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Heart valve surgery.

Introduction

Operations to restore the function of heart valves have become common. They're done to improve the health and vigor of people with heart valve diseases. We've prepared this booklet to help people who may have or have had such operations learn about them. It also tells what to expect during and after a stay in the hospital.

The surgeon who'll perform the operation is the best person to talk to about your questions or concerns. He or she can best explain the details of your surgery and recovery period. The text and drawings in this booklet array help you understand and better discuss your case with your cardiologist, internist, family physician or other doctor who will be caring for you.

The structure and Function of Heart Valves

Your heart is a pump. It pumps blood that brings nourishment (food and oxygen) to the organs and tissues of your body.

Your heart has four chambers. The right and the left atrium are thin walled and serve as filling reservoirs. The other two chambers are the right and left ventricles. They're thick walled and do most of the pumping. The chambers on the right side of your heart pump blood only to your lungs; the left side chambers pump blood to the rest of your body. The left side chambers are thicker and stronger than those on the right.

There are four heart valves. Their job is to ensure that blood flows forward as your heart contracts and relaxes. The valves are made of thin but extremely strong flaps of tissues that open and close as your heart contracts and relaxes. A human heart beats more than 100,000 times each day, so its valves must flex, stretch, and hold back pressure hundreds of millions of times in an average lifetime.

The diagram shows the four chambers of the heart and the location of the valves. It also shows, using arrows, how blood flows through the heart. Here's the sequence of steps:

First, blood that has circulated through your body has had most of its oxygen and nutrients renew. It returns into the right atrium of your heart. From the atrium it passes through the tricuspid valve into the Tight ventricle. Next it's pumped through the pulmonary valve into blood vessels leading to your lungs. The lungs add needed oxygen to the blood and remove carbon dioxide waste. Now the blood returns to your heart, moving from the lung into the left atrium. From the left atrium the blood passes through the mitral valve into the left ventricle. Finally, it's pumped through the aortic valve into blood vessels leading to the rest of your body.

Diseases Commonly Affecting Heart Valves

Heart valves may not always work as well as they should. Several things can cause problems with them. A heart valve may first be normal at birth and may need to be repaired right away. A minor defect that exists at birth may not be found but may slightly weaken the heart valve or affect blood flow patterns. As a result, the heart valve will get worse later in life. Diseases such as rheumatic fever or bacterial infections may affect the valve, causing scarring or totally destroying it (as with bacterial endocarditis). The aging process also may weaken or harden heart valves. This happens because of the enormous number of times the delicate valve tissue must flex and move.

The mitral and aortic valves are most commonly affected by diseases that degenerate the valve. The tricuspid valve maybe affected if abnormal pressure builds up because other heart values are diseased. The pulmonary valve also may become abnormal. This is usually related to some deformity present at birth, however.

The diagram shows the four heart valves as if you're looking down on the heart and the filling chambers have been removed. When disease causes the valve tissues to thicken and harden, the valve fails to open properly and blocks or interferes with blood flow. This blocking process or called stenosis. When a heart valve becomes weak or stretched, it may not close properly. If that happens, blood can leak back through the opening. This leakage is called incompetence, sufficiency or regurgitation.

Any problem with a heart valve greatly increases your heart's work. That may cause the heart to enlarge to make up for its extra workload. When the heart can no longer do that, heart failure soon follows. Over time the heart muscle is permanently damaged.

Correcting Heart Valve Problems

Some people with diseased heart valves can lead normal lives as long as they get careful medical supervision. Others, with more severe heart valve damage, need surgery.

In some cases, operating to repair a person's own valve may relieve the stenosis or leakage. In other cases, the valve is so badly damaged that it must be replaced. The best solution depends on the person's needs. Your doctor will discuss the options and recommend the best way to manage your case.

Heart Valve Repair Operations

Valve stenosis often occurs when the cusps or leaflets are scarred or fused at the edges where they touch each other (commissures). A blockage caused when a valve can't open properly may be relieved by cutting with a scalpel. This separates the parts of the valve and helps them move more freely.

Valve incompetence (insufficiency) is often caused by the weakening and lengthening of the valve leaflets. The edges that normally touch (to keep the valve closed) begin to slip past each other (prolapse). This lets based regurgitate through the valve.

