Tuesday, February 5, 2013 - Noon
Heart valve disease occurs if one or more of your heart valves does not work properly. A faulty or leaky heart valve can often be repaired through surgical intervention. Dr. Savage, Cleveland Clinic Florida and Dr. Lytle, Cleveland Clinic Ohio answers your questions about valve disease and valve surgery.
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Flor: I have an ascending aortic aneurysm and I'm facing open heart surgery soon because the size is 5.3cm (I think they measure by cm) (not sure, but, that's the measurement right now. I had a cardiac Cath 2 weeks ago and I do not have blockages. Do you think I'm a candidate to have a less invasive surgery rather than opening in the front?
Dr__Savage: Absolutely. I am doing these surgeries through the front but only using a minimally invasive half incision.
Dr__Lytle: It does depend on the extent of the aneurysm and if other procedures are needed. Either way - the opening is in the front - even with minimally invasive surgery.
PACKERS: Jan. 2011 surgery Ascen. aortic aneurysm, descen. aorta enlarged and dissecting, cardiologist had me stop working and to stop all that will raise my heart rate , descending aorta is 5.2 was extremely active now I do nothing, is this the way to handle this.
Dr__Savage: If you have demonstrated stability of this aneurysm over a 6 month to 1 years period I believe it is reasonable to resume moderate physical activity.
asgalian: Have aneurysms ever been noted to shrink, rather than grow, over time? I understand in animal studies losartan has been shown to slow the growth of aneurysms.
Dr__Savage: In general aneurysms will not shrink. They can stabilize and stop enlarging. Some drugs from the losartan class have been shown to slow growth in animal studies.
Aorta and Aortic Valve
BAV32: I'm a 32 yo recently dx BAVD, TAA of 5.1cm. Born with bicuspid pulmonary valve and now have severe pulmonic regurgitation, severely enlarged RV, also 5.1cm PA dilation, newly dx PFO. My Cleveland number for height/cross section is 11.48 and I know surgery is coming because TAA is > 4.5cm. In the waiting process will soon be referred to cardiothoracic surgeon, plan to come to Cleveland. Question: Is it possible to fix a TAA and replace AV and PV, and fix PFO in one huge surgery? Otherwise healthy, almost no symptoms (fatigue, palpitations, and dull pain in my back, but no SOB). On no meds. BP is generally 120/80 ish. Sometimes slightly higher. Also, how quickly could surgery happen?
Dr__Savage: Assuming the thoracic aortic aneurysm (TAA) is in the ascending aorta, then all procedures can be performed at once. With a bicuspid valve and an aneurysm of 5.1 cm — and with the severely enlarged RV — this should be treated soon. Don’t wait 6 months.
EJB: Regarding a bicuspid aortic valve with an ascending thoracic aortic aneurysm @ 4.5 cm, what are the latest medical therapies? At what point does the risk/benefit ratio shift in favor of surgery at 4.5 cm/ age 70 years. Living with this condition is like being a walking time bomb. Please discuss. Thank you for any info you can give.
Dr__Savage: A lot of this depends on height and weight and whether your aneurysm has been stable over years or recent progression in size. It also depends on any leak or stenosis in the valve itself. If you are tall and your aneurysm has been stable for years, and if there is no leak or stenosis in the valve, you can watch and monitor this. You need to be evaluated by a surgeon who has experience with this condition to determine if you should wait or have surgery at this time.
crispin: 5.5 cm ascending aorta with moderate aortic valve regurgitation in active 59 yr. old male. Told I must have full open heart to repair. I get different opinions from two surgeons as to type of valve. I had 4 stents installed in 2008.
Dr__Savage: It is difficult to respond without seeing your medical history, but in general, a 59 year old person should have the aortic valve taken care of. It may be possible to repair the valve depending on the cause of leak or regurgitation. You may be able to have this done through a smaller incision - it would depend on the anatomy.
