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Ask the Heart Surgeon (Dr Soltesz&Dr Johnston 2 7 11)

Monday, February 7, 2011

Douglas Johnston, MD
Surgeon, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Miller Family Heart &
Vascular Institute

Edward Soltesz, MD
Surgeon, Department of Thoracic and Cardiovascular Surgery,Cleveland Clinic Miller Family Heart & Vascular Institute

Description

As one of the largest, most experienced cardiac and thoracic surgery groups in the world; our surgeons offer virtually every type of cardiac surgery. We specialize in very complex cases as well as groundbreaking surgeries procedures, such as minimally invasive and robotically assisted cardiac surgery. Take advantage of this rare opportunity to chat live with two heart surgeons in a secure online setting.

More Information

Note: During this webchat, Dr. Johnston and Dr. Soltesz ran out of time. However, they answered more than one hundred questions offline and those answers have been included below.

Cleveland_Clinic_Host: Welcome to our "Ask the Heart Surgeon" online health chat with Douglas Johnston, MD and Edward Soltesz, MD, MPH. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us Dr. Johnston and Dr. Soltesz, let's begin with the questions.


Coronary Artery Bypass Surgery

James: I am a 64 year old white male (6'2" -220 LBS) and I was wondering if I would be a candidate of bypass surgery. I have one artery that is giving me problems since last April when I had 2 stents in a calcified RCA artery and then 2 more on 9/21/10 and 3 more on 1/10/11. The last three were inserted inside the other stents. My symptoms are a slight feeling of a lump in my throat area so I can tell that I am re-occluding as the feeling gets worse as the artery closes up. My doctor said that if it closes up again that I might need a small incision type of bypass surgery for this artery. The new stents are Xience-V and they changed me from plavix to Efient. I think I am having that slight throat lump now 20 days after the stents. It's very slight. Can I do anything to keep this artery open or does it sound like this artery is to far gone. Any advice? When I exercise and don't warm up the throat tells me that blood is trying to get thru a smaller hole until the artery dilates and after a while exercising the throat lump will go away. Does this make sense as the stent is not expanding its fixed steel? Can you advise me based on other cases similar to mine? Thank You

Dr_Douglas_Johnston: It sounds like your situation requires an evaluation by a cardiac surgeon. The most important thing would be to take a look at your catheterization films and have a thorough evaluation - that will make the decision regarding surgery.

RonL: what is the less invasive bypass surgery available anything with laser or robotic, can you provide more information for someone who is considering bypass but without being too invasive and who would be a candidate for this type of surgery and can I have this at other hospitals outside of the Cleveland clinic areas

Dr_Douglas_Johnston: There are certain people with certain coronary anatomies that are able to have minimally invasive surgery and in certain cases robotic bypass surgery can be performed. What is most important is to get the best operation to fix the coronary problem - our approach is to think about this first and then to tailor the operation to the specific patient.

Peppy: Do women have more strokes after bypass surgery? If so, why is this?

Dr_Edward_Soltesz: Some studies have shown that is the case - although others have shown that finding to not be correct. We don't really know the answer to that although we think there is no difference.  Over the past 5 - 10 years the risk of stroke during bypass surgery has gone down considerably and is at an extremely low level now.

flrp: I had double bypass surgery 11 years ago and last year it was discovered I needed by mitral valve repaired. During that analysis they discovered there was an artery that was estimated to be 50% blocked. However two different surgeons determined that it wasn't necessary to take any action on that blockage at the time my deVinci mitral valve repair. The question is when I need that artery repaired is the deVinci surgery method a candidate for that type of repair?

Dr_Edward_Soltesz: We would typically recommend bypassing most blockages that are 50% or more in severity.  Unfortunately, re-operative heart surgery can only rarely be accomplished with robotic assistance.  The thick scar tissue had formed around the heart from previous surgeries precludes the use of the robot.

hardymichalski: I'm an otherwise healthy and strong 70 yr old male, had a 4 graft bypass three years ago and 3 grafts are already closed again. I have small arteries (I'm 5'5") and my doctor feels that another bypass is impractical due to diffuse disease. I'm treated with drugs and at this time have no pain and feel fine. Is this the end of the line for me or is there a procedure that we have not heard of that could reopen arteries? Thanks for any info.

Dr_Edward_Soltesz: Reoperative coronary artery bypass surgery can be significantly beneficial for many patients.  Unfortunately, it is difficult to know the exact status of your coronary arteries without actually viewing the coronary angiogram and carefully reviewing your history.  Currently, there is no new procedure available that can reopen grafts that have become completely occluded.

joelhersh: to clarify, I was told that 10 years post-bypass, 10-20% of bypass patients require additional surgery. but what kinds of patients are they talking about? thanks for letting me clarify. I hope my bypass lasts a lot longer. all my lab results are optimum. I’m at optimum weight, exercise, eat properly, etc., etc. thanks!

Dr_Edward_Soltesz: The longevity of coronary artery bypasses depend on a number of factors, including the type of bypass used (vein or artery), the quality of the coronary arteries being bypassed, modifiable risk factors (e.g., smoking, weight, cholesterol, exercise), and inherent genetic tendencies. Overall, bypasses using arteries (and specifically, the internal thoracic arteries) function longer than those that use veins. The left internal thoracic artery bypass to the left anterior descending artery (LAD) has an 88% 15 year patency, while a vein bypass has a 32% 15 year patency.

UneElle: Can you speak to the statistics and redo prognosis of off-pump vs. traditional CABG surgery? My husband had off-pump quadruple bypass in 2008 at the Clinic. Since then he has exercised religiously and changed his diet to reduce fat and sodium as much as possible. Are there long-term differences in the efficacy and longevity of off-pump vs. traditional surgery?

Dr_Douglas_Johnston: That is a very good question.  There are a number of large studies of off-pump versus on-pump “traditional” coronary bypass.  While there is no difference in survival and early complication rate for the majority of patients, many of these have shown that on average the number of bypass grafts performed in off-pump surgery is less, and that the longevity of those grafts may be less.


Mitral Valve Surgery

Leonard: Have you been able to perform mitral valve replacement with robotic assistance? Dr. Gillinov replaced mine about seven years ago by traditional surgery.

Dr_Douglas_Johnston: Yes in some circumstances we can provide a mitral valve replacement using robotic technique although not every valve can be replaced with this method.

winona: I am a very happy and healthy person thanks to a Mitral Valve Repair at Cleveland, done by Dr Mihaljevic with DaVinci Robotic assistance. I was fortunate to see a cardiologist in NH who was up-to-date on the repair option. I understand that too many are still not told about that option. I found CC by my own research for my surgery. My frustration lies in that Mitral Valve Repair and MVP disease still is under the radar in the public info. I realize that we a small segment of the cardiac disease population, but we are there.

Dr_Edward_Soltesz: This is an issue that we battle constantly - increase public awareness of mitral valve regurgitation in a population that is healthy and told that it is not severe enough to fix.  We can fix these with near zero mortality and minimally invasively for most patients like yourself.  Thank you for supporting the cause.

elatour: I'm scheduled for mitral valve repair surgery on 2/14/11. I have to decide on a replacement valve if my valve can't be repaired. While the mechanical valve seems more logical for my age (54), I'm afraid about the medication and diet requirements that probably won't be needed with the tissue valve. Is there anything on the horizon research-wise that would favor using the tissue valve, so that in 10-12 years, some other alternative might be available? If not, what would be the disadvantages of having to have a second valve replacement?

Dr_Douglas_Johnston: That is a great question. It is very possible in 10 - 15 years that the second operation could be done by catheter. Even if that is not possible, reoperative surgery is getting safer and safer particularly if it is being done at a center with experience.

PhillipM: Concerning Robotic Surgery and Mitral Valve Repair, what are the statistics on redo's? I had a Ross Procedure in 1999 and Mitral Valve Repair in 2001 in Lexington, KY. Mitral Valve is leaking moderaty severe to severe and aortic valve is leaking moderately severe. I don't think my pulmonic valve works any more. What type of candidate am I for Robotic Surgery?