As leakage progresses, the whole valve may enlarge or dilate. Restoring the valve to normal functioning then requires remodeling its tissues.

Different approaches can be taken. Removing excess leaflet tissue and sewing the edges may be required. Shortening or connecting suspensory chords is sometimes done. Prosthetic rings (see drawing below) are used to narrow a dilated valve and to reinforce valve repairs.

One advantage of valve repair operations is that a person's own valve tissues are used. Thus repair is a more natural way to treat valve failure.

Heart Valve Replacement Operations

Sometimes heart valves are seriously deformed, degenerated or destroyed. When that's the case, repairing them isn't reasonable. Then the old, damaged valve is removed and replaced with a new valve mechanism. The new valve is firmly attached by sewing it to a rim of tissue kept from the person's original valve.

Several types of replacement valve mechanisms are used. They mainly fall into one of two groups: tissue (biologic) valves or mechanical (metal, plastic, etc.) valves.

Biologic tissue valves use animal valves that have been chemically process for the moving part of the valve. They,re mounted in a cloth-covered metal or plastic frame; this makes inserting them into a patient easier.

Another type of tissue valve uses the aortic valve from another person. This valve has been preserved by carefully freezing it using controlled methods (cryopreservation). These valves are transplanted directly into a person's aorta.

A tissue valve has the great advantage of being very similar to the natural heart valve it replaces. That's why these valves are well tolerated in the body without special medication. A disadvantage is that they're usually less durable than natural valves. The reason is that even the most scientific methods to preserve them can cause same injury.

Mechanical valves are artificial devices (prosthetic valves). They're made of hard and durable metals, carbon ceramics and plastics. A fabric ring made from Dacron or Teflon is used to attach the device to tissues in the patient's heart.

There are different types of mechanical valves. The first ones used a moving part (a ball) held in a cage. This ball-in-cage design has been successful and reliable for many years. Another group of useful prosthetic valves uses a disk that tilts to open and close. The disk is attached to the valve housing by a wire or kiosk device. Lastly, a third group of mechanical heart valves employ two half disks (bi-leaflet) that tilt to open and close. The leaflets are hinged to the valve housing.

An advantage of mechanical valves is that they're durable, due to the strong materials used in their construction. These materials aren't natural to the body, however, so they may cause blood clots to form. To keep this from happening, medications (anticoagulants are used to slow the rate of blood clotting. Most patients with mechanical valves must take anticoagulant medications every day for the rest of their lives. The effect of the drug on blood clotting also must be checked regularly by a blood test called the prothrombin time (pro-time).

Many things must be considered in selecting the bust device to use to replace a heart valve. A surgeon will draw upon his or her own experience and knowledge to recommend the valve best suited to each patient's heads. Factors to consider include a patient's age, the valve disease process, the size of the valve to be replaced, and the person's ability and willingness to take anticoagulant medications. The feelings and wishes of the patient are carefully considered in planning the operation.

Preparing for Heart Valve Surgery

If your doctor has told you that you need an operation to correct heart valve disease, it's natural for you to feel anxious. No one wants an operation. Everyone fears pain and the unknown. Even so, you can reduce your anxiety by understanding why you need an operation and meeting the health care professionals who'll handle your case. As-you hear the procedures explained and have a chance to ask a questions and voice your concerns, you'll feel better. Being well informed will help you feel more relaxed as the operation draws nearer.

The rest of this booklet explains the normal schedule of events surrounding an open heart operation. Procedures may vary somewhat from one hospital to another. That's why it's best to get specific information about your own case from members of your health care team.

Before the Operation

Hospital Admission

Admission to the hospital is usual!y scheduled for the afternoon of the day before the operation. This allows time for the staff to make some tests, give you instructions, and prepare for the operation. Sometimes patients are admitted early on the morning of the operation.

Before your operation, you'll be visited by your health care team. The team consists of the surgeons, cardiologists, anesthesiologists, nurses and therapists we'll care for you during and after your operation. Your surgeon will discuss the details of your operation. This is a good time for you to ask questions and express any concerns you have. The anesthesiologist will explain how the medications for sedation and anesthesia will be given to you. The nursing staff will give you instructions, too. Finally, respiratory therapists will tell you how to breathe and cough effectively after the operation.

