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Ask the Heart Surgeon (Dr. Gillinov and Roselli 2/15/13)

Friday, February 15, 2013 - Noon

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. Dr. Roselli and Dr. Gillinov answers your questions about heart surgery.

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Valve – Aortic

MarkR: Dr. Roselli, What is your assessment of the new clinical data surrounding gene mutations for Lp(a) and the predictive value this might have for aortic valve disease?

Dr__Roselli: This is an exciting new finding which lends some insight to our understanding of the causes of aortic valve degeneration. We are in the process of studying this association on multiple levels including looking at subsets of patients with bicuspid valve disease and pts with associated aortic disease. For now, we still need a better understanding of the causes of these disease processes before we see this finding have a direct impact on our treatment.

CamilleL: I have been diagnosed with aortic stenosis. I was told it was severe originally but the cardiologist thinks it is mild to moderate. How are the tests interpreted differently?

Dr__Roselli: Echocardiography is still the best test to evaluate valve function but any imaging study. It is an indirect assessment and so there can be some error in the ability to gather good images or our ability to interpret them. If there is discordance in the reading of a particular study it may be reasonable to get another method of imaging like TEE or MRI. Your cardiologist should be able to know if this is indicated.

Gus: What would lead you to recommend replacement instead of repair of an aortic valve?

Dr__Roselli: If the aortic valve tissue itself is destroyed by the disease process then the valve will need to be replaced. If the valve is dysfunctional because the surrounding structures like the aorta is abnormal or the valve is sitting in an unusual orientation, then we prefer to fix the valve or repair the valve and preserve it. Usually for aortic stenosis you need a valve replacement. Usually for a leaky valve we repair it.

mridder: How are the CC TAVI trials progressing?

Dr__Roselli: Great. We have been involved with TAVI since it first began in US in 2005. We are currently doing about 5 procedures a week. Our results have been outstanding, like our results for surgical valve procedures. Our TAVI results have been better than what has been reported at other centers and this is due to the collaborative efforts of our very experienced heart team.

Bicuspid: 1 yr ago this coming week I had OHS for replacement of a bicuspid aortic valve with severe stenosis along with repair of an aneurysm of the ascending aorta, both congenital and related as you know. The aortic valve was replaced with a mechanical valve, therefore the need for me to be on blood thinners/ in this case Coumadin/ Warfarin the rest of my life. I have virtually no heart disease. What are the long range problems associated with blood thinners incl longevity? Finally, with new technology is it possible now or in the future to possibly replace the mechanical valve with a swine valve using minimally invasive surgery?

Dr__Roselli: The most serious complications associated with lifelong anticoagulation and the mechanical valve are bleeding complications or clotting complications (thromboembolism). These are estimated to occur at a rate of 1 - 2% per year but may be overestimated. It is not uncommon to replace a mechanical valve with a biologic valve and it can often be done very safely at a very experienced heart center if the indications are right.

Frisky: I am 69 years of age and have BAVD. I am scheduled for surgery at the Cleveland Clinic to replace the aortic valve and repair the ascending aorta. Is it likely that the paroxysmal afib that I also have will stop after the surgery or will it have to be treated separately?

Dr__Roselli: The atrial fibrillation will most likely require additional treatment since it is unlikely to be attributable to aortic valve disease. You could potentially have an ablation procedure for your atrial fib at the same time of your operation but that depends on more details of your disease. Discuss this with your surgeon.

Frisky: What is the relationship between BAVD and hypertension? Will surgery for BAVD (valve replacement and aorta repair) have an effect on the hypertension?

Dr__Roselli: The two disease processes are not directly associated. In other words if you have treatment for your valve and aneurysm you will most likely need treatment for your hypertension but your medications may change.

easyrider: I had an aortic valve replacement with a St Judes and now it appears that my heart valve is leaking. Is it possible to fix the leak or must it be replaced?

Dr__Roselli: Usually the leaking mechanical valve is due to a leak around the valve and not from within the valve itself. depending on patient's condition, and the size of the defect, it can be either repaired through another open surgery and can sometimes be repaired with a catheter based approached where the hole is plugged with an additional device.


Valve – Mitral

jb1371: Some retrospective studies have shown that early repair of MR (prior to the appearance of symptoms, LV dysfunction, AFib, PHT) have superior long term outcomes, e.g. survival rate, than a 'wait and see' approach. Can you comment on the advisability of early repair and the criteria you would use to determine when to operate for MR?

