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Ask the Heart Surgeon (Dr. Johnston 2/9/10)

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February 09, 2010

Douglas Johnston, MD
Staff cardiac surgeon
Sydell and Arnold Miller Family Heart & Vascular Institute


As one of the largest, most experienced cardiac and thoracic surgery groups in the world, the Cleveland Clinic Cardiovascular Surgery program cares for patients from all 50 states and around the world. Cleveland Clinic surgeons offer virtually every type of cardiac surgery including elective or emergency surgery for heart valve disease, aortic aneurysm, coronary artery disease, arrhythmias, heart failure, Marfan syndrome and other less common conditions. Even complex operations, such as second and third bypass operations and aortic and great vessel surgery, are routinely performed at Cleveland Clinic with excellent results. Dr. Johnston, a Cleveland Clinic cardiac surgeon will provide answers to your questions about heart surgery during this online chat.

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MedHelp: Hello everyone. This health chat will begin at 12 pm Eastern / 9 am Pacific, but feel free to start submitting your questions now. As a reminder, this is a moderated health chat, which means that questions are reviewed by a moderator and then submitted to Dr. Johnston.

MedHelp: Hello everyone and welcome to today's chat with Dr. Johnston, a world-renowned cardiac surgeon with the Cleveland Clinic. Welcome, Dr. Johnston. Thanks for joining us today.

Dr. Douglas Johnston: Happy to be here. Thanks for having me.

Skip61: I had bypass (5 arteries) surgery on Feb. 16 '09. On 3/11 readmitted to the hospital for Atrial Flutter and underwent 5 hour ablation (successful). During Cardiac Rehab 4/1 discovered I had a frozen left shoulder (MRI). Physical Therapist said she has several heart surgery patients that had neck or shoulder problems after heart surgery. Since being released from the hospital after my ablation have had trouble with dizziness, balance and mild headaches. Have consulted 3 cardiologists who are guessing (their words) that it might be my low blood pressure (100-123). Recently ENT physician suspects I may have Superior Canal Dehiscence (hole in ear). Going to get CT scan. Are all these problems normal to have after bypass surgery?? I am 71 years old, 5'11'' and 170 lbs. Eat healthy and physically fit (work out 5 times per week at health club). Any other ideas about my dizziness?

Dr. Douglas Johnston: Dizziness is always a tricky problem to find the answer to. Some patients do have changes in their blood pressure after bypass surgery, though these usually resolve over the first few weeks. This is the kind of problem that is usually best solved by sticking with one doctor with whom you have a good rapport.

cmasse: I am diagnosed with Costochondritis and I get very bad chest pains, with pains in my upper ribs and up to my jaw. Everything came out normal EKG, bloodwork, chest x-ray, etc. I am on pain medications that are not working. I will be getting a cortisone injection in my chest eventually. I have Costochondritis for almost 2 months now.

I also had 5 episodes of trouble breathing and pressure in my chest. In fact, I woke up at 2 in the morning on Thursday and I had trouble breathing. My question is even though that it is Costochondritis, how do I know the episodes I am having are not from a heart attack?

Any advice would be greatly appreciated. Thank you.

Dr. Douglas Johnston: Costochondritis is very common and can be very painful for patients to deal with. The important thing is to be sure that heart problems have been excluded. The fact that you have had trouble breathing is concerning. I would recommend that you be seen by a doctor as soon as you can.

SOCCERMOM22: My husband will have his aortic valve replaced at Cleveland Clinic the beginning of March. I have been reading blogs and a big question keeps popping up on them. Does the surgeon actually do the surgery or does a resident perform the surgery and the surgeon supervise? Since he doesn't actually meet the surgeon until the day before the surgery, this is causing me great concern.

Dr. Douglas Johnston: That is a very good question, one that we often receive. Here at the Cleveland Clinic we work together with our residents and fellows to perform what are often very complex surgeries. We feel that it is the level of excellence of the team as a whole, not one person, which determines the outcome. A heart surgeon cannot operate successfully alone, so we rely on the entire team, not just the assistant, to give patients the best care.

jaxckie: HA 9/05 stent 5/06 two more stents. I feel fine, no pain or short of breath. I do about 30 mins on TM. No problem since my HA. My heartrate is 50bpm goes to 43 bpm. I don't feel sick. My BP on hot days stay 116/66/51bpm-44. I did not pass nuclearer stress test. I take 25mg atenolol +5mg amlodipine +20mg zocor+100mg allopurinol+bayer 81. How do I get my heart rate up? I suffer from depression, panic attacks, real bad fear got the best of me. I am 76 years old. One doctor told if you don't get dizzy or fall don't worry. I hope that I could find a cure for low pulse or get rid of my fears without meds.

