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Ask the Heart Surgeon (Dr. Lytle 11/14/12)

Wednesday, November 14, 2012 - Noon

Bruce Lytle, MD
Cleveland Clinic Miller Family Heart &
Vascular Institute Chair

Description

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. Take advantage of this rare opportunity to chat live with the chairman from Cleveland Clinic's Arnold Miller Family Heart & Vascular Institute in a secure online setting.

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Coronary Artery Disease – Lifestyle, Medications, Angioplasty and Stents, Surgery

fowens: I have been diagnosed with a blocked LAD estimated at about 50% blockage. I have no symptoms. I understand this can be fixed with a stent. I have two questions. At what percentage of blockage will a fix be needed? Do such blockages generally get worse and is there anything I can do to prevent worsening.

Dr__Lytle: The apparent percent stenosis in an asymptomatic patient is usually not used as the criteria for intervention. More important indications are the presence or absence of ischemia (decreased blood flow) and the measurement of decreased blood flow at the time of catheterization. In most circumstances, if there is not evidence of decreased blood flow through the obstruction, medical therapy is preferable to stenting or surgery in an asymptomatic patient. The progression of atherosclerosis is unpredictable but there is good evidence that diet and treatment with statin type agents may lower the risk of future clinical events.

ThomasD: on 11-12-12 I was diagnosed with the following after a cardiac cath. Dominance-Right dominant LMCA-no significant disease noted LAD-diffuse 80% proximal lesion diffuse 80% mid-lesion Circumflex-Discrete 40% mid lesion RCA- Eccentric diffuse 40% mid lesion Discrete 80% distal lesion Recommendations Consider PCI Stent to LAD and RCA Does the insertion of stents seem the most appropriate treatment or should I opt for an in depth discussion with my cardiologist regarding bypass surgery.

Dr__Lytle: In general, the more diffuse the coronary artery disease (the more obstructions there are) the greater the advantage of surgery over PCI. In addition, diabetic patients with multi-vessel disease appear to have better long term outcomes with surgery when compared to PCI. You definitely should have an in-depth discussion with your cardiologist about the advantages and disadvantages of medical therapy alone; percutaneous intervention; and bypass surgery before proceeding with any type of intervention.

jimron: A 77 y.o B/M with long history Brittle diabetic Insulin twice a day, Poor circulation to both lower extremities pitting edema, blind, infection in the throat but alert and oriented with a very diseased heart which he requires open heart CABG procedure, now they have taken him off Plavix on heparin and waiting for surgery. In the mean time he developed MRSA and they do not know why but he is very nausea only eating 5 bites of food a day; sipping water all day because of dry mouth and nausea. His 02 sats are 95 to 98 his resp 10 to 18 he has bradycardia 38 to 50 but also go into Afib. besides the text book version what are the risks should this man have surgery in present condition?

Dr__Lytle: The risks of any type of surgery for someone who is not well enough to maintain nutrition are extremely high. In addition to the risk of mortality it sounds like there would be a very high risk of the patient not being able to return to a normal activity level. Surgery should be very carefully considered before undertaken.

mooreke126: I am a 54 yo woman with extensive family history of heart disease. Have been doing what I can for the last 10 years with exercise, statin 20 mg Simvastatin. Switched to plant based diet 2 years ago. Numbers are good and controlled. TC 155, LDL 69 HDL 65, BP 115/65. Had a heart ct scan 3 years ago with calcium score of 22 and a < 50% calcified plaque in my LAD. My cardiologist says I am doing great, and see me once a year. My concern is that the plaque seems like a ticking clock to me. Do patients just wait for it to become severe enough, hopefully not by a heart attack to correct it? What do you suggest to monitor or correct? Thank You.

Dr__Lytle: There is no indication that either bypass surgery or stenting would have any benefit at this time. The rate of progression of obstructions in the coronary arteries is very unpredictable and there is evidence that it can be positively influenced by diet and with medications such as statins and platelet inhibitors (aspirin). Your program seems to be a good one and for follow up stress testing is probably a more reliable predictor of clinical course than is CT scanning.

