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Heart Valve Surgery (Dr. Gillinov 5/19/10)

Wednesday, May 19, 2010

Marc Gillinov, MD
Staff Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, Miller Family Heart & Vascular Institute

Description

Heart valve surgery is a procedure used to repair or replace diseased heart valves. Surgeons are able to repair and replace valves using traditional, minimally invasive and robotically assisted techniques. Dr. Gillinov answers your questions about valve surgery.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Gillinov. We are thrilled to have him here today for this chat. Thanks for being here, Dr. Gillinov!

Speaker_-__Dr__Marc_Gillinov: Thank you for having me today - lots of good questions.


Aortic Valve

adourian: I have mild to moderate AS and have just gotten my hypertension under control through diet and exercise (150/90 to 115/70). I am now experiencing lightheadedness on a regular basis. Is it correct to assume that AS combined with the lower blood pressure is robbing my system of needed blood flow and if so is it better to live with the symptom or allow the pressure to increase to say 140/80?

Speaker_-__Dr__Marc_Gillinov: It is best to control your blood pressure. Mild to moderate AS should not cause symptoms

adourian: While aortic valve area, pressure gradient across the valve and ejection fraction are all important measures of the progression of AS which one do you regard as most important in determine the pace at which it is progressing and in determining when surgery should be undertaken?

Speaker_-__Dr__Marc_Gillinov: A combination of aortic valve area and gradient across the valve.

SusanW: I am the 68-year old female recipient of a bovine aortic valve, successfully?

Speaker_-__Dr__Marc_Gillinov: Your valve has a good chance of lasting your entire life. There are people who have had these valves longer than 20 years. There is nothing specific for you to do regarding lifestyle. Before dental or other medical procedures take antibiotics. Enjoy yourself.

SharronT: Thank you...does surgery to replace the aorta and the aortic valve take roughly the same time as just replacing the aortic valve? I'm scheduled for this in June, with a mechanical valve...but pre-admission isn't until June 1st, as far as information goes...and wasn't sure if they'd have a team doing both at the same time....I am in London, ON and am aware of the great things they've done here. Again, many thanks

Speaker_-__Dr__Marc_Gillinov: It takes a bit longer to fix the aorta. But it can be done at the same time.

Betty: I am a 55 yo female with a bicuspid Aortic valve with an area of 1cm and I have an ascending aortic aneurysm that measures 4.3 cm. I am starting to notice more fatigue and I want to know if the wait until my aneurysm is 5 cm should be different because of my height (5 ft 3in).The dr I'm seeing doesn't seem concerned about my condition, he didn't see me this year when I had my echo and ct, just had his nurse call with the results. I’d like to know your opinion on this. Thanks for taking my question. Betty, Stokesdale, NC

Speaker_-__Dr__Marc_Gillinov: If you have symptoms, I would schedule the surgery for the next 6 months.

NancyO: Recently had an aortic valve replaced with a bovine bioprothesis. I am in my mid-fifties. How many years can one expect before considering another replacement? Or is there a way to maintain the new valve for life?

Speaker_-__Dr__Marc_Gillinov: It should last 10-20 years. You require antibiotics before dental or other procedures. I would stay physically fit and active. No diet restrictions are necessary – eat a healthy diet relatively low in fat with lean meats and complex carbohydrates.

Laura: I am a 35 year old female recently diagnosed with a bicuspid aortic valve, which has resulted in aortic stenosis, heart murmur, and some calcification of the valve. I have been told by my cardiologist that I will need valve replacement in 4-6 years. My father had a heart valve replacement in 2002 at age 58. He chose a mechanical valve and was on warfarin. He passed away last year due to a brain hemorrhage (no head trauma) as a result of his warfarin levels being 'off.' I have several questions: 1) What is the safest, most minimally invasive surgery option for aortic valve replacement? 2) What surgery options at Cleveland Clinic would I have that are not as commonplace at a hospital such as University of Michigan? 3) What is your recommendation on the replacement valve (pig, mechanical, etc.)? I am concerned about mechanical valves because of my father's history. I also wonder if it is possible to have sensitivity to warfarin which would make it more likely for warfarin levels to go 'off.' I appreciate your feedback.

