Usually, your cardiologist and a thoracic (chest) surgeon will work together to determine what type of procedure is required, and when to do it. Even if you don’t have any symptoms, these procedures are some- times necessary to prevent damage to your heart.

Valvuloplasty

Valvuloplasty, which uses a balloon catheter to open a valve, is most often done to correct moderate to severe mitral valve stenosis. It can also be done on the tricuspid and pulmonary valves, and rarely, the aortic valve. The procedure is done in a catheterization laboratory rather than an operating room and is similar in many ways to balloon angioplasty done on coronary arteries .
You will be given a local anesthetic at the site where the catheter will be inserted, usually in the groin. The surgeon makes a small incision and threads a balloon-tipped catheter (a thin tube) into an artery or vein. To open a mitral valve, he or she guides the catheter up into the right atrium of the heart, piercing through the atrial septum (the wall that separates the right and left atria), and through the left atrium into the mitral valve. He or she in?ates the balloon, which opens up the stiffened or fused valve lea?ets, pushes aside and compresses any calcium deposits, and stretches the valve opening. Then the balloon is de?ated and the catheter is removed. The hole in the atrial septum will heal by itself.
There is some risk that the valve will close up again or leak some- what after the procedure. But after a successful valvuloplasty, you can probably enjoy a lifestyle as active as your lifestyle before the procedure, if not more so.

Other Types of Valve Repair

Other types of valve repair are open-heart surgical procedures. A sur- geon may ?x a valve in several ways:
• Commissurotomy is a procedure to open a narrowed (stenotic) valve by cutting between thickened or fused lea?ets along their natural edges (called commissures).
• Annuloplasty reshapes and strengthens a regurgitating (leaking) valve by inserting a ring device that supports the valve opening and enables it to close tightly. The valve is also surgically repaired.

• Cutting out part of a lea?et and then sewing the remaining tissue back together may enable the valve to close more tightly. Some- times holes or tears in a lea?et can be patched.
• Repairing supporting muscles (chordae tendoneae) that are torn or stretched may allow the lea?ets to close fully.
• Removing calcium buildup from leaflets may improve valve closure.
Repairing your own valve instead of replacing it may produce better, longer-lasting results and minimize complications such as blood clot- ting. But repair may not be possible if valves are badly damaged or are degenerated from calci?cation. If a person had rheumatic fever, the dis- ease can continue even after repair. Some mitral regurgitation caused by coronary artery disease is particularly dif?cult to treat successfully with- out replacing the valve.

Valve Replacement

If valve repair or valvuloplasty is not feasible or successful, a surgeon can remove your heart valve and replace it with either a mechanical or a biological substitute (prosthesis). A mechanical valve is made of metal and plastic; a biological valve (bioprosthesis) is made from animal or human tissue. Each type has some advantages and disadvantages that you and your doctor need to consider.
Mechanical valves offer the practical advantage of durability: even if they are placed in a young person, they are likely to last a lifetime. Many models are available; your surgeon may prefer one model over another because of the procedure required to place it, but from your point of view, there is little if any difference between these products. However, there is a tendency for blood to clot around any mechanical valve. A blood clot could clog the valve, or break off and travel elsewhere in the body (including the brain, which could cause stroke). As a result, anyone with a mechanical valve must take warfarin, an anticoagulant med- ication (see page 172), for life.
A biological valve, unlike a transplanted heart, is not living tissue and usually does not cause rejection problems. The natural tissue is sterilized and treated with preservatives. Several options are available: an animal tissue valve (xenograft or heterograft), usually the aortic valve of a pig; a human valve (allograft), retrieved from someone who has died; or more rarely, the person’s own valve (autograft)— for example, the pulmonary valve is moved from the right side of the heart to replace the aortic valve on the left—in what is known as the Ross procedure. (The pulmonary valve is then replaced with a prosthesis.) The main advantage of a biological valve is that it is much less likely to cause clotting than a mechanical valve. You may need to take anticoagulants for several weeks or months after the procedure, but not permanently. How- ever, the tissue is not as strong as a mechanical valve and more likely to calcify over time. An animal valve might need to be replaced in 10 to 15 years (or even sooner in a child or young adult). A human valve might last longer, but may not be readily available.
Generally, a mechanical valve is a practical choice for a person under 70 years of age who can safely take anticoagulants. A biological valve may be a good choice for an older person, particularly if he or she cannot tolerate anticoagulants, or for a woman who plans to become pregnant (because taking anticoagu- lants during pregnancy is not safe).
The risks of valve replacement surgery depend on your age, the overall condition of your heart, and other medical conditions. After suc- cessful surgery, you will probably be able to return to a normal level of exercise. Any arti?cial heart valve is subject to infective endocarditis, so you will need to take antibiotics before dental or surgical procedures .

What to Expect

If you and your doctor decide that repair or replacement of a heart valve is the best option for you, you will probably be able to schedule the operation at a time that is best for you (rather than having an emer- gency procedure). As for any surgical procedure, do not hesitate to dis- cuss any questions or concerns with your cardiologist and your surgeon. Make sure that they know about all medications you are taking, includ- ing over-the-counter drugs such as aspirin. If you smoke, your doctor will recommend that you quit at least 2 weeks (but preferably 6 weeks) before surgery, because smoking can lead to problems with blood clotting and breathing.