WayneS: I am a white 48 year old male that had a heart attack at age 39 in 2004. I have 20 stents and need quadruple bypass. I have been told that my LAD has too many stents in it to bypass it. Is it possible to place too many stents in one artery? I have had the stents placed in four different hospitals as I travel on business and have had to do this while complications arose while traveling. Thank you.

Dr__Lytle: It certainly can be more difficult to do bypass surgery when multiple stents have been placed in a single artery. in general, it is not impossible but it does make surgery more difficult and in some circumstances makes the degree of correction achieved by surgery less perfect. These issues are very much related to the details of your catheterization study and if you would like us to review that study we would be happy to do so.

RayMC: I'm very leery of stenting as it seems to be only a band aid that must be reapplied every 5 yrs or so. What are your thoughts on stenting vs. more invasive surgery? What, if anything can be done to begin to reverse the buildup of cardiac plaque? I know that diet can play a role in improving LDL. Can diet play a role with plaque as well? Thanks

Dr__Lytle: Stenting plays an important and effective role in the treatment of acute myocardial infarction and in many patients who are symptomatic with limited coronary artery disease. The more severe the coronary artery disease, the greater the advantage of surgery.

In regard to the reversal of plaques, there are people that believe that occurs and some circumstances they may be correct. However, the way I read the data (and relatively little data exists regarding that issue) reversal of atherosclerosis, if it occurs, is not predictable. However, diet and often treatment with statins and platelet inhibitors are an important part of the treatment of most patients with coronary artery disease whether or not that strategy reverses plaques. There is good evidence that clinical events such as myocardial infarction and death are less common when these strategies are employed.

carmenv: post cardiac cath relief of sob is evident? Post cardiac cath chest pain persists with diminished shortness of breath. What is the length of recuperation after the procedure accompanied with healthy life style changes? Could delay in receipt of treatment after initial chest pain, left arm pain radiating, awoken from sleep w chest pain, chest pain upon rest and exertion could have caused permanent and unrepairable damage? What to do if persistent fatigue continues upon rest and exertion by formerly healthy female 61 year old, what do you recommend?

Dr__Lytle: I recommend that you have a stress test and if that test is positive, that you have a coronary angiogram. From your description, I am not sure what cardiac disease you may or may not have. An accurate diagnosis is important before deciding on any treatment.

Robbie1972: Hi Dr. Lytle. I have diabetes. I had a stent put in 3 years ago for a blocked artery and I am now having symptoms again. I am having a cath next week. I saw on TV that there was a study that showed people with diabetes may do better with bypass surgery instead of a stent. Should I talk to my cardiologist about this before my cath?

Dr__Lytle: You are correct. For diabetic patients with multivessel coronary disease, there are multiple studies including the recent FREEDOM trial that show that bypass surgery results in a higher long term survival rate, and fewer cardiac events when compared with intervention. I think it is a good idea to discuss potential options with your cardiologist prior to your catheterization.

mgaax: I had triple by pass in 2001. From your experience, how long can I expect my newer arteries to last before possibly having a problem. I exercise four times a week, eat properly, take my meds and feel great. Thanks.

Dr__Lytle: It is possible that 25 years after your operation you still will not have needed reoperation. It is impossible to predict the future for a single individual. The things that you are doing to maintain your health sound very reasonable.

Mitral Valve Disease

Dr-Ken: I had CABGX5 only on my left coronary (right was 30% occluded, stress thallium last week was normal) seven years ago. I have congenital AI and hereditary atrial fibrillation. 6 weeks following CABG I developed mitral valve prolapse. 6 months ago I got endocarditis with a fastidious coccus. I am going to have a 3D echo on Friday to determine the need for surgery on my mitral valve. Am I a candidate for mitral valve repair at the Cleveland Clinic?

Dr__Lytle: Probably. Mitral valves that have been damaged by infections are more difficult to repair than some other types of mitral valve disorders. However, it is often possible to do so and when it is possible, it is preferable. We would be able to make a better estimate of the likelihood of mitral valve repair by looking at your echocardiogram.

mvpr: How do you know when it is time for surgery (Mitral valve repair) with a diagnosis of MVP with regurgitation? Should stress echos be repeated at certain time-frames or as symptoms progress? Your expertise is greatly appreciated.