Dr. Douglas Johnston: It may be that your low heart rate is related to your medication (Atenolol) which is a beta blocker, though there are a number of other reasons to have a heart rate this low. If a doctor has reviewed your test results and is following you closely, that is the most important thing. Low heart rate alone is not necessarily a worrisome condition.

Tonydus: I had an MI a year ago and received 2 stents. After a year of rehab, loss of 35 lbs, no red meat or saturated fats, regular cardio exercise and statins, I developed chest pains. An angiogram shows further deterioration at site of stents and in other arteries. I will receive angioplasty and 2 more stents in next couple of weeks. My question is what strategies should I adopt after this intervention? Higher dose statins? more exercise? different diet? I would add that my father and both paternal grandparent died young of heart disease. I guess it is possible that nothing can beat heredity?

Dr. Douglas Johnston: Heredity is certainly important in terms of the risk of coronary disease, but clearly diet, lifestyle, and medications have a major impact on the outcome in patients who already have the disease. You are doing all of the right things. I would recommend talking with your doctor about where you are in your progress, and what medication changes if any are recommended

minmtn: Had ablation for WPW (R post septal pathway with antegrade/retro conduction Nov 2008. Successful -- the pattern disappeared on ECG. Chest pressure, tightness since. BP is erratic from 90's to 140's, usually with pulse over 100. Fatigue. 59 yo female, 125 lbs. plenty exercise -ballet dancer. Raynaud's, slight venus insuff. ECHO stress test Dec09, indicating mild tricuspid regurg and trace regurg at mitral and aortic valves. Was told the ECHO was normal. But I still have symptoms. EP told me that the accessory pathway caused one chamber to inefficiently fill and empty prior to ablation. Also had recent gallium scan to ck kidneys due to chronic UTIs for more than 2 years (edema in abdomen, legs, improves in am, worse at night). Scan did not indicate kidney infection, but report was: slightly prominent gallium activity in both pulmonary hila (probably located in hilar lymph nodes). Any connection? WPW ablation-edema-hila-valves?

Dr. Douglas Johnston: This is an excellent question, which requires some review and a more thorough answer. We will be in touch offline to provide a more complex answer than the chat allows.

sk123: My father had open heart surgery a few years ago to put an O-ring around his valve to make it smaller. From what he told me, the valve was too big and his heart was working extra hard to pump blood. This eventually would have led to an enlarged heart, but the doctors caught it early. Everything seems fine since the surgery, but are there any signs we should look for in terms of the need for a follow-up surgery? Also, is this genetic? Should my sister and I get checked for the same condition?

Dr. Douglas Johnston: Good questions. Any patient who has had a mitral valve repair, especially one for the reasons you described, should have regular follow-up by echocardiography to see how well the valve is working, and how the heart is responding. Not all causes of valve disease are genetic, but some are. I would speak to your father's doctor about getting checked.

SeansMom165: My 11 year old son had subaortic membrane removal at age 5 by Dr. Thomas Spray at CHOP. His left chamber measured mild to moderate (they could not fix all regurgitation during surgery) since surgery and now measures moderate. He is started on 5 mg. enalapril per day. He plays competitive, travel ice hockey, which now seems to be up in the air pending a stress test. (His stress test a year ago was stellar.) As a mother, I am at my wit's end - what are the chances/expectations of this change stabilizing and he lives with the regurgitation vs. needing valvoplasty and a Ross procedure and what is the worst case for when that might happen? I'm trying to dig through the clinical data online but I need a consultation or someone to explain the data, but doctors today don't have the time...I'm trying to find a resource to help me understand where we're headed. Or better, where we might be headed. My son's z score was 1.67 in 2008, 1.67 in 2009 and 2.3 in 2010 (mildly dilated).

Dr. Douglas Johnston: This is an excellent question and you ahve clearly done your homework. To get to the bottom of a complex case like this we would need to review the chart thoroughly. We would be happy to do that for you and will be in touch offline with the contact information.

jambam60: What are the latest advancements in valve repair and replacement ? And what do you see happening in the near future?

Dr. Douglas Johnston: There are a lot of exciting things going on in this area. Most exciting is the possibility of repairing or replacing valves from the inside of the heart with catheter-based devices. There are some experimental devices available now, and I anticipate in the next few years we'll be able to treat many more patients this way.

