Subtheme 1:Respiratory discomfort.

Respiratory discomfort was predominantly reported in the early postoperative period, manifesting as cough, chest tightness, dyspnea, and throat irritation—reflecting both surgical trauma and adaptive physiological changes.

1. (1) Cough:

Eight patients described postoperative cough, primarily characterized as irritative dry cough. Precipitating factors included positional changes, prolonged speech, and nebulization therapy. Concurrent back pain was reported by some, with symptoms persisting 3–5 days on average and gradually resolving with recovery. Among smokers, withdrawal-related cough was a potential contributing factor.

“Two days after being transferred out of the care unit, I felt the urge to cough. It was just a dry cough with no sputum” (P08).

“If I sit in the wrong position, stay in one position for too long, or talk for a long time, I have to cough immediately” (P01).

“Sputum couldn’t be coughed up—there was sputum, but it was difficult to expectorate, and the sputum that came out was like mucus”“After I cough, both sides of my back hurt.” (P10).

“The cough has lasted for four to five days, and it is slightly better now” (P05). “The cough symptoms are getting increasingly mild” (P06).

“I used to smoke. If I go days without one, I might also get withdrawal symptoms like this cough.”(04)

1. (2) Chest tightness and shortness of breath

Chest tightness usually has to do with things like pleural effusion, and it comes with a general feeling of discomfort. Shortness of breath usually starts around a week after surgery—it’s a new post-op symptom for some patients.

“ A few days ago, I felt tight in my chest. And when I did, I felt unwell all over. The doctor did an ultrasound, and there’s a little bit of pleural effusion. The doctor said this kind of thing can also cause chest tightness, and I’m much better now.” (05)

“Around a week or so after surgery, I started feeling a little short of breath.” (P07)

Subtheme 2: Discomfort in the pharynx and oral cavity.

Postoperative pharyngeal and oral discomfort primarily involved the pharynx, oral mucosa, and swallowing-related structures, categorized into four subtypes: pharyngeal irritation, thirst, oral ulcers, and dysphagia with a choking sensation.

1. (1) Pharyngeal Discomfort

Manifestations included dry throat, soreness, hoarseness, and a foreign body sensation, primarily attributed to endotracheal intubation. Symptoms were self-limiting and resolved within days.

“After the endotracheal tube was removed,I lost my voice. Subsequently, I developed hoarseness that persisted for one to two days before gradually resolving. My voice has now nearly returned to normal.” (P02)

“While in the intensive care unit (ICU), I experienced significant throat discomfort and a persistent sensation of a foreign object. These symptoms improved after I was transferred from the ICU.” (P07)

1. (2) Thirst

Three patients reported severe thirst, characterized by an intense subjective desire for fluids, exacerbated by medically mandated fluid restrictions. Many described it as one of the most distressing symptoms.

“The most unbearable symptom after surgery was thirst—an extreme, overwhelming dryness. I felt I could instantly finish three more bottles of water, but I had to comply with the medical team’s guidance on fluid management.” (P03)

“Thirst was the most severe issue. I had a constant, intense desire to drink throughout the day, yet I understood that adhering to the fluid restriction protocol was crucial for my recovery.” (P07)

1. (3) Oral Ulcers

One patient developed oral ulcers causing severe swallowing pain and subsequent dysphagia.

“I developed an ulcer in my mouth that caused extreme pain, making it impossible for me to swallow any food.” “The symptoms persisted for over ten days before significant improvement was observed.” (P04)

1. (4) Feeling of Pharyngeal Obstruction During Swallowing

One patient reported a feeling of pharyngeal obstruction during swallowing postoperatively. Its main manifestation was “choking sensation while eating,” without accompanying coughing. The sensation of obstruction is directly related to eating speed and the amount of food taken in a single bite, and the symptom can be effectively alleviated by adjusting eating methods.

“These days, I have been a bit prone to choking while eating. Suddenly, when I ate a little bit of apple, I choked.” “Sometimes I also choke when I eat,” “I don’t cough when eating, just choke.” “When I choke, I can drink some water, and then I can swallow the food down.” “I need to eat slowly, taking small bites at a time, and then I won’t choke.” (P07)

Subtheme 3: Circulatory discomfort.

