August 23, 2010
Brian Griffin, MD
in the Section of Cardiovascular Imaging in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, in the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.
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. Brian Griffin MD, a Cleveland Clinic cardiologist, provides answers to your questions about diagnosis and treatment of valve disease.
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Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Brian Griffin. We are thrilled to have him here today. Thanks for joining us Dr. Griffin, let’s begin with the questions.
Dr__Brian_Griffin: Thank you for having me. We have a lot of questions to go through so let’s start.
JanetJ: I am 78 years old. Have 3 leaks valves, Mitral is moderate regurgitation. Tricuspid and Pulmonic are mild. Ejection fraction is 60%. Aortic is sclerotic and calcified. Cardiologist says "normal" for my age. Also, early kidney disease stage 2.GFR 62. Controlled by diet so far. Normal left ventricular wall thickness. All chamber sizes are normal. Nuclear Stress test normal for my age. Question: how fast will this get worse so I need surgery or have heart attack. I am non smoker. Female. What do you recommend?
Dr__Brian_Griffin: It is difficult to determine how quickly the valves will deteriorate. They may not deteriorate significantly for many years. Careful follow up with echocardiography on a yearly basis is what I would recommend.
GeorgeG: In 2006 had a triple by-pass. Now, I have 3 leaky heart valves…what causes them? Also, if my only good valve goes south what are my chances of having a stroke…I'm an Insulin Dependent Diabetic…Have High Blood Pressure but under Medical review often..My age is 66..Thank You
Dr__Brian_Griffin: Most of our valves leak to some degree especially as we get older. Valve leak is usually only a real issue if the leakage is severe. The fact that the valves are leaking of itself might not have any real impact on your current state of health. If you are unsure of whether this is the case, you should see a specialist in valve disease
Aortic Valve Disease
Todd: Hello Dr. Griffin, I am 47 years old with Aortic stenosis. My History : 1975-Aorta Valvotomy / 2003-AVR Medtronics 23mm Mosaic . I am in need of another valve replacement very soon, my cath =0.7mm.. I am very good health and maintain a vegan diet with regular daily exercise. My question, I am currently considering the Carpentier Edwards Magna tissue valve because of my lifestyle and I do not want to take coumadin long term . I do realize with another tissue that I will need another AVR sometime again, I can only hope that if I choose a tissue that it last's me much longer. Do you think that I should give a mechanical valve more consideration?
Dr__Brian_Griffin: I would consider a mechanical valve carefully because you are likely to need multiple future valve replacements if you go with the biological valve again. I believe based on the data that the biological valve will last somewhat longer as you age. Nevertheless, you hopefully have many years ahead of you and if you stick with the biological valves, you could require many future operations. There is one bright hope in all this - and that is it may be feasible in the future to replace the leaflet component of the biological valve using a catheter rather than requiring surgery. However, this is experimental at this time.
mbt13: I was told that Cleveland Clinic is working on a technique to replace the aortic valve without clamping the aorta. This is important to me because I have been told that my aorta is severely calcified and the risk of clamping is very high. Is it also true that Cleveland Clinic is the only hospital that has the technology to perform the replacement through this method.
Dr__Brian_Griffin: We can already do this - clamping the aorta from within - during robotic surgery. This may not be the right procedure for you however. The other approach is for our surgeons to replace the ascending aorta and clamp the graft and we do that in many instances where the ascending aorta has a lot of disease or is very calcified.
gener: when a person with AI is able to slow the progression of the disease, how successful are they in the long run if they maintain their medication & exercise regimen?
Dr__Brian_Griffin: There are mixed data concerning the validity of drugs to slow the rate of progression of aortic regurgitation. Most doctors believe that they may have some mild slowing effects.
Exercise is good for the heart as long as it does not involve competition. Also - people with significant valve disease causing leakage such as AI should avoid lifting heavy weights.
Cindyguk: My 59 year old husband just had a Freestyle Aorta Root Valve with a dacron aorta graft implanted at a hospital here in Utah. We were told that because it is more than the valve that will have to be worked on when the valve wears out that it will be a much more difficult surgery with perhaps a mortality rate of about 40%. He does not have any other heart disease or any other complications at this time. If his valve starts to wear out, we plan on going to Cleveland Clinic. Do you believe the next aorta valve replacement will actually have that high a mortality rate if my husband continues to be in good health outside of that? Also, they put him on 325 mg aspirin for the rest of his life. Is that typical or do you think he can just go back to his daily 81 mg he used to take? They were really pushing the mechanical valve here and did not even discuss the biological valve with us till we asked the day before surgery. My husband is an avid skier, biker, hiker, etc. and did not want to be on coumadin the rest of his life.