CherylG1962: If I have MVP and thousands of PVCs a day, mostly at rest or while asleep and definitely when I'm on my left side or supine, can an ablation help, or is there a better alternative? I'm 48, female, an RN, and otherwise in good health. PVCs started to bombard me in December, after being sick with a fever for about 7 weeks, and possible having H1N1 that my daughter had. I see a cardiologist and an electrophysiologist. My MVP hasn't been diagnosed. Echo showed MV redundancy and MVR, and PVR. I hear a mid or late systolic very loud click with my stethoscope (I'm an RN), when I'm leaning left or partially on my left side. Tried Coreg for 2 weeks, but my BP fell to 70/30, as I already have a low BP of 90/60 or less, so I don't think beta-blockers are for me. The EP wants me on Flecainide, but it scares me, so what should I do?

Dr. Douglas Johnston: In general an ECHO is the best test for mitral valve disease. Since auscultation with the stethoscope can be difficult to interpret espectially when someone has PVCs or other arrhythmias, the heart sounds can be misleading. Working with a good EP is essential because often patients will need to try different medications before finding the right combination, as you've found. Don't be discouraged, though. Usually a good match can be found.

Jerry_NJ: I had a mitral valve repair in Nov 2007, and my enlarged left atrium is continuing to shrink in size. I am 70 years old, can I expect to see further shrinkage toward normal size?

Dr. Douglas Johnston: Most often the left atrium will shrink some, but not all the way to normal size. The most important outcome, though, is how the left ventricle is working and how you feel.

ChrisA282: Had an ablattion for Lone Afib on 11/6/09 (92 days ago). Prior Stress test & Catheterization confirm no other structural heart issues & I was extremely athletic/fit. . The very day after the ablation was disgnosed with gastritis in stomach. I have been experinecing about 2,000 up to 7,000 PVC/ PAC daily? Never had either condition before. EP Caroiologist is trying to tell me this is unrelated to procedure? Many posts on Medhelp reference potential Vagus Nerve damage during ablation? Is this possible? If so, how can it be diagnosed & what can be done to fix this condition?

Dr. Douglas Johnston: That is a very interesting question. While I do surgical ablation for atrial fibrillation, I'm not an electrophysiologist, and I'm not as versed in this area as I should be to answer your question well. I think you would benefit from a second opinion from an experienced EP. We'd be happy to help you with this if you'd like.

Sandy M: My husband has and implanted defibrillator. One of the leads was bad and the electrophysiologist tried to remove it. In removing the lead, he damaged my husband's tricuspid valve - which is now leaking. His cardiologist said that he doesn't want to do any repairs, unless my husband needs some other type of major heart surgery. Does this seem reasonable? Why wouldn't the cardiologist want to repair the leaky valve?

Dr. Douglas Johnston: That's a very good question. Because leads from defibrillators and pacemakers usually pass through the tricuspid valve, there is always a potential for the valve to leak with the leads in place or when they are removed. In general, patients with leaking tricuspid valves tolerate this very well, and don't need surgery unless the leak is very severe or longlasting, in which case patients will develop symptoms of right heart failure, lower leg swelling for example.

tiger317: Dr. Johnston, I am a 52 yr. old female whose last 2 echoes were as follows- 2nd last one: mod.- severe aortic reg., mild-mod. pulm. reg., trace tricus. reg. - EF 40-45%, heart enlarged for my frame - 5'1", 115 lbs. The last one in Dec. 2009 is as follows: mild-mod. aort. reg., mild-mod. pulm. regurg., trace tricusp. regurg., and trace mitral regurg., EF 45-50% - no mention of heart enlargement. I've recently been experiencing yawnathons: every few seconds: one lasted approx. 1/2 hour, last one an hour and a half. The last week I've had to sleep sitting up, due to chest pain when I lie down. The doctors (cardiologist and surgeon) say it's not yet time for surgery, however, every time I see the cardiologist, he emphasizes how terribly expensive this surgery is, although I'm in Canada and we have coverage.

Dr. Douglas Johnston: I'm not sure about the relationship between your aortic valve and yawning, but what is clear is that patients with aortic insufficiency which is causing symptoms - chest pain or shortness of breath, should be considered for surgery. I certainly think expense should not be the consideration. I would recommend you have a second opinion to review your echos, and potentially a cardiac catheterization to look at other factors that may be affecting your heart function.

Kathy2009220: After a person has had bypass surgery and is on blood thinners, can he eventually get off this medication and start taking plavix again as he did for PAD?