Dr__Gillinov: If the MR is severe, we recommend early surgery.

bradma: I am 60 years old, have severe MVR (4-4+) and my local cardiologist has suggested that I need to get the valve repaired or replaced. I'm interested robotically assisted options and would like to know more about the differences between that approach a minimal sternotomy. Is the outcome, quality of repair as good? And is the length of time on bypass extended using the robot? All things being equal, is it preferred over a more conventional approach?

Dr__Gillinov: For isolated mitral valve repair, we favor robotic surgery. The operation on the valve is identical. But people are out of the hospital at 4 days and return to their lives more quickly. The time on bypass is about 10 minutes longer—that is not significant.

teriyaki: Hello - I have MVP w/ severe regurgitation, and I’m told by my cardiologist & my surgeon here in Colorado I will likely travel to see you guys for Mitral Valve repair/replacement in the near future (it’s not a common surgery anywhere around here). They say my left atrium is already the largest they’ve ever seen. I’ve had 2 A-fib ablations in the past 14 months, the 2nd of which took 7 hrs. & seems to have worked. I’m female, 46 and in pretty good health – other than my heart. What can you tell me about the surgery? Does it have to be open heart surgery, or are there new less invasive techniques? Any insight is much appreciated. I have family there, so I could travel to do a consult with you guys. Would that be a good idea? Thanks – Teri.

Dr__Gillinov: If all you need is mitral valve surgery, we can generally offer a minimally invasive or robotic approach. We can generally get everything done in a single trip to Cleveland.

jb1371: Some retrospective studies have shown that early repair of MR (prior to the appearance of symptoms, LV dysfunction, AFib, PHT) have superior long term outcomes, e.g. survival rate, than a 'wait and see' approach. Can you comment on the advisability of early repair and the criteria you would use to determine when to operate for MR?

Dr__Roselli: The data you referred to is convincing and so I would recommend elective Mitral Valve repair for a patient with severe MR in whom I believe we can do the operation with a less than 1% mortality rate and a better than 95% confidence of achieving a repair instead of a replacement.

bradma: I have MVR (4-4+) with a severely dilated left atrium and mildly dilated LV. Towards the end of a recent stress test there was a 3 beat run of ventricular tachycardia then an 8 beat run over 24 hours of a holter monitor. Is the vtac related to the MVR and how would you suggest proceeding?

Dr__Roselli: Yes - it very could be related to your severe MR. It sounds as though you probably need an operation.


Valve – Tricuspid

clara: I have been told that I will need the tricuspid valve operated on. I had the aortic valve replaced and 2 grafts 2006. On 2009, 2010, 2011, 2012, I have had 8 stents - last on Sept. 2012. None of the stents have failed. The tricuspid valve has gone severe and the mitral valve has become moderate. The mitral valve regurgitates - not sure about the tricuspid. They said I have to wait until I go off Plavix. I have developed symptoms of SOB / lightheaded/ extreme fatigue at times / . Are these symptoms due to the tricuspid valve? It is hard for me to imagine open heart surgery again!

Dr__Roselli: Your situation sounds particularly complicated - when you have multivalve and coronary disease you would probably best served being seen at a tertiary care center.


Valve – General

Rls14136: Are there surgical options for a patient who needs heart surgery (such as a valve repair/replacement) in a patient who also have Chronic Kidney Failure to help reduce risks of further kidney damage?

Dr__Roselli: We operate on many patients with kidney disease very safely and there are certain things we do in the operating room such as how we run the cardiopulmonary bypass machine to limit the stress on their kidneys.

ForMyMomsHeart: My mother is scheduled to receive the Edwards valve next month. She has a leaking pulmonic valve, a 4.2 aneurysm, and enlarged right side and has frequent a-fib issues. Can you elaborate on the success rate of the Edwards valve? How long will it last? What are the risk involved?

Dr__Roselli: Edwards makes many kinds of valves - your surgeon will be careful in the valve selection for your mother to choose a valve they believe to be safest and most durable for her.


Aortic Root Aneurysm

nasghattas: I'm a physician I have an aortic root aneurysm measured 5.5 CM by ECHO and %.% by CTA last month I'm well aware of the seriousness of the situation, however also I'm well aware of complications especially stroke which can be devastating no matter how small it is. I calculated my ASI it is between 2.8 - 2.9 . I have a bicuspid aortic valve, I have As and AR, however I'm completely asymptomatic. I'm in great shape I have vey successful practice. I appreciate your advise. surgery was recommended to me about 2 years ago. My question is how reliable is the aortic size index and any place for endovascular repair?, is it still in its experimental phase? Thank you for your advice.