Dr__Brian_Griffin: First question: Do you believe the next aorta valve replacement will actually have that high a mortality rate if my husband continues to be in good health outside of that? No - would not expect that the mortality rate would be anywhere like that. I would agree that re-operation in this situation is more complex than average.
2. Question about aspirin - There are no studies to guide us on this specific question - we tend to recommend 81 mg of aspirin unless there are some other reasons to take the bigger dose.
ehil: My husband, age 47 was a semi-pro cyclist. Last year his Dr. detected a heart murmur and sent him for an echo showing he had a BAV. He had a mildly dilated aorta - ascending aorta diameter was 3.9 cm. Trace mitral regurgitation, mild aortic stenosis with moderate aortic insufficiency. He had left ventricular enlargement with normal systolic function and severe left atrial enlargement. His heart was large at 6.7 - he was 6'1. He reported having no symptoms. He obtained 3 cardiologist opinions about whether or not he could continue his competitive cycling and he was given the ok. He had a repeat echo in March 2010 which showed no changes from the original echo in June 2009. This June after finishing a race he collapsed and died from a sudden cardiac death. He did not have an aortic dissection nor rupture. When you have a BAV are you at a greater risk than the general population for a sudden cardiac death. I was told there appears to be a short circuit which caused the cardiac arrest. Also HCM was tested and they found myocyte fibrosis but the cells were not in disarray and the echo didn't show HCM either. Are you aware of any arrhythmias due to BAV?
Dr__Brian_Griffin: I am very sorry to hear about your husband. Bicuspid aortic valve of itself does not increase the risk of rhythm disturbance to my knowledge. However if the valve is leaky or narrowed the effects on the function of the heart might eventually make it more prone to rhythm disturbance. Usually this occurs when the patient has either symptoms or obvious reduced function of the heart or in the case of AI, a very enlarged heart.
skgoldner: My 83-yr-old mother has severe aortic stenosis but is asymptomatic. Two cardiologists locally recommend waiting on surgery until she is symptomatic. What are your thoughts on this and how is a determination made on the optimal time for valve replacement? She has no other heart problems than this.
Dr__Brian_Griffin: Generally we wait until symptoms occur in this age group. There are some exceptions: if the heart function has started to decline even in the absence of symptoms we would recommend surgical replacement. Also - if the valve is critically narrowed we would recommend elective replacement in the knowledge that this would be required in the next 1 - 2 years anyway.
Michaelanthony: What is the status of the FDA trial for the Non-invasive Sapien transcatheter aortic heart valve replacement? Any idea when the procedure will likely be approved?
Dr__Brian_Griffin: Still awaiting data from the clinical trials and it is unlikely to be approved for at least a year and maybe longer.
Mitral Valve Disease
mtn57: At what stage of mitral valve regurgitation is it recommended to repair the valve rather than taking medications to try to help with the problem? I already have thickening of my left ventricle from mild-to-moderate regurgitation? Thank you!
Dr__Brian_Griffin: We only recommend mitral valve surgery when the leakage is severe. We are very careful to estimate the severity before recommending surgery. We don't recommend surgery for mild or moderate degrees of regurgitation as it may be that it will never progress.
We don't feel that the effects of mild or moderate leakage on the heart function are sufficiently severe to warrant an operation at any stage.
Judy_Z: I have been told I have mitral valve prolapse with mild to moderate regurgitation. I was told, in time I will need surgery. Is it best to have surgery as soon as possible or to wait until the valve shows more regurgitation.
Dr__Brian_Griffin: It is better to wait until the regurgitation is severe - or national guidelines only recommend surgery when the regurgitation is severe. There is no indication for prophylactic surgery in somebody like you.
We have a valve tool for mitral regurgitation - my.clevelandclinic.org/heart/mitral_regurgitation_tool.aspx
amanda: What are the chances of a healthy 39 yr old female discontinuing beta blockade after a mitral valve repair? The left atrium is just within normal limits in size and no afib has occurred.