Dr__Lytle: In regard to valve type - either is appropriate for a 59 year old. It depends on the need to take coumadin if you have a mechanical valve – or – the need to have reoperation if you have a bioprosthesis.
elizabethb: What are the latest medical treatments for ascending thoracic aortic aneurysms less than 5.0 cm.? At what point/age does the risk benefit ratio tip to favor surgery ? Any other comments/info on ATAA or aortic valve stenosis appreciated. Thank you for any info you can give.
Dr__Lytle: Each person needs to be individually evaluated. The treatment for smaller aneurysms is blood pressure control. The transition in risk benefit is based on the size of the aneurysm relative to patient height and/or body surface area. Also important is any familial history of aneurysms and connective tissue disorders. Finally the presence of aortic valve with two instead of three leaflets increases rupture risk. Care needs to be individualized.
BillM: Would an ascending aortic aneurysm at 5.4cm be corrected at the same time as replacement of an aortic valve (X4)?
Mickey59: Is open heart surgery the only solution to aortic stenosis.
Dr__Savage: Transcatheter valves are used for patients with aortic stenosis who are not surgical candidates or for whom the risk of surgery is very high. There is no medical therapy for aortic stenosis. For most patients with isolated aortic stenosis, surgery via a minimally invasive approach is without question the best and most effective option.
Shirliann: I was diagnosed with mild aortic stenosis and then a very short time later (weeks) severe aortic stenosis. Do I need to be tested again to diagnose this properly?
Dr__Lytle: Yes. Aortic stenosis does not progress from mild to severe in weeks. So, one of the diagnoses is an error. You need an echocardiogram to sort out the situation.
bslnarayana: we went for echo test, the result are follows mNO RWMA, SCLEROTIC AORTIC VALVE WITH MILD AR?MILD MR?NORMAL CHAMBERS, NORMAL & GRADE ev SYSTOLIC FUNCTIONS.
Dr__Savage: Unsure what you are asking but this echo result requires no further action except routine follow-up with your cardiologist.
sperg: What are the symptoms of a leaky aortic valve and what are the recommended options to correct this?
Dr__Lytle: There may be no symptoms and when they do occur they commonly revolve around shortness of breath. Leaky aortic valves may sometimes be repaired and if that is not possible the valve needs to be replaced.
greendrake: what is the latest aortic valve & what is the longevity.
Dr__Lytle: It is impossible to know the longevity of the newest aortic valve as it takes long term follow up to determine longevity. The aortic valve with longest longevity currently in use is a mechanical valve which is the St. Jude valve and that has been followed for about 30 years with low incidence of valve failure. Bioprosthetic valves have less longevity but cow valves have been followed for more than 25 yrs and their longevity is based on age of the patient. The older someone is the more slowly the valves wear out.
JARED29: AORTIC VALVE, IS THERE SUCH A THING AS TOO SOON FOR SURGERY? AND WHEN IS THE TIME TO HAVE SURGERY?
Dr__Savage: Timing is based on the severity of the stenosis or leak, the effect of valve disease on heart function, and the presence of symptoms. Most patients without symptoms do not need surgery but do require close follow-up.
GAP: Several weeks ago I had an invasive bovine replacement valve for my calcified, stenotic bicuspid aortic valve. The new valve should last 10-20 years, they said. Do you think I will be able to have a non-invasive valve replacement next time?
Dr__Savage: Maybe, that depends on what the technology is when you need it done.
canopus_major: Hi, I have been diagnosed with moderate to severe Aortic valve stenosis, however I am asymptomatic and run 15 miles/week. Question is balancing benefit of valve replacement with short and long term risks. What do you consider the trigger that would drive surgery and do you believe waiting until life style is impacted before choosing surgery. I am male, 68 years old.
Dr__Savage: If you are do not have symptoms, with rare exception, there is no indication to have surgery at this time. You need to gauge when you become symptomatic. If you are running at 15 miles per week and you can no longer do what you can usually do - would consider that symptomatic. You should follow up closely with a cardiologist. For example, If you were diagnosed with a critically stenosed aortic valve you may need further evaluation and possible surgery due to increased risk of death with this condition.
