifetime, or be the result of an infection. Acquired heart valve

disease is the most common.

  Sometimes the cause is unknown, but it involves changes in the structure of your 

heart valves as a result of mineral deposits on the valve or surrounding tissue.

  Infective heart valve disease causes changes to your valves because of diseases, such

as rheumatic fever or infections.

RISK FACTORS

There are risk factors you can control and risk factors you can't control.

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  Advancing age and congenital heart problems (present from birth) are factors beyond

your control.

  Factors you can control include infections and untreated strep throat, which can lead

to rheumatic fever.

SYMPTOMS:

There are a number of symptoms that may indicate heart valve disease, including:

  Shortness of breath or difficulty catching your breath, especially after you have been

active or when you lie down flat in bed.

  Often feeling dizzy or too weak to perform your normal activities.

  Pressure or weight in your chest, especially when you are active or when you go out into

cold air.

  Heart palpitations or a feeling that your heart is beating irregularly, skipping beats, or flip-

flopping in your chest.

  Swelling in your ankles, feet, or belly. Sudden weight gain with possibly as much as 2 to

3 pounds in 1 day.

Symptoms can range from mild to none at all and do not always indicate the seriousness of 

heart valve disease.

VALVE SURGERIES

Heart valve surgery is done to replace or repair heart valves that are not working correctly.

Most valve replacements involve the aortic and mitral valves.

  Valve replacement surgery is the replacement of one or more of the heart valves with

either an artificial heart valve or a bioprosthesis (homograft from human tissue

or xenograft e.g. from pig). It is an alternative to valve repair. 

There are four procedures:

  Aortic valve replacement

  Mitral valve replacement

  Tricuspid valve replacement

  Pulmonary valve replacement

Current aortic valve replacement approaches include open heart surgery, minimally invasivecardiac surgery (MICS) and minimally invasive, catheter-based (percutaneous) aortic valve

replacement.

Other valve procedures involve:

  Annuloplasty. In this procedure, your surgeon tightens the ring of tissue around the valve

to help the valve flaps (leaflets) come together. Sometimes your surgeon will implant a

ring where the leaflets meet to make the valve opening smaller so the leaflets can come

together.

  Repair of structural support. In this procedure, your surgeon replaces or shortens the cordsthat support the valves (chordae tendineae and papillary muscles) to repair the structural

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support. When the cords and muscles are the right length, the valve leaflet edges meet and

eliminate the leak.

  Valve leaflet repair. In valve leaflet repair, your surgeon surgically separates cuts or pleats

a valve flap (leaflet) to repair a floppy or prolapsed valve leaflet.

VALVE REPLACEMENT PROCEDURE

Cardiac monitoring is instituted and general anesthesia is provided. The surgeon uses a

sternotomy to access the heart and great blood vessels. Anticoagulation is given as cannulae

are inserted into the large vessels of the heart, femoral vessels, or a combination.

Cardiopulmonary bypass is instituted. Once the pericardium has been opened, the patient is

 put on a cardiopulmonary bypass machine, also known as the heart-lung machine. This

machine takes over the task of breathing for the patient and pumping their blood around

while the surgeon replaces the heart valve. The heart is arrested as the cross clamp is appliedto the ascending aorta to stop blood flow through the organ. The surgeon opens the heart to

visualize the mitral valve. He/she may expose the mitral valve by opening the right atrium

and then opening the atrial septum. Another approach requires a large left atrium that can be

opened directly, making the mitral valve visible. For aortic valve, the incision is taken on the

aorta.

 Next, the surgeon cuts the diseased valve away from the valve annulus (outer ring). The

annulus is sized so that the proper size of valve can be selected for the patient's anatomy.

Sutures are applied around the valve annulus, the valve is sutured into place, and tied into

 position. The atrial septum is closed with suture or left to heal naturally, and the heart is

closed with sutures.

Deairing of the heart is performed prior to removal of the cross clamp. When the cross clamp

is removed, deairing continues to ensure that no air is delivered to the systemic circulation.

At this time a transesophageal echocardiogram (TEE) may be used to test that the valve is

functioning correctly and that the heart is free of air. . Once the valve is in place and the aorta

has been closed, the patient is taken off the heart-lung machine. Transesophagealechocardiogram (TEE, an ultra-sound of the heart done through the esophagus) can be used

to verify that the new valve is functioning properly. Once the surgeon is satisfied that the

valve is working correctly, cardiopulmonary bypass is terminated, anticoagulation is

reversed, and the cannulae are removed from the vessels. Pacing wires are usually put in

 place, so that the heart can be manually paced should any complications arise after surgery.

