Overview of Nicks Procedure

Surgical aortic valve replacement (AVR) is a standard surgery that’s often performed on patients who have severe aortic stenosis, which means their aortic heart valve has become narrow. This surgery is usually very successful, but sometimes complications can arise. One such complication is called ‘patient prosthesis mismatch’ (PPM).

PPM can happen when a small-sized artificial valve is placed inside a small aortic root, which is the inlet tube that connects your heart to the aorta (main artery). When PPM happens, the pressure across the valve increases, which can lead to issues like reduced ability to tolerate exercise and a delay in the shrinkage of an enlarged heart muscle.

Various techniques have been developed to enlarge the aortic root, thus allowing the implant of a bigger valve to avoid PPM. For patients with a small aortic root, options include procedures that enlarge the rear of the aortic root, such as the Nicks procedure, as well as the use of special valves that don’t require stitches.

The Nicks procedure is one of the simpler techniques available. Besides avoiding PPM, it also allows for the placement of another valve inside the first valve in the future, if needed. This procedure also helps guard against the artificial valve wearing out over time.

Anatomy and Physiology of Nicks Procedure

The aortic root is part of the heart where blood exits the left heart chamber (ventricle) to get to the rest of the body. It includes a passageway from the left ventricle, a door-like structure called the aortic valve, and the beginning of the large blood vessel called the aorta.

The aortic valve has three sections, which are like flaps or leaflets that open and close. Each leaflet has a name: the right, left, and non-coronary leaflets. Two blood vessels (coronary arteries) begin above their matched leaflets.

Unlike other heart valves, the aortic valve doesn’t have a clear “ring” or rim where it attaches. The non-coronary and left leaflets are close to the place where the aortic and mitral valves meet. Beneath these leaflets is a tough, fibrous area called the subaortic curtain. Further to the right, the non-coronary leaflet is attached high up on the left ventricular outflow tract, the exit route for the blood from the heart. This spot is close to the wall of the right atrium, the upper right heart chamber.

A particular surgical method called Nicks procedure, aims to increase the size of the aortic valve if it is too small. It involves making a careful cut through the non-coronary leaflet without disturbing the tough tissues between this valve and another heart valve, called the mitral valve.

A problem known as patient prosthesis mismatch (PPM) is when the ring-like part of the aorta (the aortic annulus) is too small, and the replacement valve isn’t large enough for the patient’s size. This can lead to poor blood flow, reduced decrease in the size of the left ventricle, and lower survival rates in patients with this issue.

If the surgeon suspects the risk of PPM, they can enlarge the aortic root, or use a particular type of heart valve replacement. Having a replacement valve that might look like it fits well but causes a high pressure difference can lead to issues with heart function and can increase the risk of illness and death, especially in patients with weak heart function.

Why do People Need Nicks Procedure

The Nicks procedure is a type of surgery often performed to increase the size of the aortic root, which is the area where the aorta (the main artery in the human body) connects with the heart. This operation may be recommended in several circumstances:

  • When the aortic root is small, hardened, or has calcium deposits, especially in adults. Enlarging the aortic root ensures that the artificial heart valve (prosthesis) fits properly, reducing the risk of complications.
  • For children who require a replacement of their aortic valve, enlarging a small aortic root is also essential to ensure the correct fit of the new valve.
  • In cases where a patient may need a valve-in-valve procedure, using a larger biological valve can make it easier for future treatment. A valve-in-valve procedure is typically done through a method called transcatheter aortic valve implantation (TAVI). This procedure involves inserting a new heart valve inside the old, failing valve without having to remove it.

This simplified version still gives accurate information about when the Nicks procedure might be used, but in language that is much more accessible for those who don’t have a medical background.

Equipment used for Nicks Procedure

In the method first explained by a group of doctors led by Nicks, a patch made from a specific woven material known as Dacron was used to enlarge the aortic root. This is part of the body’s main artery, and this patch was cut from a type of artificial tube that’s often used in artery grafts. When used, this patch was positioned in a way that its natural curve faced the inner part of the artery.

