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Interventional Procedures - Stents, Angioplasty and New Approaches to Treat Heart Disease - Dr. Kapadia

July 9, 2008
Samir Kapadia, MD

Samir Kapadia, MD
Interventional Cardiologist, Tomsich Family Department of Cardiovascular Medicine

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Cleveland_Clinic_Host: Welcome everyone, and thank you Dr. Kapadia, for being with us to discuss Interventional Heart Procedures. We look forward to an interesting chat today.
Speaker_-_Dr__Kapadia: Thank you for having me.


Heart Valves

smithvolt3: Are heart valves being replace using minimally invasive techniques at CCF?

Speaker_-_Dr__Kapadia: Yes, heart valves are currently being replaced at the Cleveland Clinic using minimally invasive techniques, involving surgical as well as catheter-based procedures. However, every patient is not a candidate for minimally invasive valve replacement, and some techniques are still experimental and can only be performed in the setting of a clinical trial. A full work-up is required prior to determining the best method of valve replacement for each patient.

SENECA: MY HUSBAND HAS HAD A MITRAL VALVE REPLACEMENT TWICE. FIRST A PIG VALVE. REPLACED BY A MECHANICAL IN 2000. STARTED TO LEAK IN JAN 2008. UNDERWENT SURGERY WHERE 44 STITCHES WERE USED [ REPLACING 12 STITCHES ] TO STOP LEAK. UNSUCCESSFUL AND A 2ND PROCEDURE IN MAY WAS ATTEMPTED T BY CATHETERIZATION THRU GROIN TO PLUG THE LEAKS. COULD NOT GET THE WIRES TO REACH THE LEAK DUE TO THE 44 STITCHES. HUSBAND NOW HAS HEMOLYTIC ANEMIA DUE TO LEAK AND IS HAVING TRANSFUSIONS EVERY 2 WEEKS. THERE SEEMS TO BE A VARIETY OF OPINIONS FROM HIS DOCTORS AS TO WHAT TO DO NEXT AND I WOULD LIKE TO KNOW IF YOU KNOW OF NEW PROCEDURES OR ANY OPINIONS YOU MAY HAVE REGARDING OUR NEXT MOVE. HUSBAND HAS REGAINED SOME STRENGTH . HE ALSO SUFFERED 1 MONTH OF HORRIBLE NOSEBLEEDS AFTER THE CATHETERIZATION PROCEDURE AND AFTER PAINFUL PACKING ,FINALLY A DIFFERENT ENT DR HAS CONTROLLED IT WITHOUT THE HORRENDOUS PACKING. I DESPERATELY NEED SOME HELP IN DETERMINING WHERE TO GO NEXT THANK YOU

Speaker_-_Dr__Kapadia: It sounds like your husband is in a difficult situation. The surgeon may have felt that it was not possible to remove the existing valve and replace it with a new one. However, this may be the best solution and it may be reasonable to obtain a second opinion to determine whether your husband is a candidate for another surgery. Alternatively, it may be reasonable to attempt another catheterization with intent to "plug" the leak; however, this should only be attempted if surgical correction is not possible. In the meantime, it is important to use appropriate medications to control blood pressure, monitor blood counts closely, and provide transfusions as needed. It is also important to take iron supplements as needed to allow the body to make its red blood cells.

jhath: Please explain what "percutaneous mitral valve repair" is? I am a 34 year old female with bi-leaflet mitral valve prolapse with associated marked insufficiency. Can you also advise what "marked" indicates? It was mild ten years ago with no tricuspid insufficiency and now I have trace tricuspid insufficiency.

Speaker_-_Dr__Kapadia: Percutaneous mitral valve repair refers to one of several procedures performed through a catheterization procedure (rather than surgery), and intended to reduce mitral valve insufficiency (mitral regurgitation). One example of an experimental percutaneous mitral valve procedure performed at the Cleveland Clinic involves the placement of a clip across the mitral valve leaflets, to hold them together and reduce the degree of prolapse and insufficiency. The decision to pursue mitral valve repair (percutaneous or surgical) should depend on the degree of insufficiency, any associated heart dysfunction, and any symptoms you have. Once a decision to pursue mitral valve repair is made, a review of the echocardiogram and discussion with the patient can determine whether the patient is a candidate for enrollment in a percutaneous mitral valve repair study.

jhath: I am a 34 year old female with bi-leaflet mitral valve prolapse with associated marked mitral insufficiency. We are trying to conceive our first child and not sure if I should be concerned about becoming pregnant with my new diagnosis. Can the valve get worse during pregnancy?

