Friday, February 10, 2012 - Noon
As one of the largest, most experienced cardiac and thoracic surgery groups in the world, our surgeons offer virtually every type of cardiac surgery. We specialize in very complex cases as well as groundbreaking surgeries procedures, such as minimally invasive and robotically assisted cardiac surgery. Dr. Marc Gillinov, cardiac surgeon and co-author of Heart 411 and Dr. Edward Savage, cardiac surgeon, Cleveland Clinic Florida answered your questions.
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Minimally Invasive Heart Surgery
JRB: Do you have surgeons at CC experienced with "minimal invasive" or "mini thoracotomy" approach to AVR... (not referring to TAVI)...??
Dr__Gillinov: We do both right mini-thoracotomy and partial upper sternotomy. Each involves about a 3 inch incision. We base the approach on the preoperative tests.
dcherie: I have heard that some people are not candidates for the minimally invasive procedure on the heart valves. Can you tell me which people would not be candidates?
Dr__Gillinov: People who need bypass surgery, people with very complicated valves and people with previous surgery may not be candidates for less invasive valve surgery. The goal is to provide the safest and most effective procedure for each person
Ashamathai: Is robotic surgery or minimally invasive surgery an option for patients with bi-leaflet prolapse? I have heard that repairing both leaflets is more complicated, and therefore, robotic or minimally invasive would not be considered as an option
Dr__Gillinov: Most people with bileaflet prolapse can have robotic surgery - the choice of approach depends on preoperative testing. We choose the approach to optimize safety.
broccoli54: would breast implants interfere with minimally invasive or robotic mitral valve repair?
Dr__Gillinov: We have operated on many women with breast implants - we work with a plastic surgeon and can usually provide a minimally invasive approach with an excellent cosmetic result.
Mitch: Dear Dr. Gillinov, have you done a robotic or minimally invasive surgery of Ostium Primum ASD with mitral valve cleft? If not, do you think that this is doable and on what does this depend?
Dr__Gillinov: We would consider repairing ostium primum defect and cleft mitral valve via robot. But it depends on preop testing and patient characteristics.
Mitral Valve Disease and Surgery
JOLLYRANCHER: I was diagnosed with mitral valve prolapse problem 1n 1996. Now the Dr is thinking this could be an electrical problem, but no recent tests have been done. I do not take any medication for this. My symptoms are starting with pressure in the neck going into my head, resulting in light headed & headache & weak. Have you had any recent updates on this issue?
Dr__Gillinov: I would see an electrophysiologist, a kind of cardiologist who deals with heart rhythm issues.
RHAZ77: In determining the timing of mitral valve repair surgery in an asymptomatic patient with moderate mitral regurgitation and ejection fraction > 60%, what would be the major factors that would lead to determining when to have surgery? Is the mere passage of time a risk factor and have you ever seen situations where no indications for immediate surgery presented themselves for long periods (say 10+ years)? Does physical fitness play a part in how fast symptoms occur--in other words would exercise help in any material respect? Thanks
Dr__Gillinov: We would only recommend surgery in a patient with severe mitral regurgitation. Moderate regurg can persist for years and may never progress. Exercise is good for you and good for your heart and will not hurt your mitral valve.
MVR: What is the most common reason for mitral valve repair failures within the first 60 days of surgery?
Dr__Gillinov: Early failures are usually due to technical issues like a torn stitch or weak heart tissue.
RHAZ77: If a chord rupture is a cause of mitral valve regurgitation that is moderate, is there more likely going to be a quicker progression to severe regurgitation than if the cause was just prolapse or can that condition of moderate regurgitation continue for a long time (10+years)? Thanks
Dr__Gillinov: Chordal rupture almost always causes severe regurg that eventually requires surgery.
broccoli54: if you have severe regurge with mitral valve would surgery be recommended if you don't have symptoms?
Dr__Gillinov: If the regurgitation is severe we usually recommend surgery because the valve is broken and it will eventually cause as serious problem.
RJBarn: I had a mitral valve repair last summer but later the valve repair failed. Since my symptoms are minimal, I have been advised to watch and wait. My only symptom is occasional lightheadedness or very mild pressure in the right eye area. Could the mitral valve regurgitation cause an oxygen deficiency in the head?
Dr__Gillinov: No - it can not cause oxygen deficiency in the head.
tractorgirl: I had mitral valve repair 6-2-11 with a diagnosis of severe Barlowe's disease (both leaflets and several chords were repaired). I haven't been able to find out much about Barlowe's except that the valve tissue is weak and stretchy. How might this affect the longevity of my repair? I am 59.