Dr__Roselli: Echocardiography is not as accurate as CT scans or MRI for measuring the diameter of your aorta but if it is truly 5.5 cm in the setting of a bicuspid aortic valve you are at a much higher risk for aortic dissection and the life threatening complications associated with it than you are from stroke during surgery. Therefore, I would recommend an operation for you. Aortic size index is most applicable for smaller sized aortas and at 5.5 you have reached a threshold for repair regardless of your body size.

Endovascular repair is not even close to being an option for aortic root aneurysms at this point in time because of the complex anatomy involving the valve and the coronary arteries in the aortic root.

chezaugie: Are there any minimally invasive surgery procedures for an Aortic Root Aneurysm repair? My cardiologist told me it can only be repaired by open heart surgery. If not, are there any minimally invasive procedures on the horizon?

Dr__Roselli: Yes - aortic root surgery does still require open heart surgery but many times we can do this with a minimally invasive approach through a small incision depending on the patient's particular anatomy and the surgeon's experience.

damian1: I have a dilated aorta root and mid-ascending aorta 93.2 and 4.4). are you aware of any symptoms attributed to the aorta as a result of having coffee or wine?

Dr__Roselli: I would assume that 93.2 is a misprint and typically patients will not have symptoms from an aortic aneurysm until it is close to too late. Coffee and wine will not cause symptoms from a dilated aorta but more likely may be associated with esophageal dysfunction like reflux.

ulysses: Does a mildly dilated aorta at 42.8mm need concomitant repair during mitral valve surgery since aortic cross clamping might cause dissection? Can we avoid aortic repair with on-pump empty beating heart without aortic cross clamping? If however aortic repair is mandatory can both operations be done minimally?

Dr__Roselli: Typically we won't replace an aorta that is 42 mm unless it is associated with bicuspid aortic valve or other connective tissue disorder. I do not perform the empty beating heart for mitral valve disease. I prefer the safety of an arrested heart. The mitral valve and ascending aorta can be replaced simultaneously with a mini sternotomy approach if indicated.


Aorta Surgery

easyrider: How many years after having the two phase elephant trunk procedure should I expect to recover to my full level of activity? How many years should I expect to live after having this surgery? What type of heart valve do you recommend when replacing a St. Judes prosthetic?

Dr__Roselli: The long term results after two stage elephant trunk repair are more dependent upon the reasons for having the repair. Most people that require this type of repair have extensive aortic disease which requires a lifetime of surveillance and may even require additional surgery in the future. You should be back to most normal activities within a few months after aortic repair but you may have restrictions on your activity level depending on the condition of your remaining aorta.

J12: How safe (or how big of a deal) is the surgery to repair a thoracic aortic aneurysm (ascending) when the aneurysm is right at the point where the aorta connects to the heart? I'm 57. The aneurism has been followed with MRI's each year for the last 10 years and has always measured about 4.8 cm. Last month I had a contrast CT scan in preparation for an RF ablation and the doctor who read the scan said it was 5.1 cm. No marfans syndrome.

Dr__Roselli: Our mortality for elective ascending aortic surgery has consistently been less than 1%. We do over 800 thoracic aortic surgeries in Cleveland. If you are considering thoracic aortic surgery, you should go to a very experienced center where it can be done successfully - especially if you are healthy otherwise.

serabuone: I have an ascending thoracic aortic aneurysm, what is minimalized in minimally invasive surgery?

Dr__Roselli: The incision - simply put - is smaller. For most patients repair of the ascending aorta still requires cardiopulmonary bypass and is an open heart procedure. For a very small number of patients we can fix the ascending aorta with a stent graft delivered percutaneously.

chuckarc: My mom who is 80, has had a stable 5.1cm ascending aortic aneurysm for 2 years. How often should she have a CT Scan to check the size? And can an aortic aneurysm still enlarge if your BP is normal to low?