MSH: How long has the ROSS Procedure been an option for aortic valve replacement? I’m interested in the long term success data. Is the ROSS ever combined w/ the DAVID Procedure? Are there other procedure names for aortic root aneurysm repair? Seems like lots of folks less than 65 yrs age are opting for tissue valves instead of mechanical. What’s the data showing for their long term success – as in how long before they actually require another surgery? Is there a database of folks being studied if it’s too soon for data 15+ years.
Dr__Lytle: The Ross operation (pulmonary valve autotransplantation) has been an option since the 1960s. Long term success data regarding Ross is not particularly robust beyond 10 years but at 10 years there is about a 25% reoperation rate, including reoperations on both the pulmonic and aortic valve.
The Ross reoperation replaces the aortic valve and the David operation repairs the aortic valve. They are not combined as the same procedure. There have been a few David type procedures performed on Ross operations that have failed.
Tissue valves can be used and are used in people at any age groups, if people wish to avoid taking coumadin. Failure of bioprostheses may happen in any age group usually with the passage of time. The likelihood of the bovine valve(there is quite a bit of data on the bovine valve longevity) failing at 15 years is age dependent and is roughly about 15% if someone is over 65 years of age when valve is replaced; and about 50% if they are over 40 years old when valve is replaced.
suek: I am 66 years old with moderate to severe aortic regurgitation. My echo has been three time, six months apart and has not changed. Is it possible that it may never change and I will not need surgery in the future.? My doctor said I have stabilized and should not need another echo for 12 months unless I develop symptoms. Also I have read about some doctors using plates and screws to reconnect the ribs after. I have read about doctors who reconnect the rib cage with plates and screws rather than wire. That it lends itself to better healing and less pain. Could you comment on that and does Cleveland Clinic do this procedure. Thank you.
Dr__Savage: You do have a leaky valve and if it has not progressed over time, it means that it has stabilized however that does not guarantee that it will not progress over time. You need careful follow up to see if your disease progresses prior to symptoms increasing.
Regards to the question about plates and screws: plates and screws are not routinely used - for most patients sternal wires and heavy sutures are more than adequate. Plates and screws may be needed after certain types of surgery for patients with infections or for people with unstable sternums.
Dr__Lytle: These are used rarely and only when we anticipate a time when there may be a problem with sternal healing and recovery.
fit4life: I am a 59 year old male with BMI of 20.8. I have enjoyed distance running & cycling for the last 40 years. I am presently diagnosed with severely stenotic bicuspid aortic valve and have associated A-fib. First diagnosed in June 2010. AVR is planned within next 2 months. I am presently on Warfarin anticoagulation therapy and this is likely to be lifelong. I would greatly appreciate any advice you could give me regarding valve selection. I am considering mechanical over tissue for longer service life. Are all mechanical valves created equal with regard to ease of implantation and service life? Thank you.
Dr__Lytle: There are no human studies that would indicate that one type of mechanical valve is significantly different than another in terms of complication rate or patient survival. Because the currently used mechanical valves entered the market at different times there are different follow up time intervals available for those valves. The current valve in use with the longest studies is the bileaflet St. Jude valve. The differences in regard to ease of implantation are subtle and rarely are tremendously important with regard to valve selection.
panther4: I have advanced aortic stenosis and developed A-fib with a recent illness. I am 66 and had quad bypass 18 years ago. What do you see as the possible options?
Dr__Savage: The main option if you have severe aortic stenosis (AS) that is symptomatic is that you need to have your valve replaced. It can be replaced surgically. If you are very high risk – then a transcatheter valve (TAVR) is an option - although this would require an assessment to look at the risk of the procedure.
LN: Would you please discuss the pros and cons of the three biological aortic valve replacements options: porcine, bovine and equine?
Dr__Lytle: It is not known whether or not the type of tissue used provides any advantage in the construction of biologic aortic valves. The biological valve that is currently used with longest follow up happens to be a bovine valve. There are also porcine and equine valves available and time may prove they function the same or better than bovine valves - but those studies don't exist at this time due to shorter follow up intervals. In addition, there have been porcine valves and bovine valves that function worse than currently used valves based on design of prosthesis not on the tissue type.