Dr__Gillinov: If the repair was initially successful, durability is usually excellent. At 10 years, 90% to 95% of valves still work well.
tractorgirl: After mitral valve repair I was instructed to take 85mg aspirin every day until the annuloplasty ring is fully endothelialized, about one year. Many valve patients I have talked to say their surgeons put all their valve patients on coumadin for three months. Is this for the same reason? What are the pros and cons of these two approaches?
Dr__Gillinov: Although we favor aspirin at Cleveland Clinic, there is little data to tell us whether aspirin or coumadin is the "best" choice. The idea is to prevent blood clots from forming on the annuloplasty ring (which is covered with cloth).
MVR: What amount of regurgitation after a mitral valve repair is tolerable and at what point is a "redo" considered necessary? If a redo is required what factors are considered when determining if another repair is possible of if a valve replacement is needed?
Dr__Gillinov: If someone develops recurrent mitral regurgitation that is severe, it is advisable to consider a reoperation.
temadden: In November of 2010 I had my mitral and tricuspid valves repaired. Less than a year later a transesophageal echo showed that the annuloplasty ring had come unstitched on one side resulting in severe regurgitation. My cardiologist feels that it is not dangerous, but it makes me more short of breath than I was before the operation. Prior to the operation I was informed of the risks of dying, stroke, or heart attack, but was not told the repair might last less than a year. What are the odds that this kind of failure would happen?
Dr__Gillinov: Three to 5% of repairs fail in the first 10 years. So - it is relatively uncommon. If your valve leaks severely and you have symptoms, we would usually recommend a re-operation. We may be able to re-repair your valve.
kcatgrg: I had my mitral valve repaired at Cleveland Clinic in 2010 and am doing very well. Two part question. First in your experience what is the percentage of repairs that need to be redone? Second, if a repaired mitral valve needs to be fixed again, what percentage of the time do you see it being rerepaired as opposed to being replaced?
Dr__Gillinov: Most mitral valve repairs last a lifetime. 10 years after surgery, 3 - 5% requires a reoperation. At 20 yrs, this figure is 6 - 10%.
When a reoperation is required we can re-repair the valve about 1/2 the time.
Kcatgrg: is a repaired mitral valve considered a week spot in the body for infection or only artificial valve replacements?
Dr. Savage: Repaired mitral valves can become infected but the infection rate is much lower then for a replacement valve
HCMGuy44: I have what my cardiologist calls peripheral venous insufficiency in my lower legs caused by my poor circulation due to my heart weakness because of my HCM, A Fib and Mitral Valve regurgitation. My legs, from mid calf down are real red and raw looking, swollen and heal very slowly if I get nicked. I'm taking 120 mg of Furosimide every day but it really doesn't help the swelling that much. I was told the blood is going down OK but my heart isn't strong enough to pump it back up. If I get the Mitral Valve, A fib etc. fixed, will this clear up my legs?? I have an appointment with Dr. Lever in 2 weeks.
Dr. Savage: This question is difficult to answer because we do not know the specifics of the case. However, I have seen patients with just this scenario of hypertrophic cardiomyopathy, mitral regurgitation and atrial fibrillation who experience dramatic improvement after surgery. This includes the swelling in the legs.
Kcatgrg: how often after a mitral valve repair do you need to get an echo? Every year or if things are staying stable every two years?
Dr. Savage: The current recommendation from the American Society of Echocardiography, which does not differentiate repair from replacement, is an initial echocardiogram after surgery, then no sooner than every three years unless there is a specific concern. For example, if there is a mild leak this should probably be monitored more frequently.
RHAZ77: For mitral valve regurgitation and normal blood pressure is it customary to put the patient on blood pressure medication and cholesterol medication during the watchful waiting period? Are there other medications recommended during the watchful waiting period? Thanks
Dr. Savage: There is no proven medical therapy to prevent the progression of mitral regurgitation though most cardiologists will place patients on drugs to reduce "afterload", the pressure the heart ejects against.
Kcatgrg: after a mitral repair does tissue grow around the annulus ring?
Dr. Savage: Yes, the endocardial tissue grows over and coats the ring with cells.
MVR: Is a person's life expectancy shorted if a mitral reoperation cannot be done and a valve replacement is needed?