Dr__Roselli: I would probably recommend an annual CT scan for her if her BP is in good control. Aneurysms are more likely to grow if BP is not well controlled but they can still grow even if it is.

milanheart: My name is William S. and I am asking a question on behalf of my friend and his wife, Attilio and Rosaria P. who live in Milan, Italy. Due to the identification of two aneurism's, one on the aorta ascending and one on the descending aorta. They have been informed that depending on the rate of growth of said aneurysms that she would require a procedure commonly referred to as "elephant trunk". this would need to be followed by a second procedure in six to weeks after the first to correct the descending aorta aneurism. The P's have had extensive discussion with an experienced surgeon in Milan who would perform the surgery the question is, could you opine on the level of risk involved in these procedures and discuss the historical success rates.

Dr__Roselli: I would be happy to review her images in more detail if we can get them sent directly. With regards to historical outcomes with the elephant trunk procedure, our results with the each stage of the operation had mortality rate of 5% or less for most patients.

islandtom: I'm 72, We found a ascending aortic aneurysm at 5.3 three years ago. It has not gotten larger. c-scans every six months. blood pressure medication and under control. in your experience, can like aneurysms stay stable for long periods of time? Can I go to having c-scans just yearly.

Dr__Roselli: If the aneurysm has been truly stable on multiple studies and your BP is well controlled - then yes - yearly imaging can be recommended.

Peppy: Does a nuclear stress test show any aneurysms, aorta problems of the heart, etc.. or do you need a CAT scna or MRI?

Dr__Roselli: Stress test will not image the aorta.


Coronary Artery Disease

chris66: Hi, I had bypass in 2005 for a block in the left main. I know a LIMA graft was used to the lad and a saphenous graft to the OBTUSE marginal. I am trying to figure out how the SVG supplies the LAD. I can see in pictures that it runs off the circumflex. Which brings me too my other question I have a 40 % lesion in the circumflex at the ostial if this began 100 % blocked who it cut off blood flow to the SVG? I also had a LIMA graft that was said to not have matured , so they stented the LIMA but it is blocked , now my LIMA is opened up a little but small , can it go back to the way it was where it was not giving blood flow thru it ? Sorry one more thing I was told I have mild diffuse disease in the LAD and could not ever have bypass because of this is this true ? Thank You Chris.

Dr__Roselli: It is difficult to comment on the details of your new anatomy without seeing the films but at least 1/3 of the surgeries at the Cleveland Clinic are reoperations. It is very rare for someone not be able to have a second operation if it is truly indicated. If you wish to have a second opinion, we would be happy to review your studies.

ritchreg: I had robotic bypass in 2011, didn't work, ended up being stented. I am still severely limited (shortness of breath) when even walking up a flight of stairs. Was a competitive swimmer. Cath, echo, stress tests, chest x-rays show nothing out of the ordinary. Are my doctors missing anything you can think of?

Dr__Roselli: I cannot comment without more details. We would be happy to provide you with a second opinion consultation.

CamilleL: I had bypass surgery in Oct 2011. I am experiencing fatigue and shortness of breath. I had an echo and a stress echo done and the doctor said there was abnormality however, he feels we should wait to see if symptoms persist before he does a heart cath. Do you feel I should get a second opinion?

Dr__Roselli: A second opinion is never a bad idea.


Septal Aneurysm

healthygourmet: Do you suggest surgery repair of left atrial septal aneurysm with no hole in the heart?

Dr__Gillinov: No.

healthygourmet: Re: previous Q for atrial septal aneurysm, how large before suggest surgery?

Dr__Gillinov: Surgery is rarely indicated, regardless of the size.

diniscc: Which of the aneurysms are the most dangerous? Is the ascending aneurysm the least dangerous of the bunch? Do you need open heart surgery to repair? How long will you live after the repair?

Dr__Roselli: Most ascending aortic aneurysms still require open heart surgery - in some situations I have successfully treated these aneurysms with endovascular approaches and many times we can repair the ascending aorta through a minimally invasive incision.


Myectomy

xdwl: Hello doctor, I am 55 year old female with HCM for 10 years, received myectomy in Sep. 2012. I felt well during the first few weeks post-surgery. However, I started feeling “chest tight” since 6th weeks post-surgery. My symptom is more obvious when sitting up than lying flat or walking around. HR is stable 60-65/min Recent NT-proBNP 869 (1999 pre-operation). Recent echo showed obstruction has been eliminated (gradient 8mmHg), LVEDD 47 mm, EF 70%, E/A 0.77. LAD 37mm; Septal thickness 10; LV PWT 10mm; and mild LV diastolic function decreased. Cardiac/chest ratio 0.54.Before the operation, my cardiac function was in NYHA II-III, I felt SOB and chest pain only when I was walking around, but never felt chest tight when sit. According to recent echo report, the operation is successful. But why I feel chest tight now? Is it related to my operation (something going wrong which echo cannot detect)? Whether it is a persistent symptom? And any treatment? I really worry about this. Many thanks!

