Monday, May 13, 2013 - Noon
Heart valve disease occurs when one or more of the heart valves do not work correctly because of valvular stenosis or valvular insufficiency. In many cases, heart valves can be surgically repaired or replaced, restoring normal function and allowing the person to return to normal activities. Dr. Griffin and Dr. Kapadia answer your questions about valve disease and groundbreaking percutaneous techniques.
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Percutaneous Valve Treatment
dougseabird: Please describe percutaneous options for aortic valve repair or replacement.
Samir_Kapadia,_MD: There is commercially available percutaneous aortic valve for replacement. There are at least 8 other valves under investigation for percutaneous treatment. The aortic valve can not be repaired percutaneously. It has to be replaced.
gusgel: Are there any percutaneous options for bicuspid aortic valve condition and, if so, what option(s) is(are) available?
Samir_Kapadia,_MD: As previously stated, there are some bicuspid aortic valves which are suitable for percutaneous therapy.
eliasdavis: How do recovery times differ for percutaneous mitral valve surgery as opposed to standard treatment?
Samir_Kapadia,_MD: Mitral clip procedure requires hospitalization for total of two - five days. Since there is no incision, recovery is faster.
genodoc: Percutaneous aortic valve replacement in Aortic Insufficiency?? When will it be standard of care in asymptomatic AI??
Samir_Kapadia,_MD: There are valves that are being investigated for aortic insufficiency (AI). The use of valve replacement for asymptomatic AI is debatable. Currently we do not recommend valve replacement unless the heart is getting dilated. There are no commercially available valves for percutaneous therapy for AI.
gusgel: Is there a percutaneous option available for correction of bicuspid aortic valve?
Samir_Kapadia,_MD: It depends on the size and shape of the bicuspid valve. There is literature now that supports the use of percutaneous valve for some bicuspid valves. However, for most clinical protocols under investigations exclude bicuspid valves.
rosegradis1: I was at Cleveland Clinic in September of 2011 to have my Aortic valve replaced and two others repaired. It was decided that it wasn't quite bad enough to operate. We discussed " TVAR " that was ruled out because I had a double By Pass in 1983 ( I'm now 82.) Since that time my condition has become a little worse, my feet and legs are a great deal more swollen. Has anything changed as to a percutaneous procedure even with my past history?
Brian_P._Griffin,_MD,_FACC: I suggest you make another appointment to be seen – percutaneous AVR is approved for high risk severe aortic stenosis but there are technical reasons why it may not be feasible in an individual patient.
kenk: My cardiologist indicated that I will need both mitral and aortic valves replaced in the near future and the procedure will require full open heart surgery as compared to newer less invasive procedures. What are some of the determining factors to arrive at that decision.
Samir_Kapadia,_MD: Currently there is no commercially available mitral valve for percutaneous replacement. Therefore if you need mitral valve replacement, you will need open heart surgery. If the mitral valve is leaking, and can be repaired, there is ongoing trial for a percutaneous clip.
DMOGIRL: I am wondering how long until the percutaneous procedure will be an available/regularly used option for aortic valve replacement?
Samir_Kapadia,_MD: It has been commercially available for one and half years for patients who are inoperable or very high risk for aortic surgery. Availability for low risk patient is under clinical research which you can participate in.
DMOGIRL: Are there any risks during the percutaneous procedure that would make open heart surgery just as safe?
Samir_Kapadia,_MD: The percutaneous procedure and open heart surgery have their pros and cons. Associated medical conditions favor the use of percutaneous therapies whereas inability to have proper access for percutaneous valves in patients who can tolerate surgery - surgery is a better option.
DMOGIRL: Hello, I received a tissue (bovine) 23mm aortic valve 3 years ago at age 28. I am just curious if this valve is ideal when considering a candidate for the percutaneous procedure in the future?
