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Valve Disease (Drs. Thomas and Soltesz 7/18/12)

Wednesday, July 18, 2012 - Noon

Description

Heart valve disease occurs when one or more of the heart valves do not work correctly and cause the heart to pump harder to circulate the right amount of blood through the body. Left untreated, heart valve disease can reduce a person’s quality of life and become life-threatening. Cardiologist, Dr. Thomas and cardiac surgeon, Dr. Soltesz answer your questions about valve disease and treatment.

More Information


Valve Disease

leakyvalveincopley: Is it safe to monitor a moderate leaky valve for another 12-months if my leak changed from mild to moderate in the past 12-months period? I am a 71-year old, active female. I have PBC, CREST and Sjogren’s Syndrome auto-immune disorders. On 5/16/12, I had a pulmonary test which determined a restricted air way and an echocardiogram which determined a moderate valve leak. On 5/23/12, I had a CAT scan which determined an enlarged esophagus and scarring with inflammation in the lungs. My local cardiologist suggested that I return for a follow up visit 5/2013 to see if there was any change in the leaking valve. On 6/ 22/12, the pulmonary and echocardiogram tests were repeated with stress added to each test. On 6/28/12, the pulmonary specialist reviewed the following results: mild leak left to aorta, moderate leak left to left (I think this is the correct information); allergic asthma (use inhaler); keep reflux in check. If valve repair is needed, I would prefer to repair at this age rather than when I am older and possibly in poor health.

Dr__Thomas: If I am interpreting your question correctly, it sounds like you have mild aortic regurgitation and moderate mitral regurgitation.

The most important issue is that you monitor your symptoms for any changes (increasing shortness of breath, for instance), but I recognize that your other conditions may also cause similar symptoms. It seems like a one year follow-up is reasonable in your case. Also, we would be pleased to arrange a comprehensive assessment at Cleveland Clinic if you would like.

leakyvalveincopley: how long would it take to schedule a second option?

Moderator: We have two methods to get a second opinion at Cleveland Clinic. Our secure online second opinion service, MyConsult offers a second opinion from one of our medical specialists without leaving your house - you can learn more about this service at http://my.clevelandclinic.org/eclevelandclinic/myconsult/default.aspx .

Or, we would be happy to see you at Cleveland Clinic for an appointment. You can call Cardiology Appointments at 800-223-2273, extension 46697. Cleveland Clinic Heart and Vascular Institute offers same day appointments. If you have more questions, please contact our heart nurses – see http://my.clevelandclinic.org/heart/chat_with_a_heart_nurse.aspx.

GeorgeS: I recently had bypass and AVR at CCF. as a result I have a "1-2+" leak. what does that indicate for the future? what can I do to limit problems?

Dr__Thomas: Not sure which valve has 1-2+ leak, but I doubt you would ever be aware of this. Unless it progresses (or has been underestimated), you should have no problems.

clara: I had the aortic valve replaced & 2 grafts 7 years ago. The last 4 years 7 stents. The last one 3 months ago. Recent tests showed the mitral valve has gone moderate, and the tricuspid valve severe. I am having symptoms of lightheaded /SOB upper chest. I was told by my cardiologist that I will need the valve replaced, but they can't do anything until the year is up with Plavix. I have been given an appointment with a vascular surgeon. I was informed that a second surgery will be more difficult. Why would I be seeing a vascular surgeon for a valve replacement? I do believe that I need other opinions.

Dr__Thomas: I agree that a second opinion sounds like it is in order, which we would be happy to provide at Cleveland Clinic.

hillcrest: I have moderate to severe aortic insufficiency and moderate mitral and tricuspid regurgitation, moderate pulmonic insufficiency and a dilated aortic root. What are the ramifications of having more than one valve problem as it pertains to when surgery should be done? Can more than one valve be fixed at the same time? I am 66 year old female. Thank you for taking my questions!

Dr__Thomas: Yes, we routinely address multiple valve issues with one operation. Cannot comment on you case without knowing more, but I suspect you will need aortic valve replacement and mitral and tricuspid valve repairs with nothing done for the pulmonic valve. We would be happy to evaluate you at Cleveland Clinic.


Valve Disease – Aortic Valve Disease

rkunglaub2: My mother is 85 with increasing aortic stenosis. She is still active without any symptoms. What are the possible solutions?

Dr__Thomas: If she really has no symptoms, then nothing may need to be done beyond periodic evaluations. When the time comes for intervention, this most likely will involve open heart surgery, which can be done safely even in patients in their 80s. Alternatively, it may be possible to replace the valve through a catheter from the leg. We would be pleased to offer an evaluation at Cleveland Clinic to give an informed recommendation.

dallas_guy: Valve Disease: I am a 76 year old male, in good health with worsening moderate stenosis of Aortic Valve as per 3 echo cardiograms over the last 18 months and probably requiring replacement in 1-3 years. I have no symptoms of same. Is there a recommend remedy available in the USA other than the established open heart procedure? I have been warned of possible adverse effects of the key-hole and the TAVR procedures. Thank you dallas guy

Dr__Thomas: Difficult to answer without knowing more specifics, but generally, aortic valve replacement (AVR) is not done until you develop symptoms. If AVR is the only procedure you need then (no other valves or bypass grafts), then the key-hole approach can be very successful. TAVR is currently approved only for high-risk patients, which doesn't seem to describe you. However, in several years you may find that these approvals have been broadened to include lower risk patients. We would be pleased to offer a personalized assessment at Cleveland Clinic.

JAK: Hello Doctors, I submitted a question last week for the Aorta web chat. I failed to note that my 16yr old son along w/ BAV has a trivial leak and an ascending aorta of 3.0cm. I had asked if it was Ok for him to have swim lessons and was told since there is no leak that would be fine. Should I not have him take swimming? Thank you.

Dr__Thomas: As long as he does not have severe stenosis (obstruction), then swimming is fine.

twerper: My aortic valve is leaking, as we speak. I have had lung cancer and I cannot have heart surgery. Is the new procedure for aortic valve repair effective if the valve is stenotic- if that's a word?

Dr__Thomas: TAVR cannot usually be performed on patients who have Aortic regurgitation without severe aortic calcification stenosis.