Dr_Douglas_Johnston: In general patients needing multiple valves or redo valve surgery are not good candidates for robotic approach. However I would be more concerned in your situation about having a safe and effective operation. These operations can usually be done safely and effectively with good recovery through a standard incision

Dawn: My mother needs mitral valve replacement surgery. She already had a new pig valve put in 9 years ago. Can they do this surgery using the robotic method?

Dr_Douglas_Johnston: See above - usually open surgery is the preferred approach with redo surgery but this can be done safely and with a good recovery.

Sue: I had a prolapsing mitral valve repaired in September with a Gortex ring and Gortex chordae, described as a complex repair. within 4 weeks two of the chordae had come loose and now the leak is as severe as it was presurgery. I was told I have been 'unlucky' can this type of repair be re-repaired? My heart rate was running fast post surgery, but I was given nothing to reduce the rate (130-40 during activity). I also have severe ME which, in my experience, seems to make the heart work harder. Could either of these things have been responsible for the failure, given that I have no other risk factors at all? Thanks, Sue 48 years old

Dr_Douglas_Johnston: Hard to know why your repair failed sometimes they do - even though things look good in the operating room. The good news is that these can often be re-repaired

Bernardo: I’m a cardiopatic man and I’m 82 year old. The question is: is possible repair my mitral valve without open my chest? I have transplanted to the aortic valve.

Dr_Douglas_Johnston: We would need more information to see what needs to be done for your heart condition.  In most of these cases, the first step is to see what can be done to repair the problems of the heart and the second step would be to see what steps to do that.

shones: I am 30 years old and I was born with Shones Complex. 2 years ago I had open-heart surgery to repair my calcified Mitral valve. However, my surgeon was not willing to repair the valve opting to replace with a bovine valve instead. This surgeon did not order an Angiography prior to surgery. Thus he sutured shut my Circumflex artery during the surgery. Immediately after taken off of the heart/lung machine I suffered an acute infarction. The cause was not discovered until 5 days later. At that point I was administered a heart catheterization and 2 stents were inserted at the point of the Circumflex occlusion. Now my bovine valve has developed a small leak near the location of the erroneous placed suture. What should be the current course of action in regards to this leak? How serious is this leak? Do I need to have some kind of corrective surgery now or later?

Dr_Edward_Soltesz: The indications for surgery in patients with perivalvular leaks depend on the severity of the leak and any consequences of the leak (for example like destruction of blood cells). So it varies from person to person as to whether you need surgery to fix this leak at all - or if it can be done surgically or done by certain interventional cardiologists who specializes in patching these leaks.

lb: I have moderate to severe mitral valve regurgitation with no symptoms. I have an appointment with a valve specialist. What questions should I ask him?

Dr_Edward_Soltesz: Important questions would include the timing of surgery, whether it can be done minimally invasively, how many that surgeon has done, what is the success rate of valve repair versus replacement, and how many heart surgeries the hospital does per year? Studies have shown that patients have better outcomes when they receive operations at hospitals that do large amounts of a particular type of surgery.

mstone0815: Good afternoon doctors. I had isolated mitral valve repair back in 2009. Recently, a TEE exam revealed I now have moderate 2-3+ regurgitation and I will need a second operation. My questions are 1) What are the percentages for a re-repair? 2) I've been told to return to the same surgeon because "he knows what he did and will be more familiar in order to re-repair". I would like your opinions on going to a different surgeon instead.

Dr_Edward_Soltesz: Typically, mitral valve re-repair is successful 75-85% of the time. This clearly varies among patients and surgeons. Since I do not know your surgeon, I cannot advise you if you should return to him for a re-operation.

vintal: I will be needing a mitral valve repair and would like to know which method would last the longest? I am considering robotic surgery but would like to know how the mitral clip is doing and do you perform that procedure? Are there any new types of repair coming out soon? thank-you

Dr_Douglas_Johnston: The mitral clip is certainly an option for patients who are at extremely high risk for surgery.  Minimally invasive mitral valve surgery or for that matter even standard mitral valve surgery provides the most durable solution for your heart problem.

elatour: For mitral valve regurgitation, what is the percentage of people who have had the valve repaired versus replaced?

Dr_Douglas_Johnston: That depends on the type of valve disease.  For degenerative mitral valve disease, which is the most common reason for mitral regurgitation for patients in the US, repair can be performed in more than 90% of cases.

RHow: I am having mitral valve surgery at Cleveland Clinic on April 21. My problem is severe regurgitation of the anterior leaflet, which I am told, is a more difficult surgery. What are the chances that the valve will be able to be repaired rather than replaced? How much more difficult and/or dangerous is surgery on the anterior leaflet? Can this surgery be done using a minimally invasive technique?

Dr_Edward_Soltesz: Surgery on the anterior leaflet of the mitral valve can usually be accomplished with a minimally invasive approach in most instances. Unfortunately, without direct review of your echocardiogram, I could not provide you with more detailed predictions regarding success of a repair.  Surgery on the anterior leaflet is normal no dangerous than on the posterior leaflet.


Aortic Valve Surgery

Gene: How close are we to a non invasive/minimally invasive procedure for aortic valve repair/ replacement in aortic insufficiency?

Dr_Douglas_Johnston: We are very close to catheter based treatment for aortic stenosis but that essentially involves a valve replacement. The good news is that we can provide aortic valve repair in those valves that are repairable using a minimally invasive incision. Doing a repair using only a catheter has not yet been done and is probably a ways away.

Bard50: My echocardiogram showed that I have some leakage and that the valve was bicuspid. I take medications for thyroid, prostate, and testim for testosterone (had testicular cancer and one testicle removed). My questions are as follows: 1. Can aortic valve leakage prevent the heart rate from increasing on a stress test? 2. With aortic valve leakage, can the valve be repaired or does it have to be replaced? 3. With a repaired or replaced aortic valve, can one regain a healthier lifestyle; one where I can run again, or swim w/o getting tired quickly? Also, will my circulation improve dramatically? Would better circulation eliminate problems with erectile dysfunction? Would the thyroid perform better?

Dr_Douglas_Johnston: If the aortic valve leakage is severe, it can certainly contribute to fatigue and poor circulation. Can you be active, swim etc after aortic valve repair or replacement - definitely yes.

Often a bicuspid aortic valve can be repaired. That should be evaluated by your surgeon looking at your echo.

Yvonne: I have been told that a need an aortic valve replacement due do a bicuspid valve. I am confused as to what option to take. Mechanical valve means blood thinner, which I really don't want. Tissue valves, no blood thinner after a few months, but will have to have surgery again do my age of 56. I have read the tissue valves have improved as far as they are lasting longer. What is the average of tissue valve life and what would you recommend for a replacement?

Dr_Douglas_Johnston: Great question. Many of our patients with tissue valves do not need to be on blood thinners at all even for a few months after surgery. Current generation tissue valves may last 12 - 17 years in someone your age. Many of our younger patients are choosing tissue valves for lifestyle reasons and we feel this is a reasonable approach. Knowing that we can perform redo surgery to replace that valve with excellent safety.

Brent: I currently have a homograph aortic valve. It's been in about 11 years. No issues but I've been told eventually it will need to be replaced. I'm an active healthy 59 year old male. I'm not on blood thinners. If I had to have it replaced today, what are my options? I know much depends on various pieces of information you don't have but with regards to blood thinners, invasive surgery, etc. what is the state of the art?

Dr_Douglas_Johnston: In general, for patients with a homograph, redo surgery would involve either replacing the valve alone or the whole root of the aorta. That would depend on your anatomy.  In most patients that can be done with either a mechanical valve or tissue valve. If you want to avoid blood thinners a tissue valve would certainly be a good approach.

Robert: I have aortic stenosis along with CHF and Afib and need a minimally invasive valve replacement or repair. I don’t wish to use the heart lung machine or have my heart stopped during surgery. I had a heart attack twelve years ago. I’m most interested in the deployment of a replacement valve by cardiac catheter but have heard that they are presently using the French 47 size through the groin, which seems to present added risk of dislodging calcification in the artery. Do you have any suggestions about other procedures Robotic etc? I’m 73 and in otherwise good health. Thanks.