Four patients reported circulatory discomfort.Postoperative circulatory discomfort was primarily manifested as palpitations, encompassing tachycardia and arrhythmias. These symptoms frequently emerged in the early postoperative phase, with some cases exhibiting a correlation with a pre-existing history of atrial fibrillation.

“After I got moved to the ward, the first two days—especially the first day—my heart was beating so fast. It was like I’d just run 1500 meters, felt like my heart was gonna jump right out of my chest. The second day was a little better than the first.” (P04)

“I have atrial fibrillation. When I get up and walk around, I feel a little flustered.” (P02)

“It feels like my heartbeat’s a bit all over the place.” (P10)

Subtheme 4: Digestive and excretory issues.

The postoperative digestive and excretory problems in patients with valvular heart disease are mainly manifested as anorexia, constipation, and abnormal urination.

1. (1) Anorexia

Eight patients reported early postoperative anorexia, marked by reduced appetite and food intake. Some developed taste preferences or swallowing-related restrictions.

“During the first three days after I was transferred out of the ICU, I basically had no desire to eat at all. I could only eat a little fruit and some eight-treasure porridge—those were the only things I could have a bit of; I couldn’t stand anything else.” (P09)

“Now my food intake is half of what it was before the surgery. Before, the total amount of vegetables and rice I ate across three meals might have been 1.5 kilograms, but now it’s probably at most 0.5 kilograms, and I might not even reach that amount.” (P10)

1. (2) Constipation

Constipation is a common short-term excretory problem after surgery and can be alleviated with recovery.

“A few days ago, having a bowel movement or urinating was difficult, but now it’s easy.” (P05)

“I feel that during the recovery period after surgery, having a bowel movement is quite difficult.” (P06)

1. (3) Abnormal urination

In the immediate postoperative period, some patients exhibited transient reduced urine output. This condition was occasionally accompanied by subjective reports of chest tightness. A trend of spontaneous improvement in urinary output was observed alongside overall clinical recovery.

“When my urine output is low, I feel chest tightness and then discomfort all over my body.”

“My urine output was also very low yesterday, but it’s okay today.” (P05)

Subtheme 5: Surgery-related pain.

Seven patients reported postoperative wound pain. The nature of the pain was diverse, including cramping pain, stabbing pain, burning pain, and pulling pain. Activity, coughing, and position changes were the main triggering factors. Some patients experienced pain with temporal regularity, and there were significant individual differences in pain intensity.

“The inside of the wound feels like it’s cramping.” (P03)

“When I walk, my wound hurts a little” and “When the wound is pulled, it hurts.” (P08)

“My wound hurts. The first time, the pain was extremely severe—it felt like being stabbed with a knife, and there was also a burning sensation.” (P09)

“My wound hurts every night around 12 o’clock, as well as in the morning —it’s really uncomfortable.”(P14)

Subtheme 6: Fatigue and weakness.

A prevalent symptom, characterized by generalized weakness, reduced activity tolerance, drowsiness, and diminished motivation. Ten patients in this study reported experiencing fatigue and weakness.Exacerbated by blood draws, chest tightness, or psychological distress, it improved with mild activity.

“Right now my body’s still weak and needs to recover—I can’t walk fast, and I can’t run around like I used to” (P01);

“After the surgery, I always feel lifeless—I don’t have the energy for anything” (P03),

“I often feel tired. After the surgery, when I walk—even just 70 meters—I start to feel a bit tired. And I also often feel like sleeping, so I’ll rest then” (P08);

“I feel fine if I don’t have blood drawn, but as soon as I do, I feel even more tired” and “When I have chest tightness, the feeling of fatigue gets worse” (P11).

Subtheme 7: Sleep disturbance.

Six patients reported poor sleep: shortened duration, frequent awakenings, and light sleep, particularly in the ICU. Contributing factors included environmental disruptions and pain; pre-existing sleep issues worsened postoperatively.

