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Heart Valve Disease (Drs. Thomas & Gillinov 8/27/13)

Tuesday, August 27, 2013 - Noon

Description

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

More Information


Aortic Valve Disease

jerry56: How much do you exercise in a week? Do you think this goal could be acceptable for a bicuspid aortic valve (BAV) patient with mild aortic stenosis (AS) and aortic regurgitation (AR)?

James_Thomas,_MD: If the AS/AR really is mild, then this should not impact your exercise capacity. In general, exercise is good for cardiovascular health. We can provide a more individualized recommendation for you at Cleveland Clinic.

bav_patient: I am 45 y.o. male, with bicuspid aortic valve, and AR and AS. Until recently, my echo results were OK (ESD 32 mm, EF 65%, and aortic diameter 32 mm). A year ago, I started swimming 4 times a week, covering 1,500 meters in about 45 minutes. My fitness level improved, with max oxygen consumption increased from 35 to 50 ml/kg/min. But my recent echo showed one odd change, with max gradient increased from 35 to 72, even though I have no symptoms of severe AS, and feel OK. My cardiologist is not concerned about the gradient change, and thinks that it may be biased in my case. He argues that the gradient depends on the stroke volume, which may be higher for two reasons: first, my AR, and second, increased stroke volume due to my recent aerobic training. Just in case, he measured my BNP level, which changed little, and remained around 10 pg/mL. So my cardiologist suggested that I ignore the odd echo result, and continue with my swimming routine as before. Would you agree with his opinion?

James_Thomas,_MD: In general, I believe your cardiologist’s analysis is correct. Increasing flow across the aortic valve by 41% will double the gradient (it is a squared relationship), and this could well reflect in part your training. However, to the extent that this reflects an increase in AR, then it may indicate primary worsening of the valve disease. This may warrant more frequent assessment, and we would be happy to see you at Cleveland Clinic.

lutsk: I have BAV with minor aortic stenosis and regurgitation. Every year, I have cardiac echo exams, which showed little change over the last 10 years. But recently I got concerned whether the echo exam is reliable enough to detect aortic aneurysm or dissection, which I heard are quite common with BAV. Do you think that cardiac echo is sensitive enough to detect possible aortic aneurism, or it is better to have also a cardiac MRI from time to time? If adding MRI is an appropriate option, how often would you recommend to have it to monitor possible problems in aorta? And I would like to use this occasion to thank Dr. Gillinov and Dr. Nissen for writing an absolutely marvelous book Heart 411, which I found to be the best patient-oriented book written by professional cardiologists.

James_Thomas,_MD: It would certainly be reasonable to get a comprehensive assessment of your aorta (CT or MRI), and if the measurements agree well with the echo, then you can follow subsequently with echo.

CLStar: Can a leaky aorta valve be the reason a person gets cardiomyopathy?

A._Marc_Gillinov,_MD: Yes. A severe leak can cause heart damage and lead to a cardiomyopathy.


Aortic Valve Disease – when to have treatment

hatterasjack: I have aortic stenosis. How many of the 5 systems have to occur for me to seek care?

James_Thomas,_MD: We are happy to see you at any stage of aortic stenosis. If it is very mild, you may need an echocardiogram every 3-5 years or so. As this becomes more severe, the frequency of monitoring should increase, up to yearly or shorter for severe AS. Once severe AS becomes symptomatic, then surgery or other intervention is needed. We would be happy to assess you at Cleveland Clinic regardless of the severity of your disease.

vervet: I've had a severe aorta valve leak for a couple lf years. On my last echo in March, my heart was not enlarged and was handling the leak. I also have COPD. When should I get surgery and how can it affect my quality of life. I am short of breath, but no one can determine whether it's the COPD or the valve leak. Thank you.

James_Thomas,_MD: This can be very challenging to determine which of two real diseases is causing your symptoms. Exercise tests may help to separate cardiac from pulmonary causes of shortness of breath. We at Cleveland Clinic have extensive experience in teasing out just such dilemmas and would be happy to help with this assessment.

greyman: When is it the proper time to have an aortic valve replacement for a severe aorta valve leak when, at the last echo in March, my heart was not enlarged and was handling it?

James_Thomas,_MD: As long as you are having no symptoms for your aortic regurgitation and there is no ventricular enlargement it is usually safe to continue watchful waiting. However, you need to have regular echocardiograms to monitor the situation.

petejanv: Hello. Our son, 38, had a commissurotomy at age 6. He has a bicuspid aortic valve. Check ups since then have been normal. Can you tell me what factors will determine surgery for him? Thank you.

James_Thomas,_MD: Determinants for intervention are mainly driven by the development of valve stenosis (too tight) or regurgitation (too leaky), which are usually assessed by periodic echocardiography. If a patient has symptoms from either stenosis or regurgitation, then surgery usually is needed. In addition, some patients develop an enlarged aorta, and if this gets large enough, then surgery is warranted even without symptoms. We would be happy to provide an assessment at Cleveland Clinic.

wfleitz: I have a bicuspid aortic valve and have been seeing cardiologists for the last 12 years for regular echo (and two CT Scans). They've never indicated I would need a replacement but still it concerns me. As I've gotten older I've noticed my stamina has decreased. I've been exercising regularly but still I wonder at what point is the right time to consider surgery. I just don't want to wait so long that the heart will become damaged before considering it. Should I just stick with cardiologist’s advice? Thanks.