Dr. Savage: I am not sure but I believe the questioner is asking if life span is shortened if the mitral valve cannot be repaired but has to be replaced. In general, if you need surgery for a problem with a mitral valve you will benefit from repair or replacement. Non-randomized comparative data suggests that it is best if the valve can be repaired. However, not all valves can be repaired. Though studies show better long term survival with repair, the slightly reduced survival after replacement has multiple causes. It may be related to problems the patient had prior to surgery that led to replacement instead of repair. The technique and type of valve used for replacement. Ideally the valve should be repaired if possible. No matter if the valve is repaired or replaced, if surgery is suggested you will receive significant long term survival benefit.
Tricuspid Valve Surgery
Masku: had MV repair at Cleveland 12 years ago, now tricuspid valve has major leakage and have recently contracted a-fib. what is urgency of Tricuspid repair operation and what are mortality/morbidity rates? also can maze procedure be done concurrently?
Dr. Savage: The atrial fibrillation may or may not be related to the development of tricuspid regurgitation. There are certain criteria for repair of the tricuspid valve mostly related to the function of the right ventricle and or the presence of symptoms. If otherwise healthy, the morbidity and mortality rates are low if operated on in a timely fashion. Historically rates of complications for tricuspid valve surgery have been high because patients were probably referred after the tricuspid regurgitation caused significant damage. Early signs and symptoms include shortness of breath, fatigue, abdominal or leg swelling. A Maze procedure can be performed at the same time if indicated.
Aortic Valve Disease and Surgery
ddavis: The selection of a mechanical aortic valve or biological type is made at the time of the surgery or previously in accordance with the conditions or patient preferences?
Dr__Gillinov: It is made pre-operatively in discussion with the patient and his or her lifestyle, age and willingness to take blood thinning medications (these are required with mechanical valves)
oakless: what are the life expectancies for an aortic valve replacement for patients with aortic regurgitation. Patient is 48 yrs and asymptomatic, EF currently 55%
Dr__Gillinov: If a person has severe AR, we recommend valve replacement or repair. Without valve surgery, life expectancy is severely reduced. With valve surgery life expectancy is excellent.
Stansil1: Average Duration of hosp. stay after AVR Surgery?
Dr__Gillinov: 4 - 6 days for isolated aortic valve.
karodonnelly: My mother is 81 with severe aortic stenosis. She is being managed with meds and has been told that she is too risk for surgery. Do you do the TAVI and would if be advisable to have her travel from Florida to CCF. I am her daughter and live in the area. Thanks, Dr. Gillinov for your time.
Dr__Gillinov: We do perform TAVI. Before making the trip, please send us her records. Please contact the Heart and Vascular Institute Resource Nurses to find out how to do this - so we can see if this is the best approach for her.
rosegradis: my question concerns transcatheter aortic valve replacement. am I a candidate for this procedure? I have had double bi pass 28 years ago, a stent implant 2 years ago and a pace maker?
Dr__Gillinov: Possibly. It depends upon your clinical condition. The transcatheter aortic valves are now approved, but only for the sickest patients.
wobwau51: Had my aortic valve replaced with a natural valve at Cleveland Clinic in July 2011 I am now working out at gym 1.5 hrs a day 5 days a week. Feel great. Question: I Will all this exercise cause my artificial valve to wear out prematurely?
Dr__Gillinov: No - keep exercising - it is good for you and your heart.
Zaius: Please describe the pros and cons of aortic valve repair vs. aortic valve replacement. I'm 46 and have a bicuspid aortic valve with accompanying aortic aneurysm. I'm having surgery at Mass General Hospital soon with an aortic graft and need to decide to repair or replace the valve. I'm particularly interested in the chances of needing another operation if repair is chosen vs. the side effects and administration of Coumadin if mechanical replacement is chosen. Thank you.
Dr__Gillinov: If you have isolated aortic regurgitation rather than stenosis, your valve may be repairable. If it is repairable, that is the best option.
cadman: I have a bicuspid aortic valve with stenosis. Echo in August 2011 showed LVOT Diam. 2.4 cm, PPG 41 mmHg, MPG 26 mmHg, AV area 1.1 cm sq. These measurements seem to be an improvement from a TEE done in March 2011 that showed LVOT 2.0 cm, PPG 58 mmhg and MPG 38 mmHG. BP is well maintained along diet modifications and CoQ10 supplements. I was told in August that my valve stenosis was severe but recent report shows "moderate". I am mostly asymptomatic with some slight fatigue occasionally. My question is it possible for these measurements to improve? and how do you feel about taking CoQ10 post surgery since I have read that is beneficial to heart healing post surgery? Thanks!
