January 22, 2008
A. Marc Gillinov, M.D.
Miller Family Heart & Vascular Institute Cardiothoracic Surgeon & Surgical Director, Center for Atrial Fibrillation
Cleveland_Clinic_Host: Welcome Dr. Gillinov, and thank you for joining us today. Let's begin with one of the questions!
Speaker_-_Dr__Gillinov: Thank you for having me.
Robotic Heart surgery and Minimally Invasive Heart surgery
rlacon: Is the Robotic heart valve surgery procedure for MVP repair only available as part of a randomized study? If so why?
Speaker_-_Dr__Gillinov: It is available to all patients with mitral valve disease who do not require bypass or aortic valve surgery at the same time. We have extensive experience with this technology, and the minimally invasive approach speeds recovery time. For each patient, we discuss all of the options and choose the approach that results in the highest repair rate and safest operation.
caquest: Can valve surgery be done without the heart lung bypass machine? How long does it take. Is it shorter if minimally invasive surgery is performed?
dant01: I have heard mixed things - I have mitral valve leak - If I get robot mitral valve, how long until you can go back to work. I have a sedentary job but I have to walk far to get to my office. Sometimes I carry a computer bag.
Speaker_-_Dr__Gillinov: Usually a person can return to light work in a couple of weeks after a robotic mitral valve repair.
abby: what are the different risks related to traditional mitral valve surgery vs. minimally invasive valve surgery vs. robotic? Are the risks less with the smaller opening?
Speaker_-_Dr__Gillinov: Robotic mitral valve surgery is one form of minimally invasive surgery; it includes a small incision (1 to 2 inches) on the right side of the chest. No bones are broken. In appropriately selected patients, the risk is the same independent of the choice of procedure. So, at Cleveland Clinic, the operative risk for isolated, first-time mitral valve repair is approximately 1 in 1000.
romag: How do the long term valve repair results from robotic surgery to compare to conventional "crack the sternum" surgery?
Speaker_-_Dr__Gillinov: So far they are equivalent, which is not a surprise as the same techniques are used on the valve as with a sternotomy. The robot simply allows a truly minimally invasive approach with superior cosmesis and faster recovery.
uma: What valves can robotic surgery be used for?
Speaker_-_Dr__Gillinov: Robotic surgery is ideal for:
- Mitral valve repair
- Tricuspid valve repair
- Atrial septal defect closure
- Removal of atrial myxoma (tumor)
stacey: My husband has had several stents. If he needs bypass surgery can they do that with a smaller incision? Are there minimally invasive or robotic options?
Speaker_-_Dr__Gillinov: There are minimally invasive approaches for bypass surgery, some of which do not involve use of the heart lung machine. The precise approach depends upon the arteries that require bypass.
romag: How can you robotically repair a valve without stopping the heart? Wouldn't the valve be "flopping" around?
Speaker_-_Dr__Gillinov: In robotic mitral repair, the heart is stopped to ensure optimal repair.
richard: I need a repair or replacement of my mitral valve. Can the doctor tell ahead of time if robotic surgery is an option? What makes you not a candidate for robotic surgery?
Speaker_-_Dr__Gillinov: If you need mitral valve surgery, the first and most important step is to choose an experienced team. You want the best chance to have a mitral valve repair, and experienced surgeons are more likely to be able to do this for you. In most instances, we can tell beforehand if robotic surgery is the best option.
MaryAnn: Where is the incision with minimally invasive valve surgery? Is it still on the breast bone - or is it under the breast?
Speaker_-_Dr__Gillinov: For mitral valve surgery, it is usually on the right side under the breast; this is cosmetically appealing and does not involve fracturing the sternum. For aortic valve surgery, a small incision is made in the center of the chest.
Cleveland_Clinic_Host: Can you comment more about the benefits of robotic surgery?
Speaker_-_Dr__Gillinov: In most patients with mitral valve regurgitation or leakage, a minimally invasive repair speeds recovery. Currently, we have several minimally invasive approaches. Robotic surgery provides excellent visualization with a special 3D camera. This, coupled with specially designed instrumentation, enables us to make a very small incision and achieve an excellent valve repair.
romagjack: Can you see the heart for robotic surgery as well as if a sternotomy is performed?
