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Valve Disease - Dr. Thomas

Tuesday, August 4, 2009 - Noon
James Thomas, MD

James Thomas, MD
Section Head, Cardiovascular Imaging, Staff Cardiologist, Cleveland Clinic Robert and Suzanne Tomsich Department of Cardiovascular Medicine

Description

There are many types of valve disease. Valve disease can be congenital or may be acquired later in life. Left untreated, heart valve disease can reduce the quality of life and become life-threatening. Cleveland Clinic is one of the largest centers in the country for the diagnosis and treatment of heart valve disease and it is the largest surgical valve practice in the United States. Dr. Thomas, a Cleveland Clinic cardiologist and Section Head of Cardiovascular Imaging provides answers to your questions about diagnosis and treatment of valve disease.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with James Thomas, MD a Cleveland Clinic staff cardiologist who will answer your questions about valve disease. Welcome Dr. Thomas and thank you for being here with us today.

Speaker_-_Dr__James_Thomas: Thank you for having me today.


Mitral Valve Disease

simfarm4: My mitral valve leak is a 2+ to 3+ and I am still asymptomatic. I have MVP with MVR since I was 11 - I am now 48. What is your opinion on asymptomatic repair?

Speaker_-_Dr__James_Thomas: As a general rule, moderate asymptomatic mitral regurgitation does not require surgical repair. The key question is whether the assessment of the severity of the regurgitation is accurate and whether it changes under any circumstances. We have found that exercise echo is an excellent way of assessing mitral regurgitation. Sometimes the regurgitation will get much more severe during exercise and lead to early breathlessness, whereas other times it provides a great deal of reassurance that the regurgitation truly is causing no problems at all. I would suggest that you get a comprehensive clinical examination, including a quantitative echocardiogram before and after maximal exercise to determine where on this spectrum your disease lies.

shones: Can a native parachute mitral valve be repaired when the posterior leaflet is significantly calcified or must it be replaced?

Speaker_-_Dr__James_Thomas: The presence of a parachute mitral valve in and of itself is a difficult valve to repair and the presence of significant calcification in the posterior leaflet does, indeed, make repair even less likely. That being said, I have been very impressed at the ability of our surgeons at Cleveland Clinic to repair valves that few thought could be repaired. It often comes down to the details of just where the calcium lies and what the mechanism of the regurgitation is and often the decision cannot be made until the patient is in the operating room. I would certainly urge you to obtain a comprehensive assessment of your valve and speak with a surgeon who has had extensive experience in the repair of all sorts of mitral valve pathologies, including parachute mitral valve.

shones: I am 28 and recently had my mitral valve replace with a Medtronic bioprosthetic valve. However, the surgeon occluded my Circumflex artery with at least one suture. This was not discovered until 5 days later at which time a cath was done and the circumflex was stented. My question is how will this affect the life of the new valve and do I have anything to worry about?

Speaker_-_Dr__James_Thomas: The occluded circumflex artery should not directly impact the performance or lifespan of your new bioprosthetic valve.

las33469: Dr. Thomas - I have had a myectomy and resection of a tethered chordae tendineae. Preop, I had trace MR and fortunately my valve did not require replacement. Post op, I have 2+ MR and am 15 months out. Can I expect the MR to remain fairly constant, or is it possible that the valve will fail eventually due to the resection?

Speaker_-_Dr__James_Thomas: This is a tough question. If it has been stable at 2+ since surgery I would hope that it may stay at this level, though it is possible that it may increase over time. Again, close clinical follow up with echo is the best way to ascertain this.

joanfmd: I have recently (4 months ago) been diagnosed with Mitral Valve Regurgitation. I also have Bilateral Internal carotid artery Fibromuscular Dysplasia. In light of those two diagnoses, is there anything specific I should be doing? Sorry, my question was not complete before it sent. I just asked about Mitral Valve Regurgitation and FMD. I am currently taking Lipitor, Lisinopril and Atenolol. Thank you.

Speaker_-_Dr__James_Thomas: The key question here is the severity of the mitral regurgitation, which should be analyzed by a quantitative echo - preferably before and after exercise. If you are not having any symptoms from your MR, there is probably no intervention that needs to be done at this time, but you must be seen by an experienced valve cardiologist.

a_dress: I was diagnosed with mitral valve prolapse at age 14 (now 32) and have had that diagnosis confirmed by several cardiologist since. Recently I went to a new cardiologist and he said I do not have prolapse but do have Regurgitation. Is it possible my prolapse went away? At what point is surgery usually needed for regurgitation?

