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Ask the Heart Surgeon (Dr Lytle 11 23 11)

Wednesday, November 23, 2011 - Noon

Bruce Lytle, MD
Cleveland Clinic Miller Family Heart &
Vascular Institute Chair


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 the chairman from Arnold Miller Family Heart & Vascular Institute at the Cleveland Clinic, in a secure online setting.

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Cleveland_Clinic_Host: Welcome to our "Ask the Heart Surgeon" online health chat with Bruce Lytle, MD. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us, let's begin with the questions.

Aortic Valve Surgery

dsivyer: Dr. Lytle. I am a 53 yo male who underwent AVR in May 2011 at CCF. Dr. Svensson was my surgeon. He and the team at CC were outstanding. My pre op diagnosis was severe aortic stenosis with some level of regurgitation in both mitral and aortic valves. No treatment for the mitral valve was deemed necessary. I am recovering well and all of my post op visits to my local cardiologist identified NO heart murmur as recent as October of this year. I relocated to Dallas in September and my new cardiologist commented during my initial exam I have a heart murmur. I am scheduled for another echo next week to obtain a new baseline. I find it odd that I could now have a murmur when one was not present just last month. Is this concerning? Thank you.

Dr__Lytle: I don't think that it is concerning. Most patients with a prosthetic heart valve of any kind will have some type of murmur with auscultation. The definitive examination for examining the function of the valve is an echo.

blamon: For a patient that will undergo aortic valve replacement and repair of ascending aortic aneurysm, do you have a recommendation of a specific type of valve and manufacturer?

Dr__Lytle: Those recommendations are different for different patients. The factors of age, co-morbidities, and the patient's wishes in regards to taking Coumadin and any contraindications to taking Coumadin are all important. In most circumstances we use biologic valves in order to avoid taking Coumadin. This is a complex question, patient preference is a factor and the question should be discussed in depth with your doctors.

PatC: 1. If one's own defective adult aortic valve is unusually small, can they still have a tissue valve replacement or must they have a mechanical valve? 2. If one postpones aortic valve replacement [due to stenosis] because they do not have the typical "triad" of symptoms[CHF, angina, syncope] isn't the risk of aortic root enlargement an issue and concern? Aortic root measurements don't seem to be routinely done when aortic stenosis is diagnosed. Why is this?

Dr__Lytle: We always measure aortic root diameter when assessing a stenotic aortic valve. If the aortic root is small, it is still possible to have a biologic valve but it may be necessary to enlarge the aortic root or to use an aortic root homograph.

Venhuizen: For an very active 74 year old male, what type of valve is best?

Dr__Lytle: Some type of biologic valve we believe.

cc2011as: How do you know when the symptoms of Aortic Stenosis are severe enough for surgery?

Dr__Lytle: Anyone that has any symptoms caused by aortic stenosis that is severe is probably a candidate for surgery. Once symptoms develop from aortic stenosis the time period where severe problems can develop is relatively short.

Gizmo: My question is about post-op exercise. I am male, 33 yrs old, had my bicuspid leaky aortic valve repaired on August 29 2011, post-op echo looked good (I am on 12.5 mg/day of metoprolol) and I feel fine (sternum feels healed). My questions: 1. What heart rate do you recommend I stay under during exercise? 2. Does lots of exercise harm the repair at all, or have any effect on the sufficiency of the valve? 3. Aside from avoiding high-impact activities, are there any other things to avoid, such as prolonged (more than 30 mins) cardiovascular activity? Thank you!!

Dr__Lytle: The exercise issue after operation for a bicuspid aortic valve tends to depend upon issues in regard to the aorta. If the aorta was not replaced during the surgery it is probably a good idea to avoid isometric and heavy weight bearing exercises. Aerobic activity, regardless of length, should be acceptable.

toddqma: I am a 53 year old man with severe stenosis of my aortic valve. With the exception of this little problem I am quite healthy and fit. I have heard that the On-X mechanical valve has claims that they are safer and have reduced risk of blood related problems. Is this a suitable substitution for the more established and proven mechanical valve products on the market?