Dr__Lytle: There is evidence that for patients at low risk of surgery, and with a high likelihood of mitral valve repair that severe mitral insufficiency is an indication for surgery even in the absence of symptoms. Stress testing may add evidence to that equation although few long term studies have correlated stress testing, surgery and long term outcomes in the setting of mitral insufficiency. If you contemplate surgery, it is important to end up with a mitral valve repair in this setting. If you would like us to review your echocardiograms, do not hesitate to let us know.

Turid215: Hello, Dr. Lytle: I have been diagnosed with severe leaking of the Mitral Valve and valve damage. I am having a TEE at 9:00 a.m. on Wednesday, Nov. 14th, so I may not make this chat in time. I am pretty frightened about the idea of cutting open my chest and having open heart surgery. For this kind of disease that I have, is there an alternative method to repair the Mitral Valve and fix the leaking? How long is the recovery? Is it very painful? I live in NY and will consider traveling to get the optional method if available rather than cutting open my chest cavity. Thank you for your wisdom, expertise, and time in answering my questions. Brenda F.

Dr__Lytle: Mitral valve repair requires open heart surgery. However, multiple different types of incisions are used to accomplish mitral valve repair, and some of these incisions are smaller and less invasive than others. In my opinion, the advisability of a robotics approach or a minimally invasive approach relates to the severity of the anatomic changes in the mitral valve. So - in short, there are less invasive approaches to mitral valve repair and if you wish, we would be glad to review your studies and comment on the advisability of a less invasive approach.

chuckarc: My mom who is 80 has a moderate mitral valve leakage. Could this cause her to have shortness of breath and hoarseness? She also has a 5.1cm aortic aneurysm.

Dr__Lytle: Yes. Mitral insufficiency may cause shortness of breath. The indications for operation on a 5.1 cm ascending aorta will depend upon your mother's general health, blood pressure and how severe her mitral insufficiency is. If she needs surgery for her mitral valve, she probably will need to have the ascending aorta replaced.

CharlieKY: Can you tell me the difference in incisions between a minimally invasive, a thoracotomy, and a robotic surgery for mitral valve? I want the smallest incision with the fastest recovery.

Dr__Lytle: There are multiple kinds of "minimally invasive" incisions. Even robotic assisted mitral valve repair has a small incision associated with it. For patients with simple disruptions of the mitral valve, robotic mitral valve repair offers a rapid recovery in many cases. The advisability of that approach depends upon the reason the mitral valve is insufficient and the severity of the anatomic disruption. We would be happy to review your choices and situation should you wish.

Aortic Valve Disease

carmen_H: I know you can't answer this specifically. I am a 51 year old female who was diagnosed in 1984 with MVP and AI. My cardiologist told me the aortic valve would need replacing by my early 50s. I had to quit work 12 years ago due to extreme fatigue ,presumably from the recent onset of full blown Sjogren's and Hashimoto's. And, I have pretty bad essential tremors. Due to being on inderal for arrhythmias , and lack of exertion(my opinion) the progression of valve deterioration has apparently slowed. My cardio says now, we just take it year to year, waiting until my heart shows further strain. My question is: can't and shouldn't I have replacement BEFORE further damage? I'm coming to you. He already knows that. Thanks. Carmen

Dr__Lytle: It is not clear from your description that your heart function is abnormal at this point. The amount of valve dysfunction is important in determining whether or not immediate surgery is in your interest. Valve replacement has some long term disadvantages associated with it and that is probably why your cardiologist has not recommended surgery as yet. With your other conditions, interpretation of your symptoms will be difficult. It sounds to me as though your situation needs careful analysis including study with echocardiography and possibly catheterization. Thank you very much.

adourian: I am 70 years old and will require an aortic valve replacement. I don't qualify for TAVR and have decided on a pericardial valve. As TAVR advances as well as my age it seems probable that if/when my replacement wears out I will be a TAVR candidate. What pericardial valve characteristics are best able to handle a valve in valve possibility? Specifically what size/profile/type of material/ general technology best accommodates a valve in valve procedure?