Speaker_-__Dr__Marc_Gillinov: Here are the answers to your questions:

  1. What is the safest, most minimally invasive surgery option for aortic valve replacement? We favor a partial upper sternotomy through a 2-3 inch incision.
  2. What surgery options at Cleveland Clinic would I have that are not as commonplace at a hospital such as University of Michigan? Minimally invasive surgery is one of our strengths.
  3. What is your recommendation on the replacement valve (pig, mechanical, etc.)? I am concerned about mechanical valves because of my father's history. I also wonder if it is possible to have sensitivity to warfarin which would make it more likely for warfarin levels to go 'off.' The choice is, of course, yours. I tend to favor tissue valves--I am 48 years old, and that is what I would choose. But medically speaking, both mechanical and tissue valves are good options. The keys are you and your lifestyle.

shaneme123: can you have multiple (more than 2) heart valve surgeries? Meaning, am 45 years old and need an aortic valve replacement (heavily leaning toward animal valve); I expect (hope) to be around for another 40 years; so could envision many surgeries. Any issues?

Speaker_-__Dr__Marc_Gillinov: Many younger people choose a biological valve and reoperations when they wear out can be performed very safely.

shaneme123: Are you a supporter of the Ross procedure for folks in their mid-40's?

Speaker_-__Dr__Marc_Gillinov: It is one of many options. In most cases, if the person wants a tissue valve we prefer a bovine or porcine valve because the operation is far shorter and produces excellent outcomes.

mbt13: I have severe calcification through my aorta and the surgeon that reviewed my films is worried about clamping the aorta to perform the aortic & mitral valve replacement. I have all of my medical records and hospital records and would like Cleveland Clinic to review my case. Who would be the most experienced surgeon to perform a risky surgery such as mine? I am reluctant to have the surgery due to the high risk of a stroke or worse.

Speaker_-__Dr__Marc_Gillinov: All of our surgeons are experienced with this type of procedure - we see many of these types of cases - in fact I just finished an operation this morning that sounds very much like your own case. Please contact the resource nurse line to find out how to send in records for surgical review - my.clevelandclinic.org/heart/chat_with_a_heart_nurse.aspx

MichaelA: How does one qualify for non-invasive or minimally invasive aortic valve replacement?

Speaker_-__Dr__Marc_Gillinov: Most isolated aortic valve replacements can be accomplished minimally invasively. We examine the echocardiogram and cardiac catheterization to determine whether or not that is the safest approach in each person.

gdstuart: What are the risks of minimally invasive aortic valve replacement as compared to full sternotomy procedures? A surgeon at a large teaching hospital in Philadelphia told me there were no demonstrably improved outcomes for minimally invasive process, so he recommended the sternotomy.

Speaker_-__Dr__Marc_Gillinov: With good patient selection, safety is equivalent with a minimally invasive approach. Advantages to a minimally invasive approach are: Less blood loss, shorter hospital stay, more rapid healing and a better cosmetic result.

pbelloff: When severe aortic stenosis is present, is it possible for a portion to break off and cause aTIA. If so, how often can it happen and what can be done to prevent it?

Speaker_-__Dr__Marc_Gillinov: It is possible for that to happen. It is relatively uncommon. A person with severe AS should have surgery to replace the aortic valve, to preserve heart function and extend life.

duncan: I am 55 years old, have a bicuspid aortic valve and an ascending aortic aneurysm. In the past I had been told I would need to have a mechanical valve with the dacron tube since, if necessary, on a redo surgery the entire surgery would have to be redone. Now I am hearing that a tissue valve is being suggested more frequently as a better option. If so, what kind of tissue valve do you usually use? I would prefer to avoid the lifetime of Coumadin if at all possible.

Speaker_-__Dr__Marc_Gillinov: Both valve choices are good. I favor the bovine pericardial tissue valve. If it does wear out in the future, you may be able to get a new valve without surgery (percutaneous valve)

witter123: What is the typical life span of an aortic valve homograft when put in a 65 year old man? If it required replacement, will another homograft be recommended? Could any of this work be done with a catheter today?

Speaker_-__Dr__Marc_Gillinov: The typical lifespan of the valve is 10 - 20 years. Today the reoperation generally involves a new homograft. It may be possible in the future to place a catheter based valve inside the homograft.

mbt13: Is there any alternative approach to dissolving calcium on the aortic valve. What about Chelation or other natural products?

Speaker_-__Dr__Marc_Gillinov: No - there are no alternative approaches for this.

C028894: I'm a 47 year old male (elite endurance athlete) recently diagnosed with a bicuspid aortic valve (mild - stenosis/regurgitation) with enlarged left ventricle due to exercising my MD thinks. Any danger in continuing to exercise hard? Also, when I have to have my BAV replaced would I be a good candidate for a bioprothesis?

Speaker_-__Dr__Marc_Gillinov: As long as your aortic size is normal there is no reason to limit your exercise. You would certainly be a good candidate for a bioprosthesis when your native valve fails.

cathyb: Please discuss how height relates to recommendation for surgery based on aortic diameter? What about gender as a factor? At what diameter would you recommend surgery to replace ascending aorta for a 5'7" asymptomatic female? Aortic insufficiency is severe, so valve replacement has definitely been recommended.