Blood will be drawn for laboratory tests and to cross match donor blood. This is done in case a blood transfusion Is needed during your operation. Modern operating methods reduce blood loss and save much blood that would otherwise be lost. This means replacing blood by transfusion is done as little us possible.

If a blood transfusion is necessary, the blood bank will have carefully tested the donor blood to be sure that no diseases infect it that could be passed to you. Family donors (directed donors) and self donation (autologous donor) are often a good idea. You can arrange such donations as long as there's enough time (at least three days before the operation). The time is needed so the blood bank can be sure that even these donor sources are safe.

Your doctors may need to make other routine examinations--such as electrocardiogram and chest X-ray.

Your hair will be shaved off at the site of the operation. This allows your skin to be cleaned better and prevents discomfort when the adhesive bands are taken off. Your skin will be washed with antiseptic soap to reduce the risk of infection. These steps are done to help your smooth recovery after the operation.

The Operating Room Schedule

Heart operations are usually planned in advance and start on time. Sometimes, however, they,re delayed if other people have emergency needs. If your operation of delayed or postponed, it's normal to be upset. Still, knowing that the reason for the delay is that a surgeon is devoting time and attention to someone who needs it can be reassuring. Scheduled operations will proceed as soon as possible.

On the Day of the Operation

Before you move from your hospital room to the operating room, give your glasses, dentures, watch, Jewelry, contact lenses, clothing and other personal items to family members. You'll be given medications to jet you rest comfortably about an hour before the operation.

As the time of your operation nears, attendants will wheel you to the operating room on a rolling bed. You'll probably be awake enough to move between the beds, but you may not remember doing so. Once you,re in the operating room, the anesthesiologist will give you anesthesia--agents that bring deep sleep, freedom from pain and absence of memory during the operation.

Heart valve operations usually take 3-5 hours. The length of the operation depends on how complex it is. Since each operation is different, how long your operation will take is hard to predict exactly. During your operation, your family and friends should stay in the waiting room so the surgeon knows where to find them to keep them informed.

After the Operation

Immediately After the Operation

After the operation is over, you'll be taken to an intensive care unit or recovery rosary. A nurse will be present at all times to provide the care you need. Special equipment also will be there to monitor your progress.

Anesthetics wear off at different rates. That's why patients awaken and become conscious at different times after operations. Some people respond in an hour or two but most take much longer. Sometimes people can hear or open their eyes before they can move their arms or legs. It isn't long before the mind and body are fully coordinated, however.

Family Visiting

Your family members may visit briefly within 45 minutes to an hour after your operation. They shouldn't,t expect you to be able to respond to them, however. Their later visits must be arranged to fit the rules of the intensive care unit. Later visits will be more pleasant since you'll be more awake and active.

The Intensive Care Unit

Heart operations are usually done through an incision along the middle of the chest through the breastbone. You'll have some discomfort in this area. At first your incision will be covered with adhesive bandages; a day or so later they'll be removed to expose the wound. Secondary paper tape dressings are also commonly used.

One of the first things you may be aware of is the breathing tube (endotracheal tube) in your mouth. This goes by the vocal cords into the windpipe. The tube isn't,t painful, but it is rather uncomfortable. It will stop you from talking, but the nurse is trained to be aware of patients, needs without having the milk. The breathing tube is removed when it's no longer needed, usually within 24 hours after the operation.

Other tubes and wires are routinely attached to the body to assure a safe, smooth recovery. For example, small tubes will be placed in your arms or neck. They,re used so drugs and fluids can be given to you, blood samples taken, and blood pressure checked at all times. Tubes coming out through the skin on your chest or abdomen drain off fluid that seeps out from around the heat. Without these tubes, the fluid would build up inside your body. Electrode patches and wires are put on the skin and used to monitor your heart rhythm and rate. Small wires may be put on there surface of your heart and lead out through the skin to permit the use of a temporary pacemaker, of needed. A tube is placed in the urinary bladder to drain away urine. Also, a tube may the put in your stomach to prevent bloating or vomiting.

Intensive care units are places where there's constant activity. Hospital staff stay busy providing 24-hour care to patients. The lights are on all the time, and it can be quite noisy. Your sleep may be disturbed frequently.