Dr__Lytle: The On-x valve is a reasonable choice as a valve substitute but the length of follow up is less than some other mechanical prostheses. At present, there are not data that clearly indicate that one mechanical valve is better than another over time.

sarczar: If a bovine biologic valve an last up to 20 years, why does Edward's show a mortality range, on average, of about 10 to 12 years in their literature?

Dr__Lytle: I am not sure which literature you are referring to. But - valve failure is a different end point than patient mortality. Many aortic valve replacements are done for patients in their 70s and 80s and so their life expectancy will be somewhat limited. We are not yet aware of anyone we have made immortal with valve replacement surgery.

toddqma: Do you recommend a tissue aortic valve for young healthy adults, favoring the risk of reoperation over the long term risk of Coumadin use

Dr__Lytle: Most of the time.

karodonnelly: My mother who is 81 has severe aortic valve stenosis and needs a new hip. She has been told that she is too high risk for surgery. Her EKG shows sinus 66 beats per min. with left bundle branch block. 44mmHg - outflow track. Are there invasive procedures that would benefit her. She is in a lot of pain with her hip, but we need to address the valve first.

Dr_Lytle: There are a variety of procedures that can be done to make your mother's aortic valve better including replacement.

Very few patients are absolutely too high risk to have aortic valve replacement depending upon their alternatives. We would be glad to review your mother's information should you wish.

Dave_s: I am 77 years old. About six weeks ago, I had open heart surgery to replace a leaky aortic valve with a pig’s valve. Just before the surgery, my ejection fraction was 45 to 50%,and I experienced no known symptoms of heart failure. After the surgery, my ejection fraction was 25 to 30%. Two weeks after the surgery, I was rushed back to the hospital with congestive heart failure symptoms. With treatment and the addition of pills (e.g.Lasix, Coreg, Lisinopril), the heart failure symptoms have diminished, but I am concerned with the decreased ejection fraction. Is it quite common, or is it only an occasional occurrence, that it will drop after this surgery? Is it often just a case of getting worse before getting much better? The reason I had the surgery in the first place was to avoid being a walking time bomb. Also. my episodes of Atrial Fibrillation have increased and are more debilitating. (I have taken Digoxin for many years.)

Dr_Lytle: Normally the ejection fraction does not drop after aortic valve surgery. It is possible with severe insufficiency before the operation to see this problem and to have symptoms of congestive heart failure. If your valve is working well the best initial approach to treatment probably is treatment with anti-heart-failure medications. If you would like us to review your situation, we would be happy to do so.

By the way, atrial fibrillation is relatively common after open heart surgery regardless of whether or not it has occurred before surgery. Those issues tend to resolve with time

dsivyer: Prior to my AVR surgery due to severe AS I had several months of hemoptsis. I have heard differing views on the commonality of this symptom/condition. Can you comment on this please?

Dr_Lytle: Hemoptysis is usually not caused by aortic stenosis and when it occurs we would look for another cause besides AS.

Venhuizen: For aortic valve replacement, what determines whether minimally invasive/robotic surgery is possible?

Dr_Lytle: The need for procedures in addition to the aortic valve replacement makes minimally invasive approach more difficult. Also the patient’s body habitus can have an impact.

flagal46: Is it best to have cataract surgery prior to or after aortic valve replacement? Should I take antibiotics for this

Dr_Lytle: If your aortic stenosis is severe it is usually best to have this treated before having other procedures.

Sept14: What is the risk of both temporary and permanent A-Fib after aortic valve replacement surgery? If a tissue valve is implanted, and a second or third operation performed later, does the risk of developing A-Fib increase with each surgery?

Dr_Lytle: It will be the case that patients with bioprostheses will be able to have a second valve procedure carried out with the use of transcatheter valves. Whether that procedure will be safer than open reoperation, we don’t yet know, and that strategy is not yet approved in the United States. In general, the minimum valve size that appears to lend itself to implanting a transcatheter valve is 23 mm. or greater. I think it is highly likely that in the future valve and valve re-implantations will be possible. Whether they will be desirable as yet remains to be seen.