That said, we routinely perform heart surgery on patients who have had prior lung cancer and lung surgery - you should be evaluated by a center with experience such as Cleveland Clinic.

dukefan55: I have moderate aortic stenosis (1.0cm) and would like to know what symptoms would indicate a worsening of the valve and should I be limiting any activities? Thanks for taking my question.

Dr__Thomas: The most common symptom is shortness of breath with exercise. Of course, this is relative to what you have been able to do in the past, so it is good to exercise regularly, so you can monitor your symptoms.

jruperrow: What is a"1-2+" aortic valve leakage. what treatment if any is required?

Dr__Thomas: Echocardiographers typically grade valve leakage on a 4-point scale (1+, 2+, 3+, 4+). 1-2+ means “mild to moderate” regurgitation. This usually just needs to be monitored with echocardiography episodically (every 1-3 years). You should remain vigilant for any symptoms from this (breathlessness with exertion).

RGambatese: I'm a 70 year old male with aortic stenosis and HOCM. I am asymptomatic. My last echo showed a peak gradient across the aortic valve of 70mmHg with a mean gradient of 43mmHg. Aortic area of approximately 1.0cm2. Peak gradient across the left ventricle outflow tract with Valsalva is 17mmHg. Would a valve replacement be indicated at this time?

Dr__Thomas: If you truly are asymptomatic, then nothing may need to be done now, though your AV gradients are getting into the severe range, so you should be vigilant for exertional shortness of breath. If you indeed have HOCM, then the surgeon would probably perform a myectomy at the same time as the AVR.

Estimator: I have a Aortic Valve disorder, how do my doctors determine when I need surgery?

Dr__Thomas: A history and physical exam is the start and echocardiography establishes the severity of the process. Symptoms related to the valve are the usual event that triggers intervention, but there are other signs on the echo that can accelerate this.

mfriedmann: Is weight loss generally associated with severe aortic valve regurgitation (prior to surgery)?

Dr__Thomas: Not sure I know what you’re asking. Unintended weight loss generally occurs only with the most severe of heart disease (cardiac cachexia), so you and your doctor should be sure to check for other causes. If you are overweight, then weight loss may help you have a smoother course with surgery and is recommended.

jlenzini: how bad of a leaking aorta before surgery is needed?

Dr__Thomas: This depends on many factors, including the volume of blood that leaks with each beat (for example, greater than 60 mL (2 ounces)), whether there is enlargement or dysfunction of the left ventricle, whether the aorta is enlarged, etc. We would be happy to provide an evaluation at Cleveland Clinic.

dorrcorp: My cardiologist has been watching the effects of my aortic stenosis, which hadn't changed a bit for three years but showed a significant narrowing most recently. Only because I feel so great (no chest pain, no dizziness, no increase in shortness of breath) has he held off on a cath exploration, and I expect I'll need an aortic valve replacement soon. I am particularly interested in the non-invasive methods that have been developed and what the likelihood might be that I'd qualify I'm secondarily interested in avoiding a ventilator but realize that's probably a long shot. Could you talk about current non-invasive approaches? Thank you.

Dr__Thomas: Transcutaneous aortic valve replacement is approved only for the highest risk patients, which doesn’t sound like you. You may be a candidate for a small (~3 inch) incision and if you are in good health overall, the risk should be quite small (typically <1%). You will be on the ventilator during surgery, but often this can be removed very soon after the operation.

Dr. Soltesz: Transcutaneous aortic valves are only approved for the highest risk patients. They, like surgical aortic valve replacement, require the use of a ventilator during the procedure in almost all cases.

VickiD: I am 62 yr. old woman, with BAV, moderate stenosis. Having symptoms, mostly SOB. What restrictions are advised if any?

Dr__Thomas: If you truly are having symptoms from the aortic valve, I suspect the stenosis is worse than moderate. I would recommend a reevaluation, which we would be happy to arrange at CCF.

Dr. Soltesz: If you care having symptoms, then a full evaluation in needed. You likely will need an aortic valve replacement. This can be done minimally invasively with minimal risk (<0.2%) if you are otherwise healthy.

BAV14: I've happened upon several supplements online (K2 is one) that are purported to slow aortic valve calcification. While none appear to be rigorously proven, they of course emphasize the "it can' hurt" philosophy. From a medical standpoint, is there any evidence that any kind of medicine, supplement, or diet decisions will help delay either native or prosthetic valve calcification?

Dr__Thomas: Nothing has been proven to slow aortic stenosis development. There are some hints that statin therapy may be of help, so if you have elevated cholesterol, you should certainly consider a statin drug.

dmack1106: I have tightness and heavy feeling in upper chest above pectoral area while on treadmill at the start of exercise thru first 5 min or so, then goes away for rest of 30 min. is this classic aortic valve disease symptom or artery blockage and should I stop exercising

Dr__Thomas: It sounds like you may have significant artery blockage (or possibly aortic stenosis) and should see a cardiologist, who may wish to do a stress test and/or an echocardiogram.

csmith: My mom is 78 yrs old and was just diagnosed with severe aortic valve stenosis. Her cardiologist recommends surgery. He said she is lucky that she hasn't had any real problems so far. She has COPD and had a pulmonary function test today. She has had symptoms for years (fainting with exertion, etc.) but they are getting worse. She is often tired and has labored breathing when climbing stairs, etc. We are currently working on getting her records to Cleveland Clinic. How soon should we be looking at getting the surgery done?

Dr__Thomas: It sounds like surgery should be arranged as soon as practical. Depending on how bad the COPD is, she may be a candidate for transcutaneous aortic valve replacement (TAVR). We look forward to having her at Cleveland Clinic.

Dr. Soltesz: Transcutaneous aortic valve replacement or minimally invasive aortic valve replacement should be considered. We await her arrival.


Valve Disease – Mitral Valve Disease

mvpr: Is it dangerous to exercise at altitude with moderate regurgitation? I have read some controversy recently regarding taking calcium supplements with heart MVR and with taking aspirin. Your advice?