Speaker_-__Dr__Marc_Gillinov: An aortic aneurysm should be repaired at the time of aortic valve surgery. In a smaller person we are more likely to fix an aorta that is between 4 and 5 .5 cm in diameter.

rfcrow1: Why do you prefer the bovine over porcine valves? I noticed that Robin Williams received the porcine valve at the Cleveland Clinic. I received a porcine valve 18 months ago at Univ. of Michigan.

Speaker_-__Dr__Marc_Gillinov: I placed a bovine aortic valve in Robin Williams and repaired his mitral valve. We have both porcine and bovine valves and choose the valve based on what valve is a better fit for a given person.

SueD: If a woman with breast cancer has had 6 weeks of radiation therapy to the right breast and axilla, how long after the completion of RT must she wait before having her aortic valve replaced? What factors do you consider when determining if an aortic valve can be replaced utilizing a minimally invasive procedure?

Speaker_-__Dr__Marc_Gillinov: Doing chest surgery after radiation therapy is always a bit tricky. I would wait about a month. I would begin with a plan to perform minimally invasive surgery. However, if the radiation has produced scarring, I would proceed to a standard approach. That said, usually we can achieve the minimally invasive approach.

lmgaiso: I have AR. Serial echos over the last ten years show a tri-cuspid valve. However, one very prominent cardiologist hears a distinctive click that he says is indicative of a bi-cuspid valve. Is there any valve in having an TEE to make sure it is bicuspid? Would there be any difference in treatment? I lift weights but lightly

Speaker_-__Dr__Marc_Gillinov: The echo is the best way to determine the status of the aortic valve. The most important findings relate to the degree of leak and the status of the left ventricle. There is no need to undergo a TEE to determine whether your valve is bicuspid or tricuspid.

MichaelA: What percentage of aortic valve replacements are currently performed using non-invasive or minimally invasive surgery?

Speaker_-__Dr__Marc_Gillinov: Most isolated aortic valve procedures can be performed minimally invasively

Steve8155: I have a rather deep pectus excavatum and I'm scheduled to have aortic valve replacement surgery in the near future. My surgeon says a "minimal invasive" procedure is not possible and that my surgery will be a little more complicated due to my chest structure. Can you please comment on how my pectus excavatum will complicate my valve replacement surgery, recuperation etc. Thank you.

Speaker_-__Dr__Marc_Gillinov: It should not complicate your surgery or your recovery. We have extensive experience operating on people with pectus excavatum. It should not be a problem for you or for your surgeon.

cdv: How do beta blockers help manage a bicuspid aortal valve? What other treatment is there short of valve replacement/repair, or if it hasn't progressed to that point?

Speaker_-__Dr__Marc_Gillinov: Beta blockers do not help to manage a bicuspid aortic valve. They may be prescribed for control of blood pressure or to reduce the rate of enlargement of the aorta, as aortic aneurysms frequently accompany a bicuspid aortic valve.


Mitral Valve

FredF: 66 male, mitral/tricuspid repair April 08. Atrial flutter as a result. Ablation 11/08. Diagnose successful. July 09, routine echo says mild/mod MV leak. April 2010 EKG show flutter back in routine check. Put back on warfarin. Ablation doctor schedules new procedure for June 10. However notes that April 2010 Echo shows mod-severe leak of MV.....In middle of house move last year, new cardiologist just on board but have had tests film of echo send to surgeon that did repair band/ring to see his thoughts. question 1) is ablation make sense without full knowledge of need for another MV surgery? 2) Can it be possible to repair without full open heart surgery. Original surgeon Mt. Sinai NYC. thanks,

Speaker_-__Dr__Marc_Gillinov: If you have a severe leak of the mitral valve, I would recommend repeat surgery and repeat ablation at that time. If the leak is only moderate, go with the ablation alone via catheter.

DennisR: I have a Rheumatic fever damaged Mitral valve. I also have afib which seems to be controlled nicely with medication. My valve is only opening a small amount (maybe 10 degrees). However I am NOT symptomatic. My breathing is fine, my heart rate with medication is normal, and I show no problems when I walk my 4 - 5 miles each day or swimming in the afternoon. My concern is when do I think about repairing that valve. Is there a negative to waiting? What dangers or risks do I encounter if surgery is required? My cardiologist is opposed to surgery at this time and doesn't seem to have any confidence in robotic surgery. He prefers, when it is time, I have the surgery in Florida. My confidence in Cleveland is much higher. If I were a member of your family what would you recommend?

