Postoperative Workup After Double Valve Replacement
Your first postoperative visit should occur within 6 weeks of discharge and must include a comprehensive baseline assessment with transthoracic echocardiography, ECG, chest X-ray, complete blood count, metabolic panel, and tests for hemolysis to establish reference values for future monitoring. 1
Initial Postoperative Visit (6 Weeks Post-Discharge)
Essential Baseline Studies
Transthoracic echocardiography to assess both prosthetic valves' hemodynamics, detect pericardial effusion, evaluate ventricular function, quantify any paravalvular regurgitation, and assess disease progression at other valve sites 1
ECG to document baseline rhythm and identify any new conduction abnormalities that may have developed postoperatively 1
Chest X-ray to confirm resolution of postoperative abnormalities and establish a baseline cardiac silhouette 1
Laboratory workup including complete blood count, blood urea nitrogen, creatinine, electrolytes, lactate dehydrogenase (to screen for hemolysis), and INR if on anticoagulation 1
Physical examination focusing on wound healing completeness, new murmurs suggesting prosthetic dysfunction or paravalvular leak, signs of heart failure, and assessment of functional capacity 1
Critical Pitfall to Avoid
Severe perivalvular regurgitation may be inaudible on physical examination, so never rely on auscultation alone—echocardiography is mandatory even in asymptomatic patients 1. This is particularly important with double valve replacements where dysfunction at either site can be missed clinically.
Ongoing Follow-Up Schedule
Routine Surveillance
Annual cardiology visits with clinical assessment for all stable patients with mechanical valves 1
Annual echocardiography is not routinely indicated for mechanical valves during the first 5 years if the patient remains clinically stable 1
Annual echocardiography after 5 years should be considered for bioprosthetic valves to detect structural deterioration 1
Earlier re-evaluation with echocardiography is mandatory if any change in clinical status occurs, including new dyspnea, fatigue, new murmur, or signs of heart failure 1
Specific Indications for Interval Echocardiography
Obtain echocardiography between scheduled visits for:
New symptoms suggesting prosthetic dysfunction (dyspnea, fatigue, decreased exercise tolerance) 1
New murmurs on examination, which may indicate paravalvular leak, prosthetic stenosis, or regurgitation 1
Suspected valve thrombosis, which can develop insidiously over days to weeks, particularly if anticoagulation has been subtherapeutic 1
Monitoring known abnormalities such as paravalvular regurgitation, sewing ring thrombus, or residual disease at other valve sites 1
Bioprosthetic valves require more frequent surveillance to detect structural deterioration, typically starting after 5 years 1
Anticoagulation Management
For Mechanical Valves
Lifelong vitamin K antagonist (warfarin) therapy is mandatory for all mechanical valves 2
Target INR should be determined by valve type and position—typically INR 2.5-3.5 for mechanical mitral valves and 2.0-3.0 for mechanical aortic valves 2
Frequent INR monitoring by an experienced healthcare professional is essential, as subtherapeutic anticoagulation dramatically increases thrombosis risk 1
Antiplatelet Therapy Considerations
Do not routinely add antiplatelet agents to anticoagulation, as this significantly increases major bleeding risk, particularly intracerebral hemorrhage 1. Consider adding aspirin only for specific indications:
Concomitant coronary artery disease or previous coronary stenting 1
Recurrent embolism despite optimized anticoagulation, but only after full investigation and treatment of other risk factors 1
Avoid triple therapy (anticoagulation plus dual antiplatelet therapy) except in extraordinary circumstances due to prohibitive bleeding risk 3
Monitoring for Specific Complications
Valve Thrombosis
Maintain high clinical suspicion in any patient with recent dyspnea or fatigue, especially if anticoagulation has been interrupted or subtherapeutic 1
Transthoracic echocardiography is the first-line diagnostic test, but transesophageal echocardiography and cinefluoroscopy may be needed if thrombosis is suspected 1
Valve thrombosis can occur in both mechanical and bioprosthetic valves, though it's more common with mechanical prostheses 1
Hemolysis
Monitor for signs of hemolysis including elevated lactate dehydrogenase, decreased haptoglobin, and anemia 1
Significant hemolysis suggests paravalvular leak or prosthetic dysfunction requiring further evaluation 4
Endocarditis Prevention
Antibiotic prophylaxis per AHA/ACC guidelines for all dental procedures with gingival manipulation 1, 3
Optimal dental hygiene and regular dental visits are essential, as prosthetic valve endocarditis carries 50-80% mortality even with treatment 4
Patient education about signs of endocarditis (fever, new murmur, embolic phenomena) is critical 2
Management of Concurrent Conditions
Heart Failure
Guideline-directed medical therapy for systolic dysfunction should be initiated and continued indefinitely, even if ventricular function improves 1
This includes ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists as appropriate 1, 2
Other Cardiovascular Risk Factors
Aggressive management of hypertension, diabetes, and hyperlipidemia using standard guidelines 1, 2
Coronary artery disease requires optimization of medical therapy and consideration of revascularization if indicated 1
When to Suspect Prosthetic Dysfunction
Mechanical Valve Dysfunction
Presents with acute or subacute symptoms due to abrupt leaflet impairment:
Bioprosthetic Valve Dysfunction
Presents with insidious onset of symptoms:
- Progressive exertional dyspnea 1
- Louder systolic murmur (suggesting stenosis or regurgitation) 1
- New diastolic murmur 1
- More abrupt symptoms may occur with endocarditis or cusp rupture 1
Advanced Imaging Considerations
Transesophageal echocardiography is indicated when transthoracic windows are inadequate or when prosthetic dysfunction is suspected but not confirmed by transthoracic imaging 1
Cinefluoroscopy can assess mechanical valve leaflet motion and detect restricted leaflet excursion 1
Cardiac catheterization is rarely needed but may be considered if non-invasive testing yields discrepant results or unresolved clinical questions 1
Long-Term Prognosis Monitoring
All patients with prosthetic valves should continue cardiac center follow-up indefinitely to detect early deterioration in prosthetic function, progression of disease at other valve sites, or development of new complications—any of which can occur with minimal symptom changes 1. This is particularly critical with double valve replacements where dysfunction at either site can compromise outcomes.
The overall rate of valve-related complications is 2-3% per patient-year, emphasizing the need for vigilant lifelong surveillance 4.