While Dacron is a common material, there are also alternatives. One of them is pericardium, which is the membrane enclosing the heart. It can be taken from the patient (autologous) and may be treated with a substance called glutaraldehyde to make it last longer, or it may also come from a cow (bovine).

To carry out the procedure named after Nicks, a number of items are needed:

  • A surgery room
  • A machine to temporarily take over the job of the heart and lungs during surgery (Cardiopulmonary bypass machine)
  • Clean covers for the patient and protective clothing for the medical staff (Sterile drapes, gowns, gloves)
  • A certain solution used to protect the heart muscle during surgery (Cardioplegia)
  • Special ultrasound equipment to look at the heart (Echocardiography ultrasound)
  • A device used to measure pressures in the heart and large blood vessels (Swan-Ganz catheter)
  • A special saw to cut through the sternum (Sternotomy saw)
  • All necessary instruments and supplies used in surgery, including stitches (sutures) and small amounts of material often used to reinforce sutures (pledgets)

Who is needed to perform Nicks Procedure?

The Nicks procedure is a surgical method seen as simple and safe for increasing the size of the back part of the heart. This is because it steers clear of the tough area between the aortic valve (which helps blood flow out from your heart to your body) and the front leaflet of the mitral valve (responsible for controlling the blood flow within the heart). Also, this procedure doesn’t need to go into the left atrium (one of four chambers in your heart). But, it’s important to note that an experienced and skilled surgeon is needed to perform this operation.

Now, running successful surgery like the Nicks procedure needs a dedicated team with a range of experts. Here they are:

  • A cardiac surgeon, who’s a doctor specializing in heart operations.
  • An anesthesia team, who make sure you are asleep and pain-free during surgery.
  • A cardiologist, who is a heart specialist, usually assisting or advising the surgeon on the intricacies of the heart and the operation itself.
  • OR nursing staff, these are nurses who assist in the operating room or theatre.
  • An assistant, often referred to as the ‘first assistant’, who primarily assists the cardiac surgeon in the operation.
  • A perfusionist, who manages the heart-lung machine. This machine keeps blood pumping through your body when your heart is stopped for the surgery.
  • Scrub techs, who ensure the operating area is sterile and pass instruments to the surgeon.
  • And finally, echo techs, who operate the echocardiogram equipment. This machine uses sound waves to create pictures of your heart, showing how it’s working in real-time during the surgery.

In short, every person in this team plays a crucial role to ensure your surgery goes smoothly and successfully. They all work together to look after your health during and after the operation.

Preparing for Nicks Procedure

Before an operation on the aortic root (the part of the heart where the main artery, the aorta, is attached), doctors use imaging scans to identify if it’s too small. These could be echocardiography (a scan using soundwaves), CT (a type of X-ray that gives a detailed image), or MRI (an imaging technique that uses magnetic fields). These scans also help to decide the smallest size of the new artificial aortic valve that can be used to prevent future problems. This is based on the patient’s body size, using established measurements.

Imaging also helps to check for other potential issues that might need to be addressed during the surgery. For instance, it may show any signs of narrowing under the aortic valve (subaortic stenosis), so that this can be remedied during the operation if necessary. It could also help to determine if there’s a need for a procedure to improve blood flow to the heart (coronary artery bypass graft), using additional tests.

When the surgery starts, the surgeon makes an opening in the breastbone (median sternotomy). When the protective layer around the heart (pericardium) is opened, part of it may be removed and treated with a chemical (glutaraldehyde) for use later in the operation to enlarge the aortic root. Next, tubes are put into the heart for circulation and emptying the left ventricle (cannulation and venting). The surgeon then makes an incision in the main heart artery and removes the valve leaflets.

The surgeon then measures the removed valve using specially designed tools (sizers). If the smallest size that would prevent a mismatch between the patient’s body size and the new valve can’t be achieved, the aortic root may need to be enlarged.

