Tuesday, November 26, 2013 - 1:30 p.m.
Bruce Lytle, MD
Cleveland Clinic Miller Family Heart &
Vascular Institute Chair
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. Lytle, Chairman of the Sydell and Arnold Miller Family Heart & Vascular Institute at the Cleveland Clinic answers your questions about heart surgery.
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Heart Surgery – General
lovebird: Can a calcium level of 8.8 prevent a doctor from performing surgery?
Bruce_Lytle,_MD: Usually not.
Cindy-VA: Can you tell me what procedure that was used back in 1988 after a heart bypass, how the chest was closed up. My father had a five bypass back then my uncle just had one and they used wire. My father just wanted to know how they normally did it in1988. Thank-you very much. Cindy
Bruce_Lytle,_MD: Under most circumstances a median sternotomy incision is closed with wire stitches - this has been true for many years.
junmar: I have read that after heart surgery, once released from the hospital, the patient required a 24 hour caregiver. Is this true in every case?
junmar: Is it true that the heart and lungs are stopped during surgery? Is a pacemaker used during and after surgery?
Bruce_Lytle,_MD: During open heart surgery, the heart and lungs are stopped. Often a pacemaker is used temporarily after surgery.
junmar: When are the drainage tubes removed from the chest? Will they still be there when the patient wakes up?
Bruce_Lytle,_MD: The drainage tubes will still be there when the patient wakes up.
junmar: Will a cold or respiratory illness prevent surgery?
Bruce_Lytle,_MD: Perhaps, if the surgery is elective.
Re-operation Heart Surgery
mabrown: My father, age 82, has had two open heart surgeries...first about four years ago and second one this past July 2013. He is having shortness of breath again and they said still not getting enough blood to back of his heart. They are going to do a catheterization...but said would not be able to do a third surgery. In the past have not been able to put in stents as too much calcium. He is still fairly active for someone his age...gets up early and goes all day taking care of things...buying/selling equipment...mowing yards at 2 houses...taking his boat out....going to grandkid's ballgames! Any other options? I know he was a patient at Cleveland Clinic probably 20 years ago for a kidney problem...and ya'll were amazing so jumped at this when I saw it!
Bruce_Lytle,_MD: Third surgeries always have risks associated with them. Whether or not if they are the best strategy relates to the problem that exists. It is important to make the diagnosis of why your father is short of breath - the process probably will include an echo as well as a catheterization. The treatment options will depend on what the real problem is and will require further evaluation.
hamradio1: I am a 74 year-old non-smoking, very active 6' 2" male weighing 205 pounds with consistent blood pressures of 104/60 and pulse rates of 70 with only slight variations. I receive 20mg injections of Sandostatin in each hip every four weeks for abdominal carcinoid tumor side effects. In a pre-operative exam for a November 6, 2012 total left knee replacement, a CT-scan revealed a 4.5 cm ascending thoracic aortic aneurysm that was "essentially stable as compared to a prior study in 2008." The CT also revealed "severe calcifications along the LAD coronary artery. Calcifications of the renal arteries bilaterally roughly causing approximately 50-60% stenosis of the origin of left main renal artery.” The cardiovascular surgeon to whom I was referred recommended another CT-scan in January, 2014 to determine if there has been a progression of the thoracic aneurysm and/or the LAD artery. Considering risks, what would you advise regarding future treatments/surgeries, etc.? Thank you.
Bruce_Lytle,_MD: It is unlikely that a 4.5 cm ascending aorta that has not progressed in four years is going to need surgery. Calcification of the LAD coronary artery by itself is not necessarily an indication for surgery. At this point in time, there is no indication for surgery of any kind.
MaggiW: Is minimally invasive surgery available for an ascending aortic aneurysm? My friend's aneurysm was recently discovered on an incidental scan and measures 4.4 cm. He lives in the Washington DC area.
Bruce_Lytle,_MD: If an ascending aorta is 4.4 cm, it is not usually the case that it requires surgery. There are limited access procedures with smaller than normal incisions available for aortic aneurysms but not truly minimally invasive.