Dr__Thomas: Your doctor is the best one to advise on exercise, but if you have no symptoms from the regurgitation, then moderate exercise at altitude usually is fine, though I'd recommend not pushing yourself till you're blue in the face (with or without valve disease!). Lots of controversy on the calcium front, and if your primary care doctor thinks you need small to moderate supplements (a gram or less per day), I wouldn't concerns for the valves.

jdvickery1: I have been diagnosed with mitral valve prolapse. It is rated from moderate to severe which means I need to have surgery. My father and brother both have had this disease and had surgery. My brother has surgery in 2002 in Nashville to repair the valve and the valve failed after 60 days. He then had emergency surgery to replace the valve. Has done well since this surgery. My question is will valve repair surgery at Cleveland Clinic have a risk of failing and what % of these surgeries fail. I am in good health other than the valve problem.

Dr__Soltesz: Over the last 3 years the mortality at Cleveland Clinic for isolated mitral valve repair surgery was 0 percent. Our long term success rate following these repairs is over 95%. Our center has the largest experience for mitral valve repair and we would be happy to evaluate you.

rsck: I am a 65 year old female. After 2 bouts of endocarditis, I had open heart surgery to repair my mitral valve. My energy never returned. Two years ago I started having AF and have since had 2 PVAs, but still have AF. I have been told that my mitral valve regurgitation has gotten worse since my third bout of endocarditis in 2010. I believe that surgery is likely for me at some point. I am having trouble with my energy level and strength. Is it safe to push myself to try to keep up my muscle strength along with walking for aerobic benefit or could I do more damage to the valve? Follow-up question: what would be an acceptable amount of exercise for me right now?

Dr__Thomas: Impossible to answer these questions without knowing more specifics in your case. In general, it is good to exercise (both aerobic and toning) as much as you can, but if you are having severe symptoms from the mitral regurgitation, that should probably be addressed soon. We would be happy to offer an evaluation at Cleveland Clinic.

Dr__Soltesz: I think it would be appropriate to be evaluated by a surgeon for reoperative surgery.

mvpr: Once a diagnosis of MVP with regurgitation has been made, how frequently should you be seen by your cardiologist (assuming no change in symptoms)?

Dr__Thomas: Depends on the severity of the MR and whether there are any enlargement of the left ventricle or atrium or elevation in pressure in the lungs. Generally guidelines: mild MR, every 2-5 years; moderate MR every 1-2 years; severe MR, every 6-12 months.

tdcampbell: I am a 50 YO male with moderate severe to severe mitral regurgitation. It is a posterior leaflet. I have a mildly enlarged LA. My last BP was 144/90. I have been told to take the conservative approach at this point. 1. What would be the benefit of waiting as opposed to having the repair now? 2. At what point is my BP a concern? 3. My echo report said I have a linear echo density on the LV papillary. Would this have any effect on repair capability? 4. Should I be limiting my physical activities at this point?

Dr__Soltesz:

  1. Patients with severe mitral regurgitation and symptoms should undergo mitral valve surgery to prevent long term damage to their heart muscle. Patients who are asymptomatic and have severe mitral regurgitation can also be considered for MV repair surgery if the surgery can be performed with a very high degree of repair success and extremely low mortality.
  2. Reducing your blood pressure may help your symptoms and may help your level of regurgitation
  3. I doubt this would be an issue however I would have to see the echo myself. 
  4. I don't think you need to limit physical activity however you should consult your cardiologist who knows you better.

Sharla: I have had an echocardiogram and an angiogram done. Are there other tests for diagnosing mitral valve failure? I had my mitral valve repaired last Sept and they say the surgery was not a success. I now need a replacement

Dr__Soltesz: Usually a quality echocardiogram can determine whether a repair has failed. Not all patients who have failed mitral valve repairs need a replacement; some would be a candidate for a re-repair.

MWindt: HI! I underwent ASD repair at the age of 5. I am now 32, I am asymptomatic, and I have severe mitral regurgitation. When is valve repair surgery necessary? I am currently a 32 yr old female, and am also 25 weeks pregnant with my 1st child and still feeling great!

Dr__Soltesz: You should probably not have surgery now being pregnant. After your pregnancy is complete, patients with severe mitral regurgitation and symptoms should undergo mitral valve surgery to prevent long term damage to their heart muscle. Patients who are asymptomatic and have severe mitral regurgitation can also be considered for MV repair surgery if the surgery can be performed with a very high degree of repair success and extremely low mortality.

Reducing your blood pressure may help your symptoms and may help your level of regurgitation.

tdcampbell: I am a 50 YO male with severe mitral regurgitation, a mildly enlarged LA and have BP 144/90... no other symptoms. I have been advised of a conservative approach. Is there a good reason not to have this fixed expeditiously? Are there risks with waiting? Thanks...

Dr__Thomas: This depends very much on the specific anatomy of the MV and any impact on left ventricular or atrial size and function and pressure inside the lung. We do often operate on MR prior to symptoms. We would be happy to evaluate you in Cleveland.

Dr. Soltesz: Patients with severe MR who are otherwise asymptomatic should be evaluated for surgery if the surgery can be performed with minimal risk of mortality and the mitral valve can be repaired with greater than 90% success. Here at Cleveland Clinic, our isolated mitral valve repair mortality has been 0% for the past three years and we successfully repair myxomatous mitral valves >97% of the time. We would be happy to see you here for consultation.

Cruiser500: I am 59 years and have mitral valve disease with moderate to severe regurgitation. I have no symptoms but am told I will need repair in the future. How to do determine the timeframe for the repair?

Dr__Thomas: Generally symptoms are what drive timing for surgery, but if ventricular function falls, you develop atrial fibrillation, or the pressure in the right ventricle rises too much, then surgery is warranted.


Valve Disease – Tricuspid Valve Disease

CThrock: Had my Mitral & Aorta Valve replaced with mechanical in 2006. I started having tricuspid leakage last year has gone from moderate to severe. I also have some water retention despite being on a low salt diet, and am trying to slowly take off weight because I am over weight also. My cardio doctor said he will not do surgery on me because I am high risk. He said that sometimes the other two mechanical valves can change the tricuspid valve done to somewhat of a normal leakage if I get my weight down and watch my salt and exercise. Is this true from your stand point? I have other health issue also. Is there anything else I can do? Other than my heart, I feel fine. Nothing else with that area. Thanks for your input.

Dr__Thomas: In general, we try to avoid isolated tricuspid valve surgery, and it sounds like you and your doctor are pursuing the right approach. By taking the fluid off, your right ventricle may get smaller in size and the tricuspid valve will work better with less leakage.