You will probably be admitted to the hos- pital the day before surgery or the morning of the procedure. Because general anesthesia is safest on an empty stomach, you will be told not to eat anything after midnight. (If you do, be sure to tell a doctor about it.) You will probably have a chest X-ray, blood tests, urine tests, and an electrocardiogram before the procedure, and you will be given a mild seda- tive to relax you before you go into the oper- ating room. Your chest will be washed, treated with antiseptic, and shaved if necessary.
You will be given a local anesthetic to numb your arm, and an intravenous line will be inserted to give you anesthesia. After you

are completely anesthetized, a tube will be placed down your trachea (windpipe) to connect you to a respirator, and another tube will be threaded through your nose and down your esophagus into your stom- ach to remove air and ?uids from your stomach. A catheter (thin tube) will be inserted in your urethra and up into your bladder to collect urine during the operation and recovery.
Your breastbone will be divided to expose your heart. A heart-lung machine will take over the function of your heart during surgery, so that your heart is immobile while the surgeon works. You will be given anticoagulant medications to prevent your blood from clotting.
Depending on the extent of surgery, the operation will take from 2 to 4 hours. When the valve repair or replacement is complete, your heart will be started again and the heart-lung machine will be disconnected. Most people spend 1 to 3 days in the intensive care unit and about a week in the hospital.
Your recovery from valve surgery may take several months, as your breastbone mends and your heart adjusts. Your doctor will advise you about physical activity, and he or she may recommend a cardiac rehabil- itation program. You may be able to go back to work in
1 to 4 months, depending on the physical demands of your job. You may need to take anticoagulant medications, either temporarily or permanently, if you have had a mechanical valve replacement.

Some people who have mechanical valves can occasionally hear a clicking sound in their chest—the sound of the new valve at work. This is a perfectly normal, and even reassuring, sign that the valve is working properly.
Valve repair or replacement is usually successful. Failure of a new valve is rare, but if you experience signs of valve failure (basically, the symptoms of valve problems, described earlier), tell your doctor imme- diately. You will also need to be on the alert for signs of infection, such as fever, weakness, chest pain, and shortness of breath. Endocarditis can affect arti?cial valves as well as natural ones.

Pulmonary Regurgitation

Pulmonary regurgitation is a condition in which some blood is allowed to leak back from the pulmonary artery into the right ventricle. It is usually caused by congenital (present since birth) disease or pulmonary hypertension (high blood pressure in the lungs and right side of the heart). It is often associated with congenital heart disease affecting other parts of the heart. Very rarely, infective endocarditis (see page 192) damages the valve.
Many people with some pulmonary regurgitation do not have symp- toms of the condition. Your doctor will monitor your heart regularly to ensure that the right ventricle is not becoming strained or enlarged. You will probably not need to limit your physical activities. If you have a valve that has been malformed since birth, you are at greater risk of infective endocarditis and may need to take antibiotics before dental or surgical procedures (see page 194).
If the regurgitation becomes serious, it causes the right ventricle to start to fail. Then you may experience symptoms such as shortness of breath, especially during exercise; fatigue; chest pain; or leg swelling. Arrhythmias may occur. Ask your doctor about any exercise restrictions. You may require surgery to repair or replace the valve .

Pulmonary Stenosis

Pulmonary stenosis is a condition in which the pulmonary valve (or the artery just beyond the valve) is narrowed, reducing the ?ow of blood into the lungs. It is usually present at birth and may progress in childhood or not until later in life. If it occurs later in life, it may have been caused by rheumatic fever , congenital heart disease, or infective endocarditis.
Pulmonary stenosis can be very mild or moderate, and it usually does not cause severe symptoms. Your doctor will check your heart regularly, watching for signs of strain on your right ventricle. You may not need to limit your physical activity, but you are at greater risk of infective endocarditis, so you will need to take antibiotics before having some dental and surgical procedures .
If the condition is severe, it may cause symptoms such as shortness of breath, especially during exercise; fatigue; chest pain; or rarely, a bluish skin tone. Severe stenosis could cause life-threatening failure of the right ventricle. Sometimes surgery to repair the valve is done early, dur- ing the preschool years of a child’s life. In an older person, balloon valvuloplasty is usually needed to open the valve, or rarely, valve replacement  may be necessary.

If the tricuspid valve fails to close fully, blood leaks back (regurgitates) from the right ventricle into the right atrium. Instead of the blood mov- ing forward through the right ventricle to the lungs to pick up oxygen, it backs into the major veins. It most often occurs if the right ventricle becomes enlarged or stiffened from another disorder, such as high blood pressure within the lungs and right side of the heart (pulmonary hypertension). Tricuspid regurgitation may also result from infective endocarditis , rheumatic fever , or car- diomyopathy .
A person with tricuspid regurgitation usually does not have any symptoms, or the symptoms may be mild enough to live with for years, and no treatment is necessary. If you have high blood pressure in the lungs, as well as tricuspid regurgitation, you may develop symptoms of heart failure such as swelling in the stomach, liver, feet, and ankles; weakness and fatigue; and decreased urine output. Treatment with med- ications such as diuretics may relieve the symptoms. If tricuspid regur- gitation is due to pulmonary hypertension, calcium channel blockers may be prescribed. In some people, surgery to replace the tricuspid valve  may be necessary.
If you have tricuspid regurgitation because of an abnormal valve, you are at increased risk of infective endocarditis, and you will need to take antibiotics before some dental and surgical procedures.