Speaker_-_Dr__Gillinov: We can see the mitral valve better in many instances with the robot.
Mitral Valve surgery
rlacon: After Mitral Valve repair surgery, how is the success of the repair monitored, additional echoes? and how often?
Speaker_-_Dr__Gillinov: We recommend yearly echocardiograms.
eric2008: How do you know when you need valve surgery? The doctor said I need mitral valve surgery but I do not have any symptoms. How do they know I need surgery?
Speaker_-_Dr__Gillinov: If you have a leaking mitral valve (mitral regurgitation), surgery is indicated when 1) The leak is severe and 2) There is enlargement of the heart, reduced function of the heart, or increased blood pressure in the lungs. In many cases, people with these changes do not have symptoms, but surgery will prevent permanent heart damage. For mitral regurgitation, most operations involve minimally invasive valve repair. Repair is preferable to replacement, but requires special surgical skill.
Aortic Valve surgery
trippstreet: I had AVR at CCF - MinInv- last May - Just want Dr. Gillinov to know that all is well - Had Echo last week and E/F was 50% also Cardiologist had me take a CT and all was well with Aorta. My question is about exercise - I worry on Treadmill that I might OVER DO IT - Can you suggest any limits at this time. Your physicians, nurses, staff at CC are First Class.
Speaker_-_Dr__Gillinov: Thanks for the note. You can exercise normally--no time limit as far as your heart is concerned.
KMR: I was diagnosed with aortic regurgitation when I was 32 yrs old. I am now 44yrs old. My last echo cardiogram was last January. The doctors here have said it is mild. The last echo read mild/moderate. The cardiologist that I see claims that the change is so insignificant. She said everything is absolutely fine and she does not foresee having to need surgery in the future. she claims from my very first echo to the most recent echo the change is extremely minimal. Everything that I have read on the computer states that the nature of aortic regurgitation DOES lead to a replacement. Is there anything I can do now to either slow down the process or avoid complications to this condition? What are your thoughts and or opinions to this matter? Through your experiences what percentages of people do end up with a replacement? Or do ALL people with aortic regurgitation end up needing surgery? What tests are done to see if I would be a candidate for the less invasive surgery? I would really appreciate any information you can help me out with. Thank you so much!!.
Speaker_-_Dr__Gillinov: You should only have surgery if the regurgitation becomes severe. This may never occur. Get an echo once a year to check, and do not think about it much otherwise. Take antibiotics before dental or other procedures.
vanhootch: What determines if an bicuspid aortic valve can be repaired vs replaced, what would eliminate the possibility of minimally invasive surgery
Speaker_-_Dr__Gillinov: Repair is a good option if: 1) The valve leaks but is not stenotic, 2) The valve is not calcified, and 3) The aorta is not severely enlarged.
Speaker_-_Dr__Gillinov: Isolated repairs can be performed minimally invasively. The need for bypass grafting or treatment of an aneurysm usually leads to a standard approach.
trippstreet: What are the options after the 10. 15, years I am 65 now had AVR last May - BOVINE
Speaker_-_Dr__Gillinov: I would get an echo once a year. There is a good chance that your valve will last you for your entire life
larry: I had rheumatic fever when I was a child. Now I need an aortic valve replacement. Does the clinic offer less invasive surgery for that?
Speaker_-_Dr__Gillinov: Yes. Most aortic valve surgery can be performed minimally invasively through a very small incision. Results are excellent with this technique.
rachel: How long does a biologic valve last? I am 53 years old. I need an aortic valve replacement but I don't want to take coumadin? Do certain types of biologic valves last longer - pig, pericardial,?