Sometimes it's hard for patients to know what time it is, and they may become disoriented or confused. If this happens to you, don't worry about it. It won't last long. Just ask the nurse what day and time it is.

The Rest of Your Hospital Stay

Relieving Pain

Most patients complain of being sore and stiff but don't have severe pain. Soreness comes from the surgical incision and from muscle spasm. Medication to relieve pain is given liberally at first. As your recovery progresses, you'll receive medication less often and in smaller doses. You are may be given medicine to relax your muscles.

Respiratory Therapy

Fluids collect in the lungs during and after heart surgery. A respiratory therapist may be asked to help clear them out. This helps reduce the chance of breathing problems. Deep breathing and vigorous coughing ate the best ways to clear out your lungs. These actions may cause some discomfort but won't harm your incision. Supporting your chest with a pillow may help make coughing less painful and thus more effective.

Breathing devices that help people breathe more deeply (incentive spirometers) are also useful. In some cases aerosol medications may be inhaled to open the airways and loosen the secretions in the lungs.

Getting Out of Bed

The first activity after your operation is simply moving about in bed. In a day or two patients usually can sit in a chair and begin walking around the room or in the hallway with help. Activity levels are prescribed for each person, depending upon his or her progress and capacity for exercise. Usually the amount of exercise and walking increases each day until a person is completely independent.

Eating and Diet

It won't be long until you'll be able to swallow water and fluids. Most people can drink they after their operation. Your diet will move from liquids to regular foods as quickly as you can tolerate the change. Salt is often restricted. Special diets may be ordered depending on a person's needs. Selecting food is usually left up to patients. Your appetite will probably be poor for a few days. Even so, it's important to drink enough liquid and eat enough food to nourish your body and provide nutrients for proper healing.

Other Aspects of Recovery

Elastic stockings may be prescribed for you. These help your blood circulate in leg veins during this time of less-than-normal activity.

Your chest incision will remain exposed once the initial surgical bandage has been taken off. External stitches or staples may be used. They're usually taken out 7-10 days after the operation. Incisions may be used with stitches under the skin that your body absorbs. Strips of adhesive tape may be used to cover the skin. These may he left on the skin for many days--as long as they stick. Your surgeon will tell you when to remove them.

You'll probably be allowed to bathe or shower within four or five days after your operation. The nurse should be close by during your first shower or bath after the operation.

You can expect to feel a little better with each passing day, although you may have a few lapses. Fatigue and emotional "ups and downs" are common during recovery. They're normal reactions. In general, though, you'll feel yourself getting better and stronger as time passes.

Length of Hospital Stay

The usual hospital stay after heart valve operations is from one to two weeks.

Returning Home

Leaving the Hospital and Going Home

It's not unusual to feel a bit wary and uncertain about going home. It may be scary to leave the security of the hospital with its expert medical team and special equipment. Remember, though, that the doctor won't let you leave, until he or she thinks you've recovered enough to safely continue your recovery at home.

Patients usually go home in a car driven by a family member or friend. You can sit up during the ride. If the drive will last more than two hours, stop, get out of the car and walk around.

If you'll travel by bus, train or airplane, you can make special arrangements with the service staff of the carrier. Then you can get help in the terminal and obtain early boarding.

Your Routine at Home

Try to get back into a normal sleeping and waking routine as soon as you can. Get up in the morning at a reasonable hour, take care of personal hygiene and dress in street clothes. Don't stay in bed clothes. Take time to rest in mid-morning, and treat yourself to a nap in the afternoon.

Take a short walk or ride a stationary bicycle every day. Try to do a little more each day than you did the day before. You'll be able to do more exercise with time, so slowly increase your periods of activity. Follow this simple formula: when rested, do same exercise; when tired, rest. Try to do enough each day to feel pleasantly tired at bedtime so you'll be sure to sleep. Taking pain medicine at bedtime for a few days may make it easier to sleep.

Take your temperature with a thermometer at 4 p.m. and 8 p.m. daily for two or three weeks. Tell your doctor if your temperature is above 100 degrees F. (38 degrees C.).

You should also weigh yourself every day on a bathroom scale. Expect a bit of weight loss for about three weeks. Report a weight gain of more than five pounds to your doctor.