James_Thomas,_MD: If these symptoms result from the aortic valve, then surgery may well be appropriate. We would be happy to provide an assessment at Cleveland Clinic. Sometimes, it is helpful to perform an exercise echocardiogram to assess your functional capacity and the impact of your valve on heart function.

HFEBOSCO: I've been diagnosed with moderate-severe aortic insufficiency. At 64 years old, I have regular echos to monitor, with the procedures done in doc's office for the past several years. There has been little to no progression although my BP is 160/75 even with meds. I live in DC area and would like to go to the best place for a second opinion and to gauge when surgery may be required, if ever. Should I come to Cleveland Clinic for a total health checkup and aortic valve evaluation or can I do it locally in northern Virginia or Washington DC? Having future surgery at Cleveland Clinic would be great.... aside from the great distance from home and the burden that would put on family, etc. You advice would be appreciated.

James_Thomas,_MD: It sounds as though it would be very appropriate for you to come to Cleveland Clinic for a full assessment of your aortic valve. We have many patients from out of state - it is fortunately only an hour flight from Washington DC. Please contact us if you are interested.

LN: I am asymptomatic and following the 2008 ACC/AHA guidelines for Indications for AVR by monitoring LV systolic function (EF = 60-65%) and LV dilation (LVED 6.7 cm) with echos every six months and the numbers seem to be stable. So I figure I'm Class III (AVR not indicated) edging toward Class IIb (AVR may be considered). I would think there are advantages to not having surgery until I reach at least Class IIa -- I am 61 and figure the longer I wait, the better the options for valves and techniques. Does this sound reasonable?

James_Thomas,_MD: It sounds like you have a good understanding of the principles of management and the guidelines. Overall, your approach seems quite rational as long as you are getting regular follow up. I believe there are new guidelines coming from ACC - AHA which may slightly modify these recommendations, so watch for their publication.


Aortic Valve Surgery

Sperg1: What are the consequences if you don't have an aortic valve repaired or replaced?

James_Thomas,_MD: If you have severe symptomatic aortic stenosis or regurgitation you can expect your symptoms to progress to the point of heart failure at which point it may be too late to obtain a good result even with surgery.

asiasoon: I have a bicuspid aortic valve that was measured as a 1.1 moderate. I am a runner (25-35 miles per week), and have changed to a near vegan diet. Is calcification reversible with exercise and diet?

James_Thomas,_MD: Despite all the research that has been done, there has never been a proven treatment to reverse aortic valve calcification. Leading a healthy lifestyle is certainly good for your heart but the aortic stenosis may still progress in spite of this.

LN: Is your experiencing showing the On-X mechanical valve to be a good option for avoiding blood thinners AND avoiding second surgeries?

A._Marc_Gillinov,_MD: There is some data to suggest that the On-X valve may not require anticoagulants (warfarin). The valve itself is an excellent valve and has exceptionally good durability.

jimmyjam: Good day. I am a 56 year old male with congenital bicuspid Aortic Stenosis disease. I expect to need valve replacement surgery sometime in the near future. As daunting as the actual surgery is to me , the thing that really scares me is the post surgery respirator & intubation (tube down my throat, etc.). I understand everyone is different but I am getting different stories as to the time involved and the degree of consciousness. Is one typically sedated during this period and if so, how deeply. 2) When doctors speak of physical trauma of open heart surgery...what exactly is involved, and what kind of pain can one expect. What pain management meds are available. My neighbor complained of severe constipation with percocet. What other pain med options are available. I did very well with torenal with a severe pulled chest muscle. Would the torenal be enough? What is typical recovery time for a 56 year old. Thank you and please forgive spelling.

James_Thomas,_MD: Everyone is different, but for someone who is young and healthy, our goal is to get the breathing tube out as quickly as possible, hopefully just about the time you become awake enough for it to bother you. Pain treatment is always individualized and we aim to give enough to keep you comfortable but not more.

Note: we have a lot of resources for our patients throughout the entire process of heart surgery. You can learn about our Heart Surgery Program on our website. In addition, we provide our patients with binders of information to explain care from day one through recovery at home and – have a section of our website devoted to home recovery as well as a 24/7 nursing phone line for patients after discharge. It is scary to anticipate but we help you through every step of the way.

azchrly: I have aortic regurgitation and need valve replacement. I want to avoid the sternum cutting. What are my options? Can this be done without the use of the heart-lung machine? Is there any plans for the TAVR to be applicable to regurgitation any time soon. Thanks.