Dr__Roselli: It is difficult to answer such a detailed question online. You need to speak with your cardiologist about the symptoms you are having. Sometimes, a simple echocardiogram is not enough to evaluate someone with HOCM postop - you may need additional testing to evaluate your symptoms. Because this is a very complex disease it is important to be seen at a center with a lot of experience. If you wish to be evaluated here, we would be happy to assist you.


Radiation Heart Disease

simtoo: I received 6000 rads to my mantle field 36 years ago and am now experiencing 2 unexplained pericardial effusions. Could they be a consequence of radiation damage?

Dr__Roselli: Yes. It is possible especially many years after having mantle radiation we can see late cardiac effects on all of the structures in your chest.


Congenital Heart Disease

krm: What is your experience with velocardiofacial syndrome patients and the need for additional surgery? in particular, valve and great vessel replacement surgery?

Dr__Roselli: Patients with velocardiofacial syndrome also known as DiGeorge Syndrome are quite variable in the amount of cardiac involvement with their problem. They may have tetralogy of fallot, interrupted aortic arch, vsd. Most of these patients are cared for by pediatric congenital heart surgeons although I have taken care of adult patients with great vessel anomalies. Commenting on success of any particular patient depends on how severe their disease is.


Minimally Invasive Heart Surgery

yellowjacket: What factors determine if robotic or minimally invasive surgery can be done?

Dr__Roselli: The approach to your heart disease depends on which valves are involved, what your anatomy inside your chest looks like based on CT scan imaging and your surgeon's experience.


Heart Surgery Recovery

dkuskowski007: My sternum did not heal from OHS back in Oct 2011. It now clicks, pops, and snaps with every twist, sneeze, cough, etc - is this a dangerous condition? Also, a sternum wire seems to be pushing against my chest wall from the inside and causes intermittent needle like pain.

Dr__Roselli: It is not dangerous. But if it bothers you we can fix the sternum with a relatively minor operation.

SV: I had an open heart surgery at Cleveland last Nov. How long do I need to wait to start doing intermediate yoga---and what do I need to know (dos and don'ts) before I resume yoga.

Dr__Roselli: Yoga has recently been shown to improve overall cardiovascular and neurological health. Glad to hear you want to get back into it. Without knowing more specific details of your problem, I cannot make recommendations for when you can start. You should ask your physician about this - but hopefully soon!

cwagener: Do you limit your patient’s exercise that have AVR for a Bicuspid Aortic Valve? Or another way to ask this - do you feel that limiting exercise (let’s say doing multiple marathons) post surgery for AVR is a good idea or is it really “as tolerated"? And if you don't limit, do you feel that endurance exercise will lower the life of the valve (when it is tissue rather than mechanical)?

Dr__Roselli: For now, there is no evidence to suggest that you can prolong the life of your biologic valve by limiting your activity or other lifestyle changes. So - I would recommend that you do things as tolerated as long as there isn't another contraindication to doing this. I have several patients who I have operated on for bicuspid valve disease including those who have had aneurysm repaired who are competitive athletes including marathon runners, rugby players, swimmers, etc.

ltba8706: Had aortic valve replace w/mechanical valve 1989. Aortic dissection & aneurysm 2006. Surgeon said no cardio or resistance exercise. Cardiologist said light cardio & resistance exercise ok. How much resistance is good? I am 69 years old in April.

Dr__Roselli: It depends on what your residually resected aorta looks like and how well controlled your blood pressure is but the least conservative recommendation would be no lifting more than 1/2 your body weight. And - don't raise your heart rate to more than 80% of the max predicted heart rate for your age during aerobic activity. I would recommend you start slowly and I typically tell my patients not to lift more than 40 or 50 pounds.


Diet

FleureM: Dr. Gillinov: After a valve surgery, does one have to be mindful of eating too many green leafy vegetables because of the vitamin K? Aspirin is the only blood thinner medication.

Dr__Gillinov: Only have to be mindful of Vitamin K if you are on warfarin (Coumadin). It does not impact aspirin. Enjoy your vegetables.


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Reviewed: 2/13

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