The likelihood of temporary atrial fibrillation occurring after aortic valve replacement surgery is around 25 to 30%. The risk of atrial fibrillation in any situation increases with increasing age and with the length of time that someone has had valve surgery, so a second operation is more likely to have atrial fibrillation than a first operation, in part because they are older.

lydia: Can biological valve ever be considered for an adolescent [ my grandson is 13/6 yr old 6' 4''] with AS and severe AI after balloon catheterization instead of mechanical valve if teenager does not want to take warfarin and wishes to lead a more active/normal life? what are statistics for how long biological valve can last before reoperation becomes necessary?

Dr_Lytle: The risk of aortic valve replacement for a patient in their mid 30s is extremely low. If someone is in good health at that age group, the risk is probably somewhere in the neighborhood of 1 in 400 operations in an experienced center. Second operations do not appear to carry with them much of an increased risk relative to first operations when the factors of age and co-morbidities are accounted for. Third operations are less common and there is less information associated with those situations but in our studies of our own patients, most of the risks are associated with co-morbidities rather than the number of operations.

Valve replacement in a teenager is a difficult issue. In general, all types of biologic operations deteriorate faster in younger patients than in older patients. Because it is less likely that teenagers would need an aortic valve replacement, there are many fewer statistics associated with those outcomes in that age group. In general most people would feel that if a biologic valve implanted in a teenager would last for 10 years that would be pretty good at that point. There are other more complex operations available and their advisability really relates to the details of what is going on. We would be happy to review your grandson’s data should you wish.

Sept14: Please compare the advantages and disadvantages of the Edwards Magna and the Medtronic Mosaic aortic valves, specifically expected longevity, opening area and performance, and viability for future transcatheter procedures.

Dr_Lytle: The Edwards Magna and Medtronic Mosaic aortic valves are both valves that are used in America today in relatively large numbers. In adequate sizes we believe that both valves will be available for future transcatheter procedures. There has not been a clear separation in longevity between these 2 valves in part because neither has been followed for a dramatically long period of time.

AlStough: I am a 74 yr old male diagnosed with moderate to severe aortic stenosis. Would you please discuss this condition along with treatment options. Are non-invasive procedures available and/or recommended? Thanks

Dr_Lytle: Aortic stenosis is a problem that is highly likely to need surgery at some point in time for someone that is 74 years old. Today the only real treatment option is aortic valve replacement. Conservative operations on calcific aortic valves have not proven to be durable. There are less invasive operations available for patients in their 70s with severe aortic stenosis as long as they don’t have other conditions that make less invasive surgery undesirable. We would be happy to review the details of your situation should you wish.

Transcatheter Aortic Valve

lmstill: What is the down side of transcath placement of a new aortic valve vs open heart surgery replacement?

Dr_Lytle: There are a series of trials that are designed to provide the answers to those questions. The concerns about transcatheter valve replacement that are so far: risk of stroke; risk of periprosthetic leak; the risk of rhythm disturbances including heart block; and the unknown longevity of transcatheter valves.

sarczar: How far along is the Cleveland Clinic on replacing Aortic valves via catheterization instead of incisions?

Dr_Lytle: We have performed over 200 transcatheter aortic valve replacements. I do not do this type of procedure myself but many of my colleagues do.

oldblueeyes: Hi, I have a bovine aortic valve and it will need to be replaced at some time in the future, is open heart surgery my only choice.

Dr_Lytle: At the present time it is the only choice available in America.

We would anticipate that transcatheter valve re-replacement will be possible in the future. We don't yet know whether it will be better and for whom it will be better.

alvine38: are there less invasive techniques to replace aortic valve then breaking the ribs?

Dr_Lytle: Ribs are rarely broke to replace the aortic valve - the standard incision is a median sternotomy which does not break ribs. There currently are transcatheter aortic valve strategies that are being investigated.