“I just lie there with my eyes closed. For almost three nights in a row, I only slept two or three hours and then couldn’t fall back asleep” (P05)

“I was in the ICU for two nights. After the tube was removed, I couldn’t sleep at all—every time I closed my eyes, the nurses would come to resuscitate another patient” (P07)

“I usually try to sleep around 8 o’clock, but I wake up again around 11 or 12. Once I’m awake, I can’t go back to sleep, and then I just end up feeling groggy. Anyway, that’s how it is—my sleep is poor” (P10)

“My sleep is bad. I’m not used to the bed, and I have some overall body aches that make me uncomfortable” (P13)

Subtheme 1: Intrinsic psychological adaptation state.

Intrinsic psychological adaptation can be categorized into two distinct types: positive adaptation and negative adaptation, reflecting patients’ psychological resilience and distress, respectively, following surgery.

1. (1) Positive Intrinsic Psychological Adaptation

Positive adaptation is manifested through spontaneously generated positive emotions—such as freedom from anxiety and optimism—as well as constructive cognitions regarding postoperative recovery and self-perception. It reflects an inherent psychological resilience and a tendency toward positive thinking, which can develop independently of external support or guidance.This also reflects the interaction between physical symptoms and psychological symptoms.

“I’ve never felt anxious or worried at all. Even when I felt unwell, I didn’t worry much.” “I’m not anxious at all—anyway, you can’t avoid it; you have to have this surgery eventually.” (P04)

“I just think things will definitely get better.” “It’s okay if it’s a bit slow—overall, I’m getting better day by day, and we can see hope.” “I’m very optimistic, and I cherish my life a lot.” (P06)

1. (2) Negative Intrinsic Psychological Adaptation

Negative adaptation is characterized by spontaneously arising negative emotions, such as fear and psychological stress. It often stems from limited understanding of one’s symptoms, concerns about surgical risks, or internal distress caused by postoperative physiological changes, reflecting a state of psychological difficulty in adjustment.

“Sometimes I feel a bit of chest tightness, and we don’t understand the medical field at all—so we felt a bit scared.” (P05)

“When my heartbeat is irregular, I feel a bit of psychological burden.” (P10)

“We all know that there are indeed risks after valve replacement, and my mindset was really bad during that time.” (P03)

“I had ventricular tachycardia (VT) twice—back then, I was really stressed out and didn’t dare to sleep at night.”(P08)

Subtheme 2: Emotional reactions triggered by external situations.

1. (1) Clinician-Related Situational Responses

Patients’ perception of a medical institution’s professionalism can strengthen their trust and confidence in treatment. Positive clinician-patient interactions—including personalized care and encouragement to participate in treatment decisions—help patients build a psychology of feeling medically supported. However, when certain clinical plans (e.g., concurrent intravenous infusion and water restriction) conflict with patients’ basic physiological needs, psychological stress and negative emotions may arise.

“Because I know this illness isn’t a big deal here at our Gulou Hospital.” (P04)

“I have confidence in my recovery—the nurses and doctors all care about us this much.” (P06)

“The IV infusion starts at 7 a.m. and goes on until 3 p.m. I just keep thinking: they won’t let me drink water, but they’re still giving me so much IV fluid.” (P06)

1. (2) Family-Related Situational Responses

These refer to patients’ psychological reactions to family as an external emotional support system, including fears about poor prognosis arising from family responsibilities and emotional distress due to separation from relatives.

“I think about my two kids—they’re in their early 20s. What if I can’t move anymore?” (P03)

“I miss my wife and kids.” (P06)

1. (3) Responses Related to Reliance on Medical Technology

These encompass feelings of security derived from technical support, or anxiety due to its absence, reflecting patients’ psychological dependency on medical technology and the clinical environment as external safety conditions.

“Now that I have the pacemaker implanted, I feel at ease—I can sleep whenever I want.” “What I’m afraid of right now is changes in my heart rate. If I don’t have a defibrillator, there’s nothing to provide protection for me. Even if I get one and might not even use it, I’ll still feel safer in my heart.” (P08)

“If they let me go home, I think I’ll still feel a bit scared to leave the hospital.” (P08)

Subtheme 1: Experience of cognitive function changes.

