Double Valve Replacement in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Adults with confirmed dual valvular pathology (most commonly aortic + mitral) documented by echocardiography and/or cardiac catheterization

• Symptomatic patients in NYHA functional Class II–IV despite optimized medical therapy (diuretics, ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists)

• Asymptomatic patients with objectively impaired left ventricular systolic function (LVEF ≤ 50–55%) attributable to valvular volume overload

• Patients with severe aortic stenosis (aortic valve area < 1.0 cm², mean gradient > 40 mmHg) and coexisting moderate-to-severe mitral regurgitation or stenosis

• Rheumatic multi-valve disease with progressive symptoms and favorable annular anatomy for prosthetic implantation

• Patients with active or healed infective endocarditis involving two valves after an appropriate course of pathogen-directed IV antibiotics and confirmed sterile blood cultures

• Patients undergoing redo sternotomy for prior single-valve repair failure who now require contralateral valve replacement

• Patients in whom concomitant CABG for significant coronary artery disease (≥ 70% stenosis in major epicardial vessels) is planned at the same operative sitting

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• 2D and 3D Transthoracic Echocardiogram (TTE) with Doppler: valvular morphology, gradients, valve areas, regurgitant volumes, LVEF, pulmonary artery pressures

• Transesophageal Echocardiogram (TEE): annular sizing, subvalvular apparatus integrity, thrombus exclusion, intraoperative guidance

• Gated Cardiac CT Angiography (256-slice or higher): aortic root geometry, annular dimensions for prosthesis sizing, coronary anatomy, calcium scoring

• Right and Left Heart Catheterization: hemodynamic quantification (PCWP, CO, PVR, SVR, Gorlin formula valve areas), coronary angiography

• Pulmonary Function Tests (PFTs): baseline pulmonary reserve for CPB risk stratification

• Carotid Doppler Ultrasound: preoperative stroke risk assessment

• Complete blood count, coagulation profile (INR, aPTT), renal and hepatic function panels, HbA1c, thyroid function

• Blood group and crossmatch (minimum 4–6 units PRBC reserved)

• Chest X-ray (PA and lateral) and 12-lead ECG

• RELATIVE AND ABSOLUTE CONTRAINDICATIONS:

• Severely reduced LVEF (< 20%) with end-stage cardiomyopathy and no expected hemodynamic benefit from valve surgery

• Severe irreversible pulmonary arterial hypertension (PVR > 8 Wood units unresponsive to vasodilator challenge)

• Active systemic infection or bacteremia (surgery deferred until source control and sterile blood cultures for ≥ 72 hours)

• Uncontrolled coagulopathy or hematologic malignancy precluding safe anticoagulation with mechanical prostheses

• High operative mortality (EuroSCORE II > 20% or STS-PROM > 15%) in frail elderly patients — multidisciplinary heart team evaluation mandatory; TAVI + MitraClip as hybrid alternatives may be explored

• Severe hepatic cirrhosis (Child-Pugh Class C) with coagulopathy refractory to correction

• Prior mediastinal radiation with hostile mediastinum — requires individualized surgical planning

STANDARD APPROACH — CONVENTIONAL DOUBLE VALVE REPLACEMENT VIA MEDIAN STERNOTOMY:

This remains the reference standard and is performed through a full median sternotomy with establishment of cardiopulmonary bypass (CPB) via aortic and bicaval venous cannulation. The aorta is cross-clamped and myocardial arrest is induced with cold antegrade/retrograde del Nido or Buckberg cardioplegia. The aortic valve is approached first (transverse aortotomy), followed by the mitral valve (via left atriotomy through the interatrial groove or the transseptal/superior approach depending on atrial anatomy). Both diseased native valves are excised with meticulous decalcification of the annuli, annular sizing, and interrupted or continuous suture implantation of the prostheses. Rewarming, de-airing, and weaning from CPB are performed under TEE guidance. Simultaneous tricuspid annuloplasty (DeVega or ring annuloplasty with Cosgrove-Edwards or Edwards MC3 rings) is added in approximately 30–40% of cases with coexisting functional tricuspid regurgitation.

PROSTHESIS SELECTION — MECHANICAL vs. BIOPROSTHETIC:

• Mechanical Valves (e.g., St. Jude Medical Regent, On-X, CarboMedics): Bileaflet pyrolytic carbon design; excellent long-term durability (> 20–30 years); require lifelong anticoagulation with warfarin (target INR 2.0–3.5 depending on valve position and thromboembolic risk); preferred in patients < 60–65 years with reliable anticoagulation access and no contraindication to warfarin.