Cargirlz: I have a 4.7 cm. aneurysm in my ascending aorta, along with a bicuspid valve and a bovine arch in the vessels directly on the top of the aneurysm. Should I have the surgery to replace the ascending aorta and the bovine arched vessels, with a Dacron graft? What are the main risks if I do the surgery, and if I do not do the surgery? I am a 54 year old woman, weight 147 lbs. Symptoms include occasional tightness in chest and pain in left upper arm. Docs don't know how long I've had the aneurysm. It was discovered in July 2013. CT Scan done in Nov 2013 shows it has not grown from the 4.7cm. My descending aorta is normal at just under 2.00 cm. The cardiac surgeon wants to operate, but my cardiologist says to wait and see, as it is a risky surgery. Am torn as to what to do.
Bruce_Lytle,_MD: As you have found - this is a complex question. Unless you are hypertensive or have a family history of sudden death, we do not always recommend surgery for a 4.7 cm aneurysm. That also depends somewhat on your body surface area. An in-depth discussion of risks, benefits and treatment strategies would need to take place at a visit to Cleveland Clinic.
tkmdak: I am a 55 year old male with an aortic aneurysm measuring 4.4 to 4.6 cm. I have two questions: 1) I am scheduled for a CT Scan in February. This will be my 5th CT Scan for this issue and another issue in the past. Obviously this is a big issue, but do I need to worry about radiation from so many CT Scans? 2) From what I have read, it does not appear that my aneurysm is going to heal itself or get better without eventual surgery. I want a surgeon that does this operation often with successful results. I plan to discuss this with my managing Cardiologist in February. However, how do I go about getting a consult with a surgeon? Do I get a second opinion? Can I come to Cleveland for a consult? I want to make sure I am managing this situation and not the situation managing me.
Bruce_Lytle,_MD: Your aneurysm will not get better. The reason it is being followed is to see whether or not it gets worse. You may come to Cleveland for a consult or second opinion at any time.
JoeSax: I am 51 and in good shape. Have had four bouts of viral pericarditis (1996, 2004, 2011 and April 2013) and been diagnosed in the 1990's with slight valve leakage including the aorta. In July 2013 had a heart CT and was initially diagnosed with a 4.4cm ascending aortic aneurysm. Yesterday I was in the Tampa General Hospital ER (I was supposed to have a MRI/MRA at 5:30 pm) with chest pains. They did another CT and told me I had no aneurysm but an ectactic aorta 3.5cm.) I am going for the MRI/MRA on Saturday to complete the study on the valve. Is this a common misdiagnosis between CT scans? my resting heart rate is 50 or less and BP is 106/ 60. Am I at risk for developing an aneurysm with this type of aorta?
Bruce_Lytle,_MD: Depending on how the aorta is measured, CT scans may differ according to size. In neither of these situations does it sound like operation is in your interest at this time.
tkmdak: I am a 55 year old male with an aortic aneurysm measuring 4.4 to 4.6. I am very active - hour of exercise five times a week. (Mainly spinning or bicycling) Should I cut back on my exercise due to my aneurysm?
Bruce_Lytle,_MD: It is probably not necessary to cut back on exercise however you should warm up before doing exercise and avoid power lifting. Both of these situations may increase your blood pressure and we don't want that to happen.
annbus: My husband (age 69) had aorta replaced with Dacron graft from aortic value to diaphragm after 2nd aortic dissection was diagnosed. Had kept B/P under good control <120/70. MD says he just has an aorta that dissects. Any suggestion to prevent any more? His aorta is still dissected from diaphragm to the bifurcation but not dilated significantly. Surgery was in Aug. 2013.
Bruce_Lytle,_MD: Blood pressure control is key. Heavy lifting should be avoided and the rest of the aorta should be followed with imaging studies.
MartinM: Is there a surgical procedure for aortic stenosis that doesn't affect the kidneys. At my hospital I was told that I have a 20 to 50% of needing a life time of Dialysis post surgery. My creatinine level is 2.6. I'm 86. Is there a procedure that take the kidney functioning into consideration.