Speaker_-__Dr__Marc_Gillinov: I would recommend surgery with an ablation to try to restore sinus rhythm. This is not urgent, but I would do it before I get symptoms or severe heart damage.

kgdetroit: The data for mitral valve repair durability is always stated as out 10 years, what data has there been out to 20 years and beyond?

Speaker_-__Dr__Marc_Gillinov: There are several reports documenting excellent durability of mitral valve repair at 20 years and beyond. In general at 20 years about 80% to 90% of people who had repair still have good valve function.

helioartur: I have mitral valve problem since I was 9yrs. lately the symptoms is getting worst (shortness of breath, Irregular heartbeat (I’m taking anticoagulants), dizziness, Low energy level and sometimes chest pain) interfering in my job. It’s time to get a mitral valve replacement surgery? Or what more symptoms I should expect until the time for surgery?

Speaker_-__Dr__Marc_Gillinov: You may be a candidate for mitral valve repair, which is generally superior to replacement. Until you get your valve fixed, your symptoms will persist or become more severe. They should resolve once your valve is fixed.

neuromanager: I had mitral valve repair March 17 and was readmitted one week after discharge in congestive heart failure. Since that time, gradually, my heart is jumping around all over the place and sometimes takes my breath away. Is atrial fib normal after valve surgery? I am on digoxin 0.125 and Lisinopril 1/2 of a 2/5 tablet daily. Should I have my cardiologist consider a holter monitor?

Speaker_-__Dr__Marc_Gillinov: 50% of patients get atrial fibrillation after valve surgery. It is usually only temporary. You sound like you are on the right medications. You should follow up with your cardiologist.

yogeshwar_k: I was diagnosed for MVP [AML prolapsing into LA] first time in 1999 during Master Health Check-up.Since 2005 I am taking medicines like Nebicard 2.5mg,Ecospirin 150,Telsartan40 and Aztor 20. My recent 2D-ECHO indicates as below-- Moderately severe MR,Trivial TR+ [GR.RVSP <30mmHg ], LA / LV Mildly Dialated, Normal LV Function,No Pericardial Effusion / No Clot], IVS Thickness :1.20cm,LV Postwall Thickness :1.00cm,Aortic Root Dia :2.90cm LA Dimension :4.80cm,LVID[ED] :5.80CM,LVID [ES] :4.20CM, EF :60%,FD :30%. Some doctors have suggested to continue on medicine,some say that I should go for replacement of mitral valve and others say that you can go to some expert doctor who can repair your valve. Pls advise me whether I can avoid any type of surgery and continue only medicines.

Speaker_-__Dr__Marc_Gillinov: You should have elective mitral valve repair. You may be a candidate for a minimally invasive or robotic approach.

cohnanita: what about mitral rheumatic valve ? There is possible to repair it, or you need to replace? WHICH VALVE IS RECOMMENDED BEFORE AGE 50? MECHANICAL OR BIOLOGICAL?

Speaker_-__Dr__Marc_Gillinov: Repair or replacement of a rheumatic valve depends upon the features of the valve. If replacement is necessary, the choice of prosthesis is up to you. Biological valves do not require blood thinners, but wear out in 10 to 20 years. Mechanical valves have far greater durability in a young person like you, but they do require anticoagulation.

shones: My latest echo images shows some calcification on my posterior leaflet. I have consulted with a heart surgeon. He has recommended surgery to repair or replace my mitral valve. The surgeon said that if the leaflet is too calcified that he would have to replace my native valve. Is there some kind of reconstructive technique that can be done to repair a highly calcified posterior leaflet? I am 29 years old and was born with Shones complex.

Speaker_-__Dr__Marc_Gillinov: There are techniques to repair such a valve, although repair is not guaranteed. This sort of valve can be challenging. It is best to have a surgical team with extensive experience in complex mitral valve surgery.

corky: I have had two open heart surgeries one in Illinois and one at the Cleveland Clinic the latest in 2003. Both were to repair my mitral valve (the first one only lasted 3 years). My Dr. said I now have a mild Mitral Stenosis. Does this mean that I may have to have another repair down the road? I also just had a MRI done due to pneumonia. They saw a shadow on a chest x-ray and wanted an MRI done. The Dr. said that my artery was not laying right and it was a birth defect. If this is so, why was it not noticed during all my test for my surgeries? Thank you. Kathy J

Speaker_-__Dr__Marc_Gillinov: Mild mitral stenosis may never require treatment. I need more information to tell you about the artery. At the time of heart surgery, all of your great arteries will have been visualized.

Gypsygirl: I have had mitral valve regurgitation and pulmonary hypertension for the last 10 years and it is progressing . My doctors have told me I am not at the point of valve surgery YET! Should I get a second opinion now from you as when the time comes, I would like to have the surgery performed by you.