• Bioprosthetic Valves (e.g., Carpentier-Edwards PERIMOUNT Magna Ease, Medtronic Mosaic Ultra, Hancock II, bovine pericardial Edwards INTUITY): No lifelong anticoagulation required after the first 3–6 months (aspirin ± warfarin bridging); valve durability 15–20 years; preferred in patients ≥ 65–70 years, women of childbearing age, patients in geographies with unreliable INR monitoring, or those with anticoagulation contraindications. Structural valve deterioration (SVD) may necessitate redo surgery or transcatheter valve-in-valve (ViV-TAVI / ViV-TMVI) intervention.

• Homograft / Allograft Valves: Human cadaveric aortic or pulmonary valves; reserved for active aortic root endocarditis or complex reconstruction; limited availability.

MINIMALLY INVASIVE DOUBLE VALVE REPLACEMENT (MI-DVR):

In carefully selected patients without prior cardiac surgery, significant obesity, or pericardial adhesions, both valves can be replaced through a right anterolateral mini-thoracotomy (5–8 cm incision) or upper hemi-sternotomy (J- or T-sternotomy). Peripheral CPB (femoral artery and vein cannulation) and endoscopic/video-assisted techniques are employed. Benefits include reduced blood loss (40–60% less transfusion requirement), shorter ICU stay (1–2 days), reduced wound complications, faster return to full activity (4–5 weeks vs. 8–12 weeks for full sternotomy), and superior cosmesis. This approach requires a center performing > 100 minimally invasive valve procedures per year and is available at select GAF Healthcare partner institutions in India and the UAE.

ROBOTIC-ASSISTED VALVE SURGERY:

Da Vinci robotic systems allow mitral valve surgery with wristed instrument articulation through 8–12 mm ports, though true simultaneous robotic double valve replacement remains technically demanding and is performed at only a handful of centers globally. More commonly, robotic assistance is used for the mitral component while the aortic valve is addressed through a small aortotomy. Available at select partner centers in Chennai, Mumbai, and Dubai.

HYBRID / TRANSCATHETER ALTERNATIVES FOR HIGH-RISK PATIENTS:

For patients deemed inoperable or at extreme surgical risk (EuroSCORE II > 15%), a hybrid approach may be considered: Transcatheter Aortic Valve Implantation (TAVI/TAVR) — using balloon-expandable (Edwards SAPIEN 3 Ultra) or self-expanding (Medtronic Evolut PRO+, Boston Scientific Acurate neo2) systems — combined with transcatheter mitral edge-to-edge repair (MitraClip NTR/XTR or PASCAL Precision system) in a staged or simultaneous procedure. This avoids the risks of sternotomy and CPB in frail patients with multiple comorbidities.

CONGOMITANT PROCEDURES FREQUENTLY PERFORMED AT THE SAME OPERATIVE SITTING:

• Coronary Artery Bypass Grafting (CABG) for significant CAD

• Surgical ablation for atrial fibrillation (Cox-Maze IV procedure using radiofrequency or cryoablation energy)

• Left Atrial Appendage Ligation or stapling (stroke prevention)

• Tricuspid valve repair (ring annuloplasty)

• Ascending aortic replacement for concomitant aneurysm

PHASE 1 — PRE-ARRIVAL & REMOTE EVALUATION (2–4 weeks before travel):

• Patient submits medical records, echocardiograms, catheterization reports, and recent labs to GAF Healthcare's clinical coordination team

• GAF's partner cardiac surgeon conducts a video teleconsultation, reviews all imaging, calculates EuroSCORE II / STS-PROM operative risk scores, and confirms surgical candidacy

• Prosthesis type (mechanical vs. bioprosthetic), surgical approach (conventional vs. minimally invasive), and concomitant procedures are planned

• GAF Healthcare initiates e-Medical Visa application for India or UAE entry arrangements

• Anticoagulation bridging protocol issued (e.g., stopping warfarin 5 days pre-op, bridging with LMWH)

PHASE 2 — ARRIVAL & PRE-OPERATIVE WORKUP (Days 1–3 in-country):

• Airport pick-up by GAF's dedicated medical escort team; transfer to pre-arranged accommodation or hospital-affiliated guesthouse for attendant

• Formal in-person consultation with operating cardiac surgeon and cardiac anesthesiologist

• Complete pre-operative investigations: 3D-TEE, cardiac CT angiography (if not performed remotely), coronary angiography, PFTs, full blood panel, crossmatch, INR, carotid Doppler

• Multidisciplinary Heart Team (cardiac surgeon, interventional cardiologist, cardiac anesthesiologist, perfusionist, intensivist) case conference

• Pre-anesthetic assessment; optimization of blood glucose, hemoglobin (target Hb ≥ 10 g/dL pre-op), electrolytes, and renal function