Dr__Brian_Griffin: I see no reason why beta blockage should be discontinued but you really should discuss this with your cardiologist as there may be other reasons for you to be on beta blockade.
caheart: what are the primary indicators to determine the appropriate point in time that mitral valve prolapse should be repaired; ie, what tests should be done, and what is the are the numbers that signal action should be taken?
Dr__Brian_Griffin: The most important determinant is the severity of the leakage. After that, the reparability of the valve, and the size and function of the left ventricle, and the pulmonary pressures.
ncmom88: MVP seems to run in my family, as my older and I have both been diagnosed with it. Is there any test to determine if my children have it or are susceptible to it? Or will we only find out if they come down with symptoms?
Dr__Brian_Griffin: MVP is a genetic condition - it is autosomal dominant but with very incomplete penetration. We know that there are three separate genetic regions on different chromosomes that may be involved. It is hard to predict whether your children will have it - it is a condition that tends to get a little worse over time and even if it is not apparent now, it may become evident somewhat later. The good news is that people with MVP live as long if not longer than the rest of the population assuming they keep a close check on the degree of leakage of their valves and get surgery if this is needed.
johndillard: Mine was submitted earlier about MVP with severe Mitral Valve Regurgitation at 58 yrs old (male) with no symptoms of breathlessness, fatigue, etc. at all. Repair yet?
Dr__Brian_Griffin: If the valve is repairable and the regurgitation is truly severe then elective repair makes sense now.
anette45: I already had 7 years ago an MV Replacement and MAZE PROCEDURE but my Atrial fibrillation couldn’t be solved. I was told that I need a touch up to solve this problem, but EP worried because my mitral prosthetic valve What can I do?
Dr__Brian_Griffin: I would say that mitral valve disease tends to give rise to a very large atrium that may not go back to normal even after successful surgery. This makes any procedure on the atrial fibrillation more prone to fail. I would recommend that you speak to an electrophysiologist in a major center used to dealing with patients such as yourself.
clara: I take the CC Heart Advisor and one of their articles said that they are not waiting until the mitral valve shows symptoms or gets severe. They said the valve maybe affecting the heart. I have moderate mitral valve regurgitation. I had the aortic valve and bypass 4 years ago and 4 stents 2009 / 2010. I have some shortness of breath and slightly lightheaded at times.
Dr__Brian_Griffin: Generally, we wait for evidence of severe leakage before recommending intervention. Obviously there may be exceptions especially in somebody who has multiple heart problems that are interconnected. I would advise you to get an expert opinion.
jmine: my ejection fraction is 35% I have had coarcation of aorta, aortic valve replaced, mitral valve repaired, the aortic valve is mechanical, my chest has been opened 2 times and the coarctation they went thru my side. my mitral valve repair has caused stenosis, at 35% ef should mitral valve be replaced or can I live with my ef fraction at 35%,my symptoms aren’t to bad but would like to have more energy
Dr__Brian_Griffin: I think you need an individual evaluation probably with a stress echocardiogram to determine to what extent the mitral valve narrowing is contributing to your symptoms.
anette45: it's possible to undergone mitral valve repair in case of rheumatic heart disease? Anita c
Dr__Brian_Griffin: Yes. It is possible if the valve is narrowed and leaky at the same time, an experience surgeon may be able to open up the valve and put in a ring in place to take care of the leakage. The long term results are not as good as with mitral valve prolapse but are often very satisfactory for many years.
debne: I am a 55 year old woman in good physical condition, exercising 5 days a week. I was recently told by my cardiologist that I have mitral valve regurgitation on the moderate level. He told me that I will probably need surgery in two to three years. He suggested robotic mitral valve repair. What are the statistics for that operation? Heart surgery scares me to death.
Dr__Brian_Griffin: There is no reason to be scared to death. Valve surgery has improved incredibly over the last 20 years and the results of any of the techniques now are superb with very low risk of death or serious consequences. The major advantage of robotic repair is a smaller incision and the ability to return to full activity faster. The results of conventional mitral valve surgery are so good that we haven't been able to show a definite advantage in terms of major complications for robotic surgery as yet. Our outcomes for these procedures are located at my.clevelandclinic.org/heart/about/outcomes/default.aspx.