Brian_P._Griffin,_MD,_FACC: Valve in valve percutaneous replacement is feasible with a size 23mm valve. This has not been approved by the FDA yet. This is a potential option in the future.
firstname.lastname@example.org: Is a valve which is inserted via TAVI/TAVR expected to last any shorter or longer than a similar valve that is implanted using OHS?
Samir_Kapadia,_MD: We are hoping that this valve will last similar to the one implanted by open heart surgery. We have data for five years in a reasonable number of patients but 10 or 15 year data do not exist.
DMOGIRL: How many times can a patient use the percutaneous procedure to replace a valve? Is it a one time thing?
Brian_P._Griffin,_MD,_FACC: No, there is the potential to put a valve inside the initial percutaneous valve, but this is not yet approved.
WALTERBLASS: I am 83 years old with moderate aortic stenosis; last Mean gradient 26. When I hit 40, will the percutaneous procedure work for me? The French cardiologist whom I consulted last year said his experience was that such a procedure resulted in more arrhythmia than sternotomy. Is this true in your practice?
Brian_P._Griffin,_MD,_FACC: Need for valve replacement in your age group is based on symptoms, not any one number. Some percutaneous valves, especially those used in Europe are associated with a high likelihood of a pacemaker being needed.
dougseabird: You said earlier that "Availability [of percutaneous procedure] for low risk patient is under clinical research which you can participate in." Please describe that clinical research, or give us a link we could go to find out more.
Samir_Kapadia,_MD: It is called PARTNER IIA protocol. You can find information at www.clinicaltrials.gov.
eliasdavis: Are the long-term results of percutaneous treatments for mitral valve regurgitation equal to standard procedures?
Brian_P._Griffin,_MD,_FACC: Percutaneous approaches are still investigational as compared to standard surgical approaches. It is still unclear how well these work over many years.
eliasdavis: Please excuse my ignorance but could you explain the difference between minimally invasive surgery and percutaneous treatment?
Samir_Kapadia,_MD: The current minimally invasive surgeries require stopping of the heart, going on the heart lung machine and direct visualization of anatomy. Percutaneous treatments are performed in beating hearts with x-ray or ultrasound visualization. They are both done through small or no incisions.
adourian: Is there any new news that shows any reduction in the incidence of strokes for percutaneous valve replacement vs. invasive valve replacement?
Samir_Kapadia,_MD: With better patient selection, the rate of stroke in percutaneous therapy seems to be declining. The most discernible decline was seen as experience with transapical access increased. The ongoing trials will help to understand risk of stroke in low risk population. There are several mechanisms for stroke including atrial fibrillation and embolization during procedure. Efforts with newer devices and medications are underway to reduce this risk.
DMOGIRL: How many percutaneous valve replacement procedures have been made at Cleveland Clinic? What is the success rate?
Samir_Kapadia,_MD: We have done more than 400 procedures. For 255 transfemoral procedures performed until end of 2012, 30 day mortality was 0.4%. This is outstanding compared to other reported studies.
Aortic Valve Disease
stayingalive: My aortic valve was replaced 8 years ago. What symptoms should I be concerned about that would indicate the valve is beginning to weaken. I understand there are a few new blood tests that should be done. Does the sound of the heart beat becoming more pronounced something to be concerned about?
Samir_Kapadia,_MD: Shortness of breath, chest pain or dizziness are important symptoms to look out for. Echocardiogram is the most important test that you need. There are options to put a new valve within the old one, but it depends on what type of valve you have. Close follow up with an expert is recommended.
sinaihospital: I have aortic valve problems since 2004 what is the treatment for it. I take medicine for it. I have stress echo stress tests, ekgs, blood tests, trips to the hospital for chest pains.
Brian_P._Griffin,_MD,_FACC: Most aortic valve problems do not require specific medical treatment, but may require surgery eventually. You need to follow-up with your cardiologists regularly and have an echo done yearly - at least.
okie17: My cardiologist said my aortic valve is moving slightly slower than normal. I am 76 years old with no heart health history. I don't take cholesterol lowering drugs. Should I? Thank you.