Speaker_-_Dr__Kapadia: You should have an echocardiogram to see the size of the heart and sometimes we use stress echocardiogram to determine how the heart will perform in stress of pregnancy.

Speaker_-_Dr__Kapadia: Typically, heart tolerates leaky valve well in pregnancy. It is not common to have worsening of the valve function just because of pregnancy.

willy: had valve replacement 12 years ago, triple by pass in December. valve is leaking. symptoms,no stamina, hard to breath, swelling of feet and legs. Is there a procedure to help without another operation?

Speaker_-_Dr__Kapadia: Yes. There are options. It depends on which valve is leaking and what is the mechanism of leaking.

brandy: i HAVE A LEAKING TRI-CUSPID VALVE. iS MINIMAL INVASIVE SURGERY AN OPTION FOR ME? WHAT CAUSES THE FLUID TO LEAK INTO THE ABDOMEN?

Speaker_-_Dr__Kapadia: Minimally invasive surgery is an option for tricuspid valve but the exact cause of leakage will determine what kind of surgery you need. The heart is connected to abdomen by blood vessels and tricuspid valve regulates the flow. When tricuspid valve is leaky the pressure in the veins of the abdomen is increased and that causes fluid to seep through and collect in the abdomen.

hardware: I'm an asymptomatic person with a rating of "3' (out of a scale of 4) mitral valve regurgitation. At what point should I seek surgical correction of my mitral valve? There has been only very slight enlargement of my left ventricle (1 mm).

Speaker_-_Dr__Kapadia: Symptoms are the best indicator therefore you should have regular exercise to monitor symptoms. The follow up echocardiogram to monitor the size of the heart and at times stress echocardiogram may be necessary to accurately time surgical intervention.

hardware: What is typically the first symptom a person would notice with a degenerating mitral valve? Possibly I have some very minor chest pains, though I'm suspect it is purely psychological.

Speaker_-_Dr__Kapadia: Typically it causes exertional shortness of breath. Chest pain is not the typical symptom of mitral valve problem. Coronary artery disease is the common cause for chest pain and should be ruled out.

mtpatel99: 45 year old, otherwise healthy, mvp grade iii severe regurgitation, asymptomatic. Is it possible to do percutaneous valve repair?

Speaker_-_Dr__Kapadia: It is possible to do so however, I would wait for symptoms, enlargement of the heart, or increased pressures in the lungs prior to any intervention.

cindyc: Why have I been diagnosed with MVP then another test showed I don't have MVP. Should I be concerned?

Speaker_-_Dr__Kapadia: No. Mitral valve prolapse is a imprecise diagnosis unless done with proper echocardiography. If there is a question about the diagnosis, it is probably not severe enough to worry about.

hardware: The wall thickness of my heart's septum is greater than normal. Does this significantly decrease my chances of a successful mitral valve repair done by an experienced surgeon?

Speaker_-_Dr__Kapadia: No. Sometimes part of the muscle from the wall of the septum has to be removed during the surgery. Very few surgeons are adapt at doing this.

brandy: i AM A TWENTY-SIX YEAR SURVIVOR OF BREAST CANCER. i HAD CHEMO AND RADIATION IN 1982. cOULD RADIATION HAVE CAUSED SOME OF THE DAMAGE WITH MY HEART? I HAVE HAD TRIPLE BY-PASS, MITRAL VALVE REPAIR, AORTIC VALVE REPLACEMENT.

Speaker_-_Dr__Kapadia: It is well known that radiation does affect the coronary arteries and valves. The type of radiation and time from radiation are factors determining its effect on the heart.

stanheck: Can minimally invasive mitral valve repair be done with a beating heart or does the heart have to be stopped

Speaker_-_Dr__Kapadia: Heart has to be stopped for minimally invasive valve surgery. However, percutaneous mitral valve repair can be performed in the beating heart.

sean_r_2: I'm 60, and I need aortic root and aortic valve replacement. I'm in otherwise very excellent health and condition. Based on family history and my health, I fully expect to live to 100. I don't like what I've read about anticoagulant therapy. Is it reasonable for me to choose a biological root&valve, with the plan for having another biological replacement around age 75, and then either biological or mechanical around age 90?=

Speaker_-_Dr__Kapadia: Sure - hopefully in next 15 years we will be able to replace your biological valve without surgery.

gundersonrg: I am 59 yrs old. I was told for the first time at age 58 that I had heart murmur. I had yearly physicals for the military and 3 preop evaluations and was never told I had a murmur before. At 59 they did a second follow up echo and told me I needed to have my aortic valve replaced. They could not tell me what was causing the problem with my aortic valve. It did not present as a stenotic valve nor a rheumatic valve. After my surgery we received the pathology report and it states "At the commissure of one of the cusps is a 1.0 x 1.0 x 1.0 cm yellow-brown soft mass. I would like to know what this soft mass was and if that could have been the cause of my valve failing? Should there be a separate pathology report of this mass?