Speaker_-_Dr__James_Thomas: Our criteria for diagnosing mitral valve prolapse has changed over the years, so it is possibly by contemporary standards, you do not meet the formal definition of MVP. However, it is the degree of mitral regurgitation that is most important and depending on the severity of this, you may or may not need an intervention on your valve.

Flower: I am a 42 yo with moderate-severe MR due to having had an ostium primum ASD repair at age 7. I would like to know: How does Cleveland Clinic rate in congenital mitral repair, and where does one research such specific surgical stats? Also, is there a way to definitively tell prior to surgery if a valve can be repaired, or is it always "wait and see" in the OR?

Speaker_-_Dr__James_Thomas: I would presume that you have a cleft anterior mitral leaflet, which often can be repaired by suturing the cleft closed. However, there often are abnormal chordal attachments to the mitral valve that may make repair impossible. We can usually assess reparability with a fair degree of confidence prior to surgery, but it will always depend on what the surgeon finds when he looks at your valve. We have a great deal of experience at repairing such valves at the Cleveland Clinic our surgeons have the capability to repair anything that can be repaired and importantly, know when replacement is the best option.

Flower: As some one who is waiting for MR repair or replacement in the not too distant future, can you tell me what to expect afterward? Do most patients go back to feeling their normal selves? Curious, since I am asymptomatic so far. Thank you!

Speaker_-_Dr__James_Thomas: As you know, there is no such thing as minor open heart surgery and you should expect 4 to 6 weeks before you really start feeling your usual degree of energy. It may be that you will even feel better than you do now, as symptoms are often very subtle. There is always some risk of complications following surgery, such as fluid accumulation and infection, but most patients have a fairly smooth recovery.

suzieq216: Here is my question: I have mitral valve prolapse with moderate to severe leakage for the past few years...the last echo shows that the leak is now severe. My cardiologist feels I can still wait since I do not have symptoms of any kind and the size of my heart hasn't enlarged...Does all this sound like I could still wait to have the valve repaired or replaced?

Speaker_-_Dr__James_Thomas: Most asymptomatic patients can afford to wait on surgery, but if there is atrial fibrillation, elevated pulmonary pressures or any signs of left ventricular dysfunction, surgery should be undertaken sooner rather than later. We have found that quantitative echocardiography before and after exercise is one of the best ways to make decisions about timing of surgery.

Understand that even severe regurgitation can have degrees of severity and it is important to quantitate how severe the regurgitation it is and what impact it is having on your heart. We would be delighted to arrange this for you at the Cleveland Clinic.

bigemm: can you tell me what + 2 mitral valve regurgitation is?

Speaker_-_Dr__James_Thomas: Cardiologists generally grade regurgitation on a 4 point scale. 2+ means that this would be in the moderate range of regurgitation. It is also possible to quantify the size of the regurgitant orifice in the valve (the "hole") and this is often more helpful than the qualitative 1 - 4+ grading.

mruhana: My mom is 78 and has had 2 mitral valve replacements. One of the first in the country at age 42. The valve is leaking and current cardiologist will not replace due to scar tissue. Her arteries are as clean as bellows and she is otherwise healthy. What do you suggest?

Speaker_-_Dr__James_Thomas: We would be happy to offer a second opinion to your mom. We have certainly operated on situations like you have described and I am confident that we can find a way to get into the heart to replace the valve, even if scar tissue limits some of the approaches. Please call to arrange follow up.

Flower: Thank you for your reply re: congenital MV repair. I do have a cleft anterior mitral leaflet, and "aberrant chordae." Is there no way to fix these? Why?

Speaker_-_Dr__James_Thomas: It is all in the details of the chordal attachments. Many times these can be repaired, but I had a patient a few months ago in whom there were so many abnormal attachments that a successful repair would have been impossible and replacement was the better option. Yours may well be repairable, but I would need to look at an echocardiogram to have a better idea.

smithvolt3: I have had my Mitral valve repaired twice and my Aortic valve replaced in 2004. What is the life expectancy normally on this time of heart repair? They were done by Dr. Cosgrove at CCF.