Dr_Douglas_Johnston: at present, all of the catheter based valves are still investigational in the US. To be eligible for one of those valves you need to be enrolled in a trial. Many of our patients have the combination you described - CHF, AFIB, MI and AS - often the best operation is one that treats as many problems as possible.  We routinely do these operations today either minimally invasively or with a standard incision with good results.

Spence: My echocardiogram shows an EF measurement between 50-60%. This appears to be within the "normal" range. I have Aortic Stenosis and am considering surgery to replace the Aortic valve. I am also a diabetic with very good non insulin treatment. I will be 88 years old July 1 and somewhat reluctant to have the procedure since I am having no symptoms other than not being able to walk as far or as fast as I did two years ago. Any thoughts? Thank you for your excellent web site

Dr_Douglas_Johnston: Great question.  We are seeing more and more of patients that are active and otherwise in good health in their 80s and 90s. 1. there is no reason why someone of your age would not be a candidate for surgery. Believe it or not, older patients may get even more benefit from Aortic Valve replacement in terms of quality of life and life expectancy. 2.  In terms of your symptoms, fatigue and lack of ability to do activities is often an early sign of aortic stenosis.

Mary: I have had my aortic valve replaced with a tissue valve (bovine) when I was 72 years old. I am now 81 and would like to know if I had to have another replacement, would I be too old. They couldn't put in a mechanical valve as I can't take a blood thinner. I had to have 8 blood transfusions during surgery. So far, I am doing OK, bit don't know how long this valve will last. Would appreciate an answer. Thanks, Mary

Dr_Douglas_Johnston: 81 is usually not too old for someone who is in otherwise good health. We would be happy to review your case if should need surgery in the future to determine if surgery would benefit you.

Tien: I would like to find out the survival rate and the post-surgery complications possibilities for my 69-year old father who possibly need aortic valve replacement

Dr_Edward_Soltesz: I presume he needs the aortic valve replacement for aortic stenosis. If that is the case, then his operative mortality is certainly far less than 1 percent and his survival would actually be greater than age and sex match controls - meaning someone just like you who does not have aortic valve disease.

Rangeman: For a mitral valve repair, should preliminary tests such as a cardiac cath and a TEE be done where I live or should it be done at the Cleveland Clinic (my location is about 1500 miles from Cleveland)?

Dr_Douglas_Johnston: It depends on your situation and whether you can stay with us to have that done - although many of our patients are from out of state and have their studies done elsewhere.

slaughterhill: How do you determine who is eligible for minimally invasive aortic valve replacement surgery.

Dr_Edward_Soltesz: The real question is who is NOT able to have minimally invasive aortic valve replacement - this is actually a small number.

slaughterhill: Percent of success rate for aortic valve replacement.

Dr_Douglas_Johnston: For someone who has isolated aortic valve surgery the success rate based on survival is 99.4%.

kathync: My 20 yr old has Aortic Valve Stenosis (after Grandmother) She had the balloon done 3 times now bleeding badly and no leaflets left. Not sure to put pig valve or Ross method. My Mother had the pig valve and lived to be 93 but she was 71 when she had it done. Which do you think would be best for her? Surgery is to be within the next three months at Wake Forest Baptist Hospital.

Dr_Edward_Soltesz: She would certainly be a Ross procedure candidate at 20 years old.  In fact, there is actually no difference in mortality in patients who have a mechanical vs. bioprosthetic valve even in taking consideration reoperations in the bioprosthetic valve.

fjpor: Had aortic valve replaced 22 1.2 yrs ago with allograft. Can minimally invasive procedure be done to replace that one now?

Dr_Douglas_Johnston: Not usually but that should not discourage you from considering a reoperation. When we look closely at the benefits of minimally invasive surgery what is clear is that discharge from the hospital may be a little sooner but even with standard open heart surgery most patients recover very well and are back to their normal activities in a few weeks.

Marieta: Can you perform minimally invasive surgery in all aortic valve and aorta repairs?

Dr_Edward_Soltesz: Minimally invasive ascending aortic aneurysm repair and/or aortic valve surgery is possible in most instances (>80%). Obviously, I would need to review your complete medical records to say with certainty this is the case.

MsFit123: I had aortic valve replacement, minimally invasive, in June, 2010 with a pig valve. Will probably need another one in 15 years. What are the risk numbers for the 2nd operation? Is it considerably higher mortality rate compared to the first?

Dr_Edward_Soltesz: At experienced centers, cardiac reoperations have become extremely safe.  The morbidity and mortality rates of reoperations at the centers approaches the rates of primary surgeries.  At the Cleveland Clinic, for instance, and we have an extensive experience with reoperative open heart surgery and our overall mortality risk for a reoperative aortic valve replacement is near 2%.

MsFit123: Ever since my aortic valve replacement surgery in June of 2010, I have had a very increased heart rate compared to presurgery..i.e. it is regularly in the 100-130 range. Mornings are particularly high. My cardiologist brushes this off. What could have caused this, and should I be concerned? I am a 59 year old, fairly athletic.

Dr_Douglas_Johnston: Many younger, healthier patients can have a resting tachycardia (elevated heart rate) early after surgery because of the adrenaline circulating in the blood after surgery, but this usually lasts only a few days.  A heart rate that is over 100 6 months after surgery warrants close investigation to be sure that you do not have an arrhythmia such as atrial fibrillation.

MsFit123: What are the failure rates for bioprosthetic valves....particularly pig valves?

Dr_Douglas_Johnston: Failure rates for all bioprosthetic valves depend on age.  For a patient between 40 and 60 years old, valves last between 10 and 12 years.  For patients 60-75 years old about 15 years, and patients greater than 75 years old, they may last 15-17 years.  The important consideration with bioprosthetic valves is that most patients will need another operation if they receive one when they are young, and the valves should be monitored with regular echocardiograms.

Venus: What is the natural history of aortic stenosis without valve replacement and is this a reasonable alternative for a very healthy woman in her mid 80s who has an otherwise healthy heart but the aorta has tightened to 1.4?

Dr_Edward_Soltesz: Patients with severe aortic stenosis who develop symptoms from their aortic stenosis have a very poor life expectancy unless their aortic valve is replaced.  Aortic valve replacement in patients older than 80 is very well tolerated and can be performed with an extremely low operative mortality of around 2%.  Once the aortic valve has been replaced, these patients typically live longer than similarly aged individuals in the general population.  If you are aortic valve area is in fact 1.4 cm², I suspect you do not have severe aortic stenosis yet and can likely be observed with repeat echocardiograms until your aortic stenosis worsens.  Feel free to send me copies of your echocardiogram for review at 216-444-5680.

Venus: Assuming that a very healthy woman in her mid 80s is a candidate at CC for M.I. AVR, is she also a candidate for any other procedures to replace the aortic valve?

Dr_Douglas_Johnston: In general the choice between a minimally invasive operation and standard sternotomy operation is made based on what other procedures are necessary at the same time.  If your cardiac catheterization reveals coronary disease, your surgeon may opt to perform bypass surgery at the same time as the valve replacement and this would usually require a sternotomy.  As of now, there is no valve which can be delivered with a catheter which is available in the United States outside of research trials, but we will be taking advantage of these devices for some healthy patients like you once they have been shown to be as safe and effective as current techniques for aortic valve replacement.

Venus: What are the risks or potential complications of each procedure, particularly M.I. AVR, on a woman in her mid 80s?

Dr_Douglas_Johnston: The risk of isolated aortic valve replacement is quite low.  At the Cleveland Clinic, isolated aortic valve replacement carries a risk of mortality of less than 1 percent for all patients undergoing this surgery.  What is very clear about aortic stenosis, even for patients in their 80’s, is that the survival and quality of life WITH surgery is much better than it is WITHOUT surgery.

ranganna: I am from India and am 84 years old in good physical shape. I may have to undergo AV Replacement shortly if symptoms develop. It is likely to be an isolated procedure as the echo and CT scans show no other problem apart from aortic stenosis. Does minimally invasive surgery provide better results with regard to morbidity and mortality as compared to standard procedures? Is the recovery period likely to be shorter? thank you

Dr_Edward_Soltesz: There is no difference in mortality between minimally invasive and standard aortic valve replacement.  Since the minimally invasive approach utilizes a smaller incision to do the same surgery, patients typically have less pain, less blood loss, and leave the hospital earlier.  Recovery with a minimally invasive incision is usually faster.