LN: I am a 60-year-old female with severe aortic regurgitation, but my echocardiograms results put me in the "compensated" category (LVEF > 55%; LVIDs < 50 mm; LVIDd < 65-70) and doing regular (6 month) echocardiograms to monitor for changes. Do you any reason to recommend surgery now or do you see continued 6-month echocardiograms as a reasonable approach?
Dr__Lytle: One key issue is whether you are having symptoms. If you are you, should have aortic valve replacement. Relying on measurements of the LV dimension is probably less accurate for women than men. This makes the timing of surgery a more complex issue. I think it would be wise to seek a second opinion because if you really have severe aortic insufficiency that is very likely to produce symptoms.
BillM: Is there any statistical data available on mortality rates for fourth AVRs? What is the life expectancy of a bovine bio-prosthetic vale?
Dr__Lytle: The risk of reoperation in experienced hands is related to comorbidities. There are fewer data involving multiple reoperations in comparison to first reoperations. Although these are often performed in patients with other co-morbidities. Anyone who is contemplating a 4th operation should seek a second opinion with people with experience with that particular type of problem.
Regis: I have been diagnosed with severe aortic stenosis, and had cardiac bypass surgery in March 2009. I do not want to have my chest opened again, and would prefer the minimal invasive surgery, but my hospital does not do that. How do the surgeries differ and what options do I have. Thank you.
Dr__Savage: If you are a good surgical candidate this can be performed in a limited upper sternotomy (minimally invasive) but in most cases it will require a surgery similar to the first surgery you had.
Dr__Lytle: It will be important to determine the status of the bypass grafts to determine the safest surgery for you.
sinaihospital: I have aortic valve stenosis with left ventricular hypertrophy also I have hypertensive heart disease which makes tired what I can for it also I have blood cholesterol and high blood pressure I just from my new I still a leaky heart valve and left ventricular hypertrophy I must still take my medicine for the rest of my life or it will get worse.
Dr__Savage: It is important to minimize progression of your heart problems - you need to take your medications and these meds are based on studies that show that taking these meds can slow or arrest progression.
mmathews234: Doctors - Thank you for your time. I am a 68 year old male who had a 4x bypass and an Aortic Valve replaced using the Mosaic Porcine 23mm valve in Feb 2011. Since then, I have been told the Valve is not working right (still have a murmur and 'velocity is not right -- not sure I understand). The cardiologist here said since it was only a 23 mm could not replace it with minimal invasive surgery. - but would have been able to if it was a larger size. I really don't understand, I though these valves were supposed to work longer and if it didn't I really wanted minimally invasive surgery. Can you shed any light on what this all means? Thanks again.
Dr__Lytle: Your cardiologist may be concerned that there is some residual stenosis of the valve and that is why flow is abnormal. The real question is the severity of residual stenosis and if you are having symptoms. Certainly if you are considering a reoperation within 2 years from previous surgery, a second opinion would be a good idea.
lutsk: I am 44 y.o. male, and have a bicuspid aortic valve, which resulted in aortic regurgitation with enlarged aortic valve. But 10 years ago I started to take ACE inhibitors (quinapril 40 mg a day), and the aortic size was greatly reduced (for example, end systolic diameter dropped from 44 to 30 mm). My ejection fraction has always been normal, with the latest estimate of 74%. To lose weight, I have been swimming 3-4 times a week for a few months, with usual distance of 1500 meters for one hour. Do you think that this amount of exercise is too much in my condition? My cardiologist is in favor, but I would appreciate knowing your opinion as well. Thank you very much for sharing your expertise!
Dr__Savage: I see no reason to limit exercise in a patient with heart disease with 3 exceptions, 1) patients with severe aortic stenosis and 2) patients with severe coronary disease should not perform stressful exercise; and 3) those with severely enlarged aorta should not do heavy weight lifting that would raise blood pressure.
jimhilbe777: I am diagnosed by C/C with "systolic anterior motion of the chordae". Is progression likely? Should I follow up on it periodically? Thank you.