Daphne: My husband, age 80, has been told by cardiologist that his mitral valve is in need of repair. Echo shows it working about 40%. He had triple bypass 15 yrs ago, and also has a pacemaker. He has not been able to have angiogram yet, due to some internal bleeding that they are unable to locate. He has been off warfarin since early May and total blood count is now 11.8. The cardiologist seemed concerned that the valve could reach a point that is beyond repair. Please may I have your comments on how crucial the situation is. We know that his risks for stroke and heart attack have increased now that he no longer is taking the warfarin.
Dr__Brian_Griffin: Valve repair is the treatment of choice in somebody with coronary heart disease and severe mitral leakage. I think I would be more concerned that the heart function may deteriorate further if there is too much delay in operating on the mitral valve. This would not be good. I would be less concerned that repair itself would be impossible because of delay.
Cholesterol, Statins and Stenosis
John_A: Dr. Griffin, your CV describes a study you are conducting regarding the relationship between cholesterol lowering drugs and the progression of aortic valve stenosis. Could you share some of your theories behind the study? I am particularly interested because I have had an HDL of around 95 & an LDL in the 50s for 20+ years and yet I have calcium buildup occurring on the valve.
Dr__Brian_Griffin: We have had a couple questions related to statins and valve stenosis.
We have had an interest in trying to slow the rate of progression of aortic stenosis with medicines. As cholesterol is implicated in the progression of aortic stenosis, we thought that perhaps drugs that lower cholesterol levels and reduce LDL cholesterol might be effective in slowing the rate of stenosis progression. Animal studies suggest that high cholesterol diets produce a change in the proteins in the valve so that they take up and store calcium and in more extreme cases the valve cells develop the capacity to make cartilage and even bone! This is an active process brought about by oxidized LDL cholesterol.
Dr__Brian_Griffin: In a retrospective study we found that indeed those on lipid lowering drugs (statins) were more likely to have a slower rate of progression of aortic stenosis than those not on statin therapy even allowing for differences in their baseline risk of progression. Others reproduced this finding. The patients included in these studies were generally patients who had relatively high LDL cholesterols. Subsequently, the indications for treatment of LDL cholesterol levels have been broadened and so statin therapy is generally indicated in patients who have known vascular or coronary disease or diabetes. In a number of recent prospective studies when statin therapy was used in patients with aortic stenosis who did not require being on a statin because of a high cholesterol, no effect on progression of aortic stenosis or need for valve surgery was seen. So given these findings we would not recommend statin therapy in aortic stenosis for somebody such as yourself. Calcification may occur on valves for many reasons other than the effects of cholesterol. The aortic valve has its own capacity to repair itself but like any tissue may get somewhat scarred by wear and tear over the passage of time and calcification is often seen in areas of scar/injury. Additionally, there are factors that may affect the calcification of tissue generally - these may include genetic factors, high calcium turnover or excess or abnormal kidney function. The simple truth is that most of us will develop some calcification on our valves over time
Congenital Valve Disease
debne: What is the difference between a congenital heart valve disease and one that happens later in life or is there a difference?
Dr__Brian_Griffin: Congenital heart disease has been present since birth. Generally the effects on the heart become obvious earlier than they do with acquired disease such as degenerative conditions like calcific aortic stenosis. This usually presents in people in their 60s and 70s whereas bicuspid aortic valve stenosis, which is congenital, may be evident at a much younger age.
sdejh: My husband had a mitral valve replacement in 2000 and is now facing an aortic valve replacement. After the first surgery, I noticed personality changes and a decline in mental sharpness that has been permanent. Is this common and do I need to prepare myself for something similar to happen again?
Dr__Brian_Griffin: I would say that personality changes and decline in mental sharpness are very uncommon in my experience - I would recommend that your husband have a full neurological evaluation before considering a re-operation.
ncmom88: I plan to have nasal surgery soon to repair a deviated septum. I have been diagnosed with MVP with mitral regurgitation. Should I be prescribed a preventative dose of pre and/or post-operative antibiotics? I have no personal history of endocarditis, but am worried if having MVP makes me at risk for endocarditis.