Speaker_-__Dr__Marc_Gillinov: If you have pulmonary hypertension, you are actually at the point of requiring surgery. I would get the valve fixed in the next 3-4 months so that the pulmonary hypertension does not progress.

Flower: Dr. Gillinov: Thank you for allowing us to access your expertise. My questions are: Do you repair many congenital defects of the Mitral valve (say from Ostium Primum ASD)? From a psychosocial standpoint, how do you counsel congenital patients with moderate to severe valve leaks who face one or more additional valve surgeries, i.e. do you have any advice for those of us who, at midlife, are preoccupied with (afraid of) the prospect of needing more intervention? Lastly, with so much PR hospitals are doing, how do you decipher the best place for your care- are those who are tops at Mitral Valve Repair (in general) ideal for congenital repair too? THANK YOU.

Speaker_-__Dr__Marc_Gillinov: For the adult with congenital mitral regurgitation we can usually achieve an excellent repair and the need for further surgery is uncommon. It is important to seek a center that performs a high volume of mitral valve surgery because such as center will also see an adequate number of people with congenital mitral valve issues.

user01: My wife has a problem in her heart (Mitral Valve), she was examined by Prince Sultan Cardiac Center in Riyadh Saudi Arabia I would like to have your kind advice when does she need a surgery ?

Speaker_-__Dr__Marc_Gillinov: We would be happy to review her records. Timing of surgery depends on severity of mitral valve dysfunction, her echocardiogram and her symptoms.

helioartur: I'm 25 and I have a mitral valve prolapse since 9 due a rheumatic fever. should I have a mitral mechanical valve or a biologic one?

Speaker_-__Dr__Marc_Gillinov: First, you should see if you can get a mitral valve repair - this may be possible. If replacement is necessary the question centers on would you rather have the most durable valve (mechanical) or would you rather avoid coumadin (biological). The question depends upon your wishes and lifestyle. Both valves are good options.

fergie: I am a 55 years old female that has been diagnosed with moderately sever mitral valve regurgitation. I have been a jogger for over 12 years and I do not have any symptoms other than being more tired than usual. Should surgery be performed at this point?

Speaker_-__Dr__Marc_Gillinov: If your leak is moderately severe or severe and you have symptoms - you should start thinking about having valve repair. It is not an emergency but the presence of symptoms is a trigger that leads us to recommend valve surgery so that you do not cause heart damage. We have a have a valve tool that may be helpful to you - my.clevelandclinic.org/heart/mitral_regurgitation_tool.aspx

genodoc: is there a similar valve tool for aortic valve?

Speaker_-__Dr__Marc_Gillinov: Actually we should have an aortic valve tool for aortic stenosis should be coming out soon - finishing touches are being put on it.

MarkT: I am a 70 year old male with valve disease. The surgeon in Pittsburgh who performed my bypass surgery in 1997 tells me that because of the severe calcification in my aorta, he is reluctant to do a valve replacement. He said because of the need to clamp of the blood supply in the aorta, he feels there is a high risk that plaque will travel and possibly cause a stroke or even death. I have compiled all of my records from last year from a variety of doctors and the hospital and am preparing to send them to Cleveland Clinic (Ct scans, cardiologist opinion, etc). My brief history is family heart disease, hodgkins disease in 1980 used upper mantel radiation & spleen removal, 1997 bypass heart surgery (5), 2007 stents (5), 2009 AAA open surgery repair, and now aortic valve stenosis and regurgitation moderately severe, mitral valve regurgitation moderately severe.

Speaker_-__Dr__Marc_Gillinov: We would be happy to review your records for you.

Stanislavovich: Hi! My mother has a leaking (regurgitant) mitral valve 3-4 stage and leaking (regurgitant) tricuspid valve 2-3 stage. She is 62 years old. She was operated 4 times for many reasons last 10 years, but not for heart. What do think: is it necessary to do a cardiac surgery? If it’s necessary which way is the best for her: minimally invasive techniques or common median sternotomy? Can your clinic makes such operation for foreign citizens? What I need to do for getting your clinic? How much does operation cost (approximately)? How long does she need to stay after operation for recovery? May I stay with her in hospital?

Speaker_-__Dr__Marc_Gillinov: The safest and best operation is dependent upon her preoperative tests. We would be happy to review her records. We have an international center that makes arrangements for 1000s of patients who travel to Cleveland from outside the United States - here is the website for GPS - my.clevelandclinic.org/global_patient_services/default.aspx

dricke: I am a 61 year old male that contracted scarlet fever when I was 12. Evidently this damaged my mitral valve. The valve opens very little now (I believe the cardiologist referred to is as severe). However, I am NOT symptomatic. No problem with breathing nor do I feel my afib. My doctor feels comfortable in not operating. Is there a harm in waiting? He also believes local care is best, but reviews clearly indicated Cleveland clinic should be preferred. How can a layman tell which is best?