Tricuspid Stenosis

If the tricuspid valve is narrowed or blocked, blood ?ow from the right atrium to the right ventricle slows down. The atrium may become enlarged and the blood ?ow to the right ventricle may be impaired. Tricuspid stenosis, which is rare, may be congenital (from birth) or the result of rheumatic fever. If rheumatic fever is the cause, other valves of the heart are usually involved.
Generally, the only symptoms of tricuspid stenosis are fatigue and the pain pressure in the liver (which you are likely to feel in your upper right abdomen). Often these symptoms, as well as some shortness of breath and ?uid retention, are caused by disease in another valve. Treat- ment is likely to focus on the other valves. If your tricuspid valve is severely damaged, surgery is possible. As with other valve disorders, you are at increased risk of infective endocarditis, and your doctor may advise you to take antibiotics before some dental and surgical procedures.

Mitral Valve Prolapse

About 2 percent of the U.S. population have mitral valve prolapse, meaning that one or both of the ?aps of the mitral valve are enlarged and the supporting muscles are too long. As a result, the lea?ets do not close tightly and they billow into the atrium as the left ventricle con- tracts. Sometimes a small amount of blood leaks back into the atrium (regurgitation). Although there may be a variety of causes, many forms of prolapse are probably inherited. It occurs more frequently in women than men, often in very slender people who may have minor chest wall irregularities or scoliosis (a curvature of the spine). But it may be more severe in men.
In the vast majority of people, mitral valve prolapse is completely harmless and does not cause any long-term problems. Some people experience symptoms and seek treatment for them; symptoms include chest pain, palpitations (the sensation of feeling the heart beat), an irregular heartbeat, fatigue, shortness of breath when lying down, trou- ble breathing after exercise, or coughing.
Your doctor may detect mitral valve prolapse when listening to your heart through a stethoscope, because the billowing lea?ets can cause a characteristic click, followed by a murmur. If necessary, he or she can con?rm the diagnosis with an echocardiogram and assess the degree of regurgitation.
If you have little or no regurgitation and an otherwise normal heart, you will not need treatment. But if signi?cant regurgitation develops, or if other illness is present, you may be at risk of a serious problem, infec- tion of the valve.
Symptoms of mitral valve prolapse may improve with regular exer- cise, a decrease in caffeine consumption, and adequate ?uids. Or you may be prescribed beta-blockers to alleviate symptoms such as palpitations.

Mitral Valve Regurgitation

A mitral valve that fails to close completely when the powerful left ventricle contracts allows blood to “regurgitate” back into the atrium, undermining the one-way flow. Mitral valve regurgitation may be caused by damage to the valve from rheumatic fever , infective endocarditis , or a heart attack that damages the part of the muscle attached to the valve. The regurgitation can also result from enlargement of the left ventricle, possibly brought on by coronary artery disease or untreated high blood pressure, which stretches the perimeter of the mitral valve so that the lea?ets do not close completely.
Many people have no symptoms; in others, symptoms develop over a period of years because the heart compensates for the problem. But over time, the extra effort can cause the left ventricle to enlarge or pres- sure to build up in the lungs as the blood leaks backward. The symp- toms of regurgitation may come on slowly and can include shortness of breath or rapid breathing, fatigue, heart palpitations, or cough.
To relieve the symptoms of mitral valve regurgitation, your doctor may prescribe medications to lower your blood pressure or diuretics to rid your body of excess ?uids. He or she may also recom- mend that you take antibiotics before some dental or surgical proce- dures to prevent infection of the valve.
If surgery is necessary to restore valve function, your doctor will time the surgery carefully to be sure that your heart muscle does not become too weak to withstand the operation. The surgeon will repair your valve if possible, but in some people, an arti?cial valve is the best solution . After surgery, the long-term outlook for most people is very good.

Mitral Valve Stenosis

Mitral valve stenosis is a narrowing of the mitral valve. The narrowing or obstruction causes an increase in the pressure behind the valve in the left atrium. In most people, this type of damage to the valve was caused by a case of rheumatic fever in childhood . Because the use of antibiotics has dramatically decreased the occurrence of rheu- matic fever, mitral valve stenosis is becoming rare in the United States. It may occasionally occur in older people as a result of calcium deposits on the perimeter of the mitral valve, combined with the degenerative aging process that affects the tissues of the heart.
Many people with mild mitral valve stenosis do not experience symptoms, and treatment is not required. If the condition does cause symptoms to develop, they may develop slowly. Symptoms may include trouble breathing at night or after exercise; coughing, perhaps with traces of blood; fatigue; or chest pain that gets worse with exertion. There is risk of abnormal heart rhythms in the left atrium (atrial ?bril- lation), which can cause blood clots to form in the heart. The clots can dislodge and travel to the brain, increasing your risk of stroke.
A person with mitral valve stenosis may need to take antibiotics before undergoing certain medical or dental procedures to prevent infective endocarditis (see page 192) in the valve. Medication to slow the heart rate may help some people feel better. In some people with moderate stenosis, a balloon valvuloplasty (a procedure to open the valve with a balloon; ) may be an option. For a person with a severely diseased valve, particularly an older person, surgical repair or replacement of the valve may be necessary.