Sept14: I understand that the Edward Sapien transcatheter aortic valve was recently given FDA approval for otherwise inoperable patients. Please discuss your expectations for the evolution of catheter valve replacement, specifically the likelihood it will be approved for younger and lower risk patient groups. Also, are there any limitations in applying this technology to patients who already have a bioprosthetic aortic valve? Is there a minimum valve size that would be required to successfully implant a catheter valve and not negatively impact the opening area? Current first time aortic valve replacement patients must consider all of these things when evaluating the long term impact of valve choice, so thanks for any advice you can give on reasonable medical expectations for the future.

Dr_Lytle: We believe that transcatheter aortic valve procedures will have an important part in the treatment of aortic valve disease in the future. At the present time the valve has been approved for use in “inoperable” patients. Patients that are not “inoperable” still can receive the valve when involved in specific clinical trials.

Sept14: Are the higher stroke events in transcatheter aortic valve replacements a fixable problem? Is it both a short term and long term risk? Is the use of an increased blood thinning regimen such as Warfarin being considered?

Dr_Lytle: The higher stroke events in transcatheter aortic valve replacement probably is a situation that there are least approaches to trying to diminish. The devices that are designed to lower the risk of stroke events are themselves investigational devices at this time. There is clear evidence that the transcatheter valve results in a slight increase of stroke events over the short term. The long-term risk is less clear because the long-term follow-up is less robust. We do not believe at the present time that warfarin is likely to be effective in preventing these events as at least some of them probably are on the basis either of calcific or atherosclerotic embolization at the time of the procedure.

Aorta Surgery

FB-Bonnie: At what point is it "time" to have surgery on an aortic root aneurysm (4.3 CM)with a leaky valve, moderate regurge and a family history or aneurysms?

Dr_Lytle: Unless you have a clear collagen vascular disorder, it is not yet time to have surgery. If the aortic root shows evidence of a clear increase in size over a short period of time, that is an indication for surgery.

Also, if the valve leakage gets worse that also is a potential indication for surgery.

Chettt: In addition to some valve problems associated with childhood rheumatic fever, I have a dilated aorta. The dilation has progressed to the point where it will have to be addressed soon. I am concerned about the repair that will be required. The latest information I can find suggests that the most successful surgery involves remodeling the aorta and supporting it. I also understand that one of the problems with this procedure is that the support is abrasive to the aorta. I am a tennis player, and it seems to me that such activity may be contra-indicated after this surgery. Will I have to give up playing tennis? What is the latest as regards this issue?

Dr_Lytle: If you have a dilated ascending aorta associated with aortic valve disease the most likely cause is not rheumatic fever but a congenital abnormality called a bicuspid aortic valve. In such situations the most successful surgery usually involves replacing the aorta rather than “supporting it”. There are times when the aortic valve is supported by the aortic graft which is called aortic valve reimplantation, but in most circumstances involving an ascending aortic aneurysm the aorta is replaced with a Dacron graft. Most of the time if someone has an operation for an aortic aneurysm they are able to play tennis afterwards. If you would like us to review your data we have a method to send in records for surgical review.

cc2011as: I have an AV Area Cont Eq vti of 0.82. Is it too early to be consulting with a surgeon about my surgery?

Dr_Lytle: That is a range of valve area where consideration of surgery is reasonable although the valve area itself is not an absolute indication for surgery.

Symptoms and exercise capacity also play roles in determining surgery.

RVer: In 2009, Dr. O.H. Frasier in Houston repaired a 6cm ascending aortal thoracic aneurysm and Dr. R. Delgado repaired 2 blockages. I currently have a 3.7 thoracic descending aortal aneurysm and a 4 cm abdominal aortal aneurysm. Currently I have scar tissue affecting my ureter (I have had 4 kidney stent exchanges). Can this scar tissue be eliminated?

Dr_Lytle: I think that would be a difficult operation although I am not a urologist.

