Dr. Bayad J.

Mahmood

Oral & Maxillofacial Surgery Fourth stage: Prosthetic heart valve

The patient with valvular heart disease undergoing oral and maxillofacial surgery
presents two main concerns. The first concern is for the decreased effectiveness of
the cardiac pump. The second is for the patient’s increased risk for developing
bacterial endocarditis. Patients with valvular heart disease frequently present with a
heart murmur graded from 1 to 6. However, the louder murmur is not always
indicative of a more severe problem. Valvular heart disease is initially diagnosed
with a stethoscope, by determining where on the chest wall the murmur is heard
loudest, in which part of the cardiac cycle it occurs (systole or diastole), the quality
of the murmur (e.g. crescendo–decrescendo), and where it radiates. However, the
final diagnosis is almost always confirmed with an echocardiogram. In mitral
stenosis, the stenotic mitral valve reduces left ventricular filling so cardiac output is
decreased and left atrial pressure is increased. The condition can worsen when the
patient becomes tachycardic. Tachycardia decreases the time for left ventricular
filling, and cardiac output can fall. Perioperative tachycardia should thus be avoided
in patients with mitral stenosis. The resultant left atrial enlargement also predisposes
the patient to develop atrial fibrillation.
Atrial fibrillation with mitral stenosis requires anticoagulation therapy to reduce the
risk of embolic stroke. With mitral regurgitation, the incompetent mitral valve also
decreases cardiac output, as a portion of blood flows back into the left atrium during
systole. This can also result in an enlarged left atrium, and predisposes the patient to
atrial fibrillation.
Aortic stenosis is of special concern. The limitation to left ventricular outflow not
only reduces cardiac output, but also causes significant left ventricular hypertrophy
with a concomitant increase in myocardial oxygen demand. Frequently fatal if left
untreated, aortic stenosis presents a significant surgical risk.
 Dr. Bayad J. Mahmood

With aortic insufficiency, systemic blood flows back into the left ventricle during
diastole resulting in left ventricular dilation (but not necessarily hypertrophy) and an
increase in stroke volume. Patients may present with an increased systolic pressure,
but with retrograde regurgitant flow during diastole, the pressure rapidly drops and
systemic diastolic pressure is low. Therefore, an enlarged pulse pressure is seen with
bounding carotid pulses.
Treatment of valvular heart disease is directed toward controlling blood pressure and
heart rate, and in treating any accompanying congestive heart failure (e.g. diuretics).
Surgical treatment includes valvuloplasty (possibly via cardiac catheterization) or
valve replacement with subsequent anticoagulation.
The American Heart Association guidelines for prevention of bacterial endocarditis
(infective endocarditis) in patients with valvular heart disease now only include
antibiotic prophylaxis for patients at the very highest risk.

Congestive heart failure

Insufficient cardiac output results in increased back pressure with fluid overload in
the pulmonic vascular system. Congestive heart failure has approximately a
50% 5-year mortality rate. Causes of congestive heart failure are multiple, and
include long-standing hypertension, prior cardiac damage secondary to infarction,
valvular heart disease, congenital heart diseases, etc. Congestive heart failure usually
begins with left-sided failure. The pulmonary fluid overload causes dyspnea on
exertion, shortness of breath, fatigue, weakness, paroxysmal nocturnal dyspnea, and
orthopnea. These symptoms are worsened at times of exertion or with gravitational
patient positioning. Long-standing left-sided failure places more
workload on the right ventricle and can progress to include right-sided heart failure
with jugular venous distention, pitting pedal edema, and liver enlargement from
hepatic congestion. Chronic medical treatment for the patient with congestive heart
 Dr. Bayad J. Mahmood

failure includes exercise and weight loss, with fluid and sodium restriction.
Medications include ACE inhibitors, beta-blockers to reduce the workload of the
heart, diuretics to reduce the fluid volume, and digoxin to improve the cardiac
inotropic function. The oral and maxillofacial surgeon must take into consideration
the volume of intravenous (IV) fluids administered to patients with congestive heart
failure. Patient positioning during outpatient surgery is important, and the patient
should be reclined a limited amount. For an acute episode of pulmonary edema, in
addition to supplemental oxygen, the patient should be treated as an emergency with
morphine, nitroglycerin, and a diuretic such as furosemide.

Infective Endocarditis
IE is an inflammation of the inner layer of the heart (the endocardium), caused by
microorganisms. The most common structures involved are the heart valves,
especially if previously damaged congenitally, from surgery, by autoimmune
mechanisms or simply as a consequence of old age. Bacteremia is a necessary event
in the development of IE and delivers microorganisms to the surface of the valve.
Although bacteremia would normally be cleared quickly with no adverse
consequences in a healthy individual, a deformed heart value with its altered
endothelial surface can be susceptible to bacterial adherence and subsequent
multiplication. Therefore, if heart valves have been damaged, or replaced with
an artificial biomaterial, bacteria have a greater chance of colonization.
In the case of IE, bacteria multiply and small clumps of material called vegetations
may develop on the infected valves. These vegetations contain microorganisms,
small blood clots, and other debris from the infection. The vegetations may prevent
function of affected valves and allow infection to spread to other areas of the
endocardium or heart tissue. Fragments of the vegetations (emboli) can detach and
 Dr. Bayad J. Mahmood

travel in the bloodstream to other parts of the body and cause distal infections with
additional signs and symptoms. Usual initial signs of IE are intermittent fever, and
subsequently heart murmurs, which result from abnormal flow of blood through
faulty or damaged valves.
Complications may appear if the infection is left untreated or if treatment is delayed.
Damage to heart valves may lead to serious heart problems, including heart failure
and heart abscess. Moreover, emboli may cause vascular obstruction
(embolism) and block blood flow in other parts of the body.
This can result in stroke, kidney failure, heart attack, and damage to gastrointestinal
organs. Splinter hemorrhages, Janeway lesions (painless hemorrhagic cutaneous
lesions on the palms and soles), Osler’s nodes (painful subcutaneous lesions in the
distal fingers), and Roth’s spots (oval retinal hemorrhages) are all related to
embolisms.
 Dr. Bayad J. Mahmood

Cardiac conditions where prophylaxis is recommended

1. Prosthetic cardiac valve
2. Previous infective endocarditis
3. Congenital heart disease (CHD)
4. Unrepaired cyanotic CHD, including palliative shunts and conduits
5. Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
6 months after the procedure
6. Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
7. Cardiac transplantation recipients who develop cardiac
8. Valvulopathy

Dental procedures requiring antibiotic prophylaxis

All dental procedures that involve manipulation of gingival tissue or the periapical
region of teeth or perforation of the oral mucosa in patients with the cardiac
conditions outlined above.
Dr. Bayad J. Mahmood