Speaker_-_Dr__Gillinov: Most biologic valves last at least 10 years, and there are occasional patients in whom they last 15 to 20 years. There is controversy over the relative durabilities of porcine and bovine pericardial valves. Both work well.
vanhootch_2: My 28 yr old son has a bicuspid aortic valve which is leaking. He has been told he needs to have it replaced now. His recent echo has shown some enlarging of the heart. He doesn't want to be on coumadin, and is considering valve repair or tissue valve. Is minimally invasive a possibility for him and more important is repair a remote possibility. They have told him locally that he would need replacement. But through your website a CC a repair based on my information of his valve condition is a possibility with your advanced aortic valve work compared to here ( Appleton, WI ). I would like to hear your advise, Thank You.
Speaker_-_Dr__Gillinov: We can frequently repair bicuspid valves that leak--we review the anatomy carefully and make a determination of the best therapy. We can almost always do this minimally invasively.
eej429: Do you foresee minimally invasive aortic valve replacement in the near couple years being possible for a 55 year-old, active female who will be facing repeat surgery after a failed homograft valve replacement in 2003?
Speaker_-_Dr__Gillinov: It is possible that a percutaneous valve will be available for this problem, but that is at least a few years off. For now, we reoperate and replace the dysfunctional valve
tommy: I had an aortic valve replacement and an aorta graft due to an aortic root aneurysm. Is it possible to get another aneurysm past the graft?
Speaker_-_Dr__Gillinov: Possible but unlikely. I would get a screening CT scan to examine the rest of the aorta.
holly: If you have a minimally invasive aortic valve surgery and then need surgery again in the future, is it easier in the future? Or does it matter? Is the risk the same?
Speaker_-_Dr__Gillinov: It is a little easier to reoperate after a minimally invasive procedure.
vanhootch: If aortic valve is repaired, what is the possibility of future surgeries in a 28 yr old?
Speaker_-_Dr__Gillinov: If you have a bicuspid aortic valve (2 leaflets instead of 3), a successful repair usually lasts at least 10 years. There are some people who are more than 20 years out from a successful repair.
eej429: If my original AVR replacement is now leaking (a homograft AVR five years ago performed at a not-so-competent hospital, and I have been told I will need another AVR in the next few years, will a minimally-invasive AVR be possible (not homograft) at the Cleveland Clinic?
Speaker_-_Dr__Gillinov: The fact that you had a homograft makes the reoperation complicated, requiring particular expertise. It will require a standard sternotomy incision.
jackie6: Can minimally invasive aortic valve be done for replacement or just repair?
Speaker_-_Dr__Gillinov: With a minimally invasive approach, we can either repair or replace the aortic valve.
eej429: Is the incision (for minimally-invasive AVR) still involve cutting through the sternum?
Speaker_-_Dr__Gillinov: We cut through the upper portion of the sternum only. Leaving the lower sternum intact speeds healing.
vanhootch: If a aortic repair lasts 10 - 15 yrs as does a tissue valve, what are the benefits of one over the other
Speaker_-_Dr__Gillinov: Aortic valve repair will frequently have superior hemodynamic performance and reduced risk of infection.
eej429: If an aortic valve has moderately severe leakage, but no symptoms are experienced, approximately how long before a replacement is usually needed?
Speaker_-_Dr__Gillinov: The time line varies from person to person. I would only seek surgery if your left ventricle begins to enlarge or fail, or if you develop symptoms. You should get an echo once a year.
General Heart Valve surgery
Speaker_-_Dr__Gillinov: Currently heart valve surgery requires use of the heart lung machine, or cardiopulmonary bypass. The operations usually require about 30 to 60 minutes on the heart-lung machine. Minimally invasive surgery, which is our first choice for most patients, speeds recovery.
cinci: can you use robotic surgery to do an aortic valve replacement?
Speaker_-_Dr__Gillinov: Not with current technology. However, we can do aortic valve replacement through a 6 cm incision.
romagjack: Can several valves be repaired during one operation?
Speaker_-_Dr__Gillinov: Yes, frequently with minimally invasive techniques.
romagjack: What is the valve ring made of and is there any rejection factor from one's body?