Dr. Douglas Johnston: By blood thinners I expect you mean coumadin. Most patients after bypass surgery don't need to be on coumadin, though it may be prescribed because of risk of stroke from poor heart function or atrial fibrillation. The key would be to understand why the blood thinners were necessary after surgery.

JBG5162: Hi Doctor - my aunt is in a rehab hospital in Boston having been diagnosed with pulmonary hypertension. At this point the only treatment left would be a heart-lung transplant and I would like to know how many of these procedures the Cleveland Clinic does each year?

Dr. Douglas Johnston: Heart lung transplantation is one of the less common procedures at most transplant centers in the country. Some patients with pulmonary hypertension can be treated with double lung transplantation, as long as the heart is still strong. Cleveland Clinic set the world record for lung transplants in 2009, breaking the previous record of 129. Some of those were heart-lung transplants. I'd be happy to look the exact number for you.

CFS1: My husband had a quadruple CABG in April. They harvested both mammary arteries to use as grafts. He is still nerve like pain on both sides of his chest, more predominant on the left. If he does work that requires the use of his chest muscles he also becomes very sore. It isn't cardiac type pain at all though. He had a stress test done in July and everything was fine.

Dr. Douglas Johnston: Often nerve-like pain is associated not with the mammary arteries but with spreading the sternum and ribs to do the surgery. Most of the time this fades over the first month or so after surgery. If it persists seeing a pain specialist is often helpful, as this type of pain responds to different combinations of pain medicine than the usual postoperative or muscle pain.

hogan59: I had two stents placed in 2009 (August and December 24th). I experienced angina but had no heart attack in both instances.I was taking nadaolol (some 30 years) along with Diovan. At my second stent I was taken off nadolol entirely and put on isosorbic mononitrate (to help prevent spasms in the artery). But on December 30th I had both a racing heart and my BP went very high. I was then put on metoprolol twice a day. Since then I have been experiencing trembling which seems to be increasing as time goes by.

Dr. Douglas Johnston: Your question illustrates a very important fact - cardiac symptoms can be related to changes in medication, but not always. Symptoms like yours require a very careful evaluation, and may need some time to sort out without rushing to change your medication regimen.

lifebuilder: How safe is an Atrial Septal Defect closure with the Amplatzer device (taking into consideration that the patient is a suitable candidate)? Specifically, I have heard that device erosion (cardiac erosion) has been reported with this device...I had an ASD repair with the device in July 2009 and live in fear of this happening. Thank you for your answer.

Dr. Douglas Johnston: That is a great question. The amplatzer device is very well tested, and very safe in general. Like with any procedure problems can occur. Device erosions are thankfully very rare. Regular follow-up echocardiograms should be performed to evaluate your progress after the device is placed. That said, you have had a very well-tested procedure and should not be afraid to live your life.

jak2009: I had a triple by-pass and mitral valve repair on January 15. My LVEF was 15-20% prior to surgery. What will be an ideal time in weeks to do a follow-up echo to see if the ejection fraction and heart function has improved after surgery? (prior history is MI in 2001, 2 stents placed (Right and circumflex), both occluded by 2008 with the LVEF of 45%, had a SCA in October 2009 due to blocked left anterior descending artery, stent was placed, but showed signs of restonbosis by January and the mitral valve started to leak since SCA in October).

Dr. Douglas Johnston: In general we wait 6-8 weeks after surgery to do a follow-up echo. It takes this long for the heart to reach a relatively steady level of function and for the inflammation associated with surgery to settle down.

marzeis: I am 55 female w/variant of marfan syndrome. Seven years ago my aortic and mitral began mild regurgitation and now they have moderate. This past year I required a five day hosptial stay for A-fib. My aortic root is 3.7. What can I do to slow the progression of my valve disease? And if I get to the point where they had to be replaced which valve is best?My mother had two pig valves. Thank you.

Dr. Douglas Johnston: In Marfan's syndrome, the progression of valve disease is related to the genetic abnormality in the tissues. Most cardiologists would recommend that you avoid very strenuous exercise and, most importantly, control your blood pressure. When it comes time for surgery, many Marfan's patients can have valve sparing surgery for the aortic valve, and mitral valve repair. I would be sure that you talk to someone at a center which is experienced with heart surgery for Marfans to achieve the highest repair rate.

auntiejessi: I have mitral valve prolapse and SVT. I do well on atenolol 25 mg. Is an ablation something I should consider?