Speaker_-__Dr__Marc_Gillinov: As long as you are asymptomatic and your heart function is good, you can delay surgery. I would seek a center with high volume – practice makes perfect – and expertise in valve surgery.


Tricuspid Valve

hasansuatrizki6: My father is 70 years old. He had mitral valve repair (annuloplasty) surgery due to mitral valve regurgitation 3 years ago. Although he also had mild/moderate tricuspid valve regurgitation at the time, his tricuspid valve was not repaired. He currently is suffering from severe tricuspid valve regurgitation and right heart failure symptoms. His cardiologist suggested that my father needs to have tricuspid valve repair surgery to improve his quality of life. How often are tricuspid valve repair surgeries performed at Cleveland clinic for such patients, what is the risk for this operation, and what is the success rate for this type of surgery? Thank you.

Speaker_-__Dr__Marc_Gillinov: Isolated tricuspid valve surgery in a patient with right heart failure is a high-risk undertaking that should only be performed at centers with extensive experience. We do this operation relatively frequently in properly selected patients.


Robotic and Minimally Invasive Heart Valve Surgery

DennisH: I'm interested in robotic repair of my recently diagnosed mitral valve prolapse. My cardiologist just did a TEE which revealed moderately to marked regurgitation at the posterior leaflet. I'm a 48 y.o. physically active male who participates in martial arts training. I believe I am asymptomatic to minimally symptomatic, how long will my stay be in the hospital and what time frame can I expect to return to work and karate? What are the precautions & physical limitations after surgery?

Speaker_-__Dr__Marc_Gillinov: You sound like an ideal candidate for robotic repair. Most people stay in the hospital 3-4 days and return to exercise within 2 weeks. I would plan on waiting a month or so before full contact karate.

faith: Do you use robotic surgery to replace mitral and aortic valves at the same time? Why would I want robotic?

Speaker_-__Dr__Marc_Gillinov: It is most applicable to mitral valve procedures alone. It is our least invasive approach. In the appropriate candidate it results in an excellent outcome and quick recovery.

SusanT: Questions for Cardiac Surgeon - On-line chat - Valve surgery May 19 at noon 1. How do you determine what type of surgical approach you use on the patient – sternotomy, minimally invasive sternotomy, thoracotomy or robotic ? 2. Why is a chest CT (I assume without contrast) performed prior to heart surgery? Does it provide some type of surgical “roadmap” for the heart surgeon? Does this aide in the decision of what type of surgical approach is best? 3. Success rate of repair? 4. Percentage of people requiring additional surgery for re-repair or valve replacement? 5. How long is the typical valve repair surgery? 6. Is a TEE performed intra-operatively ? 7. Do all mitral valve repairs include an annuloplasty? 8. Is a patient on Coumadin or wayfaring after surgery? 9. Prior to discharge(after surgery), what diagnostic testing may be performed on the post-op patient? Another echo?

Speaker_-__Dr__Marc_Gillinov: A CT scan serves as a road map to determine the feasibility and safety of minimally invasive and robotic approaches. Most valve repairs last a lifetime. Annual echos should be performed after mitral valve repair.

dricke: Can robotic surgery fix a bad mitral, afib, and prolapse all in one surgery for the mitral valve?

Speaker_-__Dr__Marc_Gillinov: Yes - provided the anatomy is suitable and there is no coronary artery disease, we can generally offer a robotic approach to fix all those conditions at the same time.

dhoykenpo: What is the success rate for a robotic repair of a mitral valve prolapse- primarily posterior and minimally anterior leaflet involvement ?

Speaker_-__Dr__Marc_Gillinov: The probability of successful repair is 99% - the operative risk is about 1 in 1000.

jpvaughan: need an aortic valve replacement and have afib - does this qualify for minimally invasvive?

Speaker_-__Dr__Marc_Gillinov: Usually that combination is most effectively treated with a standard sternotomy.

GeniZ: I have severe aortic valve regurgitation according to my cardiologist. He has encouraged me to put off surgery because robotic aortic valve replacement is still in it's early stages of experimentation. How far in the future do you see this procedure becoming available? I am S/P VSD repair and do not wish to have sternal invasive surgery again.

Speaker_-__Dr__Marc_Gillinov: Robotic aortic valve surgery is a long ways off. If you have symptoms or any heart damage, I would recommend early surgery so that you do not develop irreversible problems.

shaneme123: is there much time difference between minimally invasive approaches versus 'traditional' on the heart/lung machine?