Aortic Valve Disease

The aortic valve, which has three crescent-shaped cusps (lea?ets), regu- lates blood ?ow from the left ventricle into the aorta, where it then cir- culates to the rest of the body . Either stenosis (narrowing) or regurgitation (backward leakage) can disrupt the blood ?ow. The valve can be damaged by rheumatic fever or infection. But some people are born with a bicuspid aortic valve—a valve with two lea?ets instead of three. A bicuspid valve may be less ef?cient and more prone to infection or calci?cation with aging. The aorta may be abnormal, too, in people with bicuspid aortic valves, regardless of the severity of the valve disease.

Aortic Valve Regurgitation

When an aortic valve does not close completely, blood leaks or regur- gitates back into the left ventricle. The condition occurs more com- monly in men, often between the ages of 30 and 60. The most typical causes of mild regurgitation are structural abnormalities of the valve (such as a bicuspid valve), damage from rheumatic fever, high blood

pressure, or calci?cation on the valve as a result of aging. In the most serious cases, the valve may suddenly start leaking as a result of infective endocarditis that actually makes holes in the lea?ets or from a tear or severing of the aorta above the valve.
As with other heart valve problems, a person may not experience symptoms for years. But if the regurgitation forces the left ventricle to work harder over a long period, it may enlarge. Left untreated, irreparable damage to the left ventricle—the heart’s main pumping chamber—could take place.
Symptoms, if or when they occur, include shortness of breath, chest pain with exercise, swelling in the ankles, fatigue, and a rapid pulse. Even if you do not have symptoms, your doctor may detect aortic regurgitation by listening to your heart sounds through a stethoscope. He or she will con?rm the diagnosis and assess your heart function with tests, including a chest X-ray, echocardiogram , and elec- trocardiogram . You may be advised to take antibiotics before some dental and surgical procedures to prevent endocarditis. Medications to treat high blood pressure and reduce the heart’s workload may help reduce symptoms. Your doctor will evaluate you periodically by monitoring changes in your symptoms, your phys- ical examinations, and tests such as echocardiograms.
Your doctor may recommend surgery to replace the aortic valve (see page 206) and limit damage to the heart muscle. As with surgery for mitral regurgitation, the procedure will be carefully timed to correct the problem before the heart is substantially weakened. If the problem is corrected before damage occurs, you are very likely to be able to return to a normal lifestyle.

Aortic Stenosis

If your aortic valve (which regulates the blood ?ow between your left ventricle into the aorta) becomes narrowed, your heart must work harder to force blood through the valve. As a result, the left ventricle enlarges and thickens. Over time, the heart may be unable to maintain the workload, and ?uid may back up in the lungs.
Today the most common cause of aortic stenosis is a degeneration of the valve that occurs with aging. Calcium, a mineral found in the blood, can build up on the valve over the course of your lifetime. Some calci?- cation may not cause any trouble, but in some people, calcium deposits and scarring develop that deform or even fuse the valve leaflets so that they do not close tightly. Another frequent cause, particularly in people diag- nosed before the age of 50, is a congenital (from birth) defect in a valve, for example, the bicuspid valve, which may calcify it. Very high levels of LDL (low density lipoprotein) cholesterol also promote increased calci?cation (forming of calcium deposits) around the heart valve. Aortic stenosis is more common in men.

If the stenosis is severe, replacement of the valve (see page 206) may be required. After surgery, most people are able to resume a normal lifestyle. Balloon valvuloplasty (inserting a balloon-tipped catheter; see page 204) of the aortic artery is a temporary solu-

tion in adults if they are not able to have surgery when the stenosis is diagnosed. In some young adults or children, valvuloplasty will open the valve.

Congenital Valve Defects

Some people are born with a defective valve but may never experience symptoms or may not have problems until later in life. Then the abnor- mal valve may be more vulnerable to calcium deposits that occur as a result of aging or abnormal functioning. If the defect is severe, the symptoms may occur earlier in life.
A valve defect that is congenital (present since birth) also increases a person’s risk of endocarditis, an infection of the lining of the heart (endocardium) or heart valves. Small amounts of bacte- ria may enter your bloodstream but are usually removed by your body’s defense system. However, these bacteria are somewhat more likely to lodge on an abnormal valve, where they can cause an infection that can damage your heart valve. For this reason, if your doctor determines that you have a defective heart valve, to prevent infection you may need antibiotics to kill the bacteria before you have certain dental or surgical procedures.