Drainage tubes are also inserted to drain fluids from the chest and pericardium following

surgery. These are usually removed within 36 hours while the pacing wires are generally left

in place until right before the patient is discharged from the hospital. The sternotomy is

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closed. Permanent stainless steel wires are used to hold the sternum bone together. The skin

incision is closed with sutures, and sterile bandages are applied to the wound

A heart valve is a structure within the heart that prevents the backflow of blood by opening

and closing with each heartbeat. Replacement heart valves are either mechanical or biological

tissue valves. For patients under the age of 65, the mechanical valve offers superior 

longevity, but the use of this type of valve requires that the patient take an anticoagulation

drug for the rest of his/her life. The biological tissue valve does not require anticoagulation

therapy, but this type of valve is prone to deterioration leading to reoperation , particularly in

those under the age of 50. Women who may want to have children after a valve replacement

should usually receive a biological tissue valve, because the anticoagulant

(Coumadin/warfarin) most often prescribed for patients with mechanical valves is associated

with fetal birth defects. Aspirin can be substituted for warfarin in certain circumstances.

TYPES OF VALVES USED

The replacement valve may be:

Mechanical — It is made entirely out of artificial materials. Made of man-made materials,

such as titanium or ceramic. These valves last the longest, but you will need to take blood-

thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of your life. The

advantage to mechanical heart valves is their sturdiness. They are designed to last for many

years. There are also drawbacks. Due to the artificial material involved, people who receive

these valves will need to take life-long blood-thinner medication (anticoagulants) to preventclots from forming in the mechanical valve. These clots can increase the risk for a stroke.

Also, some people report a valve ticking sound that is usually not bothersome. It is the sound

of the valve leaflets opening and closing. There are three main types of mechanical valve

(Bloomfield, 2002):

- Ball valves are made from a silastic ball that sits in a sewing ring and is enclosed by a metal

cage. The ball is pushed forward as the pressure of blood behind it rises

- Disc valves are made from a single graphite disc coated with pyrolite carbon. This tilts

 between two struts of housing made of stainless steel or titanium. Modifications of this type

of valve have been made over the years, but concern has been raised about their durability

and function (Bloomfield, 2002)

- Bileaflet valves have two semicircular leaflets that open and close, allowing blood to flow

through three openings (Bloomfield, 2002).

  Bioprosthetic — This valve is made out of a combination of artificial materials and

tissues from a pig, cow, or other animal. Made of human or animal tissue. These

valves last 10 to 12 years, but you may not need to take blood thinners for life. The

advantage of biological heart valves is that most people do not need to take life-long

 blood thinners, unless they have other conditions (such as atrial fibrillation) that

warrant it. Biologic valves, traditionally, were not considered as durable as

mechanical valves, especially in younger people. Previously available biologic valvesusually needed to be replaced after about 10 years. However, some studies show that

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some biologic valves may last at least 17 years without decline in function. This

represents a new milestone in the durability of biologic valves

  Homograft or allograft — The valve is harvested from a donated human heart.

Homografts are ideal heart valves for aortic valve replacement, especially when the

aortic root is diseased or there is infection. The heart's natural anatomy is preservedand patients do not need to take life-long blood thinners. However, the limited

availability is a drawback in some settings.

  Ross procedure (self-donated) — In selected patients less than 50 years of age, another 

one of the patient’s own heart valves, the pulmonic valve, may be removed from its

original location and sewn in to take the place of the faulty aortic valve. A homograft

is then sewn in to take the original place of the pulmonic valve.

  Transcatheter Aortic Valve Implantation (TAVI) — A bioprosthetic valve is implanted

from a catheter-based delivery system via a small incision in either the groin or the

side of the chest.

MINIMALLY INVASIVE VALVE SURGERY 

Minimally invasive heart valve surgery is a technique that uses smaller incisions to repair or 

replace heart valves. This means there is less pain. Minimally invasive surgery also reduces

the length of the hospital stay and the recovery time. Minimally invasive heart surgery (also

called keyhole surgery) is performed through small incisions, sometimes using specialized

surgical instruments. The incision used for minimally invasive heart surgery is about 3 to 4

inches instead of the 6- to 8-inch incision required for traditional surgery.