If the tricuspid regurgitation continues to be severe and unresponsive to your treatment, then we do have surgeons who are experienced in this procedure, and we would be happy to evaluate you at Cleveland Clinic.

Dr. Soltesz: Isolated tricuspid valve surgery is limited to patients who remain truly symptomatic after optimal medical therapy. We have an extensive experience with repair and replacement of the tricuspid valve. In fact, most times we do not even need to stop the heart to accomplish this.

shih_tzu_rules: how long does a tricuspid valve replacement last?

Dr__Thomas: This depends very much on the valve type and the specifics of your case. Mechanical valves may last a lifetime, whereas bioprostheses may last 10 years or more, but there are also complications that may shorten this, for example if the valve becomes infected.


Diagnostic Testing

adourian: I have two aortic valve area measurements on my echo report; AVA (VTI) and AVA (Vmax). Are they the same thing calculated different ways? Which one is the better indicator of severity?

Dr__Thomas: They are very closely related and usually are quite similar. The Vmax method uses the maximal velocity through the aortic valve and in the left ventricular outflow tract to estimate AVA, while the other method uses the area under the velocity curves throughout systole. That's the technical difference.

dmack1106: on your aortic stenosis tool you ask for gradient, do you want mean or peak and which one is most important in determining extent of disease [note – referring to http://my.clevelandclinic.org/heart/aortic_stenosis_tool.aspx  ]

Dr__Thomas: You are quite right that this is not specified in the on-line tool and we should correct this. My interpretation is that they are seeking the mean gradient, since the guidelines use a mean gradient of 40 mmHg as a criterion for severe AS. 

Earth: How reliable is a Stress Echo test?

Dr__Thomas: This is a complex question and depends very much on using the test in appropriate patients. If one is seeking evidence for coronary artery disease, the test is about 85% accurate, very similar to a nuclear scan.

tdcampbell: My echo showed "linear echo density in the LV papillary". Would this be a factor for mitral repair?

Dr__Thomas: I would need to see the echo to know how this might impact the surgery. It may simply be a loose chord that has detached from the mitral valve, which would not lower likelihood of repair.


Valve Surgery

dmack1106: research shows 50% of people who undergo heart by pass have decline in cognitive function; does this apply to aortic valve surgery? At what point do I need a angiogram? how do I tell if I am candidate for TAVR? explain PARTNER trial results? I have peak of 57, mean of 36, value size 1.0cm , ejection of 60 to 65%, & some symptoms, am I candidate for aortic value surgery?

Dr__Thomas: Many questions here so here are some quick answers:

  1. Cognitive impairment is related to age, length of time on the bypass machine, and other factors. Isolated aortic valve replacement is typically short on the bypass machine so less risk but not zero. Impairment typically is quite mild.
  2. Angiogram routinely obtained just prior to surgery unless there are other indications, such as chest pain or heart attack.
  3. TAVR is approved for very high risk patients with AS, as PARTNER trial showed results as good as surgery and better than medicine in these patients. Most patients still are more reliably treated with surgery.
  4. If you truly are having symptoms related to the AS, the time may have come to consider surgery, though the numbers you list do not sound severe. An exercise test is sometimes helpful in this situation, which we would be happy to arrange at Cleveland Clinic.

Dr__Soltesz: There are conflicting studies regarding cognitive function after heart surgery. In fact, there are many studies even showing cognitive decline after other surgeries such as hip replacement surgery. So the question is not necessary does the heart lung machine cause cognitive decline but rather is it surgery in general.

Heart surgery today is extremely safe. TAVR has been reserved to be for the sickest patients because of the associated risks of that surgery. Based on what you have told us, you would be a very good candidate for surgery. If you have symptoms, then you likely should undergo surgery. But your cardiologist and cardiac surgeon should evaluate you further.

Titch: I am 76 years old and have severe aortic stenosis and moderate mitral stenosis. My cardiologist believes that this was caused by untreated childhood rheumatic fever and says that I am going to need heart valve surgery. I am concerned about the risks involved in surgery, not only because of my age but because of other risk factors: I am highly allergic to antibiotics such as penicillin and macrolytes and I have always been a terrible bleeder (chronic low platelets). I bruise easily and if I have a nosebleed it bleeds for days, even if it's cauterized. Is there any alternative to valve replacement, and what may happen to me if I do not have it?

Dr__Thomas: It is very difficult to answer this question without knowing all the specifics, but one recent option you may wish to pursue is transcutaneous aortic valve replacement, where the valve is inserted through a catheter placed in your groin. If you are interested in an evaluation for this, it can be arranged at Cleveland Clinic.

adourian: Aortic valve replacement mortality outcomes are published on your website. Do you also track and publish post-operative complications (stroke, infection, premature valve failure, etc.) and if so, where can I access them?

Dr__Soltesz: Yes, we track postoperative outcomes as well. We publish postoperative outcomes in the setting of peer-reviewed journal articles.

jdvickery1: I have noticed that about 30% of Cleveland Clinic valve surgeries are reoperations. Are most of these cases coming from other hospitals?

Dr__Soltesz: The majority of patients who have reoperations here have had their surgeries elsewhere. But - there are obviously many reasons for reoperations. We recommend that patients who need reoperative heart surgery carefully choose a center that has a lot of experience with it to obtain the best outcomes.

rockette: I am scheduled to have mitral valve repair surgery, t v repair and a maze procedure. How risky is this surgery. I am 67 yrs old and generally in good health. Also what is the recovery period?

Dr__Thomas: Since the risk of surgery depends on so many factors, this question would best be answered by your cardiologist and cardiac surgeon. If this is your first operation, it takes about 6 weeks for the sternum to heal (driving, lifting more than 8 pounds, etc.), but we expect you to be walking extensively during this period.

Estimator: Do I need to come back to Cleveland for all my follow-up visits after surgery?

Dr__Thomas: We are always happy to see our patients back for follow-up, but recommend patients maintain a local cardiologist. For many of our patients, all follow up is done at home, but some do like to return to the Clinic every 1 to 2 years. It is your choice entirely.

adourian: At my age, 73, the decision to go with a tissue valve replacement seems rather straight forward. How is the decision made as to which tissue valve to have implanted? The clinic videos show Dr. Svensson using the St. Jude Trifecta and Dr. Gillinov using the Edwards Perimount. Does surgeon experience with specific valves play a role?