Venus: How much advantage is minimally invasive AVR over traditional AVR?

Dr_Edward_Soltesz: There is no difference in mortality between minimally invasive and standard aortic valve replacement.  Since the minimally invasive approach utilizes a smaller incision to do the same surgery, patients typically have less pain, less blood loss, and leave the hospital earlier.  Recovery with a minimally invasive incision is usually faster.

Venus: What percentage of CC patients who have minimally invasive AVR had to stay MUCH longer than 10 days or the estimated amount of time told to them prior? How did very healthy senior citizens do regarding staying just for normal stay vs. MUCH longer stay?

Dr_Edward_Soltesz: Approximately 5-10% of patients who have a minimally invasive aortic valve replacement stay in the hospital longer than the typical 5-7 postoperative days.  This longer stay can be for a variety of reasons including medical as well as social (e.g., the need to arrange for her post discharge rehabilitation).

Nellie: What specific, detailed patient data is required for a consultation with a cardiac surgeon to determine the need for an aortic valve replacement and bypass surgery? And what would I expect would happen?

Dr_Edward_Soltesz: Typically, cardiac surgeons require a quality transthoracic echocardiogram, a left heart catheterization, a chest x-ray, routine blood work, and a detailed history and physical to determine whether or not a patient requires aortic valve replacement and coronary bypass surgery.  Other tests may be required based on the patient's medical problems and physical examination.

Marieta: bicuspid aortic valve with moderate to severe stenosis and ascending aorta 4.1 53 yo F healthy without any other medical problems and without symptoms - what is the safest time to be in circulatory arrest? how do you monitor for a stroke during and post-op? when needed can I have the valve repair but not the aorta if it does not widened more?

Dr_Edward_Soltesz: We would recommend aortic valve replacement for patients with symptomatic severe aortic stenosis.  Symptoms can be subtle; for instance, patients can develop increasing fatigue.  In patients with bicuspid aortic valve is, we would recommend replacing the ascending aorta and the size reaches 4.5 cm.  This operation can be done minimally invasively and does not require circulatory arrest per se.  Only cardiopulmonary bypass is required during which time your heart would be stopped for approximately 40-60 minutes.  Well up to 3 hours of cardiac arrest is extremely well tolerated. Unfortunately, there is no reliable way to monitor for a stroke during surgery, however, postoperatively, careful assessment by nurses and physicians can identify the early signs of a stroke and expedite early treatment. Certainly, only the valve can be replaced if the aortic diameter is not significantly enlarged.

DMOGIRL: I currently have a bovine tissue valve that was placed in May of 2010. I got the surgery because of a 4.8 cm aneurysm in my ascending aorta. My bicuspid aortic valve was fine at the time but only replaced as a convenience to avoid in the future. However, an echo 6 months later (in Oct. 2010) shows my valve area at 0.9cm. My cardiologist said that sometimes aorta Dacron replacements can make the valve area of an aortic valve seem worse then it is because of the graft. What is your opinion on this? Is it common for a tissue valve to degenerate so quickly? I am a 28 year old female. Thank you for your time!

Dr_Edward_Soltesz: Your tissue valve should not have deteriorated in such a short time. I would recommend a transesophageal echocardiogram to formally evaluate your valve function.

Beancounter4: I am a Aortic Valve replacement patient and need another surgery. I have a Homograft valve now. I would like to know of any Chicagoland area hospitals that would do a minimally invasive heart surgery. Thank you for any help.

Dr_Edward_Soltesz: Minimally invasive surgery usually cannot be done for patients who need re-operations. There are a few instances where minimally invasive re-operations are possible. Unfortunately, I do not have the details of your previous surgery to allow me to review this, but I would be happy to help if you contact me.

dawnlimburg: I have a bicuspid aortic valve with stenosis, and an aortic aneurysm. my current cardiologist says it’s all asymptomatic, I feel like I have symtoms, pain in my back, and chest tightness, and a pulling feeling.  Are  there symptoms with my conditions?

Dr_Edward_Soltesz: Symptoms of aortic stenosis can be very subtle. We would recommend aortic valve replacement for patients with symptomatic severe aortic stenosis. Symptoms can include increasing fatigue, for instance. In patients with a bicuspid aortic valve, we would recommend replacing the ascending aorta when the size reaches 4.5 cm.  This operation can be done minimally invasively. Unfortunately, without reviewing your complete records, I cannot for certain link your particular symptoms with your valve condition.

katylou: How will I know when it is time for aortic replacement surgery?

Dr_Edward_Soltesz: We would recommend aortic valve replacement for patients with symptomatic severe aortic stenosis.  Symptoms can include increasing fatigue, for instance, and can be very subtle. Most aortic valve replacement surgeries, if they do not require another concomitant procedure such as a bypass, can be done minimally invasively.

tarioko: I would like to find out the survival rate and the post-surgery complications possibilities for my 69-year old father who possibly need aortic valve replacement (additional info: I am currently pending on "Cleveland Clinic Second Opinion" as I am waiting for one of the echocardiogram of my father's medical record information from Jakarta.

Dr_Douglas_Johnston: As long as your father does not have other major medical problems, the survival rate after aortic valve replacement is greater than 98%.  We would be happy to discuss the risks with you.  Please call my office at 216-444-5613 if I can be of help in your decision.

tariokoThe other concern is, will the heart need to be stop temporarily while the surgery is performed?

Dr_Edward_Soltesz: Yes, surgical aortic valve replacement requires temporarily stopping the heart.

Beancounter4: For Aortic Valve Replacements, is it becoming more common to have a minimally invasive surgery for replacement and can you do that type of surgery with a Homograft Valve? Do you recommend any hospitals in the Chicagoland area that do the minimally invasive heart surgery for Aortic Valve replacement?

Dr_Edward_Soltesz: See my previous answer to your question above.

katylou: My aortic valve has a calcium buildup, can this be repaired?

Dr_Edward_Soltesz: Calcification of the aortic valve cannot itself be removed, per se. Typically, once the calcification has caused a significant degree of blockage that leads to symptoms (i.e., severe, symptomatic aortic stenosis), we would recommend replacement of the valve.

adourian: Dr. I get an echo every year due to aortic stenosis. My valve area is now at .9. While the guidelines say that this is now at the moderate to severe level, all other measurements are normal to very mild (EF 62%, AV mean 13.5, peak 2.65) How can that be and what does that say about the progression of the disease. I have no other symptoms and all chambers appear to be normal in size.

Dr_Douglas_Johnston: We typically recommended surgery for severe aortic stenosis when patients begin to develop symptoms. Symptoms may be very subtle. It is very important to intervene before irreversible damage to the heart muscle occurs. Since aortic valve replacement surgery can be done with an exceptionally low risk, we are more often likely to recommend surgery for patients with severe aortic stenosis who demonstrate even the mildest of symptoms or who have had definite progression of her disease even if they are asymptomatic. I would need to review your echocardiogram more closely to provide you with a more comprehensive answer.

adourian: Regarding your answer to an earlier question that a bicuspid aortic valve can be repaired. Is an aortic valve where 2 leaflets have been fused via calcification also a candidate for repair?

Dr_Edward_Soltesz: Usually, this is not repairable. A durable repair of the valve requires there to be minimal calcium.

slaughterhill: How do you determine if patient is a candidate for minimally invasive aortic valve replacement. How long after surgery can I resume normal activities.

Dr_Edward_Soltesz: The feasibility of a minimally invasive approach for cardiac surgery depends on a number of factors.  If patients require more than one valve repair or replacement or need concomitant coronary bypass surgery, a minimally invasive approach is usually not possible.  There are other patient specific factors that go into the overall decision as to whether or not a minimally invasive approach would be optimal. Overall the goal, however, is to provide the best operation for the patient's problem and not compromise the incision for quality.

Yvonne: Do you perform the aortic valve replacement thru minimally invasive surgery? If you do is this usually the standard? In the area I live in most surgeons prefer not to do the procedure that way.