Dos and Don'ts

Driving a car immediately after your operation isn't a good idea. Wait a few weeks. You should feel strong and well before trying to drive. Don't try unless you're absolutely sure that you can do it safely. Riding in a car is no problem and can be done anytime.

Walking up stairs is permitted. Having some help is a good idea at first.

Don't push or pull only heavy subject or lift anything weighing more than 10 pounds for 6-8 weeks after surgery. This keeps you from putting stress on your healing wound and gives your breastbone enough time for healing.

It's okay to help with light housework; meet with friends at home; attend the "heater, restaurant or church; and take rides in the car. These are pleasant breaks from the routine at home. People usually become tired easily for the first three weeks after their operation, and you may want to go easy on activities during that time. Between three and six weeks after your operation you'll begin to feel better and have more strength, which makes being more active easier and more pleasant.

Signals and Actions

Repairing heart valves or replacing them with prosthetic valves are very reliable operations. But the truth is, the operations, the remodeled valves, and the artificial valves aren't absolutely perfect. Problems are rare but sometimes do happen. Certain signs and symptoms indicate that a person should call the doctor at once or, if the doctor can't be reached, go to the hospital. It's important to get competent medical advice.

These signs or symptoms call for IMMEDIATE action:

1. Chest pain or tight pressure that doesn't go away after a few minutes.

2. Sudden, severe shortness of breath that isn't related to exercise.

3. Temporary blindness in one eye or noticing a grey curtain coming over an eye.

4. Weakness, clumsiness, or numbness of the face, arm, or leg on one side of your body, even if only temporary.

5. Slurred speech, even if it only lasts a short time.

6. Unusually rapid weight gain, retaining fluid or swelling of the ankles. Fatigue, especially along with a fever that doesn't go away in a few days.

8. Unusual bleeding.

9. Loss of consciousness, even if it's regained shortly after.

10. Sudden change in the normal sound or sensation of your heart valve opening and closing, or an absence of normal sound and sensation of the valve.

11. Sudden disturbing changes in your heartbeat's rate and rhythm. If any of these warning signs or symptoms occur, call your doctor right away. Don't wait until tomorrow! Getting prompt medical attention may save your life if your heart valve fails to perform properly. Your doctor won't mind being bothered even if it turns out there's nothing to worry about.

Have a plan in mind in case of a heart valve emergency:

* Keep your doctor's phone number handy. Carry it with you at all times and keep a copy at home and at work for your family and co-workers to use.

* If your surgery was done at a distant hospital, find out what hospitals close to you can perform open heart surgery in an emergency.

* Make sure members of your family, neighbors and co-workers know in advance where to take you if you have a medical emergency related to your heart valve.

* Find out if your area has "911" access to emergency medical services (EMS). If not, it may be a good idea to check with local rescue squads or ambulance services to plan the best course of action in an emergency.

Living With Your Hearth Valve

Appointments with the Doctor

How often you should return to see your doctors depends on your needs. You should be told when you're discharged from the hospital when to set u appointments with your surgeon and cardiologist. Notify your personal or family doctor when you've returned home and ask for advice about scheduling future appointments.

Diet

Eating nutritious meals is important to your healing, so watch what you eat. Limiting how much salt you eat is often advised after heart valve operations. Some medical conditions may require special diets. The hospital dietitians and nursing staff can be very helpful in giving you the dietary information and training you need to live healthfully.

Cigarettes and Other Tobacco Products

Cigarettes and other tobacco products will harm your health. The American Heart Association strongly urges people not to smoke cigarettes or use any tobacco products. They're harmful to the heart as well as other parts of the body. If you smoke, QUIT

Exercise

Exercise helps you recover your health and your. A graded exercise program usually begins in the hospital and consists of simply walking in your room or hallway. Your exercise may be monitored to be sure your heart can respond as it should to more work. By following a graded exercise program, most people can walk 2-3 miles a day within a few weeks after their operation. Such distances usually mean-walking outside or, in bad weather, in a shopping mall.

Comfortable clothing and good quality walking shoes make exercise fun and safe. If you exercise a little more each day, in time you'll be able to exercise vigorously for 30-60 minutes, three to four times a week.