Speaker_-_Dr__Kapadia: It is not uncommon to have small mass on aortic valve. It is typically a fibroelastoma. I cannot tell if that was the cause of your valve problem or not.


Coronary Artery Disease

mpetrale: Three questions: Given a 100% CTO blockage in the RCA, what is the recommended treatment - medicine, angioplasty or bypass. 2)If medicine is the recommended treatment for 100% blockage in the RCA, what is the 10 year survival rate? 3)How can I regress 100% plaque blockage in the RCA?

Speaker_-_Dr__Kapadia: The best treatment for a 100% occluded artery should depend on the patient and the specific characteristics of the occluded artery. First, it is important to understand that such an artery may have been occluded for some time and often, the heart grows "collateral" vessels to supply the heart muscle that is compromised by the occluded artery. If the patient is not having symptoms related to the occluded artery, such as chest pain/pressure, shortness of breath or fatigue, then no treatment to open the artery may be needed. It is unlikely that opening such an artery (with surgery or angioplasty) would affect survival, but it may improve any symptoms that are present. If the patient is symptomatic despite taking appropriate medications, then the decision to treat the artery with surgical bypass or angioplasty, and the likelihood of success, may depend on the characteristics of the artery, as seen on the angiogram.

Speaker_-_Dr__Kapadia: Recently, there has been some exciting evidence that with optimal control of cardiac risk factors such as high cholesterol and high blood pressure, the process of atherosclerosis in the coronary arteries can slowly reverse. Therefore, it is important for every patient to take appropriate medications to reach blood pressure and cholesterol goals, as well as to follow a heart-healthy diet and engage in an appropriate exercise regimen.

fletch: I am post CABG x3, two and 1/2 years ago. Exercise 6 days per week, weight 172, never smoked, good diet. Latest cath show substantial plaque build up. I'm on Zocor 40mg and Tricor 145mg. Is there anything else that can slow progression of CAD?

Speaker_-_Dr__Kapadia: It sounds like you are taking good care of yourself, but sometimes it is difficult to counter the genetic predispositions some patients have to coronary disease. You should always continue to follow a heart-healthy diet and an appropriate exercise regimen. Furthermore, it is important to control risk factors such as high blood pressure and cholesterol. Although you are taking Zocor, it is important to know what your LDL (bad) cholesterol and HDL (good) cholesterol, and triglyceride levels are. If these are not optimal, then they should be treated appropriately. It may also be helpful to test for diabetes, which may impact the progression of coronary artery disease.

dsmith1955: I a 52 year old male. 3 years ago I had quadruple bypass. since then all the bypasses have closed and every 3 months have had stints. Total of 16. 2 of those have closed and caused a heart attack. My interventional Cardiologist say we should stick with stints and eventually try stem cell therapy. What do you think about stem cell therapy?

Speaker_-_Dr__Kapadia: Stem cell therapy is an exciting new field but there is very little data. You may want to have a second opinion for a fresh look at your problem.

regina4242: I have CAD and I am on my second round of EECP treatment and it does not appear to be working this time. I think people would like to know what EECP is used for and why?

Speaker_-_Dr__Kapadia: EECP is used for patients with intractable angina who are not candidates for stenting or bypass surgery. EECP is thought to improve collateral circulation and help with symptoms.

israelolivieri: What are the parameters for non-critical blockages? Is there a preferred method of treatment for this type?

Speaker_-_Dr__Kapadia: Typically less than 70 percent diameter stenosis is considered non-critical. Controlling the risk factors like obesity, hypertension, smoking, diabetes, and high cholesterol are the mainstay of treatment.

Cleveland_Clinic_Host: We have approximately 10 minutes left in the chat. We received a large amount of questions and we will continue to answer as many as possible. We apologize if we did not get to your question. If you have additional questions after the chat, please use our 'Contact Us' link (www.clevelandclinic.org/contactus) to submit your questions.


Coronary Artery Disease and Stents

bzgirl21: Are there generally restrictions on physical activities subsequent to stenting procedures? Can patients engage in activities such as rowing, resistance weight training or light weight lifting?