Dr__Lytle: It is possible to place catheter borne valves inside of pericardial valves. With the current catheter borne valves, a size 23 pericardial valve is probably the smallest valve where that strategy would work, but the bigger the better.

BruceG: My name is Bruce I’m male age 56, aortic stenosis with moderately calcified bicuspid valve. I currently play racquetball at a fairly competitive level. The symptoms I have are shortness of breath after long rally and occasionally palpitations and fatigue when finished. My questions based on my states below should I still be playing at a high intensity level. Also would like to go hiking in CO with elevations up to 11,000 feet. Let me know what you think. Last echo 2/12, valve area 1.0, Max. Aortic Velocity 3.8, mean Pressure gradient 27mm, Ejection Fraction 56-60%. Thank you.

Dr__Lytle: According to your echo, you have moderately severe aortic stenosis. Whereas that degree of aortic stenosis is not an immediate indication for surgery, operation will almost certainly be necessary within a small number of years.

It sounds as though you are becoming symptomatic at a high level of exercise and my recommendation would be to back off slightly from those extremes of exercise. I also would recommend that you have close follow up of your valve and at some point in time, undergo a stress echo to see whether or not your aortic stenosis limits your activity level or your heart function deteriorates with exercise. Those would be indications for surgery.

Ronnie: I had an Edwards 3000 Bovine valve implanted in me in April 2006. The surgery took place at another institution. I was 49 yrs. old at the time. I am 56 at present. My question is a simple one, what is the life expectancy on a bovine tissue vale? Also, what is the best choice for future references, a animal tissue or a mechanical valve which one has to take Coumadin the rest of his or her life? By the way, I am a male..........Thank You.

Dr__Lytle: For someone who was 49 years old at the time of their original surgery the likelihood of needing a reoperation for valve failure b y 15 years for an aortic valve is somewhere around 30 - 40%. There are not data that show a difference in survival rate between patients that have bovine valves and mechanical valves and who are in your age group. Therefore the choice of valve relates to the lifestyle changes, risks and benefits of taking Coumadin vs. the necessity of having another operation. Unfortunately, no operation can guarantee that you will not need more surgery in the future, particularly if you are fortunate to live another 30 - 40 years.

garden: Is a tissue valve appropriate for a 68 year old who does walk and swim vs. a longer lasting one that requires blood thinner use?

Dr__Lytle: A tissue valve is very appropriate for someone 68 years old. the older we get, the slower the rate of degeneration of tissue valves.

garden: With a severe aortic stenosis with mean gradient of 35.50, and possible bicuspid aortic valve, is a catheterization appropriate for a 68 year old woman. Another institution wishes to do this to consider surgery although I do not feel symptoms.

Dr__Lytle: In most situations, we would not recommend immediate surgery for an asymptomatic patient with a 35 mm aortic valve gradient. There may be something about your situation that I do not understand; but if we had not decided upon surgery, we probably would not do a catheterization.

CharleneB: I had a mechanical valve put in 2 years ago. I have atrial fibrillation and I would like to have it fixed. Can you do ablation with a mechanical valve or should I have the mini-maze?

Dr__Lytle: Ablation can be performed with a mechanical heart valve. The ease of ablation will depend upon what position the valve is in.

Aorta Disease

BD-VA: I have a 4.3 to 4.5 cm Thoracic aortic aneurysm for about four years now. Recently I have been having more noticeable upper back pain with chest pain and also a lot of upper abdominal pain. I also have a continuous cough and at times difficulty in breathing with weakness all over. Is this a sign that my aneurysm is getting worse or are any of these symptoms related to my condition at all?

Dr__Lytle: It may or may not be related. My suggestion is to have a thorough examination and diagnostic work up by a cardiologist.

Georgia-TL: My dad is 80 and has an ascending aortic aneurysm that is over 5. His doctor said it is time for surgery but wondering how patients do in their 80s after this type of surgery - is it worth it if he will not be active after the surgery?

Dr__Lytle: Patients in their 80s can undergo surgery for ascending aortic aneurysms and be very active afterwards. We would need more information about your father's overall situation before recommending surgery in this situation.