Mitral Valve Surgery

alyoun: Hello I have been told by my cardiologist that I need mitral valve surgery before the end of January and I am researching a place to have surgery. Any information you can give me would be appreciated: What type/manufacturer of mitral heart valves do you prefer to use for someone age 65?I s there a big difference in manufacturers? What’s better mechanical or tissue? Do you prefer to repair or replace a mitral valve? Can you tell before surgery if repair is an option? How long does a repaired valve last? How long does a replaced valve last? How long does mitral valve surgery take? What is recovery from surgery like? How long till I can fly home? How long till I can drive? How long till I can exercise/have sex? What’s the mortality rate for mitral valve surgery at the Cleveland Clinic? Does the Cleveland clinic have nurses in recovery whose only task and specialty is cardiac care?

Dr_Lytle: In most circumstances we prefer to repair rather than replace mitral valves. That is possible about 90% of the time. And - in our experience when repair is possible, the valve functions for at least 10 years about 90% of the time.

When the mitral valve must be replaced, we usually use a biologic valve for someone 65 years of age and older.

duffer50: I am a 63 yr old female that was diagnosed with permanent afib and mitral valve regurgitation ( lay terms?) in May 2011. As a child I had rheumatic fever and a heart murmur. I have 50 % the energy I used to have and wondered if you feel the patient has a right to request a mitral valve repair, even if the tests don't show that I need one yet? I was a very active woman, loved to play golf frequently and feel like my quality of life is not acceptable with this heart problem.

Dr_Lytle: The critical issue is whether or not your disability is caused by your cardiac problem. That can be a difficult determination. If you would like us to review your records we would be happy to do so.

sherry_m1: I had open heart surgery in June to repair my mitral valve. Since that time I've had a hard bump by the incision that doesn't appear to be going away. It sometimes burns in that area when you move a certain way. Is there something that can be done about this? Also, I'm still short of breath quite often which is actually worse now than before the surgery. Is there something specific I should look into doing other than just continuing to exercise?

Dr_Lytle: Your residual shortness of breath is unusual this late after heart surgery. An echocardiogram to assess your valve is a good idea. A chest x-ray may also show up other causes of shortness of breath.

In regard to your incision, I would not do anything this early after operation. It may get better.

tractorgirl: I am a 59 year old female who had mitral valve repair in June. The valve had failed due to an underlying connective tissue defect. I was told there is a 95% chance that this is a lifetime repair. Is this a nationwide average or Cleveland's average? How does my connective tissue disorder affect the probability of reoperation in the future?

Dr_Lytle: The 95% success rate relates specifically to the Cleveland Clinic experience. If you have a connective tissue disorder, the likelihood of reoperation over your lifetime is greater than if you do not. Both for mitral valve problem and for other problems that may develop that do not involve the mitral valve.

tractorgirl: Are there tests to identify the type of tissue disorder? I was told the tissue was overly stretchy and fragile.

Dr_Lytle: There are clinical and genetic tests to examine connective tissue disorders.

It matters what particular connective tissue disorder you have.

cowrie: Hi, Dr. Lytle, Thank you for hosting this event. I want to ask you about my father's condition: he is 58 and has rheumatic heart disease for many many years, mitral valve calcified, moderate to severe regurgitation and stenosis. for this type of patient, you prefer to do tradition open heart surgery or small incision surgery? what kind of valve you will use? and which brand of the mechanic valve is the best so far?

Dr_Lytle: If the valve and the valve annulus is severely calcified we would use standard open heart surgery approaches. No studies have shown a particular advantage for one mechanical valve over another at this point.

For someone 58 years old we would use either a biologic valve or a mechanical valve depending on their rhythms, their risks of taking Coumadin and their wishes.

cowrie: Follow with my father's calcified mitral valve replacement surgery questions. he also has atrial fibrillation and had a pacemaker. does that mean he will do better with bio valve?

Dr_Lytle: It depends on his age and co-morbidities.

dffcpo6577: I am a 65 year old runner. After mitral valve repair surgery using a partial sternotomy can I expect to get my stamina/endurance back fully? If so about how long? Great article in PD; CCF should be commended for allowing the reporters such access. Thanks.

Dr_Lytle: We would expect that most 65 year olds would be able to resume the activities after surgery they were capable of before, including.