Bruce_Lytle,_MD: There is no interventional procedure for aortic stenosis that does not carry with it some risk for kidney function. However if you truly have severe AS and are otherwise active, it is likely to be in your interest to have a procedure to treat the AS regardless of the risk to the kidney.
CarolineAZ: I am a 71 yr. old woman. 8/21/13 Echocardiograph shows grade 3 diastolic dysfunction, mild pulmonary hyptertension(42), EF 69%, mild MV prolapse. 9/9/13 TEE shows moderate MV regurgitation; myxomatous prior MV in P2,3 and A2,3. Tricuspid moderate regurgitation, R ventricular systolic 30mmhg+CVP. R to L shunting absent. L ventricle normal. Right ventricle prominent moderator band normal variant. Atria normal. EKG sinus bradycardia. I have no palpitations. Shortness of breath and lightheaded. Low blood pressure. No medications/healthy lifestyle. Occasional pain in chest center and left jaw. Cardiologist here suggests MV and Tricuspid surgery. If so, I want it done robotically at CC. What tests do you need to clarify whether I need surgery? Thank you....
Bruce_Lytle,_MD: The critical issue will revolve around how severe the mitral and tricuspid valve insufficiency are and whether or not surgery is indicated at all. Most often, echocardiography is the initial approach to diagnosis along with coronary angiography and at times, stress testing.
tracyrwest: Hey Dr. I have a moderately/severe (3+) aorta regurgitation and a sub aortic membrane with a mild case to the mitral valve regurgitation also .I quit smoking and I'm still having shortness of breath and feeling dizzy with some pain off and on. Can you tell me when I come back to Cleveland Clinic in six months will the doctor schedule my surgery then? Thank You Tracy W. (Also can you explain what do the (3+) means.)
Bruce_Lytle,_MD: Aortic insufficiency is graded on a 1+ to 4+ scale. 3+ means it is usually moderately severe. If you continue to be symptomatic, it may be in your interest to have surgery for these conditions at this time. And it is likely that you will need to have this surgery at some time. You can come back any time you want.
Walrus1129: I am a 60 year old male. I had both my aortic and mitral valves replaced 10 years ago due to contracting endocarditis. I opted for mechanical valves (St Jude) Within the past six months I have lost 35 pounds by increasing my daily exercise, mostly cardio and limiting my intake of food. My question is: when running my heart rate jumps at the start very high (170 bpm) and than levels off at 130 - 148 bpm. I run between 30 to 60 minutes. I do this every 7 to 10 days. Is this a safe heart rate to work out at? Also in the event I ever need to have the valves replaced can my present valves be replaced by pig valves? Thank you
Bruce_Lytle,_MD: If your heart rate goes that high when you begin exercise, I would warm up longer before you do your exercise. Certainly a heart rate of 150 is safe as long as you feel well. If you need to have a re-operation, biologic prostheses can be used and at that time, the pros and cons of both biologic and mechanical valves would need a discussion.
kahuna8: Good afternoon. Male, 77, excellent overall (age related) health. ECHO aortic valve .88, gradient 52, NO symptoms. Eject - 74%. Recently my cardiologist has focused on "valve size adjusted for body size/mass." I am 5'6'' and weigh 216 - BMI around 35. What is the thinking/logic/validity as to this adjustment? If I understand correctly, this "adjustment" moves me from "severe" to "critical." Thank you!! HWH
Bruce_Lytle,_MD: If you feel well, then your aortic valve is probably severe rather than critical. If you have normal ventricular function and if you are asymptomatic, the odds are that your valve is not critical. Having said that, it is very likely that you will need surgery within large numbers of months to small numbers of years.