Dr_Douglas_Johnston: Absolutely! For most of us minimally invasive surgery is standard for patients having isolated aortic valve surgery. We have shown that these operations are safe and effective, and may provide benefit in terms of faster recovery.

adourian: I am impressed with the leadership role Cleveland Clinic has taken in minimally invasive aortic valve replacements and their resulting outcomes. Yet when go to other inputs like Barbara Walters special, I see everyone, including Robin Williams who had his aortic valve replaced at Cleveland Clinic with sternotomies. I know that the need for multiple procedures might drive the decision toward a sternotomy. Are there any other considerations why one would opt for non minimally invasive?

Dr_Douglas_Johnston: The feasibility of a minimally invasive approach for cardiac surgery depends on a number of factors. If patients require more than one valve repair or replacement the need concomitant coronary bypass surgery, a minimally invasive approach is usually not possible. There are other patient specific factors that going to the overall decision as to whether or not a minimally invasive approach would be optimal. Overall gland however is to provide the best operation for the patient's problem and not compromise the incision for quality.

warmhearted: Compared to the standard procedure for aortic valve replacement, what particular risks are associated with the minimally invasive methods?

Dr_Douglas_Johnston: Very good question. We have looked at this very carefully and found there is no difference in risk between minimally invasive and standard aortic valve surgery. 

mgibson65: I had aortic valve repair last year @ Cleveland, looks like I am going to need a reoperation. What should I expect from a second open heart surgery?

Dr_Douglas_Johnston: A second operation is typically somewhat longer because of the scar tissue that results from the first operation, however most reoperations on the aortic valve can be performed very safely and with a recovery that is only slightly longer than the first time.

katylou: What is the best type of surgery for aortic valve replacement? robotic or traditional

Dr_Douglas_Johnston: The most common operation we perform for isolated aortic valve replacement is a minimally invasive procedure using a small incision at the upper end of the sternum. With this approach the surgery and the canulation (connection to the heart/lung machine) are all done through the same incision.

Beancounter4: You mention repair minimally invasive for the Aortic Valve so is that the same for a replacement of the valve?

Dr_Douglas_Johnston: The decision about repair vs. replacement of the valve depends on the kind of valve disease. Both operations can be done, and often are done, through a minimally invasive approach.

Beancounter4: What is the Ross procedure?

Dr_Douglas_Johnston: In the Ross operation the pulmonary valve is used to replace the aortic valve, and the pulmonary valve is replaced with an artificial valve, usually a homograft (human cadaver valve) or an animal valve.

kathync: Ross method or pig valve best for 20 yr old?

Dr_Douglas_Johnston: Great question. A Ross procedure may be indicated. There are a number of studies which need to be carefully evaluated to make that decision. Please contact my office if I can help.

Beancounter4: Is it advisable to replace a Human Tissue Valve with another Homograft Valve to avoid taking blood thinners? I was 30 years old with my first open heart surgery. My valve is 1 month short of 16 years old now. I am now being told it needs to be replaced. Can this be done via the minimally invasive surgery?

Dr_Douglas_Johnston: Replacement of a homograft valve is a complex operation best performed via a sternotomy. I see patients like you quite frequently.  Deciding what to do always requires careful thought and a two-way discussion between the surgeon and patient. The decision about what type of valve to replace the homograft with is not an easy one for someone 46 years old, and would depend on lifestyle, other medical problems, and a number of other factors. If a tissue valve is chosen again, we would plan for the next operation, even though it is a number of years away. I would be happy to review your case and discuss the options with you. My office number is 216-444-5613.

Beancounter4: For a redo Aortic Valve Replacement ~ Can this be done without sawing the chest bone? This can be done through an incision?

Dr_Douglas_Johnston: Most often the best approach for redo aortic valve replacement is with sawing the sternum.  Sometimes we can open only the upper half of the sternum to do this surgery, but the most important consideration is a safe, effective, and durable operation which can set the stage for a quick recovery.


Percutaneous Aortic Valves

wino: will you be able to do redo aortic prosthetic valves and valve root combos through the catheter method in the future and if so how far away is it from being routine?

Dr_Douglas_Johnston: We hope to be able to perform reoperative valve replacements for patients with tissue aortic valves via a “valve in valve” technique using catheter delivery within a few years, but not all patients will be eligible for such procedures.  This will be one of the many techniques available to us to give our patients a safe reoperation.

MsFit123: I have 2 questions. I have a pig aortic valve replacement. 1. How far along are the trials for the NEW method of fishing the valve up the leg as opposed to cracking the sternum? 2. Are there any better valve options coming down the pipeline other than bio or mechanical?

Dr_Edward_Soltesz: 1. The PARTNER trial is completing enrolment of high risk patients for transcatheter aortic valve replacement as we speak.  This technology is being used in Europe routinely for high risk patients and will likely be available soon in the US for patient's who would otherwise not tolerate surgery. 2.  The Onyx valve is a mechanical heart valve that may not require high degrees of anticoagulation that other mechanical valves require.  There is an ongoing study evaluating this currently and results should be available soon.

Bettye: My mother lives in Florida and the trip to Cleveland would be too much , she needs aortic valve replacement , but would like percutaneous stent replacement ... any chance you will be doing this in Florida anytime soon?

Dr_Edward_Soltesz: Percutaneous aortic valves are presently only being offered to very high risk patients within the context of an ongoing clinical trial in the US. You would need to consult your medical center and cardiologist to determine if your mother fits these criteria and if your medical center is participating in the trial.

Bettye: Hello. My mother is 80 yrs. old and diagnosed with severe aortic stenosis. We have been to other hospitals to see if she will qualify for the percutaneous stent valve replacement trial. My question is ,in your opinion , is the femoral or the side entry the better option , and will this procedure be approved by the FDA soon?

Dr_Douglas_Johnston: I see a lot of patients who are in a similar situation in that they have read about, and are interested in, percutaneous therapy for their aortic valve. Both the femoral and the transapical (side-entry) approach have merit for patients with different types of disease.  One of the reasons the trials are being done is to look carefully at WHICH patients will benefit from the different approaches.  When the FDA will decide there is enough evidence to approve the device is not certain.

What we do know is that aortic stenosis is a deadly disease, and that delaying surgery usually increases the risk to the patient.  Most patients do very well with minimally invasive aortic valve surgery, and the results are well studied in 1000s of patients.  I would not delay surgery waiting for the FDA! 

Venus: Should a very healthy woman in her mid 80s pursue percutaneous AVR, and if so how would she go about entering a study?

Dr_Douglas_Johnston: At present healthy patients are not eligible for enrollment in any of the studies for percutaneous AVR in the US.  The reason for this is that while these new technologies are very promising, they have not yet been shown to be as safe as standard aortic valve surgery.


Aortic Aneurysm

Patti: I currently live in SW France and have bicuspid valve, moderate regurgitation, with ascending aorta aneurysm. My last MRI revealed 4.5mm aorta aneurysm, so I have been consulted on replacing the valve and also the aorta root. Not a Bentall procedure since the base of aorta root is not dilated. I am 46 yrs. old, in excellent health, run 6-8km three times a week and direct fitness bootcamp resort. My questions are: I have been given the choice to opt for either mechanical or bio valve and understand the options. I do not want Coumadin therapy due to my lifestyle, yet do not relish reoperation later in life. What carries the lowest mortality risk and complications long term? Finally is there even an option for minimally invasive procedure for this?

Dr_Douglas_Johnston: Question 1 - is whether you need to have this operation now. You are on the borderline regarding your aneurysm as far as having your aneurysm fixed.

Dr_Edward_Soltesz: May want to watch for a year, and see if the aneurysm is increasing or the valve is progressing to the point of needing an operation.

Dr_Douglas_Johnston: At that point you may be a candidate for minimally invasive aortic aneurysm and valve repair. We would be happy to review your records

Wino: Had Aortic valve replacement in Sept. 2009. Just had echo and am showing enlarged aorta. I have been lifting moderately heavy weights for approx. 15 hours per week. Could this be the cause of my aorta enlarging by 3 mm. since March 2010?