Speaker_-_Dr__James_Thomas: There are some details missing from your question, such as your age, and the type of aortic valve you had placed. Typically the bioprosthetic valves will last between 10-15 years, whereas the mechanical valves may last a lifetime if they don’t have complications such as blood clots or infection.In general, mitral valve repairs are quite long-lasting, although the fact that you had to have yours redone would certainly indicate that the tissue may be fragile enough that a redo repair or replacement would be required at some time.

The key to really answering your question is a comprehensive physical exam and quantitative echocardiogram, perhaps before and after exercise. If you would like, we would be delighted to arrange a visit for you in the Valve Center at the Cleveland Clinic Heart and Vascular Institute.

fevvay57: I HAVE A MITRAL VALVE PROLAPSE, THAT REALLY HASN'T CAUSED ME MANY PROBLEMS SO FAR; I JUST HAVE TO TAKE ANTIBIOTICS BEFORE INVASIVE PROCEDURES, OR DENTAL WORK, AND SOMETIMES I HAVE SOMETHING CLOSE TO "PANIC ATTACKS", ESPECIALLY IF I'VE OVERDONE THE CAFFENE, OR IF I TAKE MEDS SUCH AS DECONGESTANTS(I ALSO HAVE HIGH BLOOD PRESSURE). I AM SUPPOSED TO START CHEMO ON AUG. 4, THE DAY THIS CHAT IS ONLINE. ALSO, I WILL BEGIN RADIATION SOON. COULD THAT BE A PROBLEM WITH THE MITRAL VALVE PROLAPSE?

Speaker_-_Dr__James_Thomas: In the absence of significant mitral regurgitation, mitral valve prolapse generally does not cause a great deal of problems for the patient. You have already discovered that excessive intake of caffeine and decongestants can lead to palpitations, so I would urge you to avoid these. The need for chemotherapy and radiation is unlikely to directly impact the mitral valve prolapse, at least in the short run. Certain types of chemotherapy can cause a reduction in the pumping ability of the heart, and your doctors will likely obtain echocardiograms to assess your heart function as you go through chemo. Radiation that directly intersects the heart can produce scarring and fibrosis several decades down the road, but radiation therapists are much more aware of this now than they were in the past so they usually can block off the heart from receiving significant doses of radiation. The best way to assess your mitral valve disease would be with a quantitative echocardiogram, likely before and after exercise and we would be delighted to arrange this at Cleveland Clinic if you would like to have that done.

roullac: Dr Thomas I am an asymptomatic female and in October 2008 I was diagnosed (in England) with moderate to severe (grade 3/5) valve regurgitation of the mitral valve due to prolapse and since then I was followed up every 6 months. During my most recent evaluation in January 2009 I was told that the regurgitation was still the same but my ejection fraction was 61% and the left atrium was mildly enlarged to 4.5.

Speaker_-_Dr__James_Thomas: It sounds like you are beginning to see some enlargement of your atrium from the regurgitation, but by itself, this does not necessarily mean surgery is needed. I would suggest you have a quantitative echocardiogram before and after exercise and a clinical evaluation which we would be happy to schedule for you.


Aortic Valve Disease

jan6649: My 62 yr old husband as a bicuspid valve and an aortic aneurysm. He is to have both repaired as soon as we can get it scheduled. How long will he be in surgery and what can I expect after he's out of surgery?

Speaker_-_Dr__James_Thomas: The actual replacement of the aortic valve and the aorta can go surprisingly fast, often less than 1 hour. However, the process of opening and closing the chest and all the other monitoring procedures that go on in surgery will likely make the whole operation last 4 hours or so. Recovery typically is 1 or 2 days in the ICU, followed by 4 or 5 days on a regular nursing floor with a gradual return to full activity over about 6 weeks.

lynnlim: my husband was born with bicuspid aortic valve. this was repaired at age 3 then replaced at age 13 with a prosthetic. he now has the same valve at 50 years old. currently followed at CCF. my husband also has a v-tach condition that cropped up the past two years as well as hypothyroidism and now adult asthma. Other than that he is doing very well. I have heard that bicuspid valve is sometimes related to other connective tissue disorders. could you explain if this is true and give some examples. an explanation of bicuspid aortic valve and its related disorders in brief would likely be helpful to others as well. my husband’s valve is a borjk-schiley tilting disk and has been good for 36 years. it was implanted at Erie Hamot hospital. thank you for your time.