Speaker_-__Dr__Marc_Gillinov: Minimally invasive approaches generally require a slightly longer time on the heart lung machine - in most people this is of no consequence.

windychicago: I am diagnosed with atrial fibrillation, aortic aneurism, and bi-cuspid heart valve that need to be corrected. Can these problems be corrected via " minimally invasive" techniques? If not, what kind of surgery would be required, what is typical risk factors involved, and what is typical recovery time for this type of problem?

Speaker_-__Dr__Marc_Gillinov: In general, that combination of factors warrants a standard sternotomy. In experienced centers, the risk is very low (1%). Full recovery will usually take one month to 6 weeks.


Percutaneous Valve Treatments

genodoc: I have read about the non invasive repair of Mitral valves with the "Mitra-clip". how close are we to a similar repair capability for Aortic Valve cusp problems. ie: for a "floppy cusp". EES MD

Speaker_-__Dr__Marc_Gillinov: We do not have percutaneous technology for aortic valve repair. We do have percutaneous technology for aortic valve replacement--it is not yet FDA approved, and is most applicable to people with aortic stenosis.

Cleveland_Clinic_Host: We've had several questions related to percutaneous aortic valve replacement. Dr. Gillinov can you talk about this?

Speaker_-__Dr__Marc_Gillinov: Percutaneous aortic valve replacement (non-surgical) is available in Europe but is not yet FDA approved in the US. It appears to be a good option for patients who would be high risk for surgery. The durability of the percutaneous valves is currently unknown so at this time we do not recommend these valves in most younger and healthy people.

roadkinglarry: I have read several articles about a new Mitral valve clip procedure. What do you think of it and when will Cleveland Clinic be doing this procedure?

Speaker_-__Dr__Marc_Gillinov: We do offer this procedure at Cleveland Clinic as part of a clinical trial. It is not yet FDA approved. It is appropriate for only a minority of people who have a particular anatomy.

KibarogluI: I have a question about my brother's health problem. It is said that only 1/4 of his both valves work, and there is also an enlargement in his heart. It is said that valve operation is needed but it is risky. I have red that "Percutaneous Aortic Valve Implantation method" is less risky. Is "Percutaneous Aortic Valve Implantation method" used at any of your clinics?

Speaker_-__Dr__Marc_Gillinov: Percutaneous aortic valve replacement is not yet FDA-approved. We do apply it according to strict guidelines within a clinical trial.

DanaL: Do you think there will be a "clip" procedure in the near future to repair a mitral valve that leaks on the side rather than in the center of the valve?

Speaker_-__Dr__Marc_Gillinov: For that sort of pathology, a minimally invasive or robotic surgical approach provides a definitive and long-lasting repair. The clip is not good for that area.


Atrial Fibrillation Surgery

DianeL: my mother is 82 yrs. old, has a pacemaker and has atrial fibrillation. I would like to know if at her age this type hear valve surgery would be worth considering or would it be too risky for her. She is taking coumadin and blood pressure medicine.

Speaker_-__Dr__Marc_Gillinov: In her case, heart surgery for isolated atrial fibrillation is a stretch. We do heart surgery for atrial fibrillation in people who are younger and who have failed other therapies (medicines, catheter ablation) and in people who are having heart surgery for other indications (valve surgery, bypass surgery) and who also have atrial fibrillation.

larryfromkansas: Can valve repairs and maze procedures be combined in a single operation?

Speaker_-__Dr__Marc_Gillinov: Yes. It is very common to have atrial fib and a valvular heart issue and we can fix both at the same time.


General Heart Surgery Questions

EdwardL: I'm 79. mild heart attack 1981, heart bypasses (4) 1992, valve replacement 2001 (pigs valve). Am told I have rather strong heart murmur. My bypasses were redone when I had the valve replacement in 1992. In (my) opinion I am currently in excellent health. My question: My cardiologist seems unconcerned, should I be scheduled now or soon regarding the status of my heart valve and/or bypasses? And if so should I make appointment with the Cleveland Clinic?

Speaker_-__Dr__Marc_Gillinov: You should have an annual echocardiogram. If you are feeling fine, examination of your bypasses is not necessary.

Howsell: Does rigorous exercise shorten the "life expectancy" of my bovine valve?

Speaker_-__Dr__Marc_Gillinov: We do not think so.

Sharonk: I am 59 years old and had a mitral and aortic value repair 6 years ago. The valves need to be replaced. I am on coumadin for atrial fib. What type of valve would be best for me - mechanical or tissue? How long will I be in the hospital for the 2 valve replacement? How long is recuperation time?