Dr_Douglas_Johnston: Lifting very heavy weights has been shown to increase the risk of rupture of aortic aneurysms, but moderate exercise has not.  I suspect the growth of your aorta is related to the aorta itself more than your exercise program.  A number of younger patients with aortic valve disease also have abnormalities of the ascending aorta.  Following this closely with frequent imaging studies (CT or MRI) is important.  If the aorta continues to grow, it might need to be replaced in order to prevent rupture or dissection.

Marieta: during repair of an ascending aorta, what is the average time you keep pts in circulatory arrest?

Dr_Edward_Soltesz: Patients who need replacement of the ascending aorta do not always need circulatory arrest. They all require the use of cardiopulmonary bypass for 30-45 minutes. If the aortic arch is being replaced too, then a brief period of true circulatory arrest is needed (10-15 minutes).

Marieta: Can you do minimally invasive incision to repair a widened ascending aorta?

Dr_Edward_Soltesz: Minimally invasive ascending aortic aneurysm repair is possible in most instances. Obviously, I would need to review your complete medical records to say with certainty this is the case.

Marieta: During ascending aortic repair and valve replacement how do you keep pts from having a stroke?

Dr_Douglas_Johnston: That is a great question.  We use a number of techniques to reduce the risk of stroke.  Most important is that for larger aneurysms we connect the heart-lung machine to the axillary artery (the artery which feeds the right arm) through a small incision under the collar bone.  This allows us to do a thorough aneurysm repair with very good protection of the brain from stroke

alfiamarco: Aortic root aneurysm of 46mm; male 50 years old; 6 feet tall; 185 pounds in good physical shape. Size has not increased in the last year. What are the treatment options? Including surgery, of course. Thanks

Dr_Douglas_Johnston: The treatment options would be 1: monitor the size of the root with regular imagining studies as you are doing and 2: aortic root surgery.  The decision for surgery depends on the size, rate of growth the condition of the aortic valve (whether it is narrow or leaking) and whether there is a family history of aortic aneurysm, especially certain conditions like Marfan syndrome. A careful evaluation of those factors would lead to the best choice of treatment. If you are interested in having us take a look at your films I could provide a better answer for your particular case. My office number is 216-444-5613. I’d be happy to review them any time.

Marieta: Survival rate means going back to a normal life without any of the potential during and/or post-op complications?

Dr_Douglas_Johnston: Survival rate means exactly that – how many patients are alive after surgery.  In most cases it correlates very well with the risk of other major complications.


Tricuspid Valve Surgery

theresa: Is there a surgeon currently doing tricuspid robotic surgery repairs for AR due to birth defect of bi valve instead of the normal tricuspid aortic valve?

Dr_Edward_Soltesz: Robotic surgery is limited right now for mitral and tricuspid valve repair and certain other surgeries but we can do this minimally invasively on the aortic valve with excellent outcomes and we do not need the robot for this.


Combined Valve Surgery (Multiple Valves or Valve in Addition to Other Surgery)

robertleeh: Ten years ago they determined I had AF and leaky heart valves. I have been on warfarin ever since but I don’t detect any AF. My cardiologist says my echogram shows prolaspe and moderate to severe leakage in my Mitral valve and moderate leakage in my Aortic and Tricuspid valves. My heart shows very a small insignificant enlargement. I passed a stress test last October. My rejection factor is over 60. I’m not having any symptoms except for fatigue last summer and it seems to be gone. My cardiologist recommends surgery and thinks probably a repair would be possible. I’m 79 and reluctant to undergo serious surgery when I don’t have symptoms, but I don’t want to risk heart damage. I would hope I could have minimally invasive surgery. My cardiologist says at my age I could develop other problems that could made surgery difficult at a later time. Based on these limited facts, what would you recommend?

Dr_Douglas_Johnston: It sounds like you may need intervention in more than one valve which sometimes make minimally invasive surgery more difficult. You definitely should be evaluated by a surgeon. We would be happy to evaluate you.

Connie: Is heart valve replacement still feasible for me? I have a severe mitral & aortic valve stenosis (0.7cm2). I am also experiencing dysphagia & right scapular pain. Are these caused by my medical condition? Thank you very much for accommodating my inquiry.

Dr_Douglas_Johnston: Based on the condition of your valves alone it looks like you would qualify for valve replacement but we would need to know more about your general medical condition to see if this is right for you.

ConnieWoods: Thank you for taking time out of your schedule to host this web chat. I have a daughter 17, with Turner's Syndrome. She was diagnosed with an Aortic Aneurysm with Bicuspid Valves( minute leakage) her measurement was 3.2. She was started on Lisinipri. Within 2 months taken off Lisinipril due to adverse effects and placed on Cozar. Her current care plan is 6 month follow up cardiologist, MRI, Echo. She just had a MRI in Jan 2011. Her current measurement is 3.8 Her cross sectional index multiplied by her height is 7.6. She is followed by a team of adolescent/adult congenital trained doctors in central Ohio. I had her info sent to Dr Svensson in early 2010 and he was kind enough to review it and follow her. I have a multi-part question I would like to get info for. I would first like to know which measurement I should be most concerned about. What exactly is the measurement that is multiplied by a person’s height?

Dr_Douglas_Johnston:  Typically, we recommend replacement of the ascending aorta when the aortic diameter reaches 5 cm.  Unfortunately, this does not take into account the patient's height.  Dr. Svensson here at the Cleveland Clinic proposed a standardization based on a patient’s height (aortic valve area/height). According to this, then, we would  recommend surgery when this aortic index is greater than 10.

pinkychico: Can you do a minimally invasive aortic valve replacement with a bypass of the LAD?

Dr_Douglas_Johnston: Theoretically this operation can be done, but would require multiple incisions to do via a minimally invasive approach.  Our usual practice is to perform this operation via sternotomy in order to achieve a safe and durable repair.

Mar1130_1: When doing a mitral valve repair and a tricuspid valve repair, should another procedure for AFIB be done or would that resolve by itself with the repairs?

Dr_Douglas_Johnston: Great question. Most often we would perform an AFIB procedure at the same time, but the answer to whether the AFIB would go away on its own is not known. There is a trial organized by the NIH which is ongoing to answer this question.


Other Types of Heart Surgery

Jen: I am 33 years old and have a bicuspid aortic valve and coarctation including a small hole in my heart I am having symptoms but my doctor said he doesn’t think I am ready for surgery quite yet. I don’t like living with these symptoms including shortness of breath, palpitations, sometimes sharp pains in chest and blacking out every now and then. I want to do everything "normal" people can. What can I expect for surgery and can I get it done now? I just want to live my life... or what can i do to improve my life? I am 33 my weight is 118 lbs, 5'6 blood pressure 120/95 Thank you so much

Dr_Douglas_Johnston: Your symptoms sound very concerning. But without seeing your echocardiogram and other studies it is hard to say if you are ready for surgery. I would be happy to review your case. Please contact our resource center at 866-289-6911 if you would like to initiate this.

kathryn: I was just diagnosed with a cardiac lipoma intraseptal in the right atrium cephaled to the inferior vena cava. Can this type of cardiac tumor be removed from the right atrium robotically? I have several medical issues and would recover faster than with the traditional open heart procedure.

Dr_Douglas_Johnston: That is a very interesting question. And a tough problem to deal with. In order to answer the question regarding what treatment would be best for you we would need to go over your xrays, echocardiogram and other studies very carefully to determine what the best course is.


Post Surgery Healing and Recovery

Rangeman: If I fly from New Mexico to Cleveland for a mitral valve repair (or replacement), how long would you estimate it would be before I fly back if everything goes well in the procedure?

Dr_Edward_Soltesz: 10 - 14 days would be the usual course. The hospital stay would be about 3- 5 days and we would recommend to stay in the hotel a few days before traveling back. The majority of our patients are actually out of state patients and in the same situation as you are.

folmur: Doctor, My question relates to the recovery period and more specifically how long it takes post surgery (aortic valve replacement) to return to normal activities, including being active physically; will I be able to play hockey again?