Two patients exhibited postoperative changes in cognitive function, primarily characterized by cognitive disorientation, hallucinatory experiences, misidentification of others, and persecutory delusions. These alterations emerged in the early postoperative phase (during ICU stay). Anesthetic effects were identified as an initial trigger for cognitive changes in certain patients. The symptom duration was 2 days for Patient 01 and 5 days for Patient 14. Subsequently, both patients showed gradual symptom alleviation, and cognitive function had returned to normal by the time of interview.

“There was a period when I felt really confused, especially after the anesthetic took effect. The symptoms were most obvious at night—it felt like I was trapped in a hallucinatory state.” (P01)

“I mistook other people for family members, and I couldn’t control myself... I heard someone saying that someone was coming to kill me, and my mind just wouldn’t calm down.” (P14)

Subtheme 2: Cognition of symptoms.

Patients with valvular heart disease demonstrated distinctive perceptions regarding postoperative symptoms, reflected in the following aspects: a general belief that surgical trauma inevitably leads to symptoms such as pain and fatigue; varying tolerance levels for different symptoms (e.g., pain vs. thirst); attempts to explore potential correlations between age and symptoms such as fatigue and anorexia; and a tendency to anticipate long-term adjustment after discharge when facing appetite-related issues.

“Later, I thought—this surgery cuts from the outside to the inside, so it must hurt. When I think about it, how could it not hurt?” (P10)

“From our perspective, this is unavoidable too. If we take a knife and cut ourselves, that wound hurts for days—let alone such a big surgery.” (P03)

“This is normal too. If you have such a big surgery, you’ll definitely feel tired.” (P05)

“I can bear a little pain, but thirst is really unbearable.” (P03)

“Older people tend to have this feeling of fatigue and anorexia, right?” (P06)

“I can’t eat—there’s nothing I can do. I just have to go home and adjust slowly.” (P12)

Subtheme 1: Passive behavioral manifestations triggered by symptoms.

Severe symptoms, particularly pain and palpitations, frequently compromise patients’ physical function, resulting in the forced interruption or modification of activities. These behaviors are inherently passive and reactive. For instance, P04 stated, “When I feel flustered, I just lie down for a bit”; this action represents a compulsory physiological response rather than a volitional choice. Similarly, P08’s mobility was significantly constrained by symptoms, as evidenced by the report, “only being able to walk a little less when my wound hurts.” A more extreme form of passive adaptation was described by P04: “When I was in the ICU... coughing irritated my wound and caused pain, so I could only press this area of the wound with my fingers.” This instinctive self-protective measure underscores patient vulnerability and the restrictive impact of acute symptoms in the absence of immediate medical intervention.

Subtheme 2: Active coping strategies for symptoms.

In contrast to passive responses, patients also demonstrated substantial initiative in implementing active coping mechanisms. These strategies are broadly classified into three types: independent non-pharmacological coping, pharmacological and medical intervention coping, and support-seeking behaviors.

1. (1) Independent Non-Pharmacological Coping

Patients commonly employed a range of self-management strategies to alleviate discomfort. To manage thirst, P03 exhibited willpower-based endurance and quantitative control (“If I prepare a small amount, I’ll drink less”), whereas P14 adopted a functional alternative behavior (“When I’m thirsty, I eat ice cubes”). Coping strategies for insomnia varied considerably, encompassing ineffective cognitive efforts (P06: “I started counting”), sleep initiation contingent upon physical exhaustion (P07: “When I’m exhausted and extremely sleepy, I’ll definitely fall asleep”), and an attitude of acceptance framed as “going with the flow” (P13). Regarding pain management, some patients (e.g., P14) emphasized tolerance (“I can bear the pain; I don’t want to take painkillers”), while others engaged in positional adjustments (P03: “I turn my body a little and use the pillow to slightly protect the wound”) or pursued proactive methods such as ambulation (P11: “Walking around and doing some exercise—recovery can help relieve chest tightness a bit”).