Brian_P._Griffin,_MD,_FACC: If you have high cholesterol and cholesterol reducing drugs are needed anyway, there may be a benefit in slowing the rate of narrowing of the aortic valve. No evidence otherwise that anticholesterol therapy slows valve progression.
fpilla: I am an 80 year old male in good physical condition with progressive aortic valve stenosis that is slowly reaching the critical stage. Other than atrial fibrillation which initially was diagnosed a couple of years ago, I have no subjective symptoms. What are the deciding factors used to determine if a patient might even have an option to select a smaller incision route than the traditional method for aortic valve replacement. What are the pros and cons? Thank you.
Brian_P._Griffin,_MD,_FACC: If all you need is aortic valve replacement then the surgery can be completed with a small incision in most instances. However, if you have other problems that need addressing such as coronary disease, this would require a bigger incision at the time of surgery.
dukefan55: I am a 58yo female with moderate aortic stenosis (BAV).I am having chest pain when I exercise and have had a nuclear stress test and passed and a CPX test during which the technician had to stop due to 2 changes in my EKG. The tech said it indicated I was experiencing ischemia. My doctor said it isn't bad enough to do surgery yet. How will I know when it's time?
Samir_Kapadia,_MD: If your exercise tolerance decreases, you get dizziness with exertion, or your left ventricular function decreases, you need aortic valve operation. Regular follow-up with your doctor along with echocardiogram will be important to determine the timing of surgery.
waterdoc: Are there any positive results being seen from research into finding a way to prevent or reverse the progression of aortic stenosis?
Samir_Kapadia,_MD: Although not proven, lowering the cholesterol and minimizing excessive calcium replacement may help to decrease rate of progression of your AS.
bmwenick: 2/25/2009 at age 62 had replacement aortic valve. Edwards bovine tissue valve model 3000TFX replacement due to severe stenosis of the valve. Had rheumatic fever had a child. Mitral valve also damaged and since surgery, left atrium has continued to enlarge and latest test showed it severely dilated at 6.1.
1. I am very active and do quite a bit of physical activity at higher elevations such as X country skiing and snow shoeing about 9,000 feet elevation and backpacking about 10,000 feet. Is this contributing to enlargement of the left atrium?
2. Is a physically strenuous life style going to result is the aortic valve having to be replaced earlier?
Should repair of the mitral valve be considered at this time? Thank you both. Robert.
Brian_P._Griffin,_MD,_FACC: I doubt that physical exercise is contributing to the atrium enlargement. Exercise at a very high level such as endurance activities such as triathletes, might cause the valve to degenerate a little faster. Otherwise, unlikely that keeping fit is other than good for the valve. The need for mitral valve surgery will have to be determined when your AVR fails.
Aortic Valve Surgery
Regis: Does Cleveland Clinic still perform open chest surgery for aortic valve replacement?
VickiD: Can you please explain how the timing of valve replacement is determined? (63 yr old woman, BAV, moderate stenosis, most significant symptom SOB).
Samir_Kapadia,_MD: At the onset of heart failure, aortic valve replacement is required. The heart failure is diagnosed by onset of symptoms (shortness of breath, chest pain or dizziness) or left ventricular dysfunction (EF, dilation, hypertrophy).
Ruthonline: What would be other reasons for the A-Fib, after correcting the thyroid problem?
Samir_Kapadia,_MD: Most common causes are hypertension, coronary artery disease, valve disease.
Ribby53: Had aortic valve surgery in may 2012 one year ago. The only Meds I take is an aspirin 81mg. My blood pressure is ok, should I still be taking beta-blocker?
Brian_P._Griffin,_MD,_FACC: Not necessary unless there are other reasons than aortic valve to be on it.
fpilla: I reside in Arizona. If I come to come to the Clinic for aortic valve replacement, how is follow up care handled after the initial post operative recovery phase. Thank you.