Dr__Brian_Griffin: The recent guidelines from AHA concerning prophylaxis have dramatically reduced the need for antibiotics prior to any procedure. Unless you have had endocarditis (infection of the heart valve) or surgery on the valve in the past, antibiotic prophylaxis is not indicated - you can see the guidelines at www.americanheart.org
TedS: Recently had an Aortic Valve Replacement. During the surgery there was a "surgically created diaphragmatic hernia in the central portion of the diaphragm" which was repaired. What does this mean? Any lasting side effects? Thank you
Dr__Brian_Griffin: A diaphragmatic hernia is a small tear in the diaphragm or breathing muscle that separates the chest from the abdomen. This is easy to repair at the time of surgery and I would not anticipate any long term effects.
johnnnita: I had mitral valve repair at Cleveland Clinic in January 2007 by Gillinov. The surgery was superb. The only issue I seem to have questions about is the inconsistent readings I have with my ejection fraction. I feel great and exercise regularly. My most recent readings were taken locally (resting ech) and a month later (April) at Mayo Clinic. Mayo's was a stress echo. The resting echo reading was 57.1%; the stress was 45%. My local cardiologist recommends a Mugga test to get a more accurate reading. So, my questions are: 1. Will the mugga be useful and is it necessary? 2. Should I be concerned about the readings?
Dr__Brian_Griffin: We consider an ejection fraction of 50% or greater as normal. I am not too concerned that your ejection fraction on exercise was lower assuming that there were no other changes in the heart on exercise.
A MUGA scan might provide independent confirmation as to what your ejection fraction is but I don't think in your situation I would be concerned enough to have it done.
RossP: I had my Aortic Valve replaced with a biological device 5 months ago. your article indicated that the device would last 15 to 20 years. My questions are 1) What makes the device obsolete over the 15 - 20 year period ? and 2) What will have to happen when the device is no longer functional ? Also, since my open heart surgery I have contracted "GERD" and I have a great deal more flatulence. Is this a coincidence or are these things related? Thank you
Dr__Brian_Griffin: 1. Biological valves are made of biological tissue but are not active in the same way your own valve is. The good news about this is that our bodies don't tend to reject them. The bad news is that they lack the repair mechanisms in active tissue that can fix the wear and tear that normally occurs with the constant opening and closing of the valve. Eventually this wear and tear causes structural changes in the leaflets of the biological valve so that they either stick together (become narrow or stenotic) or develop minute holes that get bigger overtime and leak or sometimes both. 2. The valve breaks down very gradually and you should have an echocardiogram yearly and more often towards the end of life of the valve. Fortunately, it is usually apparent for a number of years that the valve is beginning to fail and elective replacement can be scheduled. 3. Not sure GERD is related to the valve surgery - the stress of the perioperativee period may increase the possibility of acidity or even of ulceration in those at risk - recommend you see a GI specialist if symptoms persist.
vak13: What surgical options for repair or replacement are available when it is too risky to open the chest? Does a concave chest in an older adult cause problems with the heart condition/health/strength? Is it possible this puts more pressure on one area of the heart and not allow proper flow
Dr__Brian_Griffin: It is sometimes possible to repair the mitral valve with a clip that is placed by a heart catheter - this is still investigational.
A concave chest (pectus excavatum) is often seen in people who have abnormalities of connective tissue and as connective tissue is what makes up valves, there is an association. Rarely is pectus excavatum so severe that it limits the space in the chest for the heart. It is actually a pretty common condition and usually fairly benign.
Robert_G: I understand that some surgeons prefer the thoracotomy approach to the mini-sternotomy approach for aortic valve replacement surgery. Can you tell me which you prefer and why?
Dr__Brian_Griffin: I am not a surgeon but I prefer a mini sternotomy for patients if that will take care of all of the heart issues that need to be operated on. Mini-sternotomy is associated with less hospital time and a nicer scar long-term. However, many patients have multiple heart problems that need to be addressed surgically and the mini-sternotomy do not allow the surgeon to get to all the areas that need to be addressed.
larryh: Why is the Ross Procedure not used in patients older than 65?
Dr__Brian_Griffin: Ross procedure (where the patient's own pulmonary valve is inserted instead of a defective aortic valve and where a human pulmonary valve is inserted at the pulmonary position) is not done in many adults anymore. It is a very complex operation that takes a long time and is therefore riskier in older patients. The main advantage of it is that in children the native pulmonary valve at the aortic position may grow as the child grows and prevents the need for multiple operations during the growth period. In adults, this is not necessary.
larryh: Can a homograft be used for aortic valve replacement and would that not require lifelong blood thinners?