Dr__Gillinov: There is no evidence that COQ10 improves heart health. As for your aortic valve, aortic stenosis does not improve, but the measurements can vary a bit based upon technique and views. I would suggest another echo in about 6 months or sooner if you develop symptoms.
MsFit123: I am a 60 year old female. had AVR June 2010. My recent scan showed insufficiency in both my mitral & tricuspid valves. Prosthetic valve had no insufficiency. The scan noted 'mild' insufficiency. I am terrified of having to go through this surgery again....should I be worried about mild regurgitation in both of these valves? THANK YOU SO MUCH. Shannon
Dr__Gillinov: NO - mild regurgitation is common and will not hurt you. I would get an echo every year - but don't worry.
rabia: my patient is a known case of CLD secondary to HCV and is also having severe aortic regurgitation. We came to know about HCV in 1997.took regular Interferon but developed decompensation and had severe ascites after first dose so further doses were not given and spiromide was started after which ascites was subsided. EGD in Dec. 2010 show grade II varices .patient is asymptomatic for CLD right now but is quiet symptomatic for severe AR with dyspnea on exertion currently he is not taking any medication. we took opinion regarding his valve replacement surgery but they say it’s not possible with this stage of CLD. My patient visited India last week they say that we have to do both surgeries simultaneously and there is no other options but they have never done simultaneous surgery in past. These simultaneous surgeries carry lots of risk and they are done at your centre we can bring the patient I need your expert advice plz send me email address so that I can send reports thanx
Dr__Gillinov: Happy to help you - can you contact my office. 216-445-8841.
Sept14: For patients that need their bicuspid aortic valve replaced, and also have an aneurysm of the ascending aorta, what factors are considered when evaluating the aortic root? If the aorta normalizes before the root, is the normal course to leave the root alone? What advantages and disadvantages are there to both approaches (leaving the root in place or replacing it), specifically regarding surgical risk to replace and risk of future surgery if left alone?
Dr__Gillinov: If the root is significantly enlarged it should be replaced. If the root is of normal size and normal caliber at the time of surgery, it is ok to leave it alone.
jimhilbe777: Dear Dr. Gillinov, thanks for taking time out of surgery and book signing to chat with us today. My wife had the privilege of receiving AVR from Dr. Lytle on 7/24/2009. He replaced her BAV with an Edwards Magna Ease 3300TFX, 21 MM. I believe it got FDA approval just months prior to implantation, having been used in other countries for maybe 5 years. Question: Is there any date yet on how long it may reasonably be expected to last? Thanks, Jim
Dr__Gillinov: We believe that the Magna Ease is an excellent valve that will almost always last at least a decade and perhaps as long as 20 years.
Adourian: All echo results for my AVS are mild except AVA (Vmax) which is .8 and AVA ((VTI) which is 1.0. I understand these are results calculated from other measurements. Which one do you regard as the more precise result and is there a more precise way to determine valve area than through an echo?
Dr__Gillinov: Echo is best way to assess aortic valve. We use an integrated method that includes measures of valve area and gradient.
Cadman: Post AVR surgery with a biologic valve do patients require blood thinning medicines - if so, what meds and for how long?
Dr. Savage: There is some difference of opinion about anticoagulation after aortic valve replacement with biologic valves. In general after 3 months, no anticoagulation with warfarin is required however many surgeons recommend aspirin use. Some surgeons will recommend warfarin for the first few month after insertion but this is not a universal recommendation. I personally don’t recommend warfarin use to my patients after biologic aortic valve replacement unless they require it for other reasons.
Sept14: Have current aortic tissue valves been around long enough, and utilized in younger patients groups (30's and 40's) to allow surgeons to give a reasonable estimate of expected longevity? If so, what might be expected for valve longevity at the ages of 35 and 45?
Dr. Savage: Each valve company can quote exact data. In general, I tell patients in the 35-45 year age group that they will likely (>50%) require another procedure within the next 20 years. Valves fail for multiple reasons but in general fail faster in younger people. There are a few early failures then at about 8-10 years the rate of failure begins to accelerate. Modes of failure are also different. While pig and cow valves can become stiff and narrowed and fail gradually, a pig valve can also have sudden failure from a tear in the leaflet.
Razor: 5 years ago I had a defibrillator inserted partly because my ejection reaction had reached a level of 29. Now, after 4-5 year my ejection fraction is 46 and my doctor says it won’t be necessary to replace my aortic valve. What would your comments be?