Returning to Work

The average convalescent period spent at home is four to six weeks. After that, the breastbone has healed to full strength. Some people who work mainly sitting down may return to their jobs on a part-time basis as early as four weeks after their operation. These who perform heavy labor will need six weeks can longer before they return to work. Your doctor will advise you about when you can return to work.

Some people aren't able to return to their former jobs after a heart valve operation. They may need vocational rehabilitation. State agencies can be helpful then.

Driving

Your doctor will probably tell you when you may drive again. The breastbone takes time to heal, so it's usually best to wait a few weeks after you're discharged from the hospital before you resume driving.

Sexual Relations

Partners may resume sexual relations whenever they want. Care should be taken while the breastbone is healing to avoid pressure against the chest wall.

Medicines

Take only those medicines your doctor has prescribed. Medical care may be changed because of your operation and any medicine that you took before surgery should be stopped unless your doctor specifically orders you to take it. Even over-the-counter (non-prescription) drugs such as aspirin shouldn't be used without first asking your doctor.

Anticoagulants

Medication to prevent blood clots from forming on artificial heart valves may be prescribed by your doctor. These medicines are often called "blood-thinners," but they're really anticoagulants. They don't really thin the blood; they just slightly prolong its clotting time. These medications (coumadin/warfarin) must be carefully monitored by taking a blood test carried a prothrombin time ("protime"). This test measures one of the factors in the blood clotting scheme. Your doctor will prescribe a dose of medicine to keep the pro-time within strict limits

It's important to follow your doctor's instructions about using this medicine very carefully and take it exactly as prescribed. It must be taken daily and should be taken at the same time each day. It's also very important to obtain the pro-time blood test at regular intervals, as advised by your doctor.

Antibiotics

Dentists and other doctors who provide care to people with heart valve problems or prosthetic heart valves must be toed of your heart valve condition and the medications you're taking. It's vital to the safety of heart valve patients that you receive antibiotics before and after dental work that is likely to cause bleeding. This includes routine professional cleaning and certain surgical procedures that involve the gums or other soft tissues in the mouth.

Bacteria may be released into the bloodstream during these procedures and could lodge in your heart on the abnormal or prosthetic valve. When this happens, an infection called bacterial endocarditis can result. Antibiotics are used to prevent this type of infection. There is a patient ID card at the back of this booklet. Carry this card in your wallet so you can show your physician or dentist. It has recommendations to follow for specific heart valve conditions.

It's also essential for your physician or dentist to know if you're taking anticoagulant medications. If you are, he or she can make needed adjustments-which may mean stopping the medication during an operation to prevent excessive bleeding.

Advantages of Heart Valve Surgery

People who have heart valve disease may be very handicapped. Heart valve surgery holds the premise of a better quality of life. Most patients can do many things after operation that were impossible before. You can expect to improve every day over three to six months. In some cases improvements continue for up to a year. Your successful recovery depends on how well you follow medical advice, exercise and stick to other forms of healthy living.

Living With a Replacement Heart Valve Over the Long Term

When you've recovered from your heart valve surgery and resumed a normal routine, it will be time to think about living with your replacement heart valve for the rest of your life. You will already have started to make some changes.

* You'll need to get regular medical check-ups at least once a year. Your doctor may tell you to get them more often.

* Stick with your exercise plan: 30-60 minutes, 3-4 times per week. If you get bored with the same exercises, try a few other kinds. But make any change gradually so you don't exert too much too soon.

* Eat a sensible diet, keeping fat, cholesterol and sodium low as your doctor or dietitian advises.

* Avoid smoking cigarettes or using any tobacco products.

* Plan ahead to take immediate action in case of a heart valve-related medical emergency.

For More Information

You may want more information about cardiac rehabilitation programs in your area. Ask your doctor, your surgeon, your hospital, or your nearest American Heart Association.