Minimally invasive valve surgery can only be done in certain patients. This type of surgery

cannot be done in patients

  With severe valve damage

  Who need more than one valve repaired or replaced

  Who have clogged arteries (atherosclerosis)

  Who are obese

Robotically Assisted Heart Surgery

Robotically assisted heart surgery, also called closed-chest heart surgery, is a type of minimally invasive surgery. The cardiac surgeon uses a specially designed computer console

to control surgical instruments on thin robotic arms. Robotically assisted technology allows

surgeons to perform certain types of complex heart surgeries with smaller incisions and

 precise motion control, offering patients excellent outcomes. In robotic surgery, small

incisions — less than 2 inches — are used, compared with the 3- to 4- inch incision used in

traditional minimally invasive heart surgery.

In some cases, minimally invasive valve surgery can be done using a robot. Robotic surgery

does not require a large incision in the chest. It is not available at all hospitals, and patients

with severe valve damage cannot have the procedure. The Texas Heart Institute has a robot.

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With robotic surgery, the surgeon has a control console, a side cart with 3 robotic arms, a

special vision system, and instruments. A computer translates the surgeon's natural hand and

wrist movements made on the control console to instruments that have been placed inside the

 patient through small incisions. The robot's controls can read even the tiniest of movements

the surgeon makes.

Robotic surgery can reduce the time it takes to do valve surgery, as well as shorten the

hospital stay and recovery time.

Benefits of Minimally Invasive Surgical TechniquesThe benefits of minimally invasive and robotic heart surgery techniques include:

  Small incisions

  Small scars

Other possible benefits may include:

  Shorter hospital stay after surgery: The average stay is 3 to 5 days after minimally invasive

surgery, while the average stay after traditional heart surgery is 7 to 10 days

  Low risk of infection

  Low risk of bleeding and blood transfusion

  Shorter recovery time and faster return to normal activities/work: The average recovery time

after minimally invasive surgery is 1 to 4 weeks, while the average recovery time after 

traditional heart surgery is 6 to 8 weeks. The recovery time and return to regular activities is

shorter for patients who undergo robotically assisted heart surgery.

  Division of the breastbone is not needed for robotically assisted heart surgery.

Minimally Invasive Valve Surgery

Valve surgeries, including valve repairs and valve replacements, are the most common typeof minimally invasive surgery.

BALLOON VALVOTOMY

During a balloon valvotomy, a specially designed catheter is inserted into a blood vessel in

the groin and guided to the heart. The tip is directed inside the narrowed heart valve. Once

there, a tiny balloon is inflated and deflated several times to widen the valve opening. Once

the cardiologist is satisfied the valve has been widened enough, the balloon is removed.

During the procedure, the cardiologist may perform an echocardiogram (ultrasound of the

heart) to get a better picture of the valve.

 New research-based, non-surgical procedures to treat regurgitation (leaky valves) are being

tested and may provide additional treatment options using a catheter for valve disease in the

future.

VALVE REPAIR 

The surgeon will perform any of the following types of valve repair procedures.

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  Commissurotomy. Fused valve leaflets, or flaps, are separated to widen the valve

opening.

  Decalcification. Calcium deposits are removed to allow the leaflets to be more flexible

and close properly.

  Reshape leaflets. If one of the leaflets is floppy, a segment may be cut out and the leaflet

sewn back together, allowing the valve to close more tightly. This procedure is calledquadrangular resection.

  Chordal transfer. If a leaflet of the mitral valve has prolapse (floppy; lacking support),

the chordae are transferred from one leaflet to the other. Then, the leaflet where the

chordae was removed is repaired by quandrangular resection (see above).

  Annulus support. If the valve annulus (the ring of tissue supporting the valve) is too

wide, it may be reshaped or tightened by sewing a ring structure around the annulus. The

ring may be made of tissue or synthetic material.

  Patched leaflets. The surgeon may use tissue patches to repair any leaflets with tears or 

holes.

The advantages of heart valve repair surgery include:

  decreased need for life-long blood thinner (anticoagulant) medication

   preserved heart muscle strength

PROGNOSIS

Most valve repair and replacement operations are successful. In some rare cases, a valve

repair may fail and another operation may be needed.