James_Thomas,_MD: Currently TAVR is not indicated for aortic regurgitation; and probably will not be in the foreseeable future. Many people have an unrealistic fear of the sternotomy but in reality it is not that bad of an incision and generally causes less pain than incisions that go through muscle. the most important thing is that you get the right operation. It may be possible that you may be operated through a small mini-invasive incision. We can evaluate you for surgery if you like.

kahuna8: Good afternoon. Primary Question - RE: Aortic valve replacement. What is the logic/thinking as to an open heart procedure, minimally invasive, or transcatheter? I realize that many factors are considered; where is the final decision made? Patient? Doctor? Insurance? Hospital? I am in overall excellent (Age-Related) health; age 77, male. My local cardiologist says that I am not high risk, frail, or otherwise would not "qualify" for a TAVR. My basis research indicates that a TAVR would be my choice, realizing the risk factors involved. Thank you.

James_Thomas,_MD: Because surgical AVR is so safe (it sounds like a risk of 1% or less for you), then TAVR is reserved for higher risk patients. Over time, I suspect TAVR will migrate to lower risk populations as we gain more experience with it. This is a very individualistic decision, and we have dedicated teams at Cleveland Clinic to help you make the right decision.

stalin: I have severe AOV stenosis with comorbid diseases. They are bronchiectasis & trigeminal neuralgia. The latter is mute, the former recently sent me to the local ER where a CT confirmed an inguinal hernia. Is it possible to have AOV surgery and within 6-7 weeks also hernia repair. I believe my harsh bronchiectasis cough would impair chest healing process. Please advise me on this. Thank you.

James_Thomas,_MD: You would need a complete evaluation prior to surgery, including a pulmonary consult. I wouldn’t think the hernia surgery would greatly impact the timing of surgery.

JayneDinan: What is involved with an aorta "root" replacement? Can the aorta be repaired instead of replaced? What is the mortality rate at Cleveland Clinic for a patient that needs both an aorta valve replacement and an aortic root replacement? Which procedure has more danger associated with it and why?

A._Marc_Gillinov,_MD: An aortic root replacement includes replacement of both the aortic valve and a portion of the aorta. This is a fairly specialized operation performed primarily at major centers. The operative risk is approximately 1%. For an isolated aortic valve procedure, the risk is a bit lower.

936rich: I need aortic valve replacement and also have a-fib. Of course , I would like a minimally invasive approach to correct both. What would keep me from having this minimally invasive procedure to perform the AVR and MAZE. Would you also remove the atrial appendage at the same time. Thank You. Rich

A._Marc_Gillinov,_MD: A standard median sternotomy is a better option for you. The best maze procedure requires a sternotomy. Through a sternotomy, management of the left atrial appendage is standard and simple.

hatterasjack: I am a 83 yr. old male with mild to severe aortic stenosis. I have no symptoms. What would the method of treatment be. Surgery or opening it with a balloon? Jack

James_Thomas,_MD: If you are at low risk for heart surgery, then standard surgery would still be recommended. However if you have increased risk, then a transcutaneous AVR (TAVR) may well be appropriate. Intervention is usually delayed until you have symptoms but it is important that you see a valve specialist regularly for follow up.

Gibson001: What are your thoughts on mechanical vs. tissue valves for a young person (23). We have been told that his surgery will require an incision down his chest and sternum separated. Are you doing any type of minimally invasive aortic valve replacements?

A._Marc_Gillinov,_MD: We can perform a less invasive aortic valve replacement via a partial sternotomy (3 inches). The choice of valve is up to you. I would personally choose a tissue valve as I would prefer not to be on coumadin.

dukefan55: I am a 58 yo female with BAV, mild to moderate stenosis and ascending aortic aneurysm of 4.4. I am 5 ft. 3 in. and weigh 175. I have been having chest pain when I walk. I failed a stress test and had a cath which showed no blockages. The pain starts about 10 minutes into my walk and goes away if I stop walking. Do you have any ideas what could be causing this? Thanks for taking my question.

A._Marc_Gillinov,_MD: If your aortic stenosis is moderate, I would say that the aortic valve is a likely culprit.

jimmyjam: Why is robotic surgery unavailable for aortic valve replacement.

A._Marc_Gillinov,_MD: The company that makes the robot and the companies that manufacture heart valves have not developed technology to facilitate robotic aortic valve surgery. However, we do have other minimally invasive options for aortic valve replacement.

MomShine: I am a 72 yr. old healthy female in need of an aortic valve and RCA bypass. I have essential thrombocytosis.

  1. Will the thrombocytosis complicate surgery?
  2. Would it be safer to have a minimally invasive aortic valve and later a stint? The blockage is close to 70.
  3. Would you recommend mechanical or tissue valve? Why?
  4. Would saphenous vein be used because of location of blockage...? Are arteries better than veins, especially because of the thrombocytosis?

James_Thomas,_MD:

  1. The thrombocytosis usually will not impact surgery.
  2. At your age, you probably are not a candidate for TAVR so we generally would recommend AVR plus CABG (bypass) though we do individualize some cases to have a stent instead.
  3. Unless you have a reason to take coumadin, tissue valve is recommended in your age group.
  4. The choice of conduit is usually made based on exactly where the blockage is. The thrombocytosis is not likely to have much impact on this.