Dr. Savage: I am afraid there is not enough information to answer this question
Primavera: I’m 61 and very fit working out 3-4 times/ week in the gym and always pushing the envelope; good nutrition. Over past year it was increasingly difficult to catch my breath; figured I was out of shape, so I just increased intensity and ended up with 3-4 episodes of being down on my back for 10 mins. to catch my breath; I was diagnosed w/bicuspid valve w/severe stenosis and an aortic root aneurysm (4.7 cm); want to have the surgery in no later than 3 weeks; trying to find out about latest techniques & technology that might make the surgery less invasive than the full blown open heart @ sternum,etc. And the 2nd ? is what is the latest in valves? The mechanical is out as I don't want to be on blood thinners. ( BTW, all else in cardio pulmonary & other organs is good to very good, or unremarkable)
Dr. Savage: You should have an aortic valve replacement and replacement of the ascending aorta. This may include replacement of the aortic root and may require replacement of the aorta up into the aortic arch. This can be performed through a minimally invasive upper (partial) sternotomy.
DAVID3352: OVER TIME (10 YEARS) DOES THE HEART GET WEAKER WITH A MECHANICAL AORTA VALVE? ANY EFFECTS?
Dr. Savage: A properly functioning mechanical heart valve should not weaken heart function over time. It should help preserve heart function.
Stansil1: In AVR----graft or prosthetic? Indications for each?
Dr. Savage: I am not sure what the patient is asking but believe the question is: What is the difference between a homograft valve and a bioprosthetic (pig or cow) valve?
A homograft valve is a valve taken from another human who has passed away. The tissue is processed and preserved. Historically the hope was that a homograft valve would be more durable than a bioprosthesis. However the homograft was not more durable. In general homografts are reserved to treat complex infections involving the aortic valve.
Sept14: I've read that the surgical risks for isolated aortic valve replacement are approximately 1% mortality and 1% stroke, with Cleveland Clinic possibly having even better success rates in recent years. Do you think aortic valve replacement will continue to become safer (lower mortality and stroke rates) over time, or is there a limit to how safe it can be due to the nature of the surgery (stopping the heart, bypass, etc)? Since the relatively new catheter valve technology potentially offers "convenience" to the patients in terms of long term recovery, do you think it's reasonable to think that one day catheter replacement will ever approach the safety levels of open heart and/or minimally invasive replacement?
Dr. Savage: Aortic valve replacement has become so safe that it will be difficult to further improve safety. Valves placed with catheter techniques demonstrate similar safety profiles. The current limitation of catheter placed valves is the quality of the result and limited information on durability. One of the problems noted with catheter placed valves is leaks around the valve. As technology improves more patients will benefit from catheter based aortic valve replacement.
LMS: What is the consequence of atrial fibrillation going into surgery and can it be treated at the same time?
Dr__Gillinov: At the time of surgery, we generally add a MAZE procedure to treat the afib while addressing the other heart problems. This procedure usually treats the atrial fibrillation.
grammarhodes: For someone with A-fib and 2 Amplatzer Septal Occluders and a left atrium that is growing in size, would some time of maze surgery be better than just attempts to control rate and/or rhythm? How dangerous is maze surgery?
Dr__Gillinov: The maze surgery would be advisable if the person is very symptomatic with the atrial fibrillation. The risk assoc. with maze is less than 1%
mackb: I'm 60, male, 6', 190 lbs, historically very fit, take no medications /supplements except Rapaflo, part of the Flomax family, for frequent peeing. 2 years ago, playing hockey I became very dizzy and almost fainted. I got a full physical with nothing found. Over the next year the same thing happened several times. A cardiologist gave me a series of tests and determined I had atrial fibrillation. He prescribed propafenone to be taken during/after attacks. 2 weeks ago I had to leave the hockey game I was playing. Last night my longevity was shortening on each shift, the dizziness accompanied each shift. My question...where is this going and what can be done?
Dr__Gillinov: If someone with atrial fibrillation has symptoms and medicines don't control them, it is appropriate to consider a catheter ablation. This is a non-surgical procedures performed by an electrophysiologist (special cardiologist).
jayp: In view of the low probability63% of being afib free after 2 or more ablations, is it worth the risk(10% PVstenosis)?
Dr__Gillinov: In expert hands, the risk of PV stenosis is 1% or less. If someone is highly symptomatic from atrial fib and medicines fail, it is worth considering ablation.
mitral2011: Dr. G, you performed a mitral valve repair on me Dec 8. After the surgery, I had some atrial flutter/fibrillation for a while. That has since cleared but my cardiologist has diagnosed me with atrial tachycardia due to a high heart beat. I am being treated with flecainide acetate and my heart beat is down to normal. Can you explain the differences between atrial fibrillation, flutter and tachycardia? Is flecainide an appropriate treatment? Are there risks to prolonged use of flecainide? My cardiologist would like me to be on the medication for a couple of months.