RGambatese: I am a 71 year old male. In Nov., 2012 I had an aortic valve (biologic) replacement with a septal myectomy (HOCM) at CC. In April, 2013 I had an atrial ablation to correct recurrent episodes of AFib in Austin, TX. During this procedure I received a urinary catheter which may have resulted in my having a UTI which infected my new aortic valve (endocarditis). After six weeks of IV antibiotic therapy there were still positive blood cultures along with vegetation on the new aortic valve. This necessitated a second aortic valve replacement performed in Austin followed by a second round of six weeks of IV antibiotic therapy. Two weeks after the second round of antibiotic therapy the blood cultures were clear and no vegetation on the new aortic valve. I'm doing well. Question? What would be my treatment options if I should develop a second bout of endocarditis that infected my new aortic valve? I've been told I would not be able to have another valve replacement. Thanks, RG
Bruce_Lytle,_MD: Your treatment options, should you develop recurrent endocarditis would likely involve a re-operation. That re-operation may not be easy but it would likely be the best choice.
junmar: If I am undergoing mitral valve repair/replacement and have noticed a marked decrease in my physical ability, how long will it be after surgery that I can expect to be back to normal, if ever?
Bruce_Lytle,_MD: Six - eight weeks.
clara: I had open heart surgery seven years ago - aortic valve replaced (tissue valve) and two grafts. I have had eight stents since the surgery. I am now being told I need the tricuspid valve replaced - it is severe. The mitral valve has changed to mild/moderate. What are the symptoms for the tricuspid valve? I have fluid retention in the stomach causing me to use a diuretic. I also have SOB that has gotten worse.
Bruce_Lytle,_MD: The symptoms of tricuspid valve insufficiency are what you are describing - shortness of breath and fluid retention.
Carlisle: I am an 88 yr. old woman with "severe aortic stenosis (AS)". I am in fair health but seem to be experiencing a rapid increase in symptoms. How much will my age influence the outcome of the recommended surgery?
Bruce_Lytle,_MD: Age by itself is less related to risk than are comorbidities such as obesity, diabetes, lung disease, etc. However if you have severe and symptomatic AS, it is very likely to need treatment with either surgery or intervention.
Carand: My cardiologist said I need MV and TR repair. If so, I want it done at CC. However, do my test results indicate need for surgery? 7/21/13 Carotid=normal. 8/21/13 EKG=sinus bradycardia. 8/21/13 Echocardiograph=grade 3 diastolic dysfunction, EF 69%, mild MV prolapse, no aortic stenosis, no shunting, moderate MV regurg, mild valvular regurgitation, mild pulmonic regurgitation, left ventricle normal, right vent normal variant, MV myxomatous prolif in p2, 3&a2,3 moderate regurg...TR valve moderate regurg. Aortic valve mild regurg. Vessels aortic root sclerosis/calcification. 9/9/13 TEE moderate Mitral and Tricuspid regurg. R ventricle 30mmHG. Shunting absent. Symptoms shortness of breath (for several years) lightheaded I thought the chat was at 12 noon at which time I have a Dr. Apt. But I'll try. Could you tell me what tests I need to clarify further testing I need?
Bruce_Lytle,_MD: We usually do not perform surgery to treat valves that are only moderately insufficient. One question would be whether or not your insufficiency is worse, particularly of the mitral valve, than has been shown. To sort that out, we would take a TEE transesophageal echo.
MASKU: Can you comment on the current mortality and morbidity rates for tricuspid valve repair on a person with previous mitral valve repair?
Bruce_Lytle,_MD: The operation to repair the tricuspid valve is a relatively straight forward one - the risks relate to the question of why the tricuspid valve is leaking and whether surgery will improve the overall situation. If the operation is needed it is not a big one. The question is: why is it needed?
Adult Congenital Heart Surgery
grammarhodes: Hi doctor. My question has to do with "hardware" in the heart. I have two Amplatzer devices in my heart that take up quite a bit of room. I developed a-fib and was told an ablation was not indicated for me because of them. I had a mini-maze operation in 2012. It worked on the a-fib but then I had flutter and SVTs. I was able to find an EP who had done ablations on people with my type of device but the svt began again. I wondered if it were possible to have surgery to remove the devices and see if that would disrupt the tachycardia. If it did recur would it be easier to ablate with a thinner patch on the septum? Have you removed devices like mine successfully? Thanks
Bruce_Lytle,_MD: It is possible to remove Amplatzer devices from the heart. Whether that would be in your interest is a more complex question. If you had open heart surgery to do that, the ablation would be done at the time of your surgery.
grammarhodes: A follow up question about feasibility of removing my Amplatzer devices. I have had three right side ablations and one left side ablation following my mini maze. The tachycardia returned just two weeks following the last procedure. I have had numerous electro cardioversions they last less and less each time. That is why I wondered if removing the devices would help break this cycle. What else would you recommend I do?