1. (2) Pharmacological and Medical Intervention Coping

Patients’ approaches to medical intervention were characterized by a combination of adherence and autonomous judgment. They typically complied with medical advice when perceived as effective, resulting in significant symptom relief. For example, after analgesic administration, P02 reported, “that night I slept well.” Conversely, interventions deemed ineffective were proactively discontinued, as illustrated by P06: “The sleeping pills didn’t work on the first day, so I stopped taking them the next day.” Similarly, negative feedback from healthcare providers prompted behavioral adjustment; after being advised that excessive fluid intake exacerbated shortness of breath, P07 stated, “Later I didn’t dare to drink water anymore, and I felt much better.” Furthermore, patients sometimes initiated personalized modifications to prescribed regimens, demonstrating self-efficacy within a framework of general adherence. A representative example is P01’s approach to using Chuanbei Loquat Syrup: “drink a little, not too much.”

1. (3) Support-Seeking Coping from Others

Social support constituted a critical component of symptom management. Patients addressed physical symptoms, such as difficulty expectorating, by soliciting physical assistance from family members (P06: “ask my family to pat my back”) or by accessing professional care (P10: “after I mentioned it to the nurse, the nurse helped me pat my back to clear phlegm”). Beyond practical aid, emotional companionship itself served as an effective coping mechanism. For instance, the presence of family mitigated psychological distress for P14, who experienced postoperative cognitive impairment: “my daughter came into the ICU to stay with me, and I felt better once she was there.” This highlights the therapeutic role of intimate relationships in alleviating the illness experience.

4.1.1 Respiratory discomfort: From surgical trauma to adaptive recovery.

Consistent with prior research, respiratory symptoms—irritative cough, chest tightness, and dyspnea—predominated in the early postoperative period [12,13]. Cough is the most prevalent clinical manifestation, with previous studies reporting an incidence rate exceeding 80%. Postoperative cough typically reaches its peak incidence between postoperative days 3–5 [14], a finding corroborated by our current investigation.Participants described position-dependent coughing and phlegm retention, aligning with mechanisms such as endotracheal intubation-induced airway irritation, reduced functional residual capacity, and pleural effusion impairing gas exchange [13]. Dyspnea, primarily attributed to heart failure and pulmonary hypertension, is a typical preoperative symptom in patients with valvular heart disease [15], and it often persists or recurs postoperatively as a common manifestation of multiple pulmonary complications (including atelectasis, pleural effusion, and pneumonia). In the present study, pleural effusion was confirmed in patients who developed dyspnea. Notably, some attributed lingering cough to smoking withdrawal, emphasizing the need to differentiate surgical sequelae from pre-existing habits during symptom assessment.

4.1.2 Discomfort in the pharynx and oral cavity: A multifactorial postoperative symptom complex.

Pharyngeal and oral discomfort is a common postoperative symptom cluster following cardiac valve surgery, comprising four subtypes: pharyngeal irritation, thirst, oral ulcers, and dysphagia with a choking sensation. Pharyngeal irritation manifests primarily as pharyngeal dryness, sore throat, hoarseness, and foreign body sensation, and typically resolves spontaneously within a few days [16]. Thirst, characterized by an intense need for fluids, exhibits a remarkably high prevalence after cardiac surgery and significantly impairs patients’ experience and quality of life [17]; indeed, several patients in this study described it as the most unbearable symptom. Oral ulcers, though less frequent, cause substantial swallowing pain due to mucosal barrier disruption, perioperative vitamin deficiencies (e.g., B-complex, vitamin C), and ICU-related mechanical friction. If untreated, these ulcers may delay recovery [18]. Dysphagia with a choking sensation, one of the most distressing subtypes, is often self-managed by patients through strategies such as slowing their eating pace and reducing portion sizes. A recent study reported that 14.8% of patients undergoing cardiac surgery experienced dysphagia [19], a finding consistent with our observation that this symptom was prevalent in our cohort.