Dr__Soltesz: Various studies would suggest anywhere from a 4.5-5 cm for this size cut off. Unfortunately, all of these studies take all patients into consideration and do not sort out patients based on their height and weight. When considering the patient's size, we will sometimes use an aortic size index which tries to take into account the patient's height and weight. Your body surface area is 1.95 m². One study has demonstrated that an aortic size index of less than 2.75 correlates with a less than 4% per year risk of aortic rupture. The risk of surgery for an otherwise healthy 63 year old patient is 0.5%. If the bicuspid aortic valve needs to be repaired or replaced, the risk of surgery is slightly higher, but still far less than 1%. All surgeons at Cleveland Clinic perform aortic valve replacements and ascending aortic aneurysms with significant frequency. Our surgeons perform more valve repairs and replacements than anywhere else. Some surgeons, like me, have a special practice in more complex aortic surgeries as well. Readmission rate for such a surgery should be less than 5%, with an infection rate less than 0.2%. You should expect to stay in the hospital for 5 days and in Cleveland for 7-10 days. Patients are usually back to normal activity in 3-6 weeks. Obviously, details about valve choice would be individualized and would be discussed with your surgeon.

Both valves are pericardial valves, which is the type of valve we prefer for aortic valve replacement. The Perimount valve is an older valve but has good established outcomes.

The Trifecta valve is a newer generation valve that may provide better outcomes but unfortunately we do not have long term outcomes on this valve yet.

jlenzini: I had a porcine valve 11/4/2004 how long will this last

Dr__Soltesz: The durability of your valve depends on many factors including your age, what type of valve was implanted, etc. It is hard to evaluate this without more data.

Bhart46: Does having a previous CABG prevent the us of the less invasive Mitral valve repairs where the sternum is not cut?

Dr__Soltesz: Typically yes.

BAV14: Hello. My cardiologist had referred me to the ACC/AHA Valve Disease Guidelines in order to start my own research into replacement valve choice (bioprosthetic vs mechanical) for my bicuspid aortic valve. The "cut-off" for bioprosthetic is age 65 and up. However, it is also my understanding that many surgeons and centers are now recommending biosprosthetic at much younger ages, even for patients in their 40s or 30s. Taking lifestyle choices out of the equation (in other words, assuming I'll adjust to either very well - able to handle the recovery of repeat surgery or able to manage my anticoagulation), how do the strictly medical risks compare...i.e. surgical risk vs stroke/hemorrhage risk over time? Why is there such a gap in age related valve recommendations between centers such as Cleveland Clinic and the Guidelines? What age would your experts say is too young for the bioprosthetic and additional surgeries route? Thanks for any wisdom you can share!

Dr__Soltesz: The decision to choose a mechanical or tissue valve is based on several factors

Importantly a patient's overall survival is not impacted by which valve is chosen. The risks of lifelong Coumadin therapy effectively balance out the risks of repeat surgery.

This valve choice requires a thoughtful discussion between you and your surgeon.

jdvickery1: In addition to the mortality rate for heart surgeries, Cleveland Clinic also shows the acuity rate for surgeries. Please explain what this means.

Dr. Soltesz: We typically show our mortality rate for certain surgeries and then the predicted mortality rate based on nationwide data. This benchmark is generated by the Society of Thoracic Surgeons (STS) nationwide database that averages the mortality rates for other centers across the country.

jer1147: How does Cleveland Clinic feel about pre and post operative hyperbaric oxygen therapy

Dr. Soltesz: We have not used this therapy for postoperative cardiac surgical patients. Some studies have been done in the UK that suggest improves outcomes for some groups of patients.

Arthur1965: Could you please give your perspective on the pros and cons to receiving a biological mitral valve from a pig or cow, on lasting so many years vs. receiving a mechanical one, Titanium or other metal based? With the mechanical replacement and the subsequent Coumadin or similar, I need to decide if the mechanical one is worth doing for a life choice vs. the biological one that has a life expectancy of 15 - 20 years. What I need to better understand is the level of activity I can do with a mechanical one, can I still stay active with my kid’s soccer, jogging, and working out yet avoid contact sports to avoid internal bleeding or bruising. What is the expected life expectancy with a mechanical? Here are my stats. I am a male, age 47, proper weight, very good diet so in shape otherwise my bad mitral valve. My mitral valve was harmed (hole in it) by a bacterial infection in my blood. Thanks

Dr__Thomas: The first choice for your valve would be a repair and I have seen many perforated mitral valves (from endocarditis) that were repaired with a patch. If repair is impossible, then you must balance the need for life-long anticoagulation (with the mechanical valve) with the higher likelihood for redo operations. The noncontact activities you mention generally can be done with anticoagulation, though you likely will see more bruising than otherwise.

Dr. Soltesz: I would think a repair is possible is there is a focal perforation of the leaflet. We would be more than happy to review.


Valve Surgery – Aortic Valve

mfriedmann: What is the outlook for general use of the Edwards Lifescience valve for aortic valve replacement? (i.e., not limited to situations when there is no other alternative)

Dr__Thomas: Currently the Edwards Sapien valve is approved only for very high risk patients. Most likely, as more experience is gained with the valve, it will be used in less risky patients. However, surgery is so safe and successful for low-risk patients that it will probably be several/many years before TAVR is recommended in these cases.

sisterlu: Good Afternoon. 5 yrs ago I had a aortic valve repair is this better than a replacement and how long will it last?

Dr__Thomas: This depends very much on the specifics of the valve repair. Depending on your age, you may have 10 years or more with good function. This likely is not as long as a mechanical heart valve, but may be similar to a bioprosthesis.

Dr__Soltesz: Durability of aortic valve repairs depend on the original pathology of the valve (bicuspid versus normal trileaflet), the age of the patient, the quality of the leaflets at the time of repair, and the degree of residual stenosis and regurgitation after the repair. Some patients with optimal characteristics can enjoy 20 years or more with their repaired valve, while others require replacement in 6-10 years.

mikedial: Given the momentum of the sapien and core valves, do you think this technology will ultimately be applicable in younger patients with aortic regurgitation (as opposed to aortic stenosis patients) as an alternative to traditional open valve replacement surgery and if so, what are the possibilities of a "valve in a valve" as the prosthetic ages? Is there any data on this?