Dr__Savage: Progression is not absolute, yes you should definitely follow-up if recommended by your cardiologist.
eliasD: Are the long term results of your minimally invasive techniques for mitral valve repair - I assume this means endoscopic and robotic procedures - comparable to the results from more "traditional" repair techniques?
Dr__Savage: In experienced hands, yes.
lcomai: I have mitral valve prolapse caused by rheumatic fever as a child. I am having a TEE performed this week and had a stress echo performed a few months back. What does a cardiologist look for in determining when surgery is needed?
Dr__Lytle: Mitral valve prolapse caused by rheumatic fever is extremely uncommon. It may be in fact not caused by rheumatic fever. The TEE will help the cardiologist determine if you have severe mitral valve stenosis or leak. When to have surgery is related to the presence of symptoms in mitral stenosis or the severity of the mitral valve leak if that is present. Although surgery is sometimes performed when symptoms are not present, when to have surgery with mitral valve stenosis is usually determined by symptoms present.
Annitchka: What kind of exercises are good and what are damaging to someone with severe mitral valve regurgitation? What is recommended before and after surgery?
Dr__Savage: Your symptoms should guide your exercise. I recommend against lifting very heavy weight prior to surgery.
Phoenix1986: My mom, 52, had a stenotic and regurgitating mitral valve (both moderate) and a highly regurgitating tricuspid valve, due to rheumatoid heart disease. She also had atrial fibrillation. Yet, during her open-heart surgery involving MV replacement with a metallic valve and TV repair with a ring, she was not subjected to maze surgery. Doctors reasoned that fibrillation could be managed through rate control drugs (like it had been for last eight years) and she would anyway be continuing with acenocoumarol to keep her INR between 2.5 and 3.5. But I have read that leaving maze also means that her tricuspid repair won't last longer than it would have if maze was done. Is that correct? I am extremely worried. Is there something we can do now to increase her life expectancy? Should she be allowed to walk 40 min a day once she recoups. We are worried if that could subject her repaired tricuspid valve to premature wear and tear.
Dr__Savage: In a patient like your mother the Maze procedure is generally not as effective - not doing the Maze will not have much impact on her long term. She should be allowed to do whatever she feels she can do - no limitations as far as level of function.
eileena: How do you deal with a patient who has mitral valve regurgitation but also von willebrands disease (blood disease) suggesting surgery could be problematic? Does Von Willebrands decrease the chances of strokes or blood clots? Thank you.
Dr__Lytle: Von Willebrand disease does present some challenges but patients usually can be managed effectively by a careful preop workup including Factor 8 work up and transfusion at time of surgery. To our knowledge this does not decrease the risk of stroke or blood clots although it is logical to think that it might. There are no studies that conclusively indicate whether or not it does.
jimhilbe777: I am diagnosed by CC with "systolic anterior motion of the chordae". Is my condition likely to progress? Should I have the echo repeated periodically? Thank you.
Dr__Lytle: It may progress but it is likely not to. It would be a good idea to have the echo repeated in a few years as long as you dont have symptoms. If you have symptoms, it should be repeated at that time.
bearpinny: so my question is; I am 34 years old I have mitral stenosis and my last echo I went from mild to severe. However, I am not having any symptoms so there is no surgery scheduled. that was the agreement from my cardiologist and all the surgeons he works with. what do you think? Also, because of my age, I realize that I will be advised from most to forego a pig valve. what’s your opinion and why?
Dr__Savage: As in other situations, the level of symptoms is difficult to assess. For example people may adjust their lifestyle to accommodate symptoms without realizing they have made a change. I ask patients to compare their current level of activity with that of a year ago and they may find they are symptomatic though seemingly not symptomatic.
The other issue with Mitral stenosis - it can create enlargement of the chambers of the heart and excessive blood pressure in the lungs (pulmonary hypertension) - if these develop it can become irreversible and pulmonary hypertension can be life shortening as can atrial fibrillation. You need close follow up and if these other situations develop possibly consider surgery.