Transcatheter Aortic Valve Replacement (TAVR)

Kinicker: I am a 53 year old male who was told I had a heart murmur early in 2010, later to discover in October of the same year that I was diagnosed with moderate aortic stenosis. My AV area was 1.4cm2. After yearly echocardiograms, my AV area was 1.1cm2 in March of 2012, and 1.2cm2 in May of 2013. Ironically enough, I have no symptoms whatsoever. I do lap swimming after work most days for a good 45 minutes/hour and I do 7-9 hour hikes out in the higher elevations (9-13,000ft) of the mountains in Colorado during September. But in May of this year my cardiologist decided to say for the 1st time these words. “There is a distinct possibility you may need a new heart valve sometime in the next 10 years. Could be sooner, could be later". Researching way in advance now!!! I've read your Valve disease & Treatment guide thoroughly. My primary question is, am I a good candidate for Transcatheter Aortic Valve Replacement(TAVR). Or am I always facing the traditional open heart surgery??? Lankenau Medical Center near Philadelphia talks about minimally invasive keyhole robotic surgery illuminating the need to split the breast bone.

James_Thomas,_MD: Currently you are WAY too young and healthy to qualify for a TAVR, which currently is reserved for high-risk patients. Also, you most likely have a bicuspid valve, which is also not acceptable for TAVR. Depending on how long it takes for your AS to become severe and symptomatic, it may be possible that the field has advanced enough to permit a TAVR. Regardless, you should be able to have an intervention at much less than a 1% risk.

A._Marc_Gillinov,_MD: You will need a new aortic valve at some point, likely in the next 5 years. When you develop symptoms, surgery will be indicated; at that time, your aortic valve area will likely be less than 1 cm2. At this time, TAVR is not approved for younger and healthier people. This will likely change over time.

MattK: Is Cleveland Clinic doing the TAVR Aorta Valve Replacement not only entering from the groin area, but also up near the heart? Will this be covered by Medicare? My doctor said going through the groin area wouldn't work for me because of narrow arteries. Also, when will a larger heart valve be available? I understand there are just two sizes. Thanks.

James_Thomas,_MD: Yes - we are doing alternative approaches for TAVR, Such as the chest wall. There is now a third TAVR size available (29 mm) but it is only available through an investigational study, which we are active in at Cleveland Clinic.

Deane: I have been diagnosed with Severe Aortic Stenosis and can only have a biological valve implanted due to liver damage and bleeding issues from a previous Hepatitis C infection. I have already had a Trans Esophageal Echocardiogram cancelled due to Esophageal Varices which I have banded regularly. My physicians and I are looking at the TAVR versus open heart valve replacement surgery. Is one procedure preferable over the other considering my circumstances? (My Child-PUGH Class is A and Score 5) Mortality rate=11%.

A._Marc_Gillinov,_MD: It is likely that TAVR is a safer option for you than is standard heart surgery. Your care would need to be individualized based upon your liver issues and other medical data.


Mitral Valve Disease

bw: Hi. I am scheduled for Mitral repair on Sept. 24th, dob(08/27/51). My question (one of many) is: Can continued daily alcohol use, above the minimal 1 or 2 drinks, lead to relaxation of the heart muscles, and over time, create heart enlargement and accelerate Mitral prolapse? Hence, the follow up question: Can abstinence of alcohol, along with good diet and exercise, reverse a mild prolapse with regurgitation and arrhythmia, as is the case in my condition. (I notice more problems after a night of 3 or 4 drinks.) Thank you, Bill.

James_Thomas,_MD: Excessive alcohol use can damage the heart in the long world, and lesser amounts can precipitate arrhythmias, and that sounds like what you are experiencing. However, I am unaware of any impact of alcohol on mitral valve prolapse per se.

texan: I am an 87 year old white male on medicare and supplemental insurance. Minimal daily medication. I have a leaking micro valve. Can this valve be dealt with using the new non-invasive procedure as opposed to the standard chest procedure? What are the chances of survival at my age? Thank you.

James_Thomas,_MD: I assume you mean mitral valve. In which case, it may be possible to repair with a small incision. However, depending on the details of your case, it may be necessary to bypass your coronary arteries or other surgeries which is best done through a larger incision. We have excellent results in patients at your age.

geronimo: I am a fit and healthy 70 year old African Caribbean male. I was diagnosed with mitral valve regurgitation (mitral valve prolapse and a flailing mitral valve leaflet) in January this year. My cardiologist has recommended watchful waiting rather than mitral valve repair surgery. How will watchful waiting impact on the state/strength of my heart, and on my life expectancy? I personally expect to live to at least 100 years old.

James_Thomas,_MD: If you truly have a flail mitral valve assoc with severe mitral regurgitation, we would generally recommend early surgery rather than waiting for symptoms. We have a method to send in records for surgical review. Please contact us if you are interested in an evaluation. www.clevelandclinic.org/heartnurse.

Sue in WDC: Hi. I have paroxysmal a-fib and flutter and was shocked to find out from a recent echo report that my aortic and mitral valves are mildly thickened and that I have mild mitral valve prolapse. My echos also show mild mitral regurgitation and trace tricuspid and pulmonic regurgitation. What, if anything, can I do to reverse or prevent the progression of valve disease? I'm 67, a woman, and have hypertension that's well regulated. My diet is good (semi-vegetarian), I exercise daily, and my BMI's respectable (21.3). Thank you for taking my question.