Infective Endocarditis

Infective endocarditis is an infection of the lining of the heart chambers (endocardium) or the heart valves. It is caused by microorganisms— usually bacteria, but sometimes fungi or other types of microorganisms— that enter your bloodstream and lodge in your heart. These microorgan- isms occur naturally and harmlessly in other parts of your body, such as your mouth or urinary tract, and may enter your bloodstream from any tiny cut or breakdown of tissue (see box, page 194). The presence of bacteria in your bloodstream (which is called bacteremia) does not nec- essarily lead to infection, and not all bacteria are even capable of causing endocarditis. It is a relatively uncommon disease.
When endocarditis does occur, the microorganisms in the bloodstream stick to the surface lining of the heart or abnormal valves, per- haps aided by microscopic blood clots that have formed at the site. Your body responds by sending in immune cells and ?brin (a clotting material) to trap the organism. A clump of cellular material, called a vegetation, forms over the organism. Vegetations can interfere with a valve’s function, or they can break off and block a
blood vessel in a vital organ.
You are more likely to get endocarditis if you have existing valve disease, if you have had heart valve surgery, if you have a congenital heart defect, if you had rheumatic fever as a child that scarred your heart valves, or if you have an arti?cial heart valve or other foreign material in your body. Drug addicts who share needles or use dirty needles are also at risk for endocarditis.
Symptoms of endocarditis are variable, but they usually include fever. Many people report other ?ulike symptoms, too, such as muscle aches and pains, fatigue,
night sweats, and loss of appetite. If you have chronic endocarditis, also known as subacute endocarditis, the symptoms can be subtle and last for months before the diagnosis is made. Sometimes symptoms of heart failure such as shortness of breath and confusion are the ?rst sign of a problem. You or your doctor may also notice changes in your skin and nails, such as red spots on the palms of your hands or the soles of your feet, painful sores on the tips of your ?ngers and toes, or dark lines (tiny hemor- rhages) under your nails that resemble wood splinters. Endocarditis can cause additional problems such as anemia and blood in the urine.
Your doctor may initially suspect endocarditis by your symptoms, especially if you are at known risk because of congenital heart disease, rheumatic fever, or valve disease. He or she will listen to your heart sounds with a stethoscope and may report a new heart murmur (the sound of turbulence in the blood ?ow through your heart) or a change in an old one. From blood samples that are sent for cultures, your doc- tor can identify if there is an infection and which microorganism is caus- ing the infection. Only rarely are blood cultures negative (that is, falsely suggesting no problem) in people with endocarditis. An echocardiogram will often con?rm the diagnosis by showing vegetations on the heart valve. The echocardiogram will also show the size of your heart and indicate how well the valves and heart wall are functioning.
To treat endocarditis, you will need to take intensive doses of antibiotics for 2 to 6 weeks to kill the infecting microorganisms in your bloodstream and to sterilize the heart valve. At ?rst, you will need to be hospitalized so that the antibiotics can be given intravenously. In some people who respond well to the initial treatment, the full course of antibiotics may be completed at home or in a long-term-care facility. Your doctor will want to do regular blood tests to ensure that the med- ication is working.
In some people, endocarditis seriously damages a heart valve (natural or arti?cial). Endocarditis can also cause heart failure, the infection can extend into the heart, or the vegetations can repeatedly break off and travel throughout the bloodstream. Surgery may be necessary to remove infected tissue and repair or replace the valve .

Rheumatic Fever

Rheumatic fever was once the most common cause of heart valve problems. This inflammatory disease, which can develop as a result of untreated strep throat in children more commonly than in adults, occurs in some people when the body’s immune response to ?ght the strep infection mistakenly attacks connective tissue (such as joints or the heart) instead. The affected tissue, often the heart valves, swells and develops scars. On a valve, the scar tissue may interfere with either opening or closing of the valve lea?ets.
Fortunately, the use of penicillin and other antibiotics to treat strep throat has almost eradicated rheumatic fever in the United States. But rheumatic fever remains a concern throughout the world. Without antibiotic treatment, anyone who gets strep throat can develop rheu- matic fever, but it is most likely to occur in children from 5 to 15 years old. There is probably a genetic factor involved that makes some people more susceptible to rheumatic fever. The damage to heart tissue can last a lifetime, although it may not be noticeable for years after the illness.
If you have had rheumatic fever, even decades ago, you are more sus- ceptible to heart attacks and valve disease. Although rheumatic fever rarely affects adults, you are more susceptible to it if you had it in child- hood. Be sure to tell your doctor if you know that you have a history of rheumatic fever; you may need to take preventive antibiotics.

To protect yourself against the rare occurrence of rheumatic fever, it is important to get prompt treatment for a strep throat (caused by Streptococcus bacteria). Symptoms of strep throat include a sore, red throat; dif?culty swallowing; a sudden fever; swelling in the glands in the neck; and sometimes a rash. If you experience these symptoms for 3 days, see your doctor to be tested for a strep infection. With antibiotic treatment, the symptoms are likely to disappear within a few days. It is essential that you continue taking the antibiotics as long as your doctor instructs, even after the symptoms are gone, to reduce the risk of rheu- matic fever (though only a small percentage of strep infections result in rheumatic fever).
Symptoms of rheumatic fever can occur in 3 days to 1 month or more after an untreated strep infection. The symptoms include fever; joint pain or swelling in your wrists, elbows, knees, or ankles; nodules under the skin on your elbows or knees; a raised rash on your chest, back, or stomach; or weakness or fatigue.
See your doctor immediately if you experi- ence these symptoms. He or she will do a throat culture (take a swab of material from your throat for analysis) and may order a chest X-ray or electrocardiogram.
If you have a strep infection that leads to rheumatic fever, your doctor will probably prescribe anti-inflammatory medications, including aspirin, to reduce swelling. You may also need to take a diuretic to get rid of excess fluids. Your doctor may prescribe antibiotic treatment monthly or even daily for life, to prevent reinfection.
If your heart has been damaged by rheumatic fever, you may need to take specific antibiotics if you undergo certain dental or surgical procedures. Surgery to repair or replace a damaged valve may be necessary .