Speaker_-_Dr__James_Thomas: Bicuspid aortic valve is often associated with other abnormalities in the aorta, such as aortic coarctation and some weakness in the aortic tissue, making it prone to aneurysm formation. Your husband seems to have done very well with his bjork-shiley valve, showing that while there are complications to mechanical heart valves and the blood thinning they require, a number of patients may go a lifetime with a single valve replacement. My only concern would be to make sure his "asthma" is not actually symptoms of congestive heart failure, but I am confident you are being well followed at the Cleveland Clinic.

lynnlim: dr thomas- (yes, his "asthma" was checked out just weeks ago by stress echo by dr stewart. valve is a-ok) thank you, and thank god for CCF. when my husband had breathing symptoms we knew to call CCF and CCF scheduled him immediately to check him. we deeply appreciate the skill and dedication of CCF and staff. )

Speaker_-_Dr__James_Thomas: Thank you for these kind words. I am glad to hear the valve is still doing fine.

wmurray8: I have undergone 3 AVRs. The last in 1998 with an Edwards bio-prosthetic valve. What is the life expectancy of the valve and does scar tissue preclude a 4th valve replacement?

Speaker_-_Dr__James_Thomas: As I understand it, you have an 11 year-old Carpentier-Edwards bioprosthetic valve, made with the pericardial lining of a cow’s heart. The typical life expectancy of such valves is in the 12-15 year range, but this varies widely, being shorter in very active young people and somewhat longer in more sedentary elderly patients. I have had some patients who have had these valves in for 20 years before they have deteriorated significantly. The key to your situation would be to obtain a quantitative echocardiogram to assess both the obstruction and leakage of this valve. Certainly as a general rule you would not be precluded from a fourth valve replacement, although that determination would have to be on the basis of other conditions, such age, kidney disease, lung disease, and vascular disease. If you would like to have your situation reviewed in a comprehensive fashion, we would be delighted to see you in the Valve Center at Cleveland Clinic.

Bungle75_2: Can a leaky aortic valve with stenosis cause chest tightness and fairly constant chest discomfort and pain? I was thoroughly worked up last year at CC and was assured the pain/discomfort was not coming from my heart. I am not convinced.

Speaker_-_Dr__James_Thomas: As a general rule, the sort of pain that comes from the heart is typically episodic, often related to exercise or anxiety, and is not constant in nature. Similarly, leaky or stenotic aortic valves typically do not cause constant chest discomfort that is more related to exertional shortness of breath and sometimes exertional chest pain.

It is also important to understand just how severe the leakage or stenosis is, as mild disease would not be expected to cause any symptoms whatsoever. Given that you have continuing symptoms, I would suggest you get back in touch with your cardiologist at Cleveland Clinic and ask for a repeat evaluation to see if there hasn’t been any progression in your aortic valve disease over the past year.

njsp996: From njsp996 I am a white male age 82 with a moderate aortic insufficiency .The last echo revealed the following; left atrium 3.70 diastolic diameter 4.32 systolic diameter 2.93 sepal thickness 1.14 left ventricular ejection is 55%. njsp 996 added when do you think the aortic valve should be replaced or is it a wait and see?

Speaker_-_Dr__James_Thomas: Thanks for giving me some numbers here! Unless you are having symptoms that can be connected to the aortic insufficiency (which I would doubt based on these numbers), I would think this is a wait and see situation. It may never progress to the point of needing surgery, but needs to be followed at least annually with a quantitative echocardiogram.

pbelloff: I have been diagnosed with aortic stenosis-.9 narrowing. Is there any protocol to slow progression? Currently taking 80mg Diovan, 10 mg Lipitor, baby aspirin and walking for exercise.