James_Thomas,_MD: It sounds like you have mild valve disease and it may actually be in the normal range for someone your age. Continue your great health habits.


Mitral Valve Disease – when to have treatment

gwort1: As mitral valve prolapse progresses, what is the best indicator for when surgery is necessary, and what is the best test(s) to regularly have? (i.e. echo vs. transesphageal echo (TEE) vs. stress echo vs.?)

James_Thomas,_MD: The standard test is an echo. But, we often perform stress echo as well to determine the impact of mitral regurgitation (MR) on your lifestyle. TEE is usually not needed except to get a detailed view of the valve for planning surgery. if you have significant regurgitation, we would recommend annual follow up and would be happy to see you here.

bchlvr: I have been diagnosed with a mild to moderate leaking mitral heart valve. Why do some doctors recommend repair or replacement and my doctor does not. I am a 67 yr old female.

James_Thomas,_MD: If the severity really is only mild-to-moderate, then surgery is unlikely to be needed. Sometimes an exercise test may be helpful, as leakage can worsen with stress. We would be happy to give a second opinion at Cleveland Clinic.

dricke: I have a bad mitral from Rheumatic fever when I was 12. I'm presently 65 with afib. My cardiologist recommends no surgery until symptoms appear. I have none of those usual suspects. It appears the valve can be repaired. He feels when it gets done is my call. My question is, if I would get it done now would I get better circulation, less stress long term for the heart, and increased vigor or will there be not much change? Thank you.

James_Thomas,_MD: The critical issue is how severe the leakage is through the valve and how obstructed it is for forward flow. If these are not severe and you have no symptoms it is usually safe to continue to observe but it is important to have a careful assessment by a valve specialist. We can certainly review your records for readiness for surgery. If you are interested - please feel free to contact us.

Helen Beatrice: I am 86. What are the criteria for mitral valve repair in a person of my age? How many repairs have you done on persons over 85? What is the success rate? I was diagnosed with a leaking mitral valve six months ago; shortness of breath had evidenced itself in Sept. 2012.

A._Marc_Gillinov,_MD: If you are symptomatic with shortness of breath, it is worth considering surgery. We operate on many people in their eighties and the risk is generally quite low.

KAN607: A study just published by the Mayo Clinic challenges the traditional "watchful waiting" approach to mitral valve surgery (for regurgitation), in favor of "prompt surgery". Under what specific circumstances does Cleveland Clinic recommend watchful waiting vs. prompt surgery?

James_Thomas,_MD: As always the devil is in the details and such a decision depends on the actual severity of the regurgitation and its impact on heart function. We certainly favor early surgery for certain cases of severe MR but try to individualize our recommendations.


Mitral Valve Surgery

jejlyons: I have mitral valve regurgitation. Best surgery? Going to see Marc Sakwa at 2:00 p.m. What's your infection rate? I also have had A-fib for 25 years plus!

A._Marc_Gillinov,_MD: We would generally recommend mitral valve repair and a Maze procedure. The Maze procedure is performed to try to free you of A-fib.

KAN607: What minimally invasive and/or "beating heart" surgical options does the Clinic offer for mitral valve repair/replacement? Please give us the gist of what these options involve.

A._Marc_Gillinov,_MD: In selected patients, our least invasive approach is robotic mitral valve repair surgery. This is suitable for people who have isolated mitral valve issues. The incision is generally about 2 to 3 inches in length. For other patients, we have alternate less invasive approaches. The key is to maximize safety.

nutzy: I asked earlier if is possible to replace a mitral prosthetic valve with a biological one. How dangerous is this surgery for 66 years person.

A._Marc_Gillinov,_MD: It is possible. The risk of surgery is likely only a few percent.

giorgio0668: Dear Doc Gillinov: I'm 45 y.o., had heart surgery on 15th. Dec. 1998 for a severe mitral regurgitation, received a repair valve with insert of artificial chorde and Taylor 33 annulus. After only less than five years, after a control, I need of a new surgery for the same problem! I know that the second surgery will be more dangerous for me and I don’t know if they can repair the valve one more time. I'm thinking of traveling to Cleveland even if I had a first surgery in the best hospital in Italy (San Raffaele of Milan). The equipe surgeon was of Prof. Alfieri Ottavio that tell to me about a new surgery. I write to you my last eco result: Aortic 33, Atrio left 50, sett iv 8, P.post.8, FEe, left Ventr.dd 52. Rigurgit +++/++++. What do you think about my situation? How much cost a sugery in your hospital? My wife is pregnant and in April we'll have our first child...how many chance for me to be a good dad? Thank you for your patient and I hope to receive your answer and suggestion. Best Regards.

A._Marc_Gillinov,_MD: In our hands, the likelihood of re-repair is about 60%: it depends upon the findings at operation and on echo. The operation is generally quite safe. I know Prof. Alfieri--he is an excellent surgeon.

tdigiaci: Should surgery for an inguinal hernia be before heart surgery pre-operative testing or should it be repaired after valve/MAZE surgery? I understand that mitral valve repair and the Maze procedure should stop regurgitation and AFib but what effect are there on the defects caused by a severely enlarged atrium. My LV Ejection Fraction is 42%. What would be an estimate of expectations for the LV Ejection Fraction after surgery? Is there any other metric besides the LV Ejection Fraction that would represent heart capacity for work? Which type of valve repair would you use in my case? Quadrangle resection? Annulus support? Which type of minimally invasive? (smaller cut of sternum? or Catheterization procedure entry from side: thoracotomy?) What can I do as preparation to reduce risk and improve results in the weeks leading to surgery? What can I do after surgery to speed recovery and improve results?