Duckfoot: I am 78 years old, have permanent Afib and mitral valve leakage and a 45-50% ejection. Should I watch and wait or have a repair/

Dr_Lytle: It depends on how bad your mitral insufficiency is and the cause - and how symptomatic you are. We would be glad to review your medical records should you wish.

Schwam17: What type of improvement in mitral regurgitation would you expect in a patient over age 80, with a grade 3+ mitral regurgitation who undergoes biologic mitral valve replacement? Also, what level of improvement would you expect in cardiac output?

Dr_Lytle: with a mitral valve replacement there should be no mitral insufficiency. The improvement in cardiac output will probably depend on the pumping capacity of the left ventricle than the amount of mitral insufficiency.

Valve Disease

lmstill: When does one HAVE to have an aortic valve replacement rather than live with the symptoms? What are the most common sx you see in pre-op patients?

Dr_Lytle: Most patients with aortic stenosis that is causing them to have symptoms should have an aortic valve replacement. The most common symptoms are shortness of breath with exertion.

John_C: I have developed an aortic insufficiency at age 50 or so and am 67 now. The valve is restricting the blood flow some. I also have a mitral valve prolapse. I read where parents of Noonan's Syndrome children sometimes develop the aortic valve problems, aortic aneurysms or maybe connective tissue issues. It looks like mine are mild or less severe at this point but I do worry or wonder about what I should do to inquire or monitor possible complications. I did have a stent put in back in January, 2008 at Fairview Hospital Heart Center. I do get semi-annual exams with my doctor and his group in Fairview Park. I do discuss things with him. What should be my concerns about the future as I age?

Dr_Lytle: Serial echocardiograms can assess the rate of valve deterioration with time.

It is not necessary to have a perfect valve in order to function very well - if the valve leaks a little bit that is not necessarily a problem.

PatandMike: I have been diagnosed by a cardiologist as having aortic stenosis with a bicuspid valve. For the past several months (beginning about 2 months after my semi-annual appt.) I have had general chest soreness, especially in pectorals. If I tense these muscles, I can especially feel it. I jog (until lately) and I have had to stop due to pain in that area after just a few minutes at a moderate pace. Pain was about 7/10. Pain stopped about 1 minute after I stopped jogging. Once I walked for 10 minutes, resumed jog, and there was no pain. Just last night I could only go 3 minutes at 5.1 mph, twice with a walk in between, before a bit of pain and some shortness of breath. I used to jog a 6 mile route last year; only 2.3 miles this year. Please advise.

Dr_Lytle: If you have severe aortic stenosis that may cause you to have angina, which is exercise related chest pain. It is also possible that you can have co-existent coronary artery disease that combines with aortic stenosis to cause you to have angina.

I would advise you to stop jogging until these issues are resolved with diagnostic tests.

fit4life: I am a 58 year old male diagnosed with persistent A-fib and moderate to severe aortic stenosis resulting from a heavily calcified bicuspid valve. I presently jog about 4 miles/day. Is this level of exercise likely to accelerate or acerbate either or both of my heart conditions?

Dr_Lytle: It depends on how severe the aortic stenosis is. Exercise probably will not make the AS get worse faster but if the AS is severe, there is some risk of exercise related sudden death.

An exercise test under supervision may help resolve the question of whether or not you should jog.

Yram22: My 21 year old daughter had her wisdom teeth out 2 years ago, had gum infections treated twice with clindamyacin, then had c. difficile as a result, 2 rounds of metronidazole, and then felt a pinch in her neck and has left sided paresthesias since then (face, arm, leg). Last year she started having severe facial pain and ongoing dry eyes (despite Restasis and punctal plugs). C1C2 instability was ruled out. Initial MRI fine (small ethmoid cyst seen) and CT scan fine but a while after these tests her face pain started, so she's having a second MRI now. Blood work was all fine except a recent test which showed fairly elevated p-anca levels (anti-MPO)....what does this mean? Could this be heart or vascular issues causing all the symptoms? What would be your diagnosis/thoughts?