Port-Access Coronary Artery Bypass (PACAB or PortCAB)
For this procedure, your heart is stopped and a heart-lung machine assumes its function. The surgeon makes small incisions, called ports, in your chest and may remove part of the rib over your heart. He or she performs bypass grafting through these ports, viewing the work on video monitors rather than directly.

Minimally Invasive Coronary Artery Bypass (MIDCAB)

This procedure is done without the heart-lung machine, while your heart is still beating. It is used only when one or two arteries are being bypassed. The surgeon creates the small ports described above, and also makes a small incision directly over the blocked artery, so that he or she can view the work area directly, instead of on a monitor. Usually, an artery from the chest wall is used for this procedure.

What to Expect

Most coronary artery bypass operations are sched- uled surgeries, rather than being done as an emer- gency measure. If your cardiologist recommends a coronary artery bypass, you will have the opportu- nity to discuss why he or she wants you to have the surgery, what the risks are, what your alternatives
are, and what your family needs to know about your surgery and recov- ery period. If you decide to proceed with the surgery, be sure to remind your doctor about any medications you are taking, including over-the- counter drugs and supplements. Make a list of your medications and bring it with you to the hospital when the surgery is scheduled. As the day of the surgery approaches, tell your doctor about any changes in your health. It is especially important to be aware of symptoms of a cold or ?u, such as fever, chills, coughing, or a runny nose. Even minor infections could affect your recovery.
You will probably be admitted to the hospital the morning of the sur- gery, or perhaps the night before. You will be asked to bathe before arriving. You will be asked not to eat or drink anything after midnight before the surgery, to prevent regurgitating the stomach contents and choking on them. (If you do have something to eat, be honest and tell the doctor or nurse about it.) Be sure to ask whether you should take medications at home—with a very small sip of water—that you nor- mally take each morning. You can expect to have an electrocardiogram (ECG), blood tests, urine tests, and a chest X-ray. Then a nurse will give you a sedative to relax you before you go to the operating room. The areas that will be operated on (your chest and leg or arm) will be washed, sterilized, and shaved if necessary.

How Bypass Is Done

In the operating room you will be wired to an ECG machine to moni- tor your heart . You will be given a local anesthetic before an intravenous (IV) line is placed in your arm, and then you will be given a general anesthetic. The surgery will probably take 4 to 6 hours, depending on the number and complexity of the blockages. When you are completely asleep, a breathing tube (endotracheal tube) will be inserted through your mouth and down your trachea to help you breathe and to enable nurses to clear secretions from your lungs. Another tube will be inserted through your nose and down your throat to your stomach to prevent liquid or air from entering your stomach, so that you will not feel nauseous or bloated after you wake up. A catheter (a thin tube) will be placed in your urethra (the passageway to your bladder) to collect urine during and after the procedure.
You will be given an anticoagulant medication  such as heparin to keep your blood from clotting. Then you will be connected to the heart-lung machine, which will take over your heart’s pumping action and oxygenate your blood during the surgery, so that your heart is still and not full of blood while the surgeons work.
The number of vessels bypassed during surgery depends on how many coronary arteries and their main branches are blocked. Your sur- geon can construct a bypass in different ways. He or she may remove a piece of a long vein in your leg (the saphenous vein) or the radial artery in your arm, neither of which is crucial to the circulation in those areas. The surgeon will stitch one end of the vessel onto your aorta (the large artery leaving your heart) close to where the coronary arteries originate, and graft the other end to the affected coronary artery below the blocked area. In effect, a new artery has been created to route blood around the blockage.
In many cases, at least one bypass will be created using a segment of one or both of the two internal mammary arteries, located behind your breastbone on your chest wall. These arteries originate from the aorta, so the surgeon does not have to entirely remove a piece of the artery. He or she can detach one end of the artery from the chest wall and reat- tach it to the coronary artery below the blockage. Remaining arteries are able to supply the chest wall with adequate blood. These arteries are used frequently because they may have less of a tendency to develop blockages after the surgery.

When the operation is complete, the surgeon makes sure that your heart is adequately supplied, that blood is not leaking, and that the area is soft to the touch. Also, an angiogram while you are still on the table veri?es that your arteries are not leaking internally. Then the surgeon restarts your heart with an electrical shock. The heart function is trans- ferred from the heart-lung machine back to your heart.

Recovery in the Hospital

After surgery you will probably spend the ?rst 1 to 3 days in the inten- sive care unit, where the staff will monitor your heart function closely. You will have a breathing tube and be connected to a ventilator for at least several hours, and you will have temporary drainage tubes in your chest to remove excess blood and ?uids. (Some people, especially those with underlying lung disease, will need to be connected to a ventilator for a longer period of time.) You will have a catheter in your neck or under your clavicle in the chest to permit monitoring of your heart function and pressure. You will also have pacemaker wires attached to the heart muscle that come out of the chest and are attached to a pace- maker generator. You will receive intravenous fluids to keep you hydrated, and you will be given pain medications.