A._Marc_Gillinov,_MD: I would have the valve surgery and Maze before the inguinal hernia. The precise repair technique depends upon results of an echocardiogram. Your ejection fraction decline indicates that you should have surgery in the near future.

jcsemba: What is the best way for someone in Louisville to connect with a world class Cleveland Clinic surgeon, and have mitral valve surgery performed at Cleveland Clinic? At the same time pre and post care will continue to be done by professionals in the Louisville area. How do you recommend this all be coordinated? Thank you.

James_Thomas,_MD: We welcome you to Cleveland Clinic, and very commonly coordinate with local cardiologists for your post-operative care. Please contact our Heart and Vascular Institute Resource Nurses who will guide you through the process. Phone: 866.289.6911 or by email or live chat - www.clevelandclinic.org/heartnurse.

vphage: Hi Dr Thomas and Dr Gillinov, my name is Victoria, and I wonder if there are any minimally invasive surgeries for dual aortic and mitral valve replacement. If not, for open heart surgery for dual AVR/MVR, what is the approximate 30-day mortality rate and rates of major complications for my mom who is 67 years old, if she has good EF and PFT function? Another dilemma we have is the type of valve to use: biological vs mechanical. For her age, is it a wiser choice to choose one versus the other. If she ends up choosing biological valve, what's the chance that she needs to do have the re-do in 10-15 years? Will it be too risky to have to re-do in 10-15 years? And I wonder when is she safe to fly an international flight about 15 hours. Thank you very much! Sincerely, Victoria

A._Marc_Gillinov,_MD: Double valve replacement will usually require a standard sternotomy, although in some cases a partial sternotomy is applicable. The 30-day mortality for a double valve procedure in centers of excellence is less than 5%. For a 67-year old I would recommend biological valves. The likelihood of a reoperation being necessary is about 10%. Travel is no problem.

RunnerChick: I'm a 50-year-old. I was diagnosed with mitral valve prolapse with regurgitation in 2008 and told to avoid ”burst activity". I began running in 2010 and always hold back because I don't want to damage my valve further. Thus I finish races but never win medals because I'm "slow and steady". I'm scheduled for minimally invasive mitral valve repair in 3 weeks (one of the cords is too long). My question: Can I reasonably expect my valve to be "like new" once it heals from the surgery? I guess what I'm really asking is, if all goes well with the surgery and recovery, should I be able to exercise more strenuously than I do now without fear of damaging my heart? (I want to run a bit faster and not worry about the "sprint to the end", doing speedwork and other things I always avoid in my workouts.) I realize that every case is different, but I'm looking for a fairly general physiological answer. I thank you in advance for your response.(BTW, my surgeon, Erik Beyer, trained at Cleveland Clinic.)

James_Thomas,_MD: I would hope that after surgery you would be able to return to full functional capacity although it is always important to warm up completely before attempting maximal effort. You should be guided by the cardiac rehabilitation program you enter after surgery.

DaveM306: I am male, 87 yr.old, in good condition otherwise, but having to consider surgery for leaking mitral valve. Also have Afib for a couple of years, being managed with medications. I understand that MV repair is open heart. Are there observations for risks and outcomes for my age?

James_Thomas,_MD: While age certainly is a risk factor for surgery, we have a great deal of experience operating on people in your age range. We should be able to get you through surgery at overall little risk but a full judgment can only be made by seeing you in person.

bw: Hi Gentlemen: I have a question about arrhythmia and heavy beats (not sure of the correct term). Can I expect relief from arrhythmia and some a-fib after Mitral valve repair for prolapse and regurgitation? If not, what are some further steps to take to alleviate this? Thanks, Bill W.

James_Thomas,_MD: Every case is different, but often surgery for MR along with a Maze procedure will relieve atrial fibrillation and the heavy beats your are feeling.

NYheart: I am a 64 year old female with moderate to severe mitral regurgitation; when the time comes for surgery I hope I will be able to have my valve repaired and not replaced. Are you able to determine how calcified the valve might be prior to surgery with a diagnostic test such as a CT scan or cardiac catheterization? My cardiologist told me that at my age my valve is probably too calcified to be repaired, but I have read that calcification is not always related to a person's age. Are there other conditions that would make repair impossible? Thank you.

James_Thomas,_MD: Every case must be individualized but most patients wit MR at age 64 can have their valve successfully repaired. Echo and CT scanning may help determine the amount of calcification. If it is so calcified that it is significantly obstructed then valve replacement would be suggested. We would be happy to evaluate you at Cleveland Clinic.

paulsheri: I had a Mitral valve repaired on 6-21-2013, How long will this repair last?