Dr__Gillinov: Flecainide is generally a very safe medicine and short term use should be no problem. As you get farther from surgery, the high heart rate will tend to go away on its own.
msflower: Does the heart muscle try to heal ablations that prevent a-fib.?
Dr__Gillinov: Ablations are designed to create scar tissue - surprisingly an ablation fails because the heart muscle heals.
DAVID3352: I AM A 70 YEAR OLD MALE AND I HAVE A TAA AT A SIZE OF 5.0 AND WILL HAVE TO HAVE OPEN HEART SURGERY IN THE ONE TO 6 MONTHS AND I WANTED TO KNOW HOW YOU COOL THE HEART AND BRAIN, AND THE LUNG PROCEDURE.?
Dr__Gillinov: we do often cool patients during heart surgery by cooling the blood as it moves through the heart lung machine. The location of the aneurysm determines our target temperature.
mherb: sir I have an aorta aneurysm that is a 4.9 and the V.A. monitors it every six months and they said it doesn’t need to be taken care of yet but if and when I must get it done I must be opened up because of where its located and they cant do it the easy way if I send you a copy of the ct scan there doing tomorrow as your doing this chat would you tell me what I need to do and what I should do and should I have it done now? I won’t be able to listen to the chat so I hope you will email me the answer. thank you HERB
Dr__Gillinov: We have a process to mail in records for surgical review. Please contact the Resource Nurses
Coronary Artery Disease and Bypass Surgery
mooreke126: 54 yo F, CT showed <50% calcified plaq in LAD. with statin and BP meds all blood work "perfect" per cardiologist. exercise 5x wk, bmi in range. Vegan diet when I got results. extensive family history. How should I monitor with another CT or something else. Feel like a foreign body in my chest just waiting to act up :)
Dr__Gillinov: We strongly discourage screening CT scans in people like you who have no symptoms. Keep exercising and following a healthy diet. And - control your cholesterol, bp, and body weight.
Teresa_S: My husband had 5 bypasses done during open heart surgery and was told 4 months later they had failed. What would cause this?
Dr__Gillinov: This is uncommon. I would guess that his left internal mammary artery, one of the arteries used for bypass is still open. The veins used for bypass may have closed. It is possible that the veins from his legs were not the best quality. It is also possible that his blood clotting is abnormal. He should see both a cardiologist and a hematologist
socrmom24: My father is scheduled to have open heart bypass surgery this month at the Clinic - we have not met with his surgeon yet. He is 69 and has CHF with blockage in 3 or 4 of his arteries. During his preop testing they also found stenosis in his right carotid. Is common place for a pacemaker/defib to be implanted as well during surgery.
Dr__Gillinov: If somebody's heart is severely damaged, a pacemaker/defibrillator may be indicated in addition to bypass surgery. We usually do not place these at the same time as the operation. It can be done a short time after surgery.
ArthurV: I would like to as Dr. A Marc Gillinov several questions about my Heart condition and see if he could answer either by future chats or by e-mail. I am a 62 year old white male. I started having health problems at 30 years of age. I have had a MI x 3, 1980, 1994,and 1997. Open Heart x 2, 1980 and 1994 with a subsequent redo on the second 18 hrs after. Four balloons/stints 1997 and a pacemaker 2008. I now have R-Aorta and an artery on the left backside that is 80% blocked. What would you suggest.
Dr__Gillinov: You have a very complicated history - we would be happy to provide you with a second opinion either online or a visit here
Orville: I had a three bypass surgery six years ago in which two veins from my legs were used. I have been on a low fat , low sodium diet and taking Lipitor, plavix, and aspirin. On Feb. 5th, I had chest pain and went to emergency. At the hospital they did an angioplasm and found the right bypass vein was blocked 100%.The doctor put four stents in the bypass the bypass. Four days later I had the same chest pain. The angioplasm showed that the vein was blocked again and the stents were plugged or collapsed. The doctor said there were arteries growing around the bypass and leave it as it is and take Amlodipine. Is this the best solution ? Can something else be done? What caused this all to happen?
Dr__Gillinov: Unfortunately sometimes bypasses and stents become blocked and medical therapy as you are on is reasonable. However, we must evaluate each patient individually. We would be happy to help by providing you with a second opinion.
waimu: After 18 yrs ,my 6 grafts are closing. Can they remove the heart and clean the grafts, eliminating a chance of a stroke, caused by loosening plaque in arteries was there in august, and was told they couldn't do surgery.