Speaker_-_Dr__Kapadia: Heart catheterization is performed by placing catheters through an artery in the arm or leg and advancing them to the heart. Following the procedure, patients are typically instructed to avoid strenuous activity and lifting >10 pounds for one week, to avoid any problems (such as swelling or bleeding) with the artery that was used. After one week, patients can typically resume their normal activities, including resistance training and weight lifting, without problems.

texas123: Good morning, Doctor. In 2004, I had 3 Cypher DES and One Taxus DES placed. Taxus and 2 Cyper are in the RCA. Recent Angiogram (cath) showed all Cyper DES open but the Taxus was 75% closed. Cath doctor did not want to place more metal into that Taxus DES. He ballooned it opened. This 3 months ago. MY fear is it will start closing again. This past week two new stents have been approved by the FDA. Xience is one of them. Would either of these stents work in placing one of them in the Ballonned Taxus for my peace of mind since Cath doctor will not use another Taxus DES or Cyper DES in that declining Taxus stent. Safety and longevity is a concern. He is appose by-pass surgery. I am thinking of mini by-pass if The failed Taxus DES cannot stay open. Your thoughts please. I am in my sixties. Thank You. axus stent.

Speaker_-_Dr__Kapadia: Balloon angioplasty for first time restenosis of a Taxus stent is a reasonable strategy. If there is recurrent restenosis, chances are about 50 percent depending on the extent of scar tissue, another DES (Cypher or Xience) would be a reasonable strategy. Bypass surgery can be considered if this is the main artery (LAD).

etshirai: which stent coated or uncoated has the better track record. In terms of becoming blocked; in terms of length of time before failure; in terms of not causing blood clots; in terms of least amount of heart attacks; How long due you have to be on anti coagulant drugs for coated stents; I have heard any where from a couple of years to rest of your life. You would think the stent after a certain time will have all the drugs dissolved out of the surface

Speaker_-_Dr__Kapadia: Coated stents have less recurrent re-narrowing from scar tissue compared to uncoated stents. The chance of blood clot formation is sightly higher with coated stents. Plavix should be continued at least for two years if not for lifetime. Although the medication is gone from the stent, the polymer coating that allows medication to stick to stainless steel is still present. This is the reason for long term Plavix treatment.

rose44: I had an MI in 02 with 2 stents in r. c.a. A recent cath. showed normal L. main Lad. has 50%. Sm circ. system with proximal 60% sten. and mid. 80% stenosis. Rca. large dominant with distal 50% sten. E fraction 60%. the Dr. says I'm fine, and that many people walk around with blockages. I'm doing everything I can now to try and stop this progression. Is stenting ever an option with sm. circ?

Speaker_-_Dr__Kapadia: The decision to perform angioplasty and stenting is different for every patient, and must take into account the size of the coronary artery, the degree of stenosis, and the presence or absence of symptoms. Your doctor is correct, many patients with coronary artery stenosis "walk around with blockages" and have no problems. However, if you are having symptoms of chest pain or pressure, shortness of breath or fatigue, it may be reasonable to consider stenting the most severe area(s). In this case, it would be reasonable to review the angiogram and determine whether the arteries involved are large enough to be stented.

eksohorg: what about replacing arteries that continue to clog with a dedicated stainless solid stents? what about some other form of replacement of bad arteries by manmade products?

Speaker_-_Dr__Kapadia: stents open up the native arteries but do not replace them. Bypass surgery with your own veins is an option but conduits made of synthetic material are not effective for cardiac bypass surgery.


Heart Failure

herbie424: Thank you for hosting this chat. I am a sixty year old with stage 2 heart failure (heart attack damage) and blockages. My LAD is about 50% blocked and in a recent cath my cardiologist decided not to try angioplasty. What is the criteria for doing an angioplasty and what factors would argue against it. Thank you kindly.

Speaker_-_Dr__Kapadia: The decision to perform angioplasty should always be made on a case-to-case basis. The most important considerations in performing angioplasty include the patient's clinical status, and the degree of blockage. First, it is important to understand that angioplasty and stents are intended to help patients with their symptoms (such as chest pain or pressure, shortness of breath or fatigue), and in patients without symptoms, angioplasty may be unnecessary. Second, it is important to understand that blood flow through a coronary artery is typically not limited until the artery is greater than 70% narrowed. If the degree of narrowing is in question, measuring pressures inside the artery with a thin wire, looking at the artery "from the inside" with an ultrasound catheter, or simply having a stress test may help to clarify the degree of narrowing. However, if you are not having cardiac symptoms, or if the degree of narrowing is not severe, angioplasty may not be necessary.


Diagnostic Tests

ojapan_2: h/o silent MI in 2000, pci2007- om2 -0% and rpls( 100% blocked 1 month post-stenting) EF 60%, June 2008 LAD stented b/c of 75% blockage. Cannot comprehend why same type of stent Taxus Paclitaxel eluting would work in one vessel and not another. stented. Contemplating a consultation with you, Sincerely, O Japanwalla

Speaker_-_Dr__Kapadia: There are many reasons for stents to close. Some of them include size of the artery, inadequate apposition of the stent to the artery, and disease before and after the stented segment. I would be happy to give you an opinion.