Dr_Edward_Soltesz: You cannot do contact sports or heavy lifting for 6 weeks but you can do anything else as far as aerobic activity. After the healing of the sternum 6 weeks you can resume all activities. Obviously if you are on Coumadin for a mechanical valve you have to be careful with contact sports due to the blood thinner.

Nellie: For an 84 year old Caucasian male who is a candidate for aortic valve replacement & bypass surgery for a 90% artery blockage, what are the differences between stenotic & robotic surgery in the following areas of concern:(a) Length of time (hours) to complete the surgery(b) Recovery time (weeks)(c) Complete recovery time period (weeks)(d) When driving a car might be permitted

Dr_Douglas_Johnston: I believe you are asking about the difference between sternotomy and robotic surgery.  If what you need is an aortic valve replacement and bypass, robotic surgery is not likely an option.  For an operation done by sternotomy the surgery usually lasts about 3-4 hours.  At discharge patients may do any activities that don’t put pressure on the sternum (heavy lifting for example).  My patients are allowed to drive when they are no longer taking pain medicine and feel up to it – usually 2-3 weeks after surgery.  At 6 weeks they may return to full activity.

tarioko: Beyond the 10-14 days, when is the next follow-up (I am trying to plan a trip for my father; he will be flying from Indonesia).

Dr_Edward_Soltesz: Postoperative follow-up varies among surgical procedures and among patients. I would consult your surgeon regarding the timing of postoperative follow-up in your situation.

Nellie: How do you weigh the value of staying close to your support system at home versus going away to get the absolute best doctor?

Dr_Edward_Soltesz: This is a very common question we are asked to answer since many of our patients actually do come from out of state and even others from out of the country. Patient's should discuss with their primary care doctor, cardiologist, and family members the best arrangements for their healthcare.  Each patient's situation is unique.  Of course, following your surgical procedure, your rehabilitation can always take place near your home.

JMB: I am 4 1/2 weeks post-surgery. I continue to have significant pain

Dr_Edward_Soltesz: I would advise close follow-up with your local doctor and/or cardiologist to help with pain control and be certain there is no underlying condition that is exacerbating your pain.

JMB: I am 4 1/2 weeks post operative aortic valve surgery--minimally invasive procedure at the Cleveland Clinic. I am progressing on schedule re: strength and energy level and I have been following up with my cardiologist. The chest incisional area --both deep and at the surface--remains significantly sore and tender. My level of discomfort remains persistent. Is this to be expected and when is it reasonable to expect this pain/discomfort to begin to subside?

Dr_Edward_Soltesz: Patients vary greatly in their recovery after heart surgery.  While some may be back to their usual selves within one or 2 weeks, others may require a few months.  I would be certain to follow up with your local physician who can more carefully gauge your recovery

slaughterhill: Estimated time lapse after surgery to resume normal activities.

Dr_Edward_Soltesz: Once patients leave the hospital, they can usually return to normal activities that do not make them too uncomfortable.  We recommend patient's refrain from lifting objects more than 10 pounds and from driving for approximately 4-6 weeks after surgery.  This is the time that is usually necessary for the sternum (breast bone) to heal.

roullac: As a patient who had mitral valve repair 18 months ago approximately, what would be the amount of daily caffeine that I could have? Would that include herbal teas as well?

Dr_Edward_Soltesz: Caffeine should not affect the mitral valve. There is no specific restriction on caffeine or herbal intake aside from general moderation.

Nellie: After surgery, will I be able to go home (I’m an 84-year old male who lives alone)?

Dr_Edward_Soltesz: I would recommend that he would spend some time recuperating in a rehabilitation facility.  These facilities are geared toward getting patient's back to their usual activities.

RHow: I am having mitral valve surgery. I am concerned because I have been reading that so many valve surgery patients experience problems like fluid in the lungs or around the heart, atrial fibrillation, elevated blood pressure, etc. following surgery. What can I expect following my surgery at CC? Thank you, Ruth Howell, Maine

Dr_Edward_Soltesz: The problems you speak about are actually common to most open heart surgeries.  Patient's typically stay in the ICU for one to 2 days and then transferred to a regular hospital room.  During your 5-7 days in the hospital following her surgery, your team will focus on removing excess fluid, exercising or lungs, and getting you back on your feet.

RHow: I am having mitral valve surgery. I am very concerned about post-operative pain because I am unable to take many of the meds usually used for pain such as Percodan, etc. How will my pain be managed if I cannot take Percodan-related drugs? Thank you, Ruth

Dr_Douglas_Johnston: There are a number of drugs which have similar action to Percodan but are not chemically similar.  We are often in the position of dealing with medication allergies and intolerance, and can rely on our pain management service to help in these cases.

Nellie: What are the factors in determining the length and focus of cardiac rehabilitation?

Dr_Douglas_Johnston: Cardiac rehab is designed to help get you on your feet and maximize your cardiovascular health and energy level.  There is no set length of time, rather your own progress through the program will determine the length of time in rehab.

Nellie: Rather than reinvent the wheel, are there resources to help me know what I & my loved ones can do to help me be more comfortable throughout the surgical and recovery process?

Dr_Douglas_Johnston: There are a number of educational resources available on the internet.  We provide patients with a binder full of educational materials when they come for their consultation.  In addition, many of my patients have found the book “A Patient’s Guide to Heart Valve Surgery” helpful.

captain gene: I had a triple bypass and got blood clots in my leg and lung and blood pressure low and causes me to get light headed, surgery was Dec 3 and still unable to go to rehab help

Dr_Douglas_Johnston: I am sorry to hear about your troubles.  Sometimes when patients develop blood clots after surgery and are placed on blood thinners they can develop a collection of blood around the heart which can make the blood pressure low.  I would be concerned that you see your cardiologist and surgeon and be sure you have had an echocardiogram.


General Heart Surgery Questions

katylou: I have not had a catheterization yet, is it necessary to have that done before surgery?

Dr_Edward_Soltesz: We recommend a cardiac catheterization preoperatively in patients with family histories of coronary disease or who are 40+ years of age.

Nellie: What specific, detailed patient data is required for a consultation with a cardiac surgeon to determine the need for an aortic valve replacement and bypass surgery? And what would I expect would happen?

Dr_Douglas_Johnston:   Typically, cardiac surgeons require a quality transthoracic echocardiogram, a left heart catheterization, a chest x-ray, routine blood work, and a detailed history and physical to determine whether or not a patient requires aortic valve replacement and coronary bypass surgery.  Other tests may be required based on the patient's medical problems and physical examination.

adourian: When I get close to needed an aortic valve replacement I will, in all likelihood, be hopping a plane to Cleveland. I am told that as I get closer to needed a new valve I will need to have a "T" or an angiogram to determine specifically what needs to be done and how. Does it matter when these tests are preformed...locally or at Cleveland?

Dr_Douglas_Johnston: If possible we would arrange the tests to occur in Cleveland right before your surgery to make things as convenient as possible for you.  We do have many patients bring outside studies but sometimes these are not complete enough and need to be repeated.

Nellie: How do you know you really do need heart surgery? What tests would I expect to have done and what significant data would I expect to see that would lead to the need for surgery?

Dr_Douglas_Johnston: See the answer to question above.  The best way to have a frank discussion with your surgeon.

Nellie: What do you do if you can’t come to the Cleveland Clinic?; What should I look for in a surgeon & hospital and how can I find the right doctor?

Dr_Douglas_Johnston: The good news is most patients are eligible for care at the Cleveland Clinic, and we do our best to make it easy for out of State patients to come to the Clinic for care.  That said there are very good valve surgeons in many parts of the country.  Researching the volume and experience of the heart surgery program and finding a surgeon with whom you have a good relationship are very important.

Yvonne: Research that I have read, has said the onyx valve which is in trial, will possibly be the first mechanical valve that will not require warfarin and maybe just low dose aspirin. What is your opinion?

Dr_Edward_Soltesz: The Onyx valve is a very good mechanical valve. I, too, await the results of these trials.