Dr__Soltesz: The Percutaneous valves typically require either calcified leaflets or a previous valve in which to insert.

So that a percutaneous valve for non-calcified aortic regurgitation is unlikely, however, we have certainly been performing valve in valve operations with failed bioprosthetic aortic valves.

fullmoon57_1: What are your thoughts on ON-X valve, for a 53 year of female. I have sever aortic valve blockage.

Dr__Thomas: It is a very reasonable choice and may last the rest of your life. The only significant disadvantage is the need for anticoagulation, currently Coumadin, but some of the newer anticoagulants may be approved in the future. You should discuss the specific valve choice with your surgeon and cardiologist.

Dr__Soltesz: The decision to choose a mechanical or tissue valve is based on a number of factors. Importantly, a patient’s survival (i.e., how long the patient is expected to live) is not impacted by which valve is chosen. The risks of life-long Coumadin effectively equal the added risks of repeat surgery. If patients are involved in heavy manual labor where injury is a risk, then patients often opt for tissue valves with the understanding that they will need one or two reoperations in their lifetimes. Other patients who have significant anxiety surrounding hospital stays and operations may opt for a mechanical valve so as to not require a reoperation. The On-X mechanical valve may be somewhat different and require lower doses of blood thinners. Preliminary results from a clinical study show the all-carbon On-X valve (On-X Life Technologies, Austin, TX) is safe with lower levels of anticoagulant therapy than normally prescribed to patients with other mechanical aortic valves.

fullmoon57_1: I am thinking about going thru the ON-X valve, ECHO shows 95% stenosis and need a valve replacement, I am getting mechanical valve and am thinking of getting ON-X valve. I am interested in being part of the study. I have bicuspid aortic valve. CAT scan shows calcification at the root of aorta. How urgent is my surgery? Can I wait 2 or 3 weeks? Thank you

Dr__Thomas: Difficult to say. It depends on your symptoms, how well your heart is pumping, and other factors. Generally delays of a few weeks are acceptable, but I hesitate to answer given that I am missing several key aspects of your case.

Dr__Soltesz: We typically grade the degree of aortic stenosis by valve area (in cm2) and mean gradients (in mmHg), so I do not really understand a 95% stenosis of your valve. That said, if you are having symptoms and have severe aortic stenosis, I would not delay surgery.


Valve Surgery – Mitral Valve

paulab55: How close are we in the United States to being able to insert a mitral valve clip robotically? I had open heart surgery a year ago to replace the aortic valve and repair the mitral and tricuspid valves. The mitral repair failed and I still have severe leakage. I had a severe inflammatory reaction to the heart-lung machine, required a pacemaker, and went into kidney failure and CHF. The mitral clip that is being used in Europe seems to be a simpler procedure and one that I may tolerate better than open heart. Is there a test study in the U.S.? Do you feel that the procedure is safe and effective? Is it performed in Canada?

Dr__Thomas: There are clinical trials underway using a mitral clip inserted using a catheter. It is impossible to tell whether you might be eligible for these trials, but we would be happy to arrange an evaluation here. See http://my.clevelandclinic.org/heart/percutaneous/percutaneousvalve.aspx

Patricia: I had mitral valve repair, tricuspid replacement and an ablation surgery done last year. My cardiologist said that I have a very mild leak on my mitral valve (the repaired one) and that if it get bad it would have to get replaced. I would rather have it re-repaired, is a re-repair procedure the same as a replacement? what are the odds? Also, I was told that I can't even take soy isoflavones because they are plant hormones, what about vaginal hormonal creams?

Dr__Thomas: Can't comment on the hormone questions. As for the mitral valve, it is common to have very mild residual leakage, which usually never progresses enough to require reoperation. If you do need reoperation (and fewer than ~5% of MV repairs do in the first decade after surgery), then we try to re-repair, but often replacement is required. Depends on the details of why the valve has re-leaked and how thickened/scarred the valve is.

Dr__Soltesz: There have been some case reports of the initiation of HRT causing a hypercoagulable state and development of clots on heart valves.

I have never suggested a patient not to take HRT if it is indicated due to a valve replacement. Please discuss this further with your doctor.

Re-repair is certainly possible.

chuckarc: My mom's cardiac ultrasound shows moderate mitral regurgitation, slight calcification of the aortic valve and trace aortic insufficiency. Since she has occasional tachycardia and shortness of breath, can these be attributed to her valve issues?

Dr__Soltesz: Unfortunately we would need to fully evaluate your mother and review her studies to answer this questions.

It is certainly possible that her valvular heart disease can contribute to her shortness of breath.

GregoryC: My question pertains to what constitutes a realistic recovery expectation following mitral valve surgery for severe regurgitation that is scheduled soon at the main campus. The exact procedure has not yet been determined, but hopefully will be a repair using robotics. Prior to diagnosis, I exercised by running and weight training. In the several years leading to surgery, I've progressively scaled down (but not eliminated) my exercise, and currently have substantially less capacity than before. However, post-surgery I would like to regain my prior "pre-symptom capacity" and include such Michigan UP activities as portaging canoes, hiking with 50 lb. backpacks, snowshoeing, X-country skiing, etc. I am 53, BMI 22, left ventricle EF 50%, no enlargement. How close can I likely come to this goal?

Dr__Thomas: The best person to answer this is the cardiologist and surgeon you are seeing, since they have access to all your medical info. In general, though, young folks (and 53 is young at Cleveland Clinic) are able to return to full activities after MV surgery.

RJBarnett: A year ago, I had mitral valve repair using minimally invasive method. The surgery was termed elective since I had no symptoms other than regurgitation shown on tests. My theory was to get it done while I was in excellent health despite being 77 years. Several months later, the repair failed. A number of tests were done and referred to both Cleveland Clinic and Johns Hopkins. After more tests, both experts recommended not undertaking valve replacement, at least while symptoms remain virtually non-existent. My cardiologist follows up with stress echo tests as well as others. If symptoms do arise, is it possible to again use minimal invasive procedures or even robotic methods?

Dr__Soltesz: No - usually not. You will most likely need a more traditional approach given the scar tissue that arises in the chest even after a minimally invasive approach.