How is Nicks Procedure performed

The patient is moved into the operating room. They are fitted with various medical equipment such as, Cordis, Swan Ganz, and an A-line. These are different types of catheters used to monitor heart health during the surgery. The surgeon then makes an incision in the middle of the chest, called a midline sternotomy, dividing the thymus; a small organ located in the upper chest and accessing the sac that surrounds the heart, known as the pericardium. The blood thickening medicine, Heparin, is administered, and the clotting time is monitored.

The aorta, the main artery that carries blood away from the heart, is then identified. The surgeon selects a spot for the cannulation process, which allows a thin tube to be inserted to deliver medicines or drain fluids. Then, the aorta is cannulated, and venous bi-caval cannulation, a procedure where two venous catheters are placed in the main veins that lead to the heart to drain the blood from the heart, is performed. At this point, a vent catheter can be inserted to help drain any fluid or air in the heart. The patient is then cooled to a certain temperature to decrease the body’s metabolic activity, protecting organs from potential harm.

Once the patient reaches the desired temperature, a clamp is placed on the aorta to temporarily halt the blood flow. A cardioplegia solution that stops the heart is then administered, to perform the surgery safely.

An oblique incision is made in the aorta to replace the aortic valve. This incision extends into an area of the heart called the non-coronary sinus. The incision can be extended towards the aortic valve, but not through it, as widening the tip with the pericardium (a membrane that envelops the heart), allows a larger valve replacement. Extending the incision beyond the aortic valve and onto the upper part of the mitral valve can make room for an even larger valve replacement.

Once the incision is across the aortic valve, it is guided towards the middle of the anterior leaflet of the mitral valve, another one of the four valves of the heart. A patch of the patient’s tissue or cow’s pericardium is stitched to the base of the incision with a 4-0 polypropylene suture, a synthetic absorbable thread. The broader end of the patch is kept at the top.

After the suture line is complete above the divided aortic valve, the artificial valve is stitched in with 2-0 pledged mattress separate sutures. These stitches are taken full-thickness from outside the patch to the inside. The remainder of the patch is used to facilitate closure of the aorta. It’s critical to examine the movement of the leaflets (flaps inside the heart valves that open and close to regulate blood flow) thoroughly because there might be a restriction when a mechanical bileaflet prosthesis (a type of artificial heart valve) is inserted. Sometimes, it may be necessary to rotate the artificial valve to get optimal closing of the valve.

Possible Complications of Nicks Procedure

Studies have found that aortic root enlargement techniques, like the Nicks procedure, can be performed easily and without added risks for patients. Generally, patients who have their aortic root enlarged may have a greater risk of critical health issues during surgery compared to patients who don’t have the enlargement. But interestingly, this higher risk didn’t make a significant difference when patients who had other simultaneous procedures were excluded from the study.

It’s noteworthy that even though patients with an enlarged aortic root had longer cardio-pulmonary bypass time (kind of like a heart-lung machine time) and their aortas were clamped off for longer (a process during the surgery), they didn’t have higher rates of heart attacks, strokes, the need for a permanent pacemaker due to complete heart block (a severe type of heart rhythm issue), or the need for reoperation due to bleeding.

In fact, these patients showed better outcomes in other areas: they had a higher average amount of blood flow through the valve area (known as iEOA) and a lower overall rate of patient-prosthesis mismatch (PPM). This is a situation when the artificial valve doesn’t exactly match the patient’s body, which could limit the amount of blood the heart can pump out.

What Else Should I Know About Nicks Procedure?

Choosing the right kind of medical treatment for a small aortic root is dependent on many factors. This is a condition where the main blood vessel leading out of the heart is smaller than normal. When making a treatment decision, important factors to consider are age, body size, the size of the aortic root, the size of the man-made valve that will replace the natural heart valve, and the specific characteristics of each patient’s heart.

To make the best choice, doctors calculate a number called the indexed Effective Orifice Area (EOA/BSA). This number describes how well blood can flow through the new valve. If this number is less than 0.85, this could lead to more pressure over the new heart valve, which can cause a condition called patient-prosthesis mismatch (PPM). This mismatch can affect how well the heart can pump and can potentially lead to arrhythmias (irregular heartbeats), heart failure, and even increase the risk of death. This shows why it’s so important to select the right valve for each patient.