Brian_P._Griffin,_MD,_FACC: We are very used to patients coming from all over the world for surgery here. Typically the follow-up would be performed by your own local cardiologist. We will communicate what needs to be followed-up to your local doctors. This has been very satisfactory for many years.
anuhak63: Mean Aortic Systolic Gradient 42mmHG; Valve Area 1.08cm2. What readings normally require an aortic valve replacement?
Samir_Kapadia,_MD: The numbers are less important than symptoms. Gradient of more than 40 or valve area less than 0.7 cm2 are typically seen in patients who develop symptoms. Many patients with one of these numbers do not have symptoms. We follow these patients closely to identify signs of early heart failure, at which time we recommend surgery.
email@example.com: Hi, I'm a 47 year old male (in B.C.) with a "functionally bicuspid" aortic valve (calcification) with severe regurg and moderate dilation. From all tests thus far (TEE, Echo, CT) it looks like a straight valve replacement. I'm waiting for AVR - likely this year - date TBD. I am debating on mechanical vs. tissue valve and likely leaning towards mechanical so that I only have to have OHS 1x. However, the possibility of going tissue now and potentially a replacement using TAVI/percutaneous treatment in 10-15 years time is something I was trying to understand (i.e. will it be pervasive enough to make this a strong likelihood or do I risk having OHS for a 2nd time?). I realize there is no 'crystal ball' and nothing is certain, and it will to vary in each country/state/province, etc. depending on how widely these new approaches are used. But I would be interested in your thoughts on this. I am quite active, younger, etc. and am trying to weigh the pros/cons. Thanks! Tony
Brian_P._Griffin,_MD,_FACC: There is no right answer in this situation. There are advantages and disadvantages of tissue vs. mechanical valves. I have no doubt that if we had a very durable aortic valve replacement that was tissue and didn’t require anticoagulation that that is what most of us would prefer. You are at the age where a tissue valve will likely last 15 years. Even if you were to have further tissue valve placed percutaneously, you would most likely need a 3rd procedure (surgical) in your 70's. So, if you have no reasons to avoid a mechanical valve that would appear to be reasonable option.
davekcleveland: I have been diagnosed with sclerosis of the aortic valve. It is being watched by my physician at Cleveland Clinic and my local cardiologist as well. I have been told that should it need replacing in the future that locally in my city only open heart surgery is available. What are the guidelines for the less invasive replacement procedure at Cleveland Clinic....? Is it available to everyone or just to a selected age group? I had open heart surgery many years ago and I am afraid to go through that experience again. Could I choose the less invasive method if it needs to be done at some point in time?
Samir_Kapadia,_MD: If your surgical risk is high, you can choose to have percutaneous aortic valve replacement. It is now FDA approved for this indication.
dougseabird: I recently heard that aortic valve repair (vs. replacement) is happening more and more for people who have regurgitation -- not calcification. Does Cleveland Clinic currently routinely do aortic valve repair? If so, could you briefly describe what factors determine whether a person is a candidate for AV repair? And briefly describe the procedure? If CC does not do aortic repair, why not?
Brian_P._Griffin,_MD,_FACC: Cleveland Clinic has pioneered the use of aortic valve repair for aortic regurgitation and has extensive experience in doing this. It is usually feasible in patients with a bicuspid aortic valve that is not calcified and where the large leaflet prolapses. There are other situations where it may be feasible also, such as, patients with an enlarged aorta, and relatively normal aortic valve.
stayingalive: I have a bioprosthetic valve. Recently underwent stenting followed by lithotripsy. Urologist wants to leave stent in for another week--almost 14 days in total. I am taking 500 mg of Amox twice daily. Is that ok or should the stent be removed sooner.
Brian_P._Griffin,_MD,_FACC: You will need to follow-up with your local cardiologist and urologist.
dougseabird: Please describe the most-used incision for minimally invasive aortic valve replacement at CC.