Patients with a biological valve may need to have the valve replaced in 10 to 15 years.

Mechanical valves may also fail, so patients should alert their doctor if they are having any

symptoms of valve failure.

Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of 

their lives. Because these medicines increase the risk of bleeding within the body, you should

always wear a medical alert bracelet and tell your doctor or dentist that you are taking a

 blood-thinning medicine.

COMPLICATIONS 

  Bleeding: The risk of bleeding is associated with the administration of blood-thinning

medications after valve surgery. As outlined by the Harvard Medical School Patient

Education Center, blood thinners are administered to patients with biological artificial

valves for a period of eight to 12 weeks, and for life to patients who have received

mechanical artificial valves. The patients needing blood-thinning medication are closely

followed by their physicians through repeated blood tests to ensure that they are not

overmedicated and thus at higher risk for bleeding. In fact, the Harvard Medical School

Patient Education Center reports that approximately 1 to 2 percent of patients with

artificial mechanical valves experience an episode of life-threatening bleeding per year.

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  Heart attack 

  Infection According to the Brigham's and Women's Hospital, all patients who have

undergone heart valve surgery are at increased risk for infection of the valves. Before

undergoing dental, urological or gynecological procedures, these patients must alert their 

treating doctors to their previous heart surgery so that they can receive prophylactic

antibiotics. Minor trauma during these procedures gives bacteria access to the blood

stream. Bacteria find abnormal and replaced valves a fertile breeding ground. The

resulting valve infection is called endocarditis.

  Surgical Failure

The American Heart Association lists surgical failure as a potential long-term consequence of 

heart valve surgery. In the case of the surgical repair of the mitral valve, the failure, if 

 present, is detected soon after the operation during early postoperative follow-up. If the valve

has been replaced by a biological artificial valve, failure is almost inevitable and long-termfollow-up is necessary to detect any deterioration of the function of the replace valve.

  Irregular heart rhythm (arrhythmia)

  Stroke

  Surgery needed for a new valve, in some instances, if the heart valve fails over time

NURSING INTERVENTIONS

The principles of nursing care for this group of patients are similar to those undergoing other 

forms of cardiac surgery. There are special considerations for patients who may already have

chronic arrhythmias, altered left ventricular function and pulmonary hypertension. Great care

is required with fluid management and haemodynamic monitoring.

 Nurses can help patients understand the nature of their disease and the risks and benefits of 

surgery. While medical treatment may provide symptomatic control and surgery can offer 

improved long-term outcomes, there is an important role for secondary prevention for these

 patients who may not be perceived as having the same risks as those with coronary artery

disease.

Incision CareIt is normal to have some discomfort, bruising, numbness, swelling and itching at your 

incision site for several weeks after the surgery. Be sure to follow the instructions from your 

doctor or nurse for proper incision care.

A shower or gentle washing of the incision site is usually recommended. Tub baths are

typically not allowed because they can affect your circulation. To help prevent infection,

avoid using creams or lotions around the incision site until otherwise directed by your doctor.

The wires holding your sternum together are permanent. Dissolvable stitches will usually

disappear within one to three weeks but can remain up to six weeks, depending on the type of 

stitches you have.

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Fluid RetentionAfter surgery, some people experience fluid retention that can overload the heart and make it

work inefficiently. To prevent fluid retention, your physician may recommend dietary

changes and/or medications.

You can help monitor this at home by weighing yourself every morning. Report any sudden

weight gain of three pounds or more in one day, or five pounds or more in one week. Youshould also contact your doctor if you experience unusual shortness of breath or swelling of 

your hands, ankles or stomach.

InfectionBacteria can enter the bloodstream during dental and some surgical procedures and cause an

infection known as bacterial endocarditis in the tissue surrounding the artificial heart valve.

Although this occurs infrequently, you should consult your doctor before you have any dental

or surgical procedure so antibiotics can prescribed. Also, be sure to tell your dentist and any

other doctors that you have had heart valve surgery.

Anticoagulants

If you receive a mechanical heart valve, your doctor may prescribe an anticoagulantmedication (blood thinner) to prevent blood clots from forming on or around the new valve.

Your doctor will determine the level of anticoagulant that is right for you and closely monitor 

the levels with blood tests. You will need to take your medication as prescribed and follow up

with blood tests as scheduled.