Some hospitals offer pain pumps that allow you to control the deliv- ery of pain medications into your vein. A small catheter is placed in your chest incision that can deliver a local anesthetic directly to the area of your surgery. You can activate the pump by pushing a button at your bedside. Studies show that when patients control their own pain med- ication, the pain is better controlled but also people tend to use less medication. Self-administered pain relief allows people to recover faster and more comfortably.
The breathing tube is removed within hours. Most patients can get out of bed within 24 hours of bypass surgery and can walk in 1 or 2 days. When your doctor is satis?ed that your heart has stabilized, you will be able to leave the intensive care unit, and the other catheters and tubes may be removed. Some people experience a rapid, irregular heart rhythm after the surgery, but this condition can be treated with medica- tions. Or there may be slowing of the heart and if necessary, a pace- maker is installed. You will probably be strong enough to leave the hospital in 5 to 7 days.
Complications of bypass surgery may include pneumonia, urinary tract infection, or stroke. Anemia is common after the surgery, but the body usually recovers over time. Heart rhythm disturbances may occur and require treatment with medication or the installation of a pacemaker.

Recovery at Home

Subsequent recovery at home generally takes several weeks until you get back to your usual self. Some people experience loss of appetite and constipation. You may feel easily tired, moody, or depressed, and it may be dif?cult to sleep. Some people experience swelling in the area from which a blood vessel was removed, such as the lower leg, and you may have some muscle pain in your shoulders and upper back. These effects are normal and will probably disappear in 4 to 6 weeks. A full recovery may take several months, in part because your breastbone must heal, which may be painful. Don’t hesitate to tell you doctor about bother- some side effects.
Your doctor can help you determine how quickly to get back to your daily routines. He or she will probably recommend that you gradually work your way back to normal activities such as walking, going out with friends, doing light housework or yard work, and climbing stairs.

Results of Bypass Surgery

A coronary artery bypass operation improves symptoms such as angina for most people (about 90 percent), and it may prolong life in certain high-risk cases. Most people can return to work or to the same activi- ties they enjoyed before surgery and remain free of symptoms for many years. But bypass surgery does not cure coronary artery disease. New blockages can form in different places in the arteries, and the grafted routes can become clogged. Some branches of arteries are too small to be corrected by a bypass, and blockages in these small arteries can cause angina. Statistically, about 40 percent of people who have bypasses show signs of a new blockage in the bypass grafts within 10 years of surgery.
Controlling the risk factors that lead to blockage is the most impor- tant way that you and your doctor can manage your coronary artery dis- ease. It is more important than ever to maintain normal weight or lose weight if necessary, quit smoking, eat a heart-healthy diet, and get reg- ular exercise. Your doctor will work with you to achieve good control of high cholesterol, high blood pressure, and diabetes. Your cardiologist will want to see you every 1 to 3 months at ?rst, and then at least annu- ally to monitor your condition.
You will almost certainly be advised to take aspirin inde?nitely. Your doctor may also prescribe medications such as ACE inhibitors, beta- blockers, or cholesterol-lowering drugs to help control your disease and improve your heart function.

Cardiac Rehabilitation

A cardiac rehabilitation program, often available through a community hospital, is a medically supervised program to help you learn to live with heart disease. This program provides you with the resources to get any kind of help you need to ease your transition back to a full, sat- isfying life. It involves a commitment of time, but it probably speeds your way to a full recovery. The trained staff can work with you to tai- lor your steps toward recovery to suit you, your medical condition, and your work and family demands. Exercise in a supervised setting, with skilled medical personnel available, usually provides a level of security that helps many people achieve exercise targets more easily and sooner than they would on their own. Many insurance plans cover cardiac rehabilitation. Your cardiologist can give you information about pro- grams near you.
A rehabilitation program usually lasts for the ?rst 3 months or so after your heart attack. It is generally organized in four phases: hospi- talization; early recovery (2 to 12 weeks after you go home); late recovery (6 to 12 weeks or more); and maintenance. The maintenance “phase” extends for the rest of your life, as your lifestyle changes become permanent and you resume your normal activities.
A cardiac rehabilitation program will help you:
• Gradually adjust your level of physical activity to strengthen your heart, monitoring your progress so that you can safely maximize your capacity for exercise
• Adjust your cooking, snacking, and eating styles to focus on a low- fat, low-cholesterol diet
• Work out a plan to balance your diet and exercise needs to control your weight
• Get counseling or other help to quit smoking
• Get advice about the impact of your job on your heart, and how you can take steps to protect yourself
• Learn about techniques (such as yoga, meditation, or massage) to manage stress on and off the job
• Deal with the emotional and psychological sides of the changes in your life
• Talk to other people who are facing the same challenges and mak- ing the same kind of changes in their lives