On the other hand, if the number calculated is greater than 0.85, this is a good sign as it can lead to a healthier heart function over time.

One of the ways to manage a small aortic root is by performing surgery to enlarge the aortic root. This approach is designed to improve the heart’s performance after the operation. However, if a small artificial valve is used in the heart, it can lead to symptoms similar to “aortic stenosis”, which mimics the condition where the heart’s valve narrows. Furthermore, using a prosthesis (an artificial part to treat a disease) that doesn’t fit well with the patient (PPM) may lead to increased risk during surgery and overall mortality. The more severe the mismatch, the larger the impact on the patient’s health and lifespan, sometimes even making the operation counterproductive and potentially harmful.

Frequently asked questions

1. What is the purpose of the Nicks procedure and how will it benefit me? 2. Are there any risks or complications associated with the Nicks procedure? 3. How will the size of the artificial valve be determined and what factors will be considered? 4. Will I need any additional procedures or treatments after the Nicks procedure? 5. How experienced are you in performing the Nicks procedure and what is your success rate?

Nicks Procedure aims to increase the size of the aortic valve if it is too small. It involves making a careful cut through the non-coronary leaflet without disturbing the tough tissues between this valve and another heart valve, called the mitral valve. If you have a small aortic valve and undergo Nicks Procedure, it can potentially improve blood flow and prevent issues with heart function, ultimately reducing the risk of illness and death.

Nicks Procedure, also known as Nicks Repair, is a surgical procedure performed to repair a tear or laceration in the eyelid. It is typically used to treat eyelid trauma or injuries, such as cuts or puncture wounds. There are several reasons why someone may need Nicks Procedure: 1. Eyelid Trauma: If you have experienced an injury to your eyelid, such as a cut or tear, Nicks Procedure may be necessary to repair the damage and restore the normal function and appearance of the eyelid. 2. Cosmetic Concerns: In some cases, Nicks Procedure may be performed for cosmetic reasons. If you have a noticeable eyelid deformity or asymmetry, this procedure can help improve the appearance of your eyelids. 3. Functional Impairment: Eyelid injuries can sometimes lead to functional problems, such as difficulty closing the eye properly or protecting the eye from debris. Nicks Procedure can help restore normal eyelid function and prevent complications. 4. Prevention of Infection: If the eyelid injury is deep or involves a puncture wound, there is a risk of infection. Nicks Procedure can help clean and close the wound, reducing the risk of infection and promoting proper healing. It is important to consult with an ophthalmologist or an oculoplastic surgeon to determine if Nicks Procedure is necessary in your specific case. They will evaluate the extent of the injury and recommend the most appropriate treatment option for you.

Someone should not get Nicks Procedure if they have a history of allergic reactions to the anesthesia used during the procedure or if they have a medical condition that makes them a high-risk candidate for surgery.

The text does not provide specific information about the recovery time for the Nicks Procedure.

To prepare for the Nicks Procedure, the patient should undergo imaging scans such as echocardiography, CT, or MRI to determine if the aortic root is too small. These scans also help determine the appropriate size of the new artificial aortic valve. The patient should also consult with a dedicated team of experts including a cardiac surgeon, an anesthesia team, a cardiologist, OR nursing staff, an assistant, a perfusionist, scrub techs, and echo techs to ensure a smooth and successful surgery.

The complications of the Nicks procedure are not mentioned in the given text.

The text does not provide specific symptoms that would require the Nicks procedure. It only mentions the circumstances in which the procedure may be recommended, such as when the aortic root is small, hardened, or has calcium deposits, or when a patient may need a valve-in-valve procedure.

There is no specific information provided in the given text about the safety of the Nicks procedure in pregnancy. Therefore, it is not possible to determine whether the Nicks procedure is safe in pregnancy based on the provided information. It is recommended to consult with a healthcare professional for personalized advice regarding the safety of any medical procedure during pregnancy.

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