Dr__Brian_Griffin: Yes a homograft can be used for aortic valve replacement and does not require blood thinner. However, it will not last a lifetime. Our most recent analysis suggests that a homograft offers little additional durability to a biological valve in most people. But, it is a more complex operation and often a more complex re-operation so we don't implant homografts now unless there are some specific indications such as infection.
rain39: I have 3 valves leaking and will need surgery sooner or later, I’m told. My choice is to come to Cleveland Clinic. I am just getting echoes now to follow the course of the disease now. Would I be better off coming to Cleveland Clinic for a more extensive work up or should I have it done here. It's not a problem to get there with my saved miles.
Dr__Brian_Griffin: It would be better to have the work up done here because we are very particular about the imaging studies that are performed and we would prefer to have those performed here.
caheart: I’ve read conflicting information regarding exercise restrictions for mitral valve prolapse with regurgitation -- what are your current recommendations and why?
Dr__Brian_Griffin: It really depends on the severity of the regurgitation. In severe regurgitation I would avoid competitive sports. In any situation you should avoid lifting heavy weights as this may make the prolapse worse.
It is a good idea to remain as fit as possible - obviously if you are getting more short of breath with exercise than in the past, this may indicate that the valve has deteriorated and you should see your cardiologist.
roar2279: Can you do a mitral valve after two stents?
Dr__Brian_Griffin: Yes - but the anti platelet agent (clopidogrel) may need to be stopped a week or two before. Depending on the type of stent, this may not be advisable in the early period after stent implantation.
tony_d: Has Cleveland Clinic ever preformed a graft repair of an ascending aortic aneurysm with the valve sparring David procedure along with a repair of the aortic valve due to a moderate insufficiency. In addition to quadruple bypass surgery? If so, what were the results? If not, can you recommend anyone in the Phila/NYC area to perform such an operation?
Dr__Brian_Griffin: I can't be certain but I am sure that we could if this was the appropriate thing to do. Our surgeons could review your records to determine the best approach for you.
Radiation Heart Disease
Beverly: I AM A 53-YEAR-OLD FEMALE. IN THE MID-80'S, I WAS DIAGNOSED WITH MILD MVP. I WAS ORIGINALLY PUT ON A BETA-BLOCKER, BUT AFTER AN ECHO WAS DONE, THE CARDIOLOGIST SAID IT WAS ALMOST UNNOTICEABLE, AND TOOK ME OFF THE BETA BLOCKER. IN JUNE OF '08, I WAS DIAGNOSED WITH CANCER OF THE TONGUE. I HAD SURGERY TWICE, THEN IN JAN. OF '09, I HAD ANOTHER SURGERY TO REMOVE A CANCEROUS LYMPH NODE IN MY NECK. I THEN TOOK 6 WEEKS OF CHEMO AND 7 WEEKS OF RADIATION. MY QUESTION IS, COULD THE CHEMO OR RADIATION HAVE AFFECTED MY HEART IN ANY WAY? ALSO, WHAT ARE THE CHANCES THAT MY MVP MAY WORSEN AS I GET OLDER?
Dr__Brian_Griffin: Yes chemo/radiation therapy can affect the heart. There are specific chemo drugs that are toxic to the heart. Usually you have to have had a lot of these drugs to affect heart function and as we know which ones are likely to be toxic, oncologists tend to restrict their use. Similarly with radiation if the heart is in the beam of the radiation, as may occur with breast cancer, long term scarring of the heart may occur. You should check with your oncologist as to what drugs were used and whether the radiation could have interfered with your heart function.
Dr__Brian_Griffin: MVP does tend to get a little worse as we get older. Fortunately women are somewhat protected and are much less likely to progress than men. I would recommend you have a yearly echocardiogram to follow the MVP.
Cleveland_Clinic_Host: I'm sorry to say that our time with Brian Griffin MD, is now over. We didn't get a chance to get every question, but did cover a lot. If you have a question on other medical concerns not related to this condition, please follow-up with your personal health care provider or use our contact link clevelandclinic.org/webcontact to submit your questions.
Cleveland_Clinic_Host: Thank you again Dr. Griffin for taking the time to answer our questions about Valve Disease.
Dr__Brian_Griffin: We had a lot of great questions today. I see we will need to schedule another chat! Thank you for having me today. The transcript will be posted on our site next week.
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