A._Marc_Gillinov,_MD: In most cases, a valve repair will last a life time. The 10-year freedom from reoperation is more than 90% after a successful repair for mitral valve prolapse.

dluebke: I have a Medronic mitral valve from May 2000. What would one normally predict long term with this type of implant. I have been active every day since(and before) the surgery working out 1.5 hrs, daily and am 65 yrs. old. Thank you!

James_Thomas,_MD: Medtronic makes both mechanical and biological valves, if yours is mechanical, it may last the rest of your life as long as you take your blood thinner. If it is a biological valve, it is reaching an age where you may see leakage or stenosis in the valve and this can be followed with an echocardiogram. In general, exercise is good for prevention of cardiovascular disease.

giorgio0668: Dear Dr. Gillinov and Dr. Thomas: In 15th December 2008 I had a surgery for a plastic mitral valve in Milan (Equipe of Dr. Alfieri Ottavio). They put some artificial chorde and annulus (Taylor). After only four years and half, after some exam echocardiogram, I knew that I need of one more surgery always for the same problem Mitral valve severe regurgitation! Before to receive the first operation I spoke with someone of your fantastic centre because I had the idea to travel to Cleveland; after knew the amount of the surgery (Eur 70.000!) I decided to stay in Italy (Milan). Now I really scared to have another surgery because I know that the second surgery is more difficult of the first. I received a traditional surgery and not mini-invasive method; I’d like to know if should be possible receive a mini-invasive surgery and if it's possible to repair the valve (already operated) without change with an artificial valve. I hope to receive an answer from the best doctors in the world!

James_Thomas,_MD: This sounds like a difficult situation. One approach to get started would be to have a recent chest wall echocardiogram (and ideally a transesophageal echo) sent to us for assessment, so we can give you an idea of the likelihood of repair. Please contact our Global Patient Services who can walk you through the process of sending in records for evaluation.

jcsemba: Is minimally invasive mitral valve surgery more risky than conventional surgery? If not, why aren’t all mitral valve surgeries done in this way?

Generally the best surgeons would be those who have done many of the same procedures that I will be undergoing, and are recognized by their peers as excellent practitioners. How would you recommend that a person go about finding this information that would lead to the best surgeons? Are there two or three mitral valve (hopefully) repair specialist that you would recommend?

How safe is the dye test to check narrowing of coronary arteries? Does it make sense to do this prior to having mitral valve surgery? How high is the risk of some brain deterioration (due to micro strokes, anesthesia, etc.) as a result of mitral valve surgery? My heart rate is fairly low (around mid fifties at rest.) Does low heart rate present significant risk during mitral valve surgery?

Procedurally, what is the best process to link the cardiology care I get here locally (Louisville metropolitan area) with a surgeon at Cleveland Clinic? Will I also need a cardiologist at Cleveland Clinic? Going into a mitral valve surgery, is it predictable as to whether the surgery will be a replacement or repair? Are there diagnostic procedures done the day of surgery that would provide the surgeon with more precision as to the condition of the valve? If replacement, which is better: organic or mechanical?

A._Marc_Gillinov,_MD: A select, small group of surgeons is skilled at minimally invasive surgery. The key is to choose the safest and best operation for each individual; we do this by examining all preoperative studies. In most cases, we can tell you if repair is likely. Nearly all prolapsing mitral valves can be repaired.

At Cleveland Clinic, we always function as a team that includes you (the patient), a cardiologist and a heart surgeon. To reach us you can go online at www. clevelandclinic.org/heartnurse.

Lotus72: Dr. Gillinov and Dr. Thomas, from the first echocardiogram (August, 2012) I underwent, I was told that I have a moderate case of mitral valve regurgitation. From a second echocardiogram (February, 2013), I was told that the condition had not worsened. I am to undergo a third echocardiogram in September. I am very interested, as I am sure many others are, in the least invasive method of valve repair. In Patient Education, on Cleveland Clinic's web site, I have read the information in Percutaneous Treatments for Valve Disease, dated Tuesday, April 13, 2010 - 12 Noon with Murat Tuzcu, MD. This information is now more than 3 years old. What progress has been made and what is the current status of approval for, and use of, the less invasive procedure of catheter based treatment for mitral valve problems? Thank you.

James_Thomas,_MD: The percutaneous approach for mitral regurgitation is not yet approved in the United States. There is a very long wait to get into any trial. However, depending on the details of your circumstance you may be a candidate for a very small mini invasive incision or even a robotic approach. Dr. Gillinov is a specialist in this approach.

Note: our most current web chat transcript on this specific topic is 3/2012 – but most of the valve chat transcripts discuss TAVR

KAN607: How long can one expect a mitral valve repair or replacement to last?

A._Marc_Gillinov,_MD: Mitral valve repairs usually last a lifetime. The durability of mitral valve repair for prolapse is 95% at 10 years and around 85% to 90% at 20 years. On the replacement side, mechanical valves generally last forever and bioprosthetic valves (cow or pig) usually last at least 10 years but usually less than 20 years.

NBI: What are the parameters that dictate which type of minimally invasive surgery can be employed for a mitral valve repair?