Speaker_-_Dr__James_Thomas: There are no good protocols to prevent progression of aortic stenosis, and with a valve area of 0.9, I would anticipate yours will progress to needing surgery some time in the not too distant future. There have been some inconclusive studies involving the use of cholesterol reducing statin medication, but no definitive proof that they reduce progression of aortic stenosis. I would simply maintain an optimal cholesterol level and carefully control your blood pressure and maintain close follow-up with your cardiologist. When the time for surgery comes, you should be sure to use a very experienced surgeon in a high volume center.

ejordan1963: my son, now 18 years old, was born with BAV, with stenosis. Up until last September it was thought he would not need surgery to replace his valve until he was in his 30's or 40's. However this last September an aneurysm was found in his ascending aorta. It's 4.5cm. It has been re-checked this past spring, still the same. He is due back over Christmas break for another check. He is a candidate for the Ross Procedure, at which the same time they would replace the ascending aorta too. Have thought about coming to Cleveland for another opinion as far as treatment, etc... for this. He is on a blood pressure pill to slow the progression. In your opinion how long could his aneurysm stay at 4.5 and not need surgery. Do these things progress quickly, or can they stay the same for a long time. He is just going to be starting his Freshman year in college in a few weeks.

Speaker_-_Dr__James_Thomas: You describe a fairly common situation, in which patients with bicuspid aortic valve also have an associated aortic dilation. Although initially most parents and patients anticipate that it will be the valve itself that will dictate when they go to surgery, we find that it is often the aorta that first dictates the timing of intervention. I cannot predict the time course of aortic dilation, but given a size of 4.0 cm, he certainly requires very close follow-up in this. We have a number of physicians and surgeons at Cleveland Clinic that have extensive expertise in just this sort of situation and would be delighted to arrange a visit for your son. One of our surgeons in particular, Dr. Pettersson, has an active interest and a great deal of expertise in the Ross procedure and would be able to advise you as to whether it is the best sort of operation for your son or not. I would strongly urge you to get an assessment and at very experienced Valve Center.

pgbrady_2: I am a 68 year old male with moderate/severe AI. I have been told I will probably require AVR in the next year. Other than Dish Arthritis I am in good health. 3 months ago I had a prostatectomy using the deVinci S. I am now a "fan" of minimally invasive surgery. Is it possible to have a minimally invasive procedure for AVR?

Speaker_-_Dr__James_Thomas: At this time, the robotic approach is being used for mitral but not aortic valve surgery, although this may change in the future. If it is just the aortic valve that needs to be addressed, this can often be performed through a 3 inch incision in the chest, which heals similar to the robotic approach.


Diagnostic Tests for Valve Disease

kevin007: Good morning my major is biomedical engineering and I would like to know about the valve disease. what kind of machines do you use to detect that. are you working on building new imaging devices to be more efficient with that disease?

Speaker_-_Dr__James_Thomas: WE use imaging extensively in valvular heart disease, most commonly echocardiography. Additionally, we may use MRI or CT scans to address specific questions. One of the recent advances we have participated in is called Three dimensional echocardiography, which can improve the visualization of the valve pathology in question. This will undoubtedly get better in the future as computer processing speed increases.


Symptoms of Heart Valve Disease

roxann: what is the symptoms of heart disease?

Speaker_-_Dr__James_Thomas: This is only a fragment of a question, but I presume you’re asking about the symptoms of heart disease. Most commonly these are symptoms of chest discomfort or shortness of breath, which most commonly arises on exercise or with anxiety. Certain types of heart disease can produce more constant pain, such as pericarditis or severe shortness of breath in the case of congestive heart failure.

kim: Question: Mitral Valve Regurgitation and C.A.D.: Periodically, awake in the early morning hours(5:00a.m.), you’re nauseous, what seems to be fatigue or very tired, sleep most of the day, difficulty staying awake(like your exhausted) until late into the evening. Would these symptoms be related to Valvular disease or CAD?

Speaker_-_Dr__James_Thomas: It is difficult to say what is causing this but I would be concerned that you have sleep apnea that is preventing you from getting a good night's sleep. Valve disease and CAD typically cause chest discomfort or shortness of breath when you exert yourself but can occasionally present with generalized fatigue as you are describing. A formal sleep study may help diagnose sleep apnea.


Exercise and Valve Disease

rich: About a year and a half ago, I developed Viridans Streptococcus which caused endocarditis which resulted in aortic heart valve replacement surgery. My aortic valve has been replaced with a Carpentier-Edwards Perimount Magna Model 3000 tissue (cow) valve. I’m 50 years old. Prior to the surgery, I was an avid bicycle rider. When riding my bicycle on rides of up to 100 miles, my heart rate would steadily reach 150 bpm and spike to as high as 190 bpm. After the surgery, my doctor told me that my heart was in great shape and the new heart valve should last about 10 years. What he couldn’t tell me is the effect of hard exercise on the replacement valve. I’d like to return to my exercise regime but need to know whether hard exercise and the resulting increased heart rate will cause the valve to wear out faster or cause it to tear.