Dr__Gillinov: If surgery is not an option, we would recommend medical therapy which generally includes aspirin, a statin, beta blocker and in some cases additional medicines. A healthy lifestyle with a good diet and exercise always helps as well.
Pyewacket: I am nearly 79 years old. what can I expect in longevity from bypass/valve replacement as opposed to drug therapy
Dr. Savage: This question cannot be simply answered. There are specific criteria for surgery or medical therapy for each disease process and the answer in relation to your specific situation should be discussed with your doctor.
Symptoms of Valve Disease
smbowen: I have biscupid aortic valve and mitral valve prolapse. All tests show normal (no problems) with either. I have chest pain (sharp, stabbing). My cardiologist says it is likely the mitral valve prolapse causing the pain. I've read that symptomatic patients are more likely to require surgery. Is this true? Am I likely to have problems with either of these conditions because I have symptoms?
Dr__Gillinov: The symptoms that lead to surgery for these conditions usually include shortness of breath, fatigue and swelling of the ankles. Chest pain usually does not lead to surgery for these conditions.
RHAZ77: As to shortness of breath--do you worry about it if you are a bit out of breath after walking 3 flights of stairs or do you worry when you get it doing everyday tasks such as walking at a normal pace?
Dr__Gillinov: Shortness of breath can be a symptoms of valve dispense particularly if it represents a change. We evaluate every patient who has shortness of breath to help determine why and help them feel better.
johnnnita: I may have asked this question before: since mitral valve repair surgery in Jan 2007, I have only one reoccurring random issue: low pulse (below 50) and very occasional lightheadedness. The lightheadedness occurs maybe once every other month or so. It appears quite random and very short. I've had continual cardiologist check ups,etc. Any ideas or thoughts on this?
Dr__Gillinov: I would get a holter monitor if you haven't already. If your heart rate drops to a very low rate at the time you have lightheadedness, you may be a candidate for a pacemaker.
johnnnita: I did have a holter monitor performed for 24 hours during the past month. results showed that my heart rate was ok. The challenge is that I very rarely have the lightheadedness episodes. I had none during the holter monitor use.
Dr__Gillinov: You may try a long term monitor or event recorder and it can be challenging to capture the event.
General Heart Surgery and Recovery
Stansil1: How are surgeons assigned for surgery? Can you ask for a particular surgeon?
Dr__Gillinov: Yes - you can ask for a particular surgeon.
pei2: What should I use on my chest to help clear up the scar from open heart surgery?
Dr__Gillinov: Once the scar has finished maturing, the only way to change it would be with plastic surgery.
ptaug11: I am 5 mos. postop, very active and exercise regularly. My resting heart rate is always in the 90's and with moderate exertion (skiing) it goes way to fast that I need to stop and wait for it to come back down. Is this a postop remnant? What can I do about it?
Dr__Gillinov: That is uncommon - we would like to get a holter monitor to determine your heart rate and rhythm, then we can determine the best treatment to make you feel better.
FlaGrl23: Under normal circumstance how long does usually take for full recovery after open heart surgery? Is it normal to feel tightness, pulling, tugging in the chest area with slight movement? A general question not looking for medical advice.
Dr__Gillinov: Minor aches and pains sometimes persist for a few months but by 6 months they should normally be gone.
roadkinglarry: Hi Dr. Gillinov, you did my surgery on a couple years ago and put in an annuplasty ring, on the question of aspirin I was told to take the 81mg.. Was this only for the first year or should I continue on this regiment the rest of my life?
Dr__Gillinov: We usually recommend it for lifelong.
CLSTAR: Is there anything a surgeon can do for an enlarged stiff heart muscle?
Dr__Gillinov: It depends on the causes of enlargement.
Luis_C: Last September I had open heart surgery to replace my aortic valve with a cow tissue. I bicycle and wear a heart rate monitor when I do. I also have a pacemaker implanted several years ago. The heart monitor always worked well. After surgery the monitor stopped working. After contacting the manufacturer a number of times and trying different ways to reset the monitor it was found that the monitor works well in other people but it does not work with me. Can you please tell me what may be the reasons for this and if I have any options? I would certainly be very grateful for any information you can provide.
Dr__Gillinov: We do not generally recommend a heart rate monitor for exercise, so I would not be concerned about this
kcatgrg: When doing open heart surgery is it possible to any nerves that go to the esophagus causing a person to have mild spasms in their throat when leaning forward? Are their nerves near the heart that control the esophagus?