In general, someone in their 30s, unless they are considering pregnancy, should get a mechanical valve. There are situations where a mitral valve repair can be done to open up the stenotic valve although this is usually not possible. If you have a bioprosthetic valve there is a very good chance you will need to have a replacement later in life.
HaroldS: I'm a0 68 year old female with mitral valve regurgitation and a-fib problems. Experienced a non-debilitating stroke about two years ago and recovered. In reasonable good health and weight, but feels fatigue often possible due to valve problem. At what age or condition should valve replacement surgery be recommended. My valve is between a moderate to severe condition. I think waiting too long to have it repaired could be a mistake. What do you think?
Dr__Savage: If you have undergone a thorough evaluation and no other reason for symptoms can be found, with moderate to severe regurgitation – that can be the cause of your symptoms. You should be evaluated for possible surgery. I would suggest an exercise assessment to determine cause of compromise to see if the leak has gotten worse with exercise. This will help to determine degree of symptoms.
Annitchka: Can EECP be used as a preventive treatment for mitral valve regurgitation? Can it revert the need for surgery?
Dr__Lytle: At the present time there is no data that shows EECP has any use in prevention or treatment of mitral regurgitation. It is hard to imagine if you have significant mitral regurgitation, EECP will not help your valve.
SHEA31: DO YOU EVER REPLACE MORE THAN ONE VALVE DURING THE SAME PROCEDURE ?
Dr__Savage: Yes, often 2, sometimes 3, rarely 4.
Medications - Anticoagulation
BigCCFFan: Had min. inv. mitral valve repair at CCF 5/11. Now looking at vol. lapros. repair of bilat ign hernia. Should I expect to have to go off Warfarin and take Lovanox before hernia repair?
Dr__Savage: The decision to reverse warfarin anticoagulation is the decision of the surgeon performing the procedure.
mkuczynska: Aspirin regime question: I had MV repair done 1 1/2 year ago at age 45.Overall I am rather healthy, active women. I am not talking any medicine. I am advised by my cardiologist not to take any aspirin since the fix of my valve was "mechanical" type, however I was told by surgeon after the heart surgery that I will probably need to take the aspirin for the rest of my life. Can you kindly shade any light on aspirin intake after valve repair ?
Dr__Savage: I put all these patients on aspirin and tell them to stay on aspirin. There is no down side to it.
Neildiane: I had a mechanical bileaflet aortic valve replacement 25 years ago and I am on coumadin. I need a hip replacement and want to know (1) how you treat going off the coumadin and (2) how do you see the risk level for any surgery when the coumadin is stopped.
Dr__Savage: There is a standard protocol for coming off coumadin - it usually involves heparin or heparin analog injections. During perioperative period you should maintain injections of the medication until INR is back to the normal level in the post op period.
The risk of stopping coumadin is blood clots on the valve - but the surgeon wants to also stop bleeding with hip operation. That is why you will require close care by cardiologist or someone who specializes in anticoagulation to minimize formation of clots on valve and bleeding with surgery.
Left Ventricle Enlargement
whvastine: Hello, I have a diagnosed left ventricle enlargement (as best I comprehend) treated in Dominican Republic by (assumed) one of the best cardiologists, now on regiment of : Lasix 40mgs, aldactone 25 mgs, carvedilol 6.25 mgs, warfarin 7.25 mgs. Is there new treatments/other technology available since 2008, when I was put in this treatment? Doctor records are in Spanish, but I rely on English explanation at time of treatment. I am looking for some form of new possibility, as in 2008, doctor explained, I would now live with this rest of life...un-identified virus attacked heart, and seems I shall endure meds forever now...I realize this is very little info...have med records scanned into computer and can send for analysis, again, records in Spanish....may you touch at least on the overall subject and any new technology since 2008? Thank you.
Dr__Lytle: Left ventricular enlargement by itself is not necessarily a problem that is not well treated by those medications. Sometimes, the importance is not the type but the amount of medication and that is something that needs to be managed by your physicians. If you would like to send records for analysis, the heart failure team in Weston or Cleveland would be glad to look at your data.
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