Food, alcohol and other medications, including over-the-counter products, can affect your 

anticoagulation level. Follow your doctor’s recommendations to maintain healthy

anticoagulation levels.

 Notify your dentist, oral surgeon or doctor that you are on an anticoagulant before having any

dental or medical procedures. Adjustments may need to be made to your medication prior to

any procedure.

When taking anticoagulant medication, consult your doctor if any of the following occur:

  Excessive bruising

  Excessive bleeding

  Blood in your urine

  Bloody or black, tarry stool

  Unusual nosebleeds

  Bleeding gums

  Pregnancy or trying to become pregnant

  Fever or other illnesses that, include vomiting, diarrhea or infection

In general, contact your doctor if you develop any of the following symptoms:  Redness or drainage of your incision

  Shortness of breath

  Swelling of your feet or ankles

  Chest, jaw, shoulder or arm pain

  Bruising

  Excessive bleeding

  Blood in your urine

  Bloody or black, tarry stool

  Unusual nose bleeds  Fever 

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   Numbness or tingling in your arms or legs

  General weakness or loss of energy

  Blurred or loss of vision

  Unusual chest sensation

FOLLOW-UP CAREAfter your heart valve surgery, it will be important for you to adhere to your doctor’s orders

and advice for follow-up appointments as recommended. As always, ask your doctor if you

have any questions about potential risks or if you have more questions about heart valve

repair. 

 Nurses can provide support for patients as they adapt to living with a prosthetic valve. Those

with a mechanical prosthesis will start long-term anticoagulation therapy that will demand

changes in lifestyle and self-management. The risks of native and prosthetic valve

endocarditis should be raised with patients who are waiting for or who have had valve

surgery; education about prophylactic antibiotic therapy for dental and other invasive

 procedures should be discussed.

Hospital-acquired infection plays a greater role in infective endocarditis than has previously

 been emphasised. Good infection control practices in hospital can reinforce education

messages given to valve patients who are learning to reduce the risk of developing infective

endocarditis.

Those undergoing surgical intervention require specialist support throughout their diagnosis

and treatment. Surgery can affect the long-term outcomes for these patients, but quality of life

and benefit from surgery is likely to be enhanced by effective patient education and by

encouraging patients to be involved in decision-making.

HEALTH EDUCATION:

  Be sure to keep the incision site clean and dry

  Contact your physician if you experience fever; chills; redness, swelling or bleeding

at the incision site; or extreme pain

  Do not lift, pull or push more than 5 to 10 pounds (2-4 Kg) until given clearance by

your surgeon — which means no lifting laundry baskets, small animals or any

housework or yard work while you are healing

  If necessary, any sutures or surgical staples will be removed during your follow-up

doctor’s appointment 

  On average, patients return to work about 6 to 8 weeks following discharge from the

hospital, but be sure to consult with your surgeon on when it is safe for you to returnto your job

  When riding in a car with passenger-side airbags, it is safest to sit in the backseat —  

the airbag deploy could damage your healing breastbone — but if you cannot

comfortably ride in the backseat try to sit as far back as possible from the airbag

compartment

  You can shower daily but avoid soaking in the bathtub, hot tub or swimming pool

until your incisions are completely healed

  You will not be able to drive until your surgeon has determined your breastbone has

healed and it is safe for you to drive

  You will receive an updated, accurate list of your medications and any prescriptions

you require; be sure to bring your medication list to each follow-up appointment withyour doctor 

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BIBLIOGRAPHY

  http://www.wikipedia.com/

  http://www.medtronic.com/patients/heart-valve-disease/index.htm

  http://uvahealth.com/services/heart/treatment/103224

  http://www.hopkinsmedicine.org/heart_vascular_institute/clinical_services/specialty_ 

areas/valve_surgery.html

  http://www.medicinenet.com/heart_valve_disease_treatment/page3.htm

  http://www.livestrong.com/article/220181-complications-of-valve-surgery/

  http://cardiacsurgery.ctsnetbooks.org/cgi/content/full/3/2008/465?ck=nck 

  http://www.nursingtimes.net/surgical-management-of-aortic-and-mitral-valve-

disease-an-overview/199449.article

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 VALVE

SURGERIES

SUBMITTED TO: Mrs Shubhangi Jadhav

Lecturer, BHCON.

SUBMITTED BY: Diana Thomas

Final Yr M.Sc. Nsg