Bruce_Lytle,_MD: You need to be evaluated by an electrophysiologist. We would be happy to see you here.
Willzzz: I am a heart transplant recipient out 16 years. After 12 years my kidneys failed and I was started on home hemo. The kidney transplant surgeon turned me down because I had stents placed in my Iliac arteries a couple of years earlier. He said there was no place to put the kidney. The dialysis has torn up my heart valves. My tricuspid and mitral valve are leaking severely. My aortic valve is now also leaking. My blood pressure is falling. According to my last echo (3/13) I have a septal aneurysm. My transplant team said there is nothing that can be done because my aorta has serious blockages of calcium and plaque. Their surgeon agreed. He told me that there was no place to clamp off the aorta without me having a stroke or dying on the table. He told me to just enjoy the time I have left. I have read online about the elephant trunk procedure. Do you have any ideas? I have come to peace with dying-but at only 59 I would rather die trying to have it fixed then just wait around for it.
Bruce_Lytle,_MD: Unfortunately your problem is a complex one - to give you an opinion we would need to see the details of your records and medical condition. Please contact us directly and would be happy to review your records.
Christine: I had triple bypass seven years ago following an MI. I have lost 22 pounds recently and my sternum wires are protruding and causing pain in my chest. Can these be removed easily? My fear is they may break through the skin. They are close to the surface now. What type of surgeon would do this kind of surgery and how involved is it. Thank you
Bruce_Lytle,_MD: At this point the sternal wires can be removed. It would require small incisions. It is not a tremendously involved surgery but it is best to have general anesthesia to do it. A cardiac or thoracic surgeon would be capable of doing this.
Chrissilou813: Follow up to the sternum wires question. If they do protrude through the skin is this an emergency/ER situation ?
Bruce_Lytle,_MD: It is not a middle of the night emergency - but it should be removed.
Symptoms and Diagnostic Testing
mabrown: Now my issue...I am 52 years old and my dad has heart disease. I have some shortness of breath and feel pressure in my neck (carotid artery area) periodically. I am very active but don't exercise like I should...except play tennis. I had a nuclear stress test yesterday...and stayed on for about 10 1/2 minutes getting my heart rate to 158 or so...then got off treadmill and my blood pressure had plummeted to 80 over 40. after 10 min it was up to 88 over 60...then back to around 105 over 70 which is about what it was before the test. What does that indicate?
Bruce_Lytle,_MD: Although you had a good workload on your stress test, the drop in your blood pressure can be a sign of serious cardiac disease. It is likely that that is a positive stress test and needs to be investigated.
Vpedroza1: Went to cardiologist today and had EKG done, while I was waiting I read results and said borderline abnormal t wave.... When cardiologist came in he told me it was normal.... Still going to schedule a stress test but he doesn't think I have heart disease. Last time I had EKG it read normal, what can cause abnormal t wave results on EKG?
Bruce_Lytle,_MD: T wave changes may or may not indicate abnormality. A stress test sounds like a good idea.
Lifestyle, Diet, Supplements and Risk Factors
cpk2001: I am 58 with heart failure and an ICD. Heart condition caused by sudden heart attack with no prior personal or family history. It has been eight months. Does the ejection fraction ever improve? I have a good diet, exercise, medication. Do certain supplements help rebuild the heart muscle?
Bruce_Lytle,_MD: The left ventricular ejection fraction may improve. We are not aware of supplements that would rebuild the heart muscle. The strategies that you have mentioned, good diet, exercise and medications are all good things to do.
nailivic: I had an aortic valve replaced because of calcification. I was told it would last 10 to 15 years. Why does it go bad? Is it a result of calcification? Is there any thing one can do diet wise to reduce the probability of calcification.