Claudia: My name is Claudia. I am 38 years old & I have RA. I had my first heart attack Feb. 2, 2007. My doctor took me off plavix (it had only been 3 weeks) & I had my second heart attack Feb 27, 2008. How do I find out exactly how much heart damage that I have & is there a test that measures how thin my blood is? I live in TN and have no health insurance, so I am sure that I am not my cardiologist's favorite patient. What kind of questions should I be asking my cardiologist? He has told me not to do anything strenuous & I don't even know what that means? Thanks you for any information & God Bless.

Speaker_-_Dr__Kapadia: Echocardiogram is the best test for judging the damage to the heart.

Speaker_-_Dr__Kapadia: I would try to find out if there are any blockages in the arteries and whether they need to have stents or bypass surgery. Try to control your cholesterol, exercise under supervision (cardiac rehab), and control other risk factors.

Speaker_-_Dr__Kapadia: There are some tests to determine effectiveness of plavix but typically they are not required in all patients.

ginger2626: when looking at a CD of a heart catheterization is it possible to tell the characteristics of the persons heart that is. Their sex, approximate age,approximate weight,etc.. i have reason to believe that surgical decisions were made based on a catheterization CD that may not have been mine.My name and correct info is on it but I still believe it may not be mine.Could you actually be sure when looking at a catheterization CD that in fact it was mine based on gender,age,weight,etc.. ?

Speaker_-_Dr__Kapadia: It is difficult to be sure but sometimes we can see breast shadows, bone density and the size of the patient to assure that this is same patient. More importantly, there is time and date of each picture recorded on the CD which would tell you that this is a CD from you.

israelolivieri: What tests should heart disease patients have done and when?

Speaker_-_Dr__Kapadia: It depends on the type of the heart problem. If arteries are blocked, stress test is helpful. If valves are a problem, echocardiogram can help. Severity of the problems will determine the frequency of testing.

martzj: How do women get themselves referred for cardiac testing in the first place when a family care provider with a stethoscope is the required first step? Thank you.

Speaker_-_Dr__Kapadia: You do not need a referral to come to the Cleveland Clinic unless your insurance requires it.


Symptoms

cindyc: I have rapid heart beats 60-130 resting,I take 25 mg. of atenolol at night to help, I have arrhythmias, had a coronary spasm during heart cath, have esophageal spasms as well. My cardio doc & gastro doc said it is not my heart. How can I be sure because I have terrible pain everytime I try to walk or work out.

Speaker_-_Dr__Kapadia: You may need a second opinion to rule out heart disease. We do see this in some patients with coronary spasm. But, exertional chest pain is not typical for coronary spasm.

imtaur_2: Why does my husband have variant or prinzmetals angina one year after left main bypass followed by nine stents to all three major arteries. He has never had previous heart problems, high blood pressure or any heart attack.

Speaker_-_Dr__Kapadia: Your husband should have second opinion as this is not common.


Supplements and Alternative Medicine

eksohorg: what is the effectiveness of taking Grape Seed extract, 300mg, 95% Polyphenols 2 of these a day and GNC Cholesterol formula which contains Phytosterols 800mg how effective are these in clearing or maintaining clear arteries and veins as well as lowering the bad cholesterol or raising the good cholesterol

Speaker_-_Dr__Kapadia: The supplements are not tested in rigorous clinical trials. Therefore, it is difficult to know whether they are beneficial.

israelolivieri: what are your feelings about alternative and/or complementary interventions for patients?

Speaker_-_Dr__Kapadia: I always encourage people to change lifestyle. I think it is very important to pay attention to alternative treatments.


Arthritis Medications

eksohorg: what about arthritis medications for heart patients, medications that work. could celebrex be a cause of heart conditions just as vioxx was

Speaker_-_Dr__Kapadia: All arthritis medications have potential side effects that affect the heart. Tylenol is probably the safest. Celebrex may also have effects like Vioxx but it has not been apparent in current literature.


Inflammation

fletch: There have been some blood test that indicate elevated levels of c-reactive protein and lupus-antibodies. Can these be culprit in disease progression?

Speaker_-_Dr__Kapadia: Inflammation has been associated with disease progression in coronary artery disease. CRP is a marker for inflammation.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Kapadia is over. Thank you again Dr. Kapadia, for taking the time to answer our questions today.

Speaker_-_Dr__Kapadia:Thank you for having me.

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

Reviewed: 07/08


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