• Informed consent obtained with GAF-provided language interpreter

• Patient admitted to hospital the evening before surgery; NPO after midnight

PHASE 3 — THE OPERATION (Day 4 — approximately 5–8 hours):

• Induction of general endotracheal anesthesia with invasive arterial line, central venous catheter, pulmonary artery catheter (Swan-Ganz), and intraoperative TEE probe

• Median sternotomy or minimally invasive incision; systemic heparinization; CPB established

• Myocardial arrest with cold cardioplegia; aortic cross-clamp time typically 90–150 minutes for double valve replacement

• Sequential excision and replacement of aortic valve (transverse aortotomy) and mitral valve (left atriotomy)

• Any concomitant procedures performed (CABG, Maze, tricuspid repair, LAA ligation)

• Systematic de-airing of cardiac chambers under TEE guidance; aortic clamp released; cardiac rhythm restored (spontaneous or DC cardioversion)

• CPB weaning with inotropic support (dopamine, milrinone, norepinephrine as needed); TEE confirmation of prosthetic valve function (no paravalvular leak, normal leaflet motion, gradients within acceptable range)

• Protamine reversal of heparin; meticulous hemostasis; chest drain placement; sternal closure with wire cerclage

PHASE 4 — CARDIAC ICU (Days 4–8):

• Mechanically ventilated for 6–12 hours post-op with lung-protective strategy (target PaO2/FiO2 > 200)

• Continuous hemodynamic monitoring: arterial BP, CVP, PA pressures, cardiac output via thermodilution

• Chest drain output monitored hourly (re-exploration threshold: > 200 mL/hour × 3 hours)

• Early extubation protocol; transition from IV to oral analgesia; incentive spirometry initiated

• Warfarin initiated on post-operative Day 1–2 for mechanical valve recipients; target INR 2.5–3.5 (mitral mechanical) or 2.0–3.0 (aortic mechanical)

• Bioprosthetic valve recipients receive aspirin 75–100 mg daily ± warfarin for the first 3 months

• Rhythm monitoring for post-operative atrial fibrillation (incidence 30–40%); rate control (beta-blockers, amiodarone) and anticoagulation management

• Repeat bedside TTE on post-op Day 2–3 to confirm prosthetic function and rule out pericardial effusion

PHASE 5 — STEP-DOWN WARD (Days 8–14):

• Transfer from ICU when hemodynamically stable, extubated, and on oral medications

• Cardiac rehabilitation Phase I: supervised ambulation progressing from bedside sitting → corridor walking → stair climbing

• Daily INR monitoring and warfarin dose adjustment

• Chest drain removal (typically Day 1–3 post-op); wound care and sternal precaution education

• Dietary counseling (low-sodium, vitamin K-consistent diet for warfarin users)

• Patient and attendant education on mechanical valve anticoagulation management, INR self-testing, signs of prosthetic valve thrombosis (sudden dyspnea, decreased valve click), and endocarditis prophylaxis

• Discharge planning: prescription for 3-month medication supply, INR monitoring schedule, dietary guidance documents in patient's native language

PHASE 6 — POST-DISCHARGE IN-COUNTRY RECOVERY (Weeks 2–8):

• Patient stays in GAF-arranged recovery accommodation near the hospital for a minimum of 4–6 weeks post-surgery

• Outpatient follow-up at Week 2: wound inspection, sternal healing assessment, repeat TTE, INR check, 6-minute walk test

• Outpatient follow-up at Week 4–6: repeat TTE confirming stable prosthetic valve gradients, LVEF trend, resolution of pulmonary hypertension; chest X-ray; sternal stability confirmed clinically

• Milestone for flight clearance (Week 6–8): LVEF ≥ 40%, stable INR in therapeutic range, sternal stability, no active infection, no pericardial or pleural effusion on imaging, no arrhythmia requiring IV management

• Surgeon issues Fit-to-Fly certificate; GAF Healthcare provides complete discharge summary, imaging CDs, and medication plan for the patient's home cardiologist

PHASE 7 — LONG-TERM RECOVERY AT HOME (Months 2–12):

• Full sternal healing: 8–12 weeks; no lifting > 5 kg or strenuous upper body activity during this period

• Return to sedentary desk work: 6–8 weeks post-op

• Return to moderate physical activity and driving: 8–12 weeks (surgeon-dependent)

• Annual echocardiographic surveillance for life: prosthetic valve function, ventricular remodeling, detection of structural valve deterioration

• Lifelong endocarditis prophylaxis with amoxicillin (or clindamycin if penicillin-allergic) before invasive dental or urological procedures

• INR monitoring: weekly for first month, then monthly when stable (mechanical valve recipients)