How Angioplasty Is Done

An angioplasty is usually done in a catheterization laboratory, often called the cath lab. Electrodes will be placed on your chest and you will be connected to an electrocardiogram machine to monitor your heart during the procedure. You do not need a general anesthetic, but you will receive an intravenous sedative. The area of your leg (or sometimes the arm) where the catheter will be inserted will be anesthetized, then cleansed and shaved. After this area is numbed, you will not feel any pain during the procedure, but you will be awake.
The doctor will locate the appropriate artery and insert a catheter (a thin tube) through the skin. He or she will guide the catheter through the artery up the aorta and into your heart, watching its path on a monitor. When the catheter is at the opening of the coronary artery, a dye is injected so that the doctor can take an image of the arteries (an angiogram; ) and see on the monitor if there is a blockage of blood ?ow within the artery. After studying the size and extent of the blockage, he or she may insert a tiny balloon-tipped device, guide it to the site of the blockage, and then in?ate the balloon, which will expand against the walls of the artery. The in?ated balloon is kept in place for up to 2 minutes and then de?ated. The doc- tor can inflate it several times if necessary to shape the inside of the artery. When the results are satisfactory, the de?ated balloon and catheter are removed.
How Stents Are Placed

A stent is a piece of tubing made of springy wire mesh. It is placed over the balloon on the tip of the catheter and guided into position in the cleared artery. Then the balloon is in?ated and the stent expands, locks in place, and props the artery open, with the compressed plaque behind it. The balloon is de?ated and removed, and the stent remains permanently. Within a few weeks, new tissue forms over the surface of the stent so that the interior passageway is smooth. Stenting can be done alone, but is usually done in combination with angioplasty. The surgeon can work on several blocked arteries during one procedure.

After the Procedure

An angioplasty procedure is likely to last from 45 minutes to more than
2 hours. After the procedure is done and the catheter is removed, the doctors or nurses will stop the bleeding by applying pressure, either manually or with specially designed pressure devices, for 20 minutes or more over the place where the catheter was inserted, and then will bandage the area. You will feel sleepy until the sedative wears off. You will be asked to lie very still during the recovery period for up to 8 hours. A nurse will monitor your heart and blood pressure and will check the incision site fre- quently for signs of excessive bleeding or damage to the blood ?ow through the artery. You will probably spend from 1 to 2 days in the hospital.
You will have to arrange to have someone drive you home, and you should not drive for several days after- ward, while the incision is still healing. Your doctor will ask you not to bathe, or stand and walk for long periods of time, for at least 2 days after the procedure. Once you get home, call your doctor promptly if you see any bleeding or swelling at the site of the incision or if you have a fever, which is a possible sign of an infection. If you have a stent, you should probably avoid exercising vigorously for about 30 days. However, there are many cases on record of people returning to work or exercise

sooner than that; ask your doctor what is best for you.
Your doctor may prescribe medications such as nitroglycerin to relax the coronary arteries, calcium antagonists to guard against coronary artery spasm , or aspirin and other antiplatelet drugs to prevent blood clots in the area of the blockage. If you have a stent, you will have to take blood thinners (such as aspirin) inde?nitely. You will also take an antiplatelet such as clopidogrel  at least one month after a bare-metal stent is placed in your artery and two or more years after a drug-eluting stent is placed in your artery. Because of the presence of the metal stent, you should not have magnetic resonance imaging (MRI) for at least 4 weeks with- out checking with your doctor ?rst. But you can go through a metal detector at an airport without a problem.

Restenosis

Restenosis (renarrowing or constriction) can occur in the same area of the blood vessel where your angioplasty was done, often within about 6 months of the original procedure. Although placement of a stent greatly reduces the likelihood that this will happen, restenosis can occur in an artery with a stent (in-stent restenosis). The artery becomes blocked again because, in addition to the healthy new tissue that forms over the stent, scar tissue can develop under the surface that becomes so thick it obstructs the blood ?ow again. People with diabetes have a higher risk of restenosis, but it can occur in other patients as well, depending in part on the location of the blockage and the pattern of scar tissue growth.
If a restenosis occurs, the person is likely to experience the same types of symptoms (chest pain after exertion) that he or she felt before the ?rst angioplasty was done. (A patient with diabetes may have fewer or less typical symptoms.) Fortunately, restenosis very rarely causes a heart attack. Your doctor will be watching closely to detect restenosis and to check for blockages in other arteries by monitoring your symp- toms and having you take a follow-up exercise stress test. Be sure to report promptly any symptoms that you experience after your angio- plasty. If a restenosis does occur, another angioplasty or bypass surgery may be required to correct the blockage.
Of course, doctors are searching for ways to prevent restenosis. A major advance has been the development of drug-eluting stents—that is, devices that are coated with slow-release medications that penetrate the surrounding tissue to prevent the growth of scar tissue. Drug- eluting stents appear to substantially improve the long-term success of angioplasty procedures, though they also increase the short-term risk of clot formation. If you have a drug-eluting stent, you will need to take clopidogrel for at least two years and aspirin inde?nitely. Before sur- gery, ask your cardiologist if a bare-metal stent or drug-eluting stent is best for you.
Doctors at some medical centers are working with a procedure called brachytherapy, which uses radiation to stop tissue growth around a stent. A catheter with a radioactive tip is threaded into the blockage around a stent and a dose of radiation is administered. Although the radiation lasts only about 10 minutes, it inhibits long-term growth of tissue. Brachytherapy is not widely available, however, and needs study.
You can help protect yourself from restenosis by leading a heart- healthy lifestyle after angioplasty. Quit smoking, eat a low-fat diet, get regular exercise, take your medications, and follow up regularly with your physician to contribute to the success of your angioplasty. A car- diac rehabilitation program will offer advice and support to help you incorporate these vital changes into your life .