Speaker_-_Dr__James_Thomas: It is likely that very vigorous exercise and tachycardia may lead to a somewhat shortened valve lifespan, although I don't know that this has ever been proven. This should be balanced about the obvious benefits of your exercise program which may well outweigh any slight reduction in the valve longevity.

clara: I have a Mosaic Porcine Heart Valve. I heard different theories about how long they can last. Could you tell me the average amount of years that they hold up. I do a lot of working out in a gym. Does it matter how active one becomes.

Speaker_-_Dr__James_Thomas: As noted above, younger more active people tend to wear out biological valves faster than older more sedentary people. I would hope you could get at least 10 years out of the Mosaic Heart Valve but this must be monitored through echocardiography and physical exam.

Flower: Can you tell me what whether excessive exercise can put too much stress on a leaky mitral valve if it is already 2+ to 3+? I am on lisinopril to lower my BP, and wonder if exercise could be detrimental in anyway. One primary MD told me to be careful about raising my heart rate too high.

Speaker_-_Dr__James_Thomas: In general exercise is always a good thing. I tell my patients to avoid heavy isometric exercise, such as extreme weight lifting, but that aerobic exercise is fine. However, given that the mitral valve tissue may be somewhat "stretchier" , it is conceivable that intense long term exercise could place slightly more strain on the valve than otherwise. However, I suspect that the beneficial aspects of exercise will outweigh this. It is probably prudent to keep your heart rate at a moderately high rate (maybe 150 or less?), though there is no proof of this one way or another.


Percutaneous Valves

roullac: Dr Thomas what is your view on the new treatment for Mitral Valve Repair for regurgitation? I am referring to the Percutaneous Evalve Mitral Clip repair. Do you regard this as being an alternative treatment to valve repair for non high risk patients instead of having to undergo heart surgery? Do you consider it to be a long term solution either now or in the foreseeable future?

Speaker_-_Dr__James_Thomas: Percutaneous mitral valve repair is still highly experimental and is suitable for only a few patients that fit the specific trials that are being done with this valve. It does not have FDA approval and is not likely to for several more years at least.

Roullac: Dr Thomas how to you compare the risks for the Percutaneous treatment versus the risks for Robotic Mitral valve repair and do you consider it likely that a second procedure will be necessary using the Percutaneous treatment in years to come?

Speaker_-_Dr__James_Thomas: Robotic and minimally invasive mitral valve repair are a much more established and are available routinely for appropriate patients today. Before a determination can be made for possible enrollment in a percutaneous trial, you would need a comprehensive evaluation at the Cleveland Clinic including a quantitative echocardiogram. We would be delighted to arrange this for you.


Innovations in Valve Disease Therapy

Cleveland_Clinic_Host: Can you tell us about any of the new innovations in care of patients with heart valve disease?

Speaker_-_Dr__James_Thomas: This is a very exciting time in valve disease when we are seeing dramatic advances in surgical technique as well as new percutaneous approaches to aortic stenosis and mitral regurgitation. We have been heavily involved in trials for both of these percutaneous treatments and look forward to having them more readily available over the next few years.

Robotic approaches to surgery have now progressed to the point that many complicated repairs can be undertaken with confidence.


Aorta Disease

bpapadopoulos: I am 29 yr old female, 2 time AVR, and recently was told I had aortic dilatation. Echo showed size 4.2. I had a TEE which showed size to be 4.4, I have a CT Scan scheduled for 7/31. I am 5'1 and weigh 115 pounds. My blood pressure usually runs 90/60. I was wondering at what point do we worry about correcting the problem. Am I at risk for rupture?

Speaker_-_Dr__James_Thomas: Your clinical situation is quite complex and likely cannot be reduced to a simple answer. In general, patients with aortic dilation greater than 5 cm should be considered for surgical repair. However, you are a quite small woman, and so an aortic diameter of 4.4 cm may well be enlarged enough for your body size to consider intervention. Balancing this out, somewhat, is the fact that simply because you have had prior open heart surgery, there is some scar tissue around the aorta that may be somewhat protective against a catastrophic rupture. I would suggest you get a comprehensive evaluation from both a cardiologist and cardiac surgeon experienced in aortic aneurysms following open heart surgery. We would be delighted to arrange such an appointment for you at Cleveland Clinic.