Dr. Douglas Johnston: This would depend in part on the reason you have SVT, and how high your heart rate goes. An electrophysiologist can help you go through the risks and benefits of ablation vs. continued medical treatment.

cmclean: Hi, I'm a 32 year old woman with b aortic valve moderate a stenosis. They performed an angiogram and found an enlarge of 5.2 aortic root. Please can you tell me what options I have. I'm on the waiting list for the surgeon but I really don't understand the risk or complications of my heart. Thanks.

Dr. Douglas Johnston: A 5.2 cm aortic root is at the size where we would strongly consider repair because of the risk the aorta can rupture. At your age, the consideration would be to give you a longlasting aortic valve, and fix the aneurysm to remove the risk of rupture. This requires some careful consideration by a surgeon who is used to doing these procedures.

erijon: How important is an enlarged left atrium? I do not have afib and my echos have always shown normal heart valve structure with only trace regurgitation. I have never had any symtpoms of heart disease, work out daily at 80 - 85% of my max heart rate and have lost 70 pounds. BP is controlled and no other risk factors other than being a male over 40.

Dr. Douglas Johnston: An enlarged left atrium can be a risk factor for atrial fibrillation, but in a patient who is active and otherwise healthy with normal valves is not something to be very worried about.

cdel825: I am considering EP study/ablation for SVT. I have read that ablations can create new arrhythmias and increase PVC's. Is this a common side effect? I am very nervous about the procedure and not sure if the risk outweigh the benefits.

Dr. Douglas Johnston: Another good question about the risks / benefits of ablation. This is a little outside my area of expertise, but I'd be happy to follow up with you and refer you to the right people to answer that.

Tonydus: Further to your reply, where do you stand on the aggressive diet regimes recommended by Esselstyn, Ornish etc? I eat only monounsaturated fats, and lots of oily fish, which would be forbidden under those diets.

Dr. Douglas Johnston: I'm no diet expert, but my sense is that most very aggressive / restrictive diets later turn out to have some negative effect. Following the general guidelines set out be the American Heart Association is a good start, together with regular exercise.

LindaTX: Do high blood sugar levels have an effect on electrical nerve pathways in the heart? If so, can they destroy the vagus nerve connection to the heart and can the damage be reversed if neuropathy has occured?

Dr. Douglas Johnston: Diabetes certainly affects the nerve connections to the heart, though this is not well understood. Many diabetic patients do not have typical symptoms when they have a heart attack, which can make the diagnosis difficult. I'm not aware of any treatment for this, other than to be very vigilant and have good regular medical care.

ces143: Hi, I had a mitral valve repair last Dec 1 and last week I had ablation but my heart rate is still in the 90s despite atenolol. What do you think is my problem?

Dr. Douglas Johnston: Answering your question would require knowing a little more about your rhythm before and after the ablation. Sometimes a heart rate in the 90s can be in the range that is expected but that very much depends on the situation.

Jo846: Is there ever a time when a heart patient can take LESS medicine - once there is some improvement. The heart medicines do put a "drag" on the overall body - at least that has been my experience from over 2 years on coreg,inspra,pletal,imdur, simvastatin,plavix and diovan.

Dr. Douglas Johnston: Definitely. Changes in heart function, for better or for worse, can mean a patient needs a different combination of drugs. In particular after surgery, many patients get by with less medicine than what they started with.

auntiejessi: My biological mother (did not raise me) just had an aortic valve replacement at 61 years old. Is that something that I should be concerned about for myself, especially since I have MVP and SVT? If so, any prevention? Thanks!!

Dr. Douglas Johnston: That would depend on why she had the aortic valve replacement. Having that surgery at age 61 suggests she may have bicuspid aortic valve disease, which is common and does run in families. Having an echocardiogram would be the best place to start.

hogan59: what's the ideal heart rate and BP for a male at 60 years old and what's the best determining factor for cholesterol now besides ldl?

MedHelp: This will be the last question for today.

Dr. Douglas Johnston: That would depend on how active you are and what the overall condition of your heart is. The combination of LDL (bad cholesterol) and HDL (good cholesterol) is the best way to measure a patient's overall cholesterol status. Thanks!

MedHelp: Thanks everyone for joining today's chat on heart surgery with Dr. Douglas Johnston. It's been quite an educational chat with a lot of great questions. And thank you, Dr. Johnston, for taking time out of your busy schedule to answer everyone's questions today. We really appreciate it!

Dr. Douglas Johnston: Thanks very much for having me. There were a lot of very good questions.

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

Reviewed: 02/10

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