Speaker_-__Dr__Marc_Gillinov: The choice of valve is yours. At the time of valve surgery, I would ablate your atrial fibrillation, hoping to cure the abnormal heart rhythm. If you wish to be off coumadin, you should choose tissue valves; of course, there is a chance that such valves will wear out in your lifetime, necessitating a third operation. If avoiding a third operation is the top priority, choose mechanical valves, which work very well and do not wear out.

mbt13: I am 70 years old and need both the aorta & mitral valves replaced. Is the surgery more difficult as I age or is waiting more prudent because of advances in medical procedures continue to improve. I have had bypass (5), stents (5) and a recent AAA repair. I am not anxious to go through more operations, especially since my surgeon told me I am at high risk.

Speaker_-__Dr__Marc_Gillinov: If your valvular dysfunction is severe - there is no advantage to waiting.

MS_LakeForest: Prior to discharging patients, how does the Cleveland Clinic prepare them for life after surgery? In particular, does anyone discuss the drug regimen and the importance of compliance? Is there any follow-up?

Speaker_-__Dr__Marc_Gillinov: We devote a great deal of time and effort to ensuring that patients go home with all of the key information that they need to ensure a good recovery. We also communicate with the local doctors so that everybody is on the same page.

Gypsygirl: what determines whether a valve can be repaired vs. replaced

Speaker_-__Dr__Marc_Gillinov: The extent of damage to the valve including the presence or absence of calcium coupled with the surgeon's expertise determine the probability of valve repair.

roadkinglarry: I am scheduled for mitral valve & atrial fibrillation surgery next month, my family would like to know what to expect after the operation as far as time in intensive care and the recovery time before leaving Cleveland?

Speaker_-__Dr__Marc_Gillinov: Each year we help more than 2,000 people who travel to Cleveland from out of state. We have a very smooth process in place to make sure their experience is a good one.

Most people arrive in Cleveland 2 days before their surgery and have preoperative testing and meet their surgical team.

After surgery the normal ICU stay is one day - this is followed by a 3 to 5 day stay in a private room on the regular floor.

After discharge, people usually stay 1 - 2 days in town before traveling home. We also offer a follow up appointments for all patients and many choose to return to Cleveland for their cardiac care.

RHAZ77: If mitral valve surgery is not likely for a few years is it advisable to meet now with the folks at the Clinic to set things up if surgery becomes necessary and the decision to do so at the Cleveland Clinic is made?

Speaker_-__Dr__Marc_Gillinov: We would certainly be delighted to see you - it is not absolutely necessary but we are always happy to talk to you and offer you an opinion

rvangrouw: What lifestyle changes are mandatory following heart valve surgery?

Speaker_-__Dr__Marc_Gillinov: If the patient has a valve repair or replacement with a biologic valve - no lifestyle changes are necessary. If the patient receives a mechanical valve, anticoagulation is necessary and activities that involve physical risk must be avoided.

A healthy lifestyle including diet and exercise improves outcomes in all people.

cathyb: When travel to Cleveland Clinic is not a factor, is it possible to obtain a surgical review in person, simply by scheduling an appointment with one of your surgeons? Would you still desire echo and cath films to be sent in advance?

Speaker_-__Dr__Marc_Gillinov: Yes - Yes - Yes. We do that all the time. We would still have you send in all records and test results/films ahead of time so that we can give you the best opinion concerning your case. You would then schedule an appointment with the surgeon.

Tennis: On release from my valve replacement surgery at Cleveland Clinic what do you recommend for the first phase of recovery and rehab (ie) rehab facility or return home with nursing care etc.?

Speaker_-__Dr__Marc_Gillinov: Most patients return to their homes - if we determine that outpatient or inpatient rehab will speed recovery we will arrange that with you. We do recommend that you have a friend or relative with you for the first week back home.

kgdetroit: Is pleural effusion common after heart surgery and if present how long does it last and what can I do to resolve this?

Speaker_-__Dr__Marc_Gillinov: It is relatively common. Usually diuretics and time result in resolution. Sometimes a larger effusion is drained.

leslieb: Does drinking 2 glasses of wine a week have any affect on a mitral valve with mild to moderate regurgitation?

Speaker_-__Dr__Marc_Gillinov: No - moderate alcohol consumption does not affect the mitral valve.

I am sorry I have to leave now but I will review your questions that are remaining and try to answer some that we have not touched on the topic yet.

Cleveland_Clinic_Host: Thank you Dr. Gillinov! We appreciate your time!

Speaker_-__Dr__Marc_Gillinov: It was a pleasure to be here today.

Technology for webchats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 05/10


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.


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