Brian_P._Griffin,_MD,_FACC: A mini sternotomy that involves 4 inches long incision in the midsternum. I suggest you look at the website - there are diagrams that explain the incision.
Mitral Valve Disease
mvpr: Hello and thank you for hosting this chat. What are the safest over-the-counter pain killers to take with the diagnosis of moderate mitral valve regurgitation. I rarely take any medications, but wanted to know for when it is really warranted. Thank you for your response.
Brian_P._Griffin,_MD,_FACC: Probably acetaminophen (tylenol) or naproxen (alleve).
smartheart63: Dr. Griffin, I was told that I have mild mitral valve prolapse; the doctor told me I have a mid-systolic click. I had a strep throat infection as a 3 yr old that caused me to have Brights disease. Do you think the strep infection attacked both my heart and kidneys causing both? I have had an Echo and was never placed on any medications, do you think as I get old I will require surgery for the Mitral Valve? My family has a very bad history of heart bypass surgery.
Brian_P._Griffin,_MD,_FACC: Mitral valve prolapse is not related to strep infection and it is inherited abnormality of mitral valve tissue. Deterioration in MVP occurs in mid to late age, but is not inevitable. Would recommend to be followed yearly with an ECHO.
Samir_Kapadia,_MD: Prolapse is unlikely from a strep infection. Most commonly the infection gives rise to scarring of the mitral valve with mitral stenosis and/or regurgitation. Prolapse is likely to be unrelated to infection. If the leakage is not severe, this can be managed without operation. You may need a detailed echocardiogram to evaluate this problem.
smartheart63: My echo results read trace mitral and trace tricuspid regurgitation. Is this serious will I need surgery later in life.
Mitral Valve Surgery
eileena: If you have a patient with mitral valve regurgitation who is healthy and asymptomatic, would you recommend immediate surgery. If so, would you prefer to treat with percutaneous options or open heart options?
Brian_P._Griffin,_MD,_FACC: Generally we recommend surgery for mitral regurgitation if there is a severe leak and the valve appears repairable even in the absence of symptoms. This is not an emergency. Typically surgical repair is associated with more complete resolution of the leak and is preferred to percutaneous procedures in healthy individuals.
dricke: What "numbers" should I be asking my doctor to help Cleveland Clinic know when a mitral valve needs repair or replacement? I am not symptomatic other than my afib which I never feel. I am on warfarin and Diltiazem HCL. The last seems to be slowing down my heart rate more and more as the years progress. I started in 2006 with 250MG every day and now I take 120MG every third day. How do I know when it is time before too much damage and the chance for repair is gone?
Brian_P._Griffin,_MD,_FACC: The most appropriate data would be to send an echocardiogram or a series of echos over that number of years.
bipbip10: I am a 55 year old male and have been diagnosed with a bicuspid valve with aortic stenosis and a dilated aorta which is approximately 4.6 to 4.7. This has been an ongoing issue that my doctor's check every four months for a few years now. How does the dilation generally progress and when should you actually consider having surgery?
Samir_Kapadia,_MD: Depending on the family history, type of dilitation, and rate of progression, surgery for aortic valve and aorta can be recommended. The numbers are close for recommending surgery. An expert evaluation is not unreasonable at this time.
clara: I had bypass & aortic valve replaced 2006. 2009, 2010, 2011, 2012 - 8 stents. All in major arteries and none have failed. I am now told that the tricuspid valve is severe, and I will probably need surgery when I can go off Plavix. The mitral valve has changed from mild/moderate to moderate. I am not sure if that is a problem. Would it benefit me to send records to Cleveland Clinic for their opinion. I have shortness of breath at times and fluid retention in the abdomen. Would I have to go through open heart surgery again?
Brian_P._Griffin,_MD,_FACC: Sounds like your problems are complex. I would recommend you come to Cleveland for a full evaluation.