Dr_Lytle: From your description it does not sound like heart and vascular issues are the most likely cause of your daughter’s problems. Facial pain is not one of my specialties and I’m not exactly certain what to give you in terms of a possible diagnosis but should you wish to send us your information we can get one of my colleagues that does have expertise in this area to look at it.

Coronary Artery Disease and Bypass Surgery


Dr_Lytle: At this point there is not good evidence that there is some form of treatment that will “clear out” arteries that are affected with atherosclerosis. There are, however, treatments that have been shown to decrease the likelihood of future bad events caused by coronary artery disease and those include taking statin type drugs, taking platelet inhibitors, and eating a relatively low fat diet.

In regard to any invasive treatments, the logic really relates to the specific problems that you have and we will be happy to review your information should you wish.

clara: I had bypass surgery and the last 3 years I have had 6 stents - 2 of them 5 weeks ago. They are DES - 2.5mm although the last one in the L M is 3,o. I also have 2 grafts. My concern is will they be able to keep stenting these arteries. I guess I want to know if I continue this path, will I possible face bypass again. I was told that I have an aggressive disease that is not connected to cholesterol. My stents are Xience V

Dr_Lytle: You have a complex situation that needs review in detail. Briefly there is a limit to the value of stenting and whether or not you need bypass surgery again is difficult to predict. It is good that you do have two bypass grafts working. Your problem is not common and should you wish we would be happy to review your information in detail.

nadiadncr: My dad who lives in Greece had an nstemi HA last week. Angiogram showed:Left coronary artery Anterior descending diffuse atherosclerotic vessel with successive bottlenecks until Section 80%Circumflex: vessel diffusely atherosclerotic particularly in the distal part of the limbic and circumflex branch 90%Right coronary artery Small residual, diffuse atherosclerotic vessel, narrowing to 85% in the middle left ventriculography Left ventricle with hypokinesis peak. Ejection fraction 50%. He saw a bunch of surgeons and cardiologists. The opinions vary between triple bypass and des stents. We are confused. The one surgeon suggested surgery but without endarterectomy cleaning of his artery from the atheroma. Is his condition that bad that can't handle a bypass? Would stents/meds/life changes be the answer? We are trying to figure out the best solution for my dad to have a long healthy life.

Dr_Lytle: For patients with severe multi-vessel coronary artery disease there are two goals of treatment. The first is to relieve angina. If relieving symptoms is the goal then medical treatment certainly can be attempted first, followed by an invasive procedure if symptoms don’t resolve.

The other issue is whether or not the treatment is expected to prolong life expectancy. For some patients with multi-vessel coronary artery disease there is evidence that surgery prolongs life expectancy. Other than the situation of acute myocardial infarction, it is not clear that stenting prolongs life expectancy. The decision between these forms of therapy really relates to the specific characteristics of the situation. In general, the more obstructions the better patients do with surgery. For patients with relatively small numbers of obstructions either surgery or stenting can be done to relieve symptoms. We do have methods to review medical records for a surgical review or to provide a second opinion if you would like us to do so.

Hypertrophic Cardiomyopathy and Myectomy

RGambatese: Would you ever perform a septal myectomy on someone who is asymptomatic to HOCM but wants the surgery as a "preventative" measure to eliminate possible future complications?

Dr_Lytle: Yes - there is some evidence that patients with severe outflow tract obstruction have a better survival rate with surgery over time than patients treated medically even if they are asymptomatic.

This is a complex question and the details would be very important

frannie4: I had a myectomy in 2000 and Dr. Lytle performed the surgery. it was a success and no palpitations since. I have a new life and would just like to say thank you to him from the bottom of my heart!

Dr_Lytle: We are grateful you are doing so well.

HCMGuy44: I am a 67 year old male with HCM and A Fib with mitral valve regurgitation. My latest EF was 45. My cardiologists is recommending a valve fix or replacement informing me that if I let it go much longer we may past the point of no return. He also is telling me this will require full blow OH surgery with the usual long recoup period. My interest in your clinic and the lest invasive valve fix technique great interests me. My PCP says to find out your success rate and how many of these procedures have been done. I sense he is trying to discourage me from getting involved in your technique. What can you tell me regarding this and with the little I've described, do you think I would be a candidate for the procedure there? Should I go ahead and make an appointment to come in for a screening? Thank you for taking my question.