Speaker_-_Dr__Gillinov: The annuloplasty ring is a cloth covered device that may include a metallic core. It is not rejected because it is inert.
romagjack: I am in excellent shape by swimming, working out, and biking. I have several leaky valves and recently have become short of breathe and a bit weaker. I take much longer to recover from exercise. My internist says the cardiologist need to watch closely but my cardiologist doesn't see much deterioration. If I'm going to need surgery, I would like to do it while otherwise healthy. What is your opinion?
Speaker_-_Dr__Gillinov: If you have one or more valves with severe leakage (regurgitation) and you are having symptoms, you should consider surgery earlier rather than later.
rlacon: I had a TEE in Aug 07 and was going to send it along with my medical records for the surgical consultation / appointment for MVP repair. The TEE copy I received from Hilton Head Regional MC is on a VHS tape (not on a digital CD as expected). Is the VHS tape acceptable for review? Is it too old?
Speaker_-_Dr__Gillinov: VHS tapes are acceptable, but you should have an echo done within a month of your anticipated surgery in order to provide the most up to date guidance for the surgeon in his or her discussions with you.
rlacon: Does the placement of an annuloplasty ring require Coumadin afterwards?
Speaker_-_Dr__Gillinov: We do not routinely require coumadin for an annuloplasty placement.
oggi-3: I have an atrial myxoma? What is it? I was told I need surgery - can they remove it with robotic or minimally invasive surgery?
Speaker_-_Dr__Gillinov: An atrial myxoma is a benign (non-cancerous) growth in the heart. It should be removed, as there is some risk that a piece can break off and cause a stroke. This is an ideal condition for a minimally invasive, robotic approach in experienced centers.
Percutaneous Valve procedures
ted44: Is it possible to have your valve repaired without being opened up? I read something about that somewhere. Can you tell me more about that? Can anyone do that? What if you have a leaky mitral valve?
Speaker_-_Dr__Gillinov: There are experimental trials of percutaneous (catheter-based)valve repair. In many cases, early results are promising. Today, the gold standard is a minimally invasive surgical repair, which involves a 1 to 2 inch incision and has excellent long-term durability.
rick: My grandmother is 83. She has aortic stenosis. She needs surgery but may be too high risk. Can you tell me more about transapical replacement of the aortic valve? What does that involve? Is it safer than minimally invasive surgery?
Speaker_-_Dr__Gillinov: Transapical aortic valve replacement is an experimental procedure that can be performed only within a clinical trial. It is currently reserved for high risk patients at a small number of leading centers. In most patients, a minimally invasive surgical approach is currently chosen, but the highest risk patients can be considered for the transapical approach.
Atrial Fibrillation Surgical Treatment
Phx: Is minimaze or Cox-Maze iv a viable option for A-Fib if I do not respond successfully to my radio ablation at the CC next month? What are the chances for becoming A-Fib free?
Speaker_-_Dr__Gillinov: This is a reasonable option after failed catheter ablation and has 90% success.
saturn: For the minimal invasive MASE procedure...Without stopping the heart pumping blood through the 4 pulmonary veins how can on do an accurate ablation of those four veins?
Speaker_-_Dr__Gillinov: The surgical approach involves direct, safe visualization of all 4 veins.
saturn: Can one stop taking Coumadin after a successful minimal heart ablation procedure?
Speaker_-_Dr__Gillinov: Yes, but this is controversial.
General Heart surgery
sherri: My dad had bypass surgery a year ago. He is still having trouble with his sternum. It has never healed properly. Should he go back to his surgeon? I am a little nervous for him to go back to that same surgeon. Are there minimally invasive methods to fix a sternum that is not stable - or do you need to be opened up all the way?
Speaker_-_Dr__Gillinov: Usually best if he goes back to the same surgeon, who is familiar with the case
lhamm01: I am a 46 year old woman who recently was given a pacemaker for Bradycardia, block 3. Are there any "procedures" available to correct this?
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Marc Gillinov is over. Dr. Gillinov, thank you again for taking the time to answer our questions today.
Speaker_-_Dr__Gillinov: 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).
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.