Bruce_Lytle,_MD: Often, failure of biologic aortic valves is related to calcification. We believe that diet that is extremely high in calcium may lead to premature calcification of biologic valves. Usually as long as someone does not take supplemental calcium, their dietary calcium is not too much.
mastahl: How concerned should I be with heart health based on family history? Both parents had high blood pressure. I do not smoke and drink little alcohol. Father (who drank regularly) had a stroke and Mother (smoker) had emphysema and heart failure.
Bruce_Lytle,_MD: Cardiac risk is related in part to your family history but also to your cholesterol and triglyceride levels, whether or not you have diabetes, high blood pressure, and whether or not you are obese. Without these data, it is pretty hard to tell what your risk might be.
stosh: Dr. Lytle: in your experience, have you witnessed and do you believe heart disease can be reversed with an improved lifestyle: healthy eating, daily exercise, no smoking, healthy weight, no soda pop, etc.?
Bruce_Lytle,_MD: Predictable reversal of cardiac disease has never been documented in large numbers of patients. That does not mean it can't be possible. And - for most patients prevention of their cardiac disease worsening is more important than reversal. Healthy eating, daily exercise and no smoking are important regardless of the lack of data indicating reversal of heart disease.
Rainbow77: I have a porcine artificial heart valve. I experienced AFib in September and my internist gave me Eliquis and my Cardio agreed with the med. I had Cardioversion and am now back in sinus. What is your opinion on this matter and why? My 2nd question is I am scheduled for a colonoscopy and my Cardio told me I do not need antibiotics prior to the procedure.
Bruce_Lytle,_MD: The issue of antibiotics prior to relatively risk procedures with an artificial heart valve in place is not completely resolved. My opinion is that they are indicated with an artificial heart valve. In regard to eliquis - if you stay in sinus rhythm for another four months it probably is ok to stop it.
Rainbow77: It is stated that Eliquis in not recommended for use when you have an artificial heart valve, however my internist and my Cardio prescribed it for me. What is the issue with using Eliquis other than it was not tested and approved by FDA in trials. Rainbow77
Bruce_Lytle,_MD: The issue is that it has not been tested in patients with artificial heart valves. So, it is not known whether it prevents clot formation on heart valves similarly to warfarin. It may, but it is not known.
Rainbow77: I have a porcine heart valve and I want to take antibiotics prior to a colonoscopy, but my Cardio says no. Can I just request that the Gastro give antibiotics to me?
stosh: Doctor Lytle: 58 year old, male, 6' 1", 213 lbs. good overall health, walking four-five miles each day, had five bypasses and endarterectomy surgery in April to fix my LAD and RCA which were both 100% occluded. Currently on 6.25 mg daily dose of Coreg. No high BP. Daily 80 mg aspirin regimen. Diet: strongly vegan, fruits, veggies, eggs, farm raised chicken, fish, and no processed foods, and no pop, and avoid anything with HFCS. Never smoked, weightlifter many years. Still on 10mg daily dose of statin. Blood numbers all look great. Just had cholesterol particle test completed. No other medical concerns. Q: Would it be recommended that I'll need to stay on the statin medication long term? Do the studies actually indicate that there's an anti-inflammatory benefit to statin treatment for someone with my profile? I do not wish to go through bypass surgery again in my lifetime.
Bruce_Lytle,_MD: It is probably the case that statins have benefits that are not just related to lowering cholesterol. I would continue to take statins unless you have side effects.
cpk2001: What tests do you recommend on an ongoing basis for a patient with an ICD and heart failure? I routinely have an Echocardiogram, EKG, etc. I have also completed cardio rehab and am on medications and strict diet.
Bruce_Lytle,_MD: That sounds like a good medical and follow up program.
hamradio1: Dr. Lytle, Thank you, the moderator and Cleveland Clinic for this wonderful opportunity to have our questions answered. Happy Thanksgiving to you and your families!
Bruce_Lytle,_MD: It is our pleasure. Thank you as well.