Dr__Gillinov: It would be very unusual for heart surgery to affect nerves that control the esophagus.
PaulT: I had my mitral and tricuspid heart valves repaired in April of 2010 and I am ever grateful to Dr Marc Gillinov and the Cleveland Clinic for giving me a better quality of life. I recently started working out at a health club and my question is do I have to limit the amount of weight that I lift during my workouts? I weigh around 145 pounds and am 5 foot 7. Thank you in advance. Sincerely...Paul.
Dr__Gillinov: I would not become a power lifter, but, in general, you can lift weights.
MaryJo_K: I had a double by pass and a Maze on April 19th by Dr Gillinov. I am thrilled to say that the a-fib is a thing of the past, and my cardiac rehab was a success, but suddenly the past 2 days the three holes in my right leg where the artery was cut out hurts like crazy... this pain lingered longer after my heart surgery than the chest pain, but once it healed I have not been bothered with it. I thought I would check with the Clinic, and hopefully Dr. Gillinov if this is normal or should I have my leg looked at? thank you very much Mary Jo
Dr__Gillinov: It is not normal to have pain so late after the operation. We should have a look. It is probably not serious, but we'd like to make you feel better
Pyewacket: how long after bypass/avr before I can take a plane home.
Dr. Savage: I generally recommend that my patients who must travel far to remain in the local area for a few days after discharge. Unless a patient has a specific problem they should be able to travel either by car or plane within a few days of discharge.
Dcherie: What precautions are taken to avoid infection such as MRSA in surgery and what is your rate of infection?
Dr. Savage: Patients are tested in advance with nasal swabs for MRSA and if positive treated with intra nasal therapy and retested. All patients receive perioperative antibiotic therapy for 48 hours based on recommendations from the Society of Thoracic Surgeons.
Dcherie: Does an enlarged heart affect whether a person is eligible for these types of surgery?
Dr. Savage: An enlarged heart can affect candidacy and will also impact long term success of surgery. However, sometimes the enlargement of the heart might be reversed after the heart operation. Decisions regarding the effect of enlargement need to be individualized after discussion with your doctor. An enlarged heart will increase the risk of heart surgery. If your heart is enlarged, I suggest seeking multiple opinions prior to a final decision whether or not to proceed with surgery.
Dcherie: How many surgeries have your doctors done in general?
Dr. Savage: Our treatment outcomes are online.
Shauna: with hypertrophic obstructive cardiomyopathy and the presence of Lambl's escrence, would you recommend anticoagulation and/or surgery?
Dr__Gillinov: sometimes, HOCM requires surgery -but that would be the only indication.
Shauna: under what conditions does hypertrophic obstructive myopathy require surgery
Dr. Savage: Hypertrophic obstructive cardiomyopathy is cause by abnormal focal growth of part of the heart muscle which causes it to protrude into the ventricular cavity. The protruding muscle contact one of the leaflet of the mitral valve obstructing blood flow as the heart ejects. Surgery is recommended based mostly on symptoms and failure of medical therapy. Most symptomatic patients get short of breath with physical activity. Also taken into account is the geometry of the muscle and the gradient (pressure difference) caused by the protruding heart muscle. Surgery may be recommended for patients with very high gradients because of a risk of sudden death.
Shauna: with hypertrophic obstructive cardiomyopathy would you recommend taking a baby aspirin every day in addition to a beta blocker?
Dr. Savage: A daily aspirin is neither recommended nor contraindicated for patients with hypertrophic obstructive cardiomyopathy.
CIBGIWWII: I have Pulmonary Arterial Hypertension (PAH) - shortness of breath - lungs test ok. C.C. installed St. Jude PM2210 Pacemaker 1-7-11. C.C. Echocardiography test at the time indicated "moderate severe PAH". Advise any techniques, medications, etc. that might improve my breathing capacity. Ex-Dr. Gillinov heart surgery patient 2-24-03
Dr__Gillinov: We would recommend an echocardiogram to assess the heart valves. And, then consideration of certain medicines that can reduce Pulmonary Hypertension. We would be happy to see you back at Cleveland Clinic.
Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again Dr. Gillinov and Dr. Savage for taking the time to answer our questions about heart surgery.
gotigers: Thank you Dr.Gillinov...see you next month!
Dr__Gillinov: You are welcome!
mooreke126: This was great....Thank You !!!!
Dr__Gillinov: We answer many of your questions in our new book Heart 411 - the only guide to heart health you will ever need.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.