Coronary Artery Disease

sunny: Hello Dr Thomas, I had a severe heart attack (MCI) at the age of 30. I am 35 now. I had ballooning done & a cypher drug eluted was inserted in the RCA. I never complained for anything & am still very active. Brisk walk 5 times a week & does weight training. But after 3 yrs I had 3 more cyphers inserted in my LAD. In total I have 4. I am getting missing heart beats lately, What should I do?? I am taking all prescribed drugs including Plavix & Lipitor. Thank you

Speaker_-_Dr__James_Thomas: Your question is a bit outside my focused expertise in valvular heart disease, but it is clear that you have had very premature atherosclerosis and the key to successfully treating this is to be very vigilant in your prevention of progressive atherosclerosis. We have a dedicated clinic in the Heart and Vascular Institute specifically to address preventive cardiology issues, and we would be delighted to arrange a visit for you with them. You clearly are very motivated to treat your disease, and they may have some novel therapies that would be available for you.

sunny: I have one 5 yr old cypher drug eluted stent in RCA & three 2 yrs old cypher drug eluted stents in LAD. Do I need to get myself checked or any other suggestion to find out if everything is working fine?

Speaker_-_Dr__James_Thomas: Anyone who has had coronary stents placed needs to have regular follow-up with a cardiologist to assure that cholesterol, blood pressure, blood sugar, and weight are all well controlled. You also need to be vigilant for any return of exertional chest pain or shortness of breath symptoms as this would require more intensive investigation. This area is a bit outside my expertise in valvular heart disease, but we would be delighted to arrange follow-up for you with one of our interventional cardiologists or in the Preventive Cardiology Center.


Supplements and Valve Disease

factotum: I have a bicuspid aortic valve, am 67 years old, and have been told by my cardiologist that a valve replacement down the road is highly likely. I have searched the medical literature for ways to reduce stenosis of the aortic valve, and so far two supplements stand out due to their having demonstrated potential in animal studies: menaquinone-7 and resveratrol. I now take about 200mg Menaquinone-7 daily and will start taking 500mg resveratrol next week when it arrives. Please comment on your assessment of the up and down side of such supplements (or others) for a bicuspid aortic valve owner. My goal is to defer need for surgery. By the way, I am athletically active, having participated for over 20 years in an 8 mile footrace and sprint triathlons.

Speaker_-_Dr__James_Thomas: In some early animal studies, Resveratrol has been shown to reduce the thickening of the heart muscle in the presence of pressure overload, such as what happens in aortic stenosis. To the best of my knowledge, it does not have any direct impact on progression of the valve disease, per se’, and none of the studies have been replicated in humans.

Similarly, there is antidotal evidence that Menaquinone 7 may have some impact on deposition of calcium in the blood vessels, but no study has ever demonstrated any impact in aortic stenosis. These would both be considered very unconventional therapies without proven benefit and would be no substitute for careful follow-up with your cardiologist, including quantitative echocardiography. The good news is that although it is no fun to have heart disease, you have chosen a very good one to have, as we have very good options for aortic valve replacement these days and the surgery has become safer over the years, when performed at high volume centers.


Heart Failure

SOLSON8: Hi my 25 year old has chf and has developed fluid has had two have thoracoscopy done twice first time they put doxycline in and he had recurring fluid two weeks later and was back in the hospital they did a chest tube again and this time they put talc in so I guess I'm asking if this is going/g to fix the fluid problem for good.

Speaker_-_Dr__James_Thomas: The situation you describe is obviously very complex on multiple dimensions. While the installation of talc into what I presume is a pleural effusion is often effective at reducing re-accumulation of fluid, I certainly can’t guarantee that it will fix the fluid problem for good. More importantly is what is causing the fluid, which I presume is very poor pumping function of the heart. This patient should be under the care of a very experienced heart failure physician, so that all therapeutic options are available. If you do not already have a fully qualified heart failure cardiologist following your son or daughter, we would be delighted to put them in touch with our heart failure specialists at Cleveland Clinic.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Thomas is now over. Thank you again Dr. Thomas for taking the time to answer our questions about valve disease today.

Speaker_-_Dr__James_Thomas: Thank you for having me today.

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

Reviewed: 08/09


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