MWindt: What is the benchmark for young patients (I am a 32 yr old active female) with severe mitral regurgitation that are asymptomatic to indeed undergo mitral repair surgery?

Dr__Soltesz: The guidelines suggest that MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved LV function in whom the likelihood of successful repair is greater than 90%

Alexcincy: I’ve been diagnosed as having Mitral Valve Prolepses, I'm 55. Should I have it repaired? My Cardiologist says it "may" be necessary. My biggest symptom is "skipped beats".

Dr__Thomas: Unless you have severe mitral regurgitation, then surgery generally is not needed, not simply for prolapse. An EKG or Holter monitor may be able to diagnose the skipped beats and let your doctor recommend the right therapy for this. We would be happy to see you at Cleveland Clinic.

tdcampbell: In regards to severe mitral regurgitation, is there an exercise threshold? Thanks

Dr__Thomas: If you truly have severe MR, then any reduction in your exercise capacity may be an indication for surgery.

Alexcincy: Is robotic surgery to repair the mitral valve safe, and how does it compare to open heart surgery?

Dr__Thomas: In carefully selected patients, robotic MV repair is as safe as the open procedure.

Sharla: What is the advantage and disadvantages of re-repair of mitral valve over replacement?

Dr__Thomas: This requires a very careful analysis of your mitral valve by echocardiography and ultimately may not be known before the surgeon actually looks at your valve. Generally, if it appears that the valve can be repaired effectively, then this is a preferred path.

Dr. Soltesz: Re-repair of the mitral valve in experienced hands can lead to a very good long term outcome. The decision, however, can rarely be made definitively until actual visual and tactile inspection of the valve at the time of the re—operative surgery.

shih_tzu_rules: My repaired mitral valve has a very mild leak, my cardiologist told me that if it comes to it, she'll replace it instead of re-repair it, as far as risks go, is a re-repair less risky for the patient than a replacement?

Dr__Thomas: If the leak truly is very mild, then you will probably never need a reoperation. If this does become necessary, the cardiologist and surgeon will carefully assess the valve to decide on the best course. At Cleveland Clinic, we re-repair many mitral valves with good long term results.


Aortic Root, Aorta Disease and Aortic Valve

Spiderman: I am a 57 yr old male and I had my bicuspid aortic valve with extreme calcification replaced in 2007, In 2010 a MRI test revealed that I now had an aorta aneurysm 5cm x 4.6cm. How likely percentage wise could this aneurysm be related to the aorta valve disease. Are there studies relating the two diseases, or is it of the same disease. And is open chest surgery required to repair the aneurysm? My aorta valve was replaced with a biological valve and will have to be replaced again in the future, how many times is it healthy to access the sternum in this manor

Dr__Thomas: There is a very clear connection between bicuspid valve disease and aortic enlargement. There is no simple answer as to the threshold for aortic repair (depends on where the enlargement is and whether it is enlarging), but if you are concerned, we would be happy to provide an evaluation at Cleveland Clinic.

Dr__Soltesz: Your aneurysm is most certainly related to your bicuspid aortic valve. We recommend replacing the aorta when the diameter exceeds 4.5-5.0 cm in patients with bicuspid aortic valves. Reoperative heart surgery is very safe. Your surgeon will discuss the options related to your aortic valve, namely whether to switch it to a mechanical valve, re-replace it, or leave it in position. This will also all depend on your comorbidities.

cdemmers: After an aortic valve replacement 18 years ago, an aortic root aneurysm (just under 5 cm) has been found with no changes in a three month period. Your website advocates the "watch and wait" approach and 6 month monitoring is planned. But, what is the prognosis for future problems in otherwise healthy 57 year old woman? Other than the usual heart-healthy practices, is there anything specific that could prevent additional enlargement? (Blood pressure med dosage was also increased). Thank you.

Dr__Soltesz: Aside from close surveillance of the size of your aortic root, good blood pressure control will likely have be the best way to prevent enlargement.

rsinacola: Is a mis-shaped valve due to a dilated Aortic root considered a "valve disease"?

Dr__Soltesz: if the valve is malfunctioning because of regurgitation, then it is considered valve disease.

rsinacola: What are the latest techniques for Aortic Root replacements, like the Modified David Procedure? Are there any non-evasive procedures yet for Aortic root & valve replacement?

Dr__Soltesz: There are no catheter based techniques designed to replace the aortic root. The modified David procedure remains the best valve sparing root replacement surgery.

jrbmba: I had Aortic valve replacement 4 months ago, due to severe to critical aortic valve stenosis, in addition to replacing part of the ascending aorta during the same procedure... Other than a somewhat elevated resting heart rate off-and-on, the recovery I'm told is normal... However, it was recently suggested a condition called "aortopathy" can be related to "bicuspid aortic valve", especially given my ascending aortic aneurysm which was replaced as I mentioned, though there is no current indication of this... Should I be concerned about "aortopathy" in the future, and is there any way to minimize this possible future situation with other parts of my aortic artery... My age is 54, aside from the specific condition I was diagnosed and underwent surgery; my health history is excellent, normal height/weight, nonsmoker, organic, 147 cholesterol, normal blood pressure, etc, etc... The only prescription Rx I'm on at this point is "metoprolol" (Beta blocker), 100mg/day...

Dr__Thomas: Most likely, they replaced the part of the aorta most at risk for "aortopathy" and you should be OK for the foreseeable future. Metoprolol is a standard medication to prevent further aortic enlargement. You should have periodic (every year or two) echocardiograms with occasional CT or magnetic resonance scans to monitor the aorta.

yehoot: What is the risk of dissection/stroke or whatever in operating on a 63 yr. old male with an ascending aortic dilation of 5.1 (bicuspid valve) compared to the risks associated with surgery? How many valve replacements does the best surgeon at Cleveland Clinic perform per year? Hospital infection rate? # of readmits post-surgery? Risk and frequency of a-fib after surgery? What type of valve replacement do you use? Assuming surgery in Cleveland (we're from NYS), how many days would we have to be in Cleveland - both pre and post surgery, as well as # of hospital days for the surgery? What is the recovery time from this type of surgery? Thanks very much.

Dr__Thomas: of developing ascending aortic aneurysms. It is thought that these two processes are genetically linked. In general, a patient requires surgery when the maximum diameter of the ascending aorta reaches 5 cm.