Recommendation's for Preventing Bacterial Endocarditis

For Dental/Oral/Upper Respiratory Tract Procedures

I. Standard Regimen In Patients At Risk (includes those with prosthetic heart valves and other high risk patients):

Amoxicillin 3.0 g orally one hour before procedure. then

1.5 g six hours after initial dose For amoxicillin/penicillin-allergic patients:

Erythromycin ethylsuccinate 800 mg or erythromycin stearate 10 g orally 2 hours before a procedure, then one-half the dose 6 hours after the initial administration.(*)

-OR-

Clindamycin 300 mg orally 1 hour before a procedure and

150 mg 6 hours after initial dose.(*)

II. Alternate Prophylactic Regimens For Dental/Oral/Upper Respiratory Tract Procedures In Patients At Risk:

A. For patients unable to take oral medications:

Ampicillin 2.0 g IV (or IM) 30 minutes before procedure,

then ampicillin 1.0 g IV (or IM) OR amoxicillin 1.5 g orally 6 hours after initial dose.(*)

-OR- For ampicillin/amoxicillin/penicillin-allergic patients unable to take oral medications:

Clindamycin 300 mg IV 30 minutes before a procedure and

150 mg IV (or orally) 6 hours after initial dose.(*)

B. For patients considered to be at high risk who are not candidates for the standard regimen:

Ampicilin 2.0 g IV (or IM) plus gentamicin 1 5 mg/kg IV

(or IM) (not to exceed 80 mg) 30 minutes before procedure, followed by amoxicillin 1.5 g orally 6 hours after the initial dose. Alternatively, the parenteral regimen may be repeated 8 hours after the initial dose.*

For amoxicillin/ampicillin/penicillin-allergic patients considered to be at high risk:

Vancomycin 1.0 g IV administered over one hour, starting one hour before the procedure. No repeat dose is necessary.*

(*) Note: Initial pediatric dosages are listed below. Follow-up oral dose should be one-half the initial dose. Total pediatric dose should not exceed total adult dose.
Amoxicillin: [dagger]     50 mg/kg Vancomycin: 20 mg/kg
Clindamycin:              10 mg/kg Ampicillin: 50 mg/kg
Erythromycin ethylsuccinate Gentamicin: 2.0 mg/kg
or stearate:               20 mQ/kq


[dagger] The following weight ranges may also be used for the initial pediatric dose of amoxicillin:
<15 kg (33 lbs), 750 mg
15-30 kg (33-66 lbs), 1500 mg
>30 kg (66 lbs), 3000 mg (full adult dose)


For Genitourinary/Gastrointestinal Procedures

I. Standard regimen:

Ampicillin 2.0 g IV (or IM) plus gentamicin 1.5 mg/kg IV (or IM) (not to exceed 80 mg) 30 minutes before procedure, followed by amoxicillin-15 g orally 6 hours after the initial dose. Alternatively. the parenteral regimen may be repeated once 8 hours after the initial dose.,

For amoxicillin/ampicillin/penicillin-allergic patients: Vancocmycin 1.0 g IV administered over 1 hour plus gentamicin 1.5 mg/kg IV (cr IM) (not to exceed 80 mg) one hour before the procedure. May be repeated once 8 hours after initial dose.(**)

II. Alternate oral regimen for low-risk patients: Amoxicillin 3.0 g orally one hour before the procedure, then 1.5 g 6 hours after-the initial dose*,

(**) Note: Initial pediatric dosages are listed below. Follow-up oral dose should be one-half the initial dose. Total pediatric dose should not exceed total adult dose.
Ampicillin:    50 mg/kg       Gentamicin: 2.0 mg/kg
An amoxicillin.  50 mg/kg        Vancomycin: 20 mg/kg


Note: Antibiotic regimens used to prevent recurrences of acute rheumatic fever are inadequate for the prevention of bacterial end carditis. In patients with markedly compromised renal function, it may be necessary to modify or omit the second dose of gentamicin or vancomycin. Intramuscular injections may be contraindicated in patients receiving anticoangulants.

Adapted from Prevention of Bacterial Endocarditis Recommendations by the American Heart Association. JAMA 1990;264: 2919-2922, O 1990 American Medical Association (also excerpted in J Am Dent Assoc 1991;122:87-92).

Please refer to these recommendations for more complete information as to which patients and which procedures require prophylaxis.
COPYRIGHT 1991 American Heart Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1991 Gale, Cengage Learning. All rights reserved.

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Publication:Pamphlet by: American Heart Association
Article Type:Pamphlet
Date:Jan 1, 1991
Words:5971
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