Nellie: Would robotic or stenotic surgery be an appropriate choice for an 84 year old Caucasian male diagnosed 4 years ago with atrial fibrillation & a 90% heart artery blockage and, more recently, with aortic stenosis?AM Medications• Diltiazem XT (300mg capsule)• Lisinopril (10mg tablet)• Furosemide (20mg tablet• Vitamin C (500mg tablet)• Centrum multi-vitaminPM Medications• Simvastatin (40mg tablet)• Omeprazole (20mg capsule)• Warfarin (5mg tablet)• Omega 3 Fish Oil (1200mg)• Vitamin D3 (1000IUs)

Dr_Douglas_Johnston: Based on your list of medications, I suspect there are a number of medical conditions we would need to evaluate in terms of making a recommendation for surgery. I would be happy to look at your records and studies to provide a more knowledgeable opinion. My office number is 216-444-5613.

Nellie: Should I get a 2nd and 3rd opinion before making a decision about surgery?

Dr_Edward_Soltesz: All patients should feel comfortable with the surgical procedure they are undergoing.  For some patients, a single opinion is adequate, while for others, 2 or 3 or more opinions may be necessary before they feel comfortable to make an informed decision regarding their care.

Nellie: Does it make sense to take a tour of the hospital before my surgery to ask staff to walk me through what will happen during the surgery and afterward?

Dr_Edward_Soltesz: Most hospitals will provide patient's with a video that walks them through various stages of their stay. You can certainly ask for a tour of the hospital.

tarioko: Is there a possibility that the heart will not work afterwards?

Dr_Edward_Soltesz: This is a very rare complication with modern cardiac surgery and usually is only limited to patients who have severely reduced heart function before surgery.

katylou: My cardiac surgeon is watching the valve with echo cardiograms and is not saying other than each cardio is worse.

Dr_Edward_Soltesz: I would stay in close contact with your surgeon and cardiologist. They will recommend when you need your valve replaced.

Nellie: What are the decision points for deciding if a person is a candidate for minimally-invasive surgery?

Dr_Douglas_Johnston: This depends mostly on the type of operation we are planning. Minimally invasive surgery is most appropriate for isolated valve repair or replacement, some ascending aneurysm repairs, and some types of bypass surgery. In general the combination of valve and bypass surgery means sternotomy is more appropriate.

Nellie: Should I instruct the medical team to keep me under anesthesia until they could remove my breathing tube?

Dr_Douglas_Johnston: Each anesthesia program and ICU has a protocol for weaning patients from the ventilator and extubating them safely.  Removal of the breathing tube is a critical part of the early recovery from surgery and should be done according to the best judgment of the ICU team taking care of you. 

vanjeda: Is it still possible for someone with a blood clotting disorder (antiphospholipid syndrome) to do minimally invasive surgery, or is the risk significantly higher and hence, not worth it? To clarify, the surgery type to the previous question, it is an anterior mitral valve prolapse.

Dr_Douglas_Johnston: There should be no difficulty with a minimally invasive procedure in the setting of antiphospholipid antibody syndrome.

mstone0815: Is it true that repairs done utilizing the DaVinci robot can only be performed one time? More specifically, if the repair fails, can it only be re-operated on via full sternotomy?

Dr_Douglas_Johnston: It is not always true that a sternotomy is required for reoperation, but in most cases sternotomy is the safest approach.


Non-Surgery Questions

Honnie: I had open heart surgery in 1991 & 2001 again at Cleveland Clinic. Been very well until pneumonia bout in September 2010. I am 79 yrs. old & now have A-Fib really bad. Exhausted & out of breath. My cardiologist does not think I should have any more surgery. Can you tell me what, if any, options I might have to feel healthy again? Thanks.....my name is Honnie.

Dr_Douglas_Johnston: I’m sorry to hear that you are feeling so badly. Without knowing more about your history and how your heart is doing now I can’t say what treatments might help you.  I would be happy to review your records.

coshocton: Thank you for your time today. Is there a correlation between thyroid disease and heart disease?

Dr_Edward_Soltesz: Some research suggests a link between hypothryroidism and heart failure.

CHAUMONT: I have SVT. I had a stress test and was in tachycardia for hours. I am on cardizem 180 mg. It seems to work but sometimes my heart seems to skip a beat. The dr. wants to do the procedure rather then increase the meds. Also, have 3 mildly prolapsed heart valves. Does this contribute to the electrical problem? If, I am on a low dose of cardizem-could it not just be increased? I feel fine most of the time, but do retain fluid on the medication. That procedure is nasty, I have heard.

Dr_Edward_Soltesz: Typically, mild prolapse of heart valves does not directly contribute to SVT. I would consult your cardiologist for medication adjustment.

CHAUMONT: I had a question about SVT. I had a stress test and was in tachycardia. I am on cardizem 180mg. I also have 3 mildly prolapsed valves. Does this effect the electrical part of your heart. Sometimes, it feels like my heart skips a beat but not fast. The Dr. here would rather do the procedure then increase medication.

Dr_Douglas_Johnston: I think your question is asking whether valve disease can affect heart rhythm..  The answer is yes.  In many cases valve disease can cause structural changes in the heart muscle which affect the electrical conduction of the heartbeat.  There are a large number of different types of arrhythmias which affect our patients, some of which are best treated with a procedure.  This is often a complex decision which requires a thorough evaluation with an expert electrophysiologist.

Peppy: Fish oil raises my LDL. Is this common? Is it unhealthy for a heart patient?

Dr_Douglas_Johnston: Certainly an elevated LDL is something to be avoided. I would suggest discussing this with your primary care doctor or cardiologist and making an overall plan for control of your cholesterol.

vikram: HELLO DOCTOR--I AM AN ASIAN / INDIAN MALE OF 45 YEARS AGE LIVING IN U.K -MY MEDICAL HISTORY IN BRIEF IS--- 1)M.I. IN 2003 +ANGEOPLASTY & STENTING IN THE PROXIMAL LAD. EF 32% ---2)AFTER FIVE YEARS IN 2008-CARDIAC ARREST +ICD IMPLANTED+ EF IS NOW 21%- MY QUERRIES ARE--HOW DID THE EF GO DOWN FROM 32 TO 21 IN FIVE YEARS WHEN I WAS TAKING REGULAR MEDICINES- WHY DID THE CARDIC ARREST HAPPEN IN 2008 AND NOW IN 2011- I HAVE BEEN DIAGNOSED A CLOT IN MY LV- I HAVE STARTED WARFRIN. PLEASE CAN YOU TELL ME WHAT I CAN DO NOW- REG. MY LV CLOT AND OVERALL HEART CONDITION.

Dr_Douglas_Johnston: Unfortunately, I would need to your echocardiogram and left heart catheterization to fully understand your situation. I suspect that you have ischemic cardiomyopathy, that is, blockages in your coronary arteries have progressively caused muscle loss and reduced the function of your heart.  The left ventricular clot as a result of the poor function of the tip of your heart. There are multiple options available from medications to surgery for your heart problem.

rogelio2754: My echocardiogram showed that I have some leakage and that the valve was bicuspid. I take medications for thyroid, prostate, and testim for testosterone (had testicular cancer and one testicle removed). My questions are as follows: 1. Can aortic valve leakage prevent the heart rate from increasing on a stress test?

Dr_Douglas_Johnston: Aortic regurgitation (leakage) can have effects on the heart rate.  What is important would be to know how severe the leakage is and whether the heart function is affected.

roullac: I had mitral valve repair (median sternotomy) in August 2009 - 16 months ago. My valve is working fine - no regurgitation. During my last routine check up my cardiologist noticed something different when he performed an echo - doppler. He feels that this is post surgery related and the comments on his report is: paradoxal movement of IVS - possible collection of blood behind the posterior leaflets. How serious could that be and what treatment would it be required if any? I am really worried and very anxious as I thought that everything would be o.k. and I would be able to get on with my life. Despite suffering post surgery complications such as fluid in my lungs, my surgery was successful. Thank you.

Dr_Douglas_Johnston: Based on your description, I do not think that there is a major concern.  However, I would need to review the actual echocardiogram to be able to say with certainty this is the case.

Peppy: Do low doses of Crestor reduce plaque build up as well as the higher doses? I can tolerate 5mgs. My LDL is 49, tri's 53, total 115.

Dr_Douglas_Johnston: I would defer that answer to your cardiologist.

Reviewed: 02/11

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.

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