The reason for this recommendation and threshold is that once the aneurysm size approaches 5.5 cm there is a significantly increased risk of aortic rupture and/or aortic dissection. Both of these latter conditions are associated with a significant morbidity and mortality and would then require emergency surgery which places patients at much higher risks. The risk of aortic dissection and/or rupture when an aneurysm is less than 5 cm is near 0%. There is some data however to suggest that patients with a bicuspid aortic valve and an ascending aortic aneurysm should actually have their aortic aneurysm replaced at a lower size threshold.

LorynB: My wife, aged 62, wt. 130 lbs.,Ht. 5' 4" was diagnosed with BAV in Aug 2007 with ascending aorta of between 4.0 and 4.2 CM. As of 4/2012, LV size is normal with good systolic function, ejection function of 60 to 65%,ascending aorta is dilated measuring 5.2cm. Aortic arch measuring 3.7 cm with aortic arch at 3.8 cm. No significant stenosis but moderate aortic insufficiency. We are in a 6 month monitoring mode with echoes in wait and see . Is this a good plan for now?

Dr__Thomas: It sounds like the aorta is enlarging progressively, though I would really need to look at the two studies side-by-side to be sure that these measurements are in the same location. If it is as you have described, though, many would consider surgery at this time, especially since your wife is relatively short (tall people naturally have larger aortas). If you would like an evaluation at Cleveland Clinic, we would be happy to provide this.

Dr__Soltesz: In patients with bicuspid aortic valves and ascending aortic aneurysms we usually set the threshold for surgery at 4.5 - 5.0 cm aortic diameter.

This measurement however needs to be done with a dedicated CT scan of the ascending aorta.

rsinacola: What is the size of the Aortic root where replacement is no longer voluntary, but required?

Dr__Thomas: This depends on many factors, such as age, height of the patient, and associated diseases such as Marfan’s syndrome and bicuspid aortic valve. Any aorta over 5.5 cm would certainly have surgery recommended, but in many patients the threshold is lower.

Dr. Soltesz: Aside from a standard diameter, we also review an patient’s aortic size index; this is the diameter of the patient’s aorta (in this case, root) indexed to body surface area. For example, a 5.0cm aortic root is obviously more concerning in a 5’3” female than a 6’4” male.

cdemmers: After an aortic valve replacement 18 years ago, an aortic root aneurysm (just under 5 cm) has been found with no changes in a three month period. Your website advocates the "watch and wait" approach and 6 month monitoring is planned. But, what is the prognosis for future problems in otherwise healthy 57 year old woman? Other than the usual heart-healthy practices, is there anything specific that could prevent additional enlargement? (Blood pressure med dosage was also increased). Thank you. -- oh yes, can I confidently travel from US to Thailand/Cambodia on very active month-long excursion?

Dr__Thomas: These are questions you should discuss with your doctor, who knows you best and has access to your detailed aortic measurements. Blood pressure control and the use of a beta blocker is important. If the situation truly is stable then travel is probably OK, though one must always consider the small but real risk that an issue could arise when you are in a remote location. Again, your doctor is the best one advise you.

rsinacola: I am 60, have a dilated aortic root, regurgitation: no matter how much I exercise or reduce my food intake; I continue to gain weight mostly from the waist down. Is this at all related to the aortic root enlargement (I am 6'4" and weigh 240)

Dr__Thomas: Aortic root enlargement per se would not cause lower extremity weight gain. If the regurgitation is severe, then this possibly could cause heart failure and edema, in which case you should be considering surgery. Most likely, though, the weight gain is unrelated to your aortic disease.


Anticoagulation - Blood Thinners

mfriedmann: What is the status of Dabigatran as an alternative for Warfarin for those having had a valve replacement?

Dr__Thomas: Dabigatran is not currently approved for heart valves. There is an on-going clinical trial to study this, the full details of which you can find at http://clinicaltrials.gov/ct2/show/NCT01452347 .

It will be several years before we have the results of this trial and any decision by the FDA to extend the approved use.

mikedial: How is the On-X PROACT trial progressing and do you think Plavix will be a real alternative to warfarin with this or other mechanical valves in the near future?

Dr__Soltesz: Preliminary results are promising but we do not have the final results from the study yet.

We are certainly hopeful that plavix can become an alternative for warfarin.

Estimator: Thank You Dr. Thomas & Dr.Soltesz for a great job in answering the questions.


Arrhythmia Questions

Moderator: We had a couple arrhythmia questions during the chat. I asked Dr. Kanj, Section of Electrophysiology and Pacing to assist us.

Question: What is the "track record" for Flecainide (50 mg)/Tambacor in the treatment of heart arrythmia/atrial fib? It has been prescribed for me, but both my internist and GP think it is a risky drug to take. The reading I've done online indicates that it may cause problems if taken an extended time. Any comments or opinions would be helpful. Thank you.

Dr. Kanj: Its 1 year efficacy is around 30 to 40 percent. The risk of cardiac arrhythmias in patients with no structural heart disease is quite low. However, the risks are high in patients with prior history of blocked heart arteries and or weak heart. Patients who are at risk for these diseases should be evaluated prior to starting flecainide. There are other antiarrhythmic medication that one could consider but none is absolutely safe either. The other alternative is to consider ablation. It carries a much higher success rate but it is an invasive procedure that requires a heart catheterization to cauterize or freeze areas that could cause the atrial fibrillation.

Paulab55: I have a pacemaker which "kicks in" 10% of the time. It is set at 70 beats per minute. I take Toprol ER 25 mg BID to keep my heart rate lower. Should my pacemaker be set at a lower "kick-in" rate?

Dr. Kanj: It depend on the patient. Usually I would program the lower heart rate to around 50 or 60. However in some patients this is too low and they need a higher heart rate to feel better. ( Some of us have heart rates in the 50. Some in the 60 and some in the 70). I would try to lower the programmed lower heart rate to 50-60. Because this will save the battery and may prevent other risks that are brought up by pacing especially if the pacing is occurring in the lower part of the heart (ventricle). However, if after lowering heart rate the patient started developing symptoms: fatigue, exertional shortness of breath, then we may need to go back and keep it at a higher rate.

Reviewed: 07/12

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