Terra: Hi - thank you for considering my question. I have a history of atrial fib and recently a stress echo found severe tricuspid valve regurgitation (three out of four) without heart failure. Normally active all of my life, I now have very little exercise tolerance and find myself breathing harder even with walking. Also, if I lie flat especially after eating, I feel distressed and go into afib. I am 69 years old and otherwise healthy. My questions are -- do heart valves fail slowly and what would cause one valve to fail so severely and the others appear to be normal? What are my treatment options? Thank you for your help.
Brian_P._Griffin,_MD,_FACC: Isolated tricuspid valve leak is uncommon. It is important that you see a valve specialist as the most appropriate treatment for you will need an expert opinion. It is difficult to say based on your story what that might be. The tricuspid leak maybe contributing to the afib.
Terra: Is it possible to injure the tricuspid valve during a catheter radio frequency ablation for afib? Terra.
Samir_Kapadia,_MD: It is possible but rare.
Terra: What are the surgical options for moderate to severe tricuspid valve leakage? At what point is surgery recommended? Terra.
Brian_P._Griffin,_MD,_FACC: Generally we try and repair tricuspid leakage. Surgical intervention is only indicated for severe leakage with evidence of symptoms, enlargement of the right heart, or dysfunction of the right ventricle.
Terra: I had intermittent afib for four years before my tricuspid failed - is Pradaxa still a suitable anticoagulant to use? Terra.
Brian_P._Griffin,_MD,_FACC: Pradaxa is not approved for valve associated atrial fibrillation.
Ruthonline: Is there a relationship between thyroid levels and A-Fib onset? I was diagnosed with low thyroid levels and given thyroid medicine to take. Shortly, the A-Fib started. Symptom was fainting spell twice. Thank you.
Samir_Kapadia,_MD: There is a relationship. Once you correct your thyroid problem, if it persists, there may be other reasons for atrial fibrillation.
adourian: I have AS with valve area moderate but all other measurements mild including no affect to atria or left ventricle walls. I have also developed adrenergic paroxysmal afib over the past year, am experiencing episodes every several months lasting 8-11 hours with no symptoms other than palpitations. The trigger is unknown at this time and am told it is unlikely that it is the AS. All blood work, BP and stress test excellent. My cardiologist and I have been discussing whether to let the episodes run their course for the time being since they aren't long enough to risk blood clots (have been on baby aspirin regimen for years) and the symptoms are manageable. My question is if I don't control these episodes now might they become more frequent and longer in duration over time, become more difficult to prevent, and have an adverse affect on the outcome of my future valve replacement surgery? I am a minimalist when it comes to medications and would prefer not to regularly take cardizem or another calcium blocker unless I need to be proactive because of that future surgery.
Samir_Kapadia,_MD: Paroxysmal atrial fibrillation has risk of blood clot formation similar to persistent afib.
bipbip10: I also went into A-Fib last year with cardioversion. Do you think that this was related to the aortic stenosis and what constitutes an expert evaluation?
Samir_Kapadia,_MD: It is possible. If you want to decrease recurrent events of atrial fibrillation, expert opinion is indicated with an electrophysiologist.
waterdoc: I am a 71 year old male diagnosed two years ago with aortic stenosis. My symptoms leading to this diagnosis were a heart murmur and infrequent episodes of atrial fibrillation. The latter have been controlled for the past two years by Multaq, but because of severe itching all over my body, I am to switch to Flecainide next week. I would be interested in any comments on the use of drugs to control atrial fibrillation related to aortic stenosis. I might add that I never had an episode of atrial fibrillation until my general practitioner switched me from a beta blocker (Ziac) to Lisinopril. My cardiologist reported recently that there has been no change in the valve since my first echo-cardiogram two years ago and that there is no apparent restriction in blood flow. I am active, watch my diet and exercise regularly. What is the prognosis for how long before this valve will need replacing and is there anything I can do to forestall this?
Brian_P._Griffin,_MD,_FACC: There are no specific drugs used for control of atrial fibrillation in aortic stenosis.