What is the post-operative management for a patient after Mitral Valve Replacement (MVR)?

Post-Operative Management After Mitral Valve Replacement (MVR)

Comprehensive post-operative management after mitral valve replacement must include regular monitoring, anticoagulation therapy, rehabilitation, and vigilance for potential complications to optimize patient outcomes.

Immediate Post-Operative Assessment

• Perform baseline echocardiography 6-12 weeks after surgery to assess:

  • Prosthetic valve function
  • Transprosthetic gradients
  • Absence of paravalvular regurgitation
  • Ventricular function 1

• Obtain baseline chest X-ray, ECG, and blood tests during this initial assessment 1

Anticoagulation Management

Mechanical Valve Prosthesis

• Lifelong oral anticoagulation is mandatory for all patients with mechanical prostheses 1
• Target INR:
  • Mitral position: 2.5-3.5 1
  • Add low-dose aspirin (100mg daily) for patients with:
    • Concomitant atherosclerotic disease
    • History of thromboembolism despite adequate INR 1

Bioprosthetic Valve

• Oral anticoagulation recommended for first 3 months after implantation 1
• Lifelong anticoagulation for patients with other indications (atrial fibrillation, heart failure, LV ejection fraction <30%) 1, 2
• Low-dose aspirin may be considered after the initial anticoagulation period 1

Monitoring for Valve Thrombosis

• Valve thrombosis should be suspected in any patient with:

  • Recent increase in shortness of breath or fatigue
  • Recent period of interrupted or sub-therapeutic anticoagulation
  • Increased coagulability (dehydration, infection) 1

• If valve thrombosis is suspected:

  • Confirm with transthoracic/transesophageal echocardiography or cinefluoroscopy
  • Transfer immediately to cardiac center with surgical facilities after giving 5000 U heparin IV 1
  • Urgent valve replacement for obstructive thrombosis in critically ill patients without serious comorbidities 1

Long-Term Follow-Up

• Annual clinical assessment by a cardiologist 1

• Echocardiography:

  • Immediately if new symptoms develop
  • Annual echocardiographic examination after the fifth year for bioprostheses
  • Earlier and more frequent monitoring for young patients 1

• Additional imaging when prosthetic dysfunction is suspected:

  • Transesophageal echocardiography
  • Cinefluoroscopy
  • MSCT for suspected valve thrombus or pannus 1

Rehabilitation Program

• A multidisciplinary rehabilitation program should be available for all patients after valve surgery 1
• Exercise training should be offered to selected patients, recognizing that exercise tolerance after MVR is lower than after aortic valve replacement 1
• Patient education should include:
  • Anticoagulation management and drug interactions
  • Recognition of important symptoms
  • Elements of a healthy lifestyle 1

Monitoring for Complications

• Common complications to monitor for:
  • Valve thrombosis (0.7-3.5% per patient annually) 3
  • Paravalvular leaks
  • Bleeding complications related to anticoagulation
  • Prosthetic valve endocarditis
  • Structural valve deterioration (particularly for bioprostheses) 1

Special Considerations

• Elderly patients have higher operative mortality with MVR, especially with concomitant CAD or other valve lesions 1
• Bioprostheses should be considered for:
  • Patients aged >70 years in mitral position
  • Patients where good quality anticoagulation is unlikely
  • Young women contemplating pregnancy
  • Patients for whom future redo valve surgery would be at low risk 1

By following this comprehensive management approach, patients who have undergone MVR can achieve optimal outcomes with reduced risk of complications and improved quality of life.