A._Marc_Gillinov,_MD: The ideal patient has isolated mitral valve leakage caused by prolapse, does not need any bypasses, has not had previous heart surgery, and has relatively good cardiac function. We work with patients to choose the best and safest option.

Mary415: Hello, my 82-year old father has been diagnosed with mitral valve prolapse, with the next step being an angiogram to determine if a repair or replacement would be necessary, then surgery (small hospital in central Illinois). Would your hospital be able to do the diagnostic via imaging, then do minimally invasive surgery if just a repair is needed? And what if a replacement is needed? What would the expected inpatient time be for each, replacement or repair? Thank you.

A._Marc_Gillinov,_MD: We would perform routine preoperative testing to determine the best approach. In general, a 4 to 5 day hospital stay is standard for the uncomplicated patient.

KiddColt: Hello, I recently had a fantastic mitral valve repair at Cleveland Clinic (thanks again Dr. Gillinov). Assuming nothing changes this 1st year what are my basic odds of ever needing a reoperation?

A._Marc_Gillinov,_MD: The odds are more than 80% that this repair will last a lifetime. Glad you are doing well!

cycampbell: Hello, I'll be having mitral valve surgery at Cleveland Clinic this October 15th with Dr. Gillinov as the surgeon. I am 58 years young, female, with severe mitral regurgitation, etc. I am frightened by the thought of daunting surgery (though I have read Dr.Gillinov and other surgeons there are the best!). You must stop my heart and may I ask how the heart/lung machine operates to take over?!

A._Marc_Gillinov,_MD: We do stop your heart, but this is very routine--none of the drama that you see on medical television shows.

massey199: I had an unsuccessful cryoablation procedure May 2012 due to an underlying moderate to severe MVP. My current Cardiologist agrees the MV must be repaired/replaced as a precursor to addressing the A-Fib. How can I assess the best course of action without draining my funds for talk but no real path forward.

A._Marc_Gillinov,_MD: If you have severe mitral regurgitation, you should have a combined mitral valve repair and Maze procedure. This is very standard surgery.


Pulmonic Valve

MTLiving: I am a 41 year female born with pulmonic stenosis. I have HBP that I control with medication, I have always been active and I have not had any problems until recently. 2008 I had a echo, peak gradient was 37mmhg. June 2013 echo, peak gradient is 59.9 mmhg. My cardiologist said I will need to have a valvuloplasty done when the peak reaches 64 greater or if I have symptoms. I have mild symptoms of edema, mild shortness of breath, light headed and tiredness. My Dr. said Cleveland Clinic was an option for me to have this done. Is it necessary to wait until I get to peak gradient of 64 or more severe symptoms? I do not have the physical energy that I use to have and I am not enjoying the things I like. (hiking, yard work, camping etc.) Is this procedure good for long term or will it have to be again? Is it sometimes better to replace the valve? Should I inquire about making an appointment at Cleveland Clinic? I will be revisiting my Dr. on the 28th of this month. Thank you

James_Thomas,_MD: If you are having symptoms from your pulmonic stenosis it is probably time to get it fixed. We would be delighted to see you at Cleveland Clinic.

Valve Disease and Surgery General

marycc: In mini minimal valve repair does the heart have to be stopped and restarted?

A._Marc_Gillinov,_MD: Yes. We do use the heart-lung machine and stop the heart for about an hour. This is generally safe and extremely well-tolerated.

ds1939: Please discuss the advantages and disadvantages of minimally invasive valve replacement. When is this not advised for the patient.

James_Thomas,_MD: The most important thing is for the surgeon to be able to do the right operation and the approach should be tailored to that need. Sometimes it is possible to do a complete operation minimally invasive or with the robot but if more extensive surgery is needed a full sternotomy may be best. Fortunately a sternotomy incision is not as bad as it sounds for most patients.

sinaihospital: I have had heart valve disease since 2004. It makes me tired, can it raise blood pressure? I have migraine headaches and I also have hypertensive heart disease, is there link besides heart valve disease and migraine headaches? What tests and treatment are needed for heart valve disease? Do an ok from my cardiologist for surgery with heart valve disease yes or no.

James_Thomas,_MD: Hypertension can cause both valve disease and may be a consequence of it. Not much link between valve disease and migraines except that excessive use of the ergonovine drugs can cause valve thickening.

Salrich: During surgery if blood is needed can I use my own? How many days or weeks ahead should it be stored?

James_Thomas,_MD: In the vast majority of valve surgery cases, no blood is needed. if you are very concerned about this it is possible to bank blood ahead of time - but usually this is unnecessary.

NBI: Is AFIB typically also treated surgically when performing valve repair? Do you ever assume that AFIB will resolve itself once the valve is working properly?

James_Thomas,_MD: If you are undergoing open heart surgery, it is often reasonable to add on a MAZE procedure or related technique which will increase the likelihood that you stay in normal rhythm. Most patients go back to regular rhythm unless the afib has been very long standing.

gwort1: Is it ok to have minimally invasive repair done through your side vs. open heart repair?

A._Marc_Gillinov,_MD: Yes. We have a very large experience with operating on the mitral valve via the right chest. The least invasive option in this regard involves the use of the surgical robot.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

Reviewed: 08/13

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