Traditional clinical thinking often frames these symptoms as isolated events: sore throat is typically attributed to endotracheal intubation. However, a growing body of indirect evidence suggests that these four symptoms—sore throat, thirst, oral ulcers, and dysphagia with choking sensation—not only exhibit a high incidence in patients following cardiac valve surgery but also demonstrate significant overlap in onset time, potential triggers, and mutual pathophysiological influence [20–22]. For instance, prolonged endotracheal intubation is not only a direct cause of postoperative sore throat but also a key risk factor for inducing dysphagia. Additionally, thirst resulting from inadequate postoperative fluid replacement, coupled with xerostomia, can exacerbate pharyngeal irritation and may compromise the mucosal barrier function, thereby elevating the risk of oral ulcers. This phenomenon implies that conceptualizing these symptoms as an interconnected “symptom cluster” may offer greater clinical guidance than managing each symptom in isolation.

4.1.3 Circulatory symptoms: Arrhythmias, palpitations, and the mind-body feedback loop.

Palpitation, defined as an unpleasant awareness of abnormal cardiac rhythm (e.g., tachycardia, bradycardia, irregularity, or forceful beats), is one of the most common chief complaints among postoperative patients and often indicates underlying arrhythmias. Postoperative arrhythmias—particularly atrial fibrillation (AF), the most frequent subtype—are closely associated with palpitation and represent a major clinical concern: they not only prolong hospital stays and increase medical costs but also correlate with severe adverse outcomes, including hemodynamic instability, exacerbated heart failure, elevated thromboembolic risk (especially stroke), and even sudden cardiac death [23,24]. This phenomenon driven by key pathophysiological mechanisms: myocardial ischemia (which disrupts atrial electrical remodeling), electrolyte imbalances (e.g., hypokalemia, which impairs cardiac conduction), and sympathetic overactivation (which increases atrial excitability) [25–27].

For participants like P02 (“My heart felt like it was leaping from my chest”), palpitations exacerbated fatigue and anxiety, creating a self-perpetuating cycle where physical symptoms fuel psychological distress and vice versa. This interplay necessitates holistic management: pharmacological control of arrhythmias paired with psychological support to mitigate anxiety-related tachycardia. As one participant noted, “Walking eases chest tightness,” graded activity tailored to cardiorespiratory fitness could serve dual roles—physical rehabilitation and psychological coping.

4.1.4 Gastrointestinal and excretory issues: Nutritional recovery and hydration dilemmas.

Reduced appetite, a major barrier to postoperative recovery, can result in insufficient caloric intake, muscle atrophy, and immunosuppression. These issues not only prolong hospital stays but also increase mortality rates, with up to 25.7% of malnourished patients dying [28].

The causes of appetite loss are multifactorial, including inflammatory responses [29], cardiac insufficiency, mechanical ventilation effects, and psychological distress from anxiety or depression [30]. This study shows that most patients recognize the importance of postoperative nutritional support, collaborate actively with healthcare teams, and adapt individualized strategies to improve their nutritional status. Therefore, healthcare providers should conduct early nutritional risk assessments and implement multidisciplinary interventions tailored to each patient’s condition.

4.1.5 Pain, fatigue, and sleep disturbances: A vicious cycle of interrelated symptoms.

Postoperative pain presents diverse manifestations (cramping, stabbing, burning) triggered by activity or position changes. The intensity and duration of pain vary from person to person but are universally prevalent. Studies have shown that many patients still experience moderate to severe pain for weeks or even months after surgery [31]. Frailty is prevalent among patients undergoing cardiac valve surgery; a study demonstrated that approximately 18% of patients presented with frailty at discharge [32]. Studies have reported that approximately 50% of patients undergoing cardiac surgery experience sleep disorders during hospitalization, and this problem may persist for weeks, months, or even longer [33].

These three symptoms are not mutually exclusive; instead, they form an intertwined, complex vicious cycle that severely hinders patients’ functional recovery, mental health, and overall well-being. Postoperative pain acts as a direct barrier to early mobilization and sleep [31]. Frailty, induced by physiological and psychological stress, impairs patients’ capacity to manage pain and facilitate recovery [32]. Furthermore, sleep deprivation or poor sleep quality not only amplifies pain perception but also delays tissue repair and may trigger or exacerbate negative emotions such as depression and anxiety [34].Our study has also identified the phenomenon of the intertwining of these symptoms.