Multiple Cardiovascular Issues

clara: I had open heart surgery - aortic valve & 2 grafts 2006. Starting 2009 - 2012 I have had 8 stents. The last 2 stents were done May and Sept. 2012. All the stents are in major arteries and none have had restenosis. I have now been told that I will need tricuspid valve surgery, because it is severe. It can not be done until I can go off Plavix. My mitral valve is moderate. I was told that I have aggressive heart disease and a difficult case. Right now I am experiencing SOB and lightheaded that has seemed to be getting more severe. They did not use the mammary artery which the cardiologist does not understand. I am not sure that helps with information. I would appreciate some direction.

Dr__Lytle: You have a complex situation and happiness is in the details. I am afraid we cannot give you good advice with this limited amount of information. If you would like us to review your studies and information we would be happy to do so.

Congenital Heart Disease

Goldi: I am a 38-year-old female who was born with a congenital heart anomaly: Transposition of the Great Vessels and an inter-atrial defect. 1976: Mustard/Baffle procedure, 1994: Revision Mustard. Recently, my cardiologist established that my condition is degrading (right ventricle dysfunction, significant tricuspid regurgitation, dilated ventricle, pulmonary hypertension). A recent catheterization couldn’t correct my worsening condition. The b-blockers and ACE inhibitors appear to have less of an impact on my condition. The doses of these were increased and Pradaxa, furosemide and KCL added to regimen. He told me that I will need to undergo heart transplantation soon, and that this next step is an inevitability. Is this the last option that I have? Is there any other conservative treatment option to improve my worsening condition? Any advice and guidance would be appreciated. THANK YOU!

Dr__Lytle: From your description, your cardiologist has taken a detailed approach to your condition, which is a complex one. It is probably not the case that a more conservative approach would make a major difference in your situation. But your situation is a very complex one. It can help to get a second opinion but that second opinion will have to involve a detailed analysis of the situation.

Goldi: Thank you very much, Dr. Lytle. In your experience with patients who have this congenital anomaly and have undergone the Mustard procedure, what is the probability that they will eventually need to undergo heart transplant? Is there any hard data out there?

Dr__Lytle: Most patients who undergo surgery for transposition of the great vessels (that is a Mustard procedure) will eventually need some type of secondary procedure. I cannot provide you with the long term follow up references off the top of my head but if you contact us we would be glad to give you characteristic references.

Sub Aortic Membrane

PaulKL22: I have a sub aortic membrane. What is your experience with this type of surgery? Is this always done with surgery? Can it be done mini invasive?

Dr__Lytle: A sub aortic membrane is a relatively common occurrence. Whether or not we do that operation through a minimally invasive incision depends on how confident we are concerning the preoperative diagnosis. To date, there is no catheter borne solution to this problem.

After Heart Surgery

JacobK: I had heart surgery a couple weeks ago. I started having a toothache this week and my dentist said I need to have dental work done. Is it too soon?

Dr__Lytle: If you have normal valve function and your heart surgery did not involve valve replacement or repair, the timing of your dental work is probably not an issue. If your heart surgery did involve valve repair, it is an issue. But if you have a severe dental problem it may cause risk whether or not you have surgery. In my opinion, if you have dental surgery, you should receive intravenous antibiotics for that procedure.

Leslie_L: Dr. Lytle, my aunt had Open Heart Surgery back in 1998! She was recently diagnosed with Alzheimer's Disease! My question to you is, is it true that when they place a patient on the Bypass for the Open Heart Surgery they actually lose proper blood flow to the frontal lobe of the brain (which is my understanding the main area that Alzheimer's Disease affects)? Is there anyway to counteract this problem? I am just a concerned family member who would hate to see anyone else's family have to go through this situation!! Leslie

Dr__Lytle: There is no known association between Alzheimer’s disease and open heart surgery. Patients have been followed for more than 30 pr 35 years and it has not become apparent that any type of degenerative neurological condition is related to open heart surgery. Blood flow to the brain occurs without as much pulsatile flow during open heart surgery as compared to the normal situation. But - is equal in amount. The studies that have been done about cerebral function after open heart surgery appear to show that within the first year or two cerebral function returns to normal. But - no studies have been done in detail more than 20 years after surgery.


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