Dr_Lytle: The issue here really relates to the presence or absence of hypertrophic cardiomyopathy. It is the details of your hypertrophic cardiomyopathy that are important in terms of deciding what to do with your mitral valve. In general, it is difficult to repair the mitral valve if someone has hypertrophic cardiomyopathy and outflow tract obstruction although there are specific techniques that can be used to do this. The atrial fibrillation adds another issue and, in general, I would say that a minimally invasive approach would probably not be the best way to undertake an operation that was meant to deal with hypertrophic cardiomyopathy without outflow obstruction and mitral insufficiency and atrial fibrillation. We would be glad to review the specifics of your situation should you wish.

Left Ventricular Aneurysm

yankee: what is the procedure to repair a aneurism on left side of heart?

Dr_Lytle: When a left ventricular aneurysm is an indication for surgery, it is usually removed and the heart wall patched with an artificial patch.

Minimally Invasive and Robotic Heart Surgery


Dr_Lytle: Whether or not you would be a candidate for “minimally invasive or robotic heart surgery” depends upon what kind of heart surgery you need. There are some types of valvular problems and cardiac tumor problems that are very possible to perform robotically and others that are not. We would be happy to review your information should you wish.

Venhuizen: Can aortic valve replacement be done via minimally invasive surgery?

Dr_Lytle: Yes it can.

AW: Is there minimally invasive surgery available for repair of (i) ascending aorta aneurysm (root currently dilated at 4.3 and ascending aorta at 4.8), with (ii) aortic valve moderate regurgitation? Or is the only option fully open chest surgery if/when the aorta dilates a little further? I have read that minimally invasive surgery is becoming more available nationwide for such valve surgery, but is it also becoming more available (if at all) when combined with the required ascending aorta aneurysm surgery?

Dr_Lytle: First of all, it is not perfectly clear from the information you have provided that immediate surgery is in your interest at all.

Second, less invasive surgery is possible.

Whether or not it is the best choice depends on the details of your situation.

Heart Surgery - General

Venhuizen: Coming from out of town,, what would be the plan for follow-up; and how long a stay after surgery?

Dr_Lytle: The stay is a week to 10 days. Follow up is in the Clinic, by phone in conjunction with your local physicians and every couple of years thereafter.

cc2011as: At age 59 am I too young to be contemplating a tissue valve over a mechanical valve?

Dr_Lytle: No.

cc2011as: What is a normal rehabilitation time after replacement surgery? When can I resume playing golf and riding my bicycle?

Dr_Lytle: 4 - 6 weeks.

ruthelaine: can a person obtain a normal, active lifestyle after mitral and aortic valve replacement. I am 69 and very active, playing tennis twice a week, doubles and water exercise. how long is the recovery and what's the quality of life afterwards? margo

Dr_Lytle: People can usually return to a normal activity and the recovery is about 2 months.

nadiadncr: Dr. Lytle thank you so much for your response. How can you provide me a second opinion? My parents live in Greece and right now they are not coming to visit us her in Columbus. What records do I need to have for me to come see you

Dr_Lytle: Please contact us at and we can provide you with information on how to obtain a surgical review.

Sept14: I've heard of an interesting tissue valve in development, ValveXchange, in which worn out leaflets can be exchanged without an open heart procedure. What are your impressions of this technology in concept, and do you have any expectations for actual practice viability of it and how long a learning and approval window might be required?

Dr_Lytle: The idea of replacing the leaflets at reoperation for a tissue valve is not new. There have been valves of this type that have been evaluated since the early 1980s. Relatively few have been used. The problem with the concept is that valve reoperation itself is something that is not impossible to do and it has been hard to prove whether there is incremental benefit of just replacing the tissue in the valve.

Cleveland_Clinic_Host: We had a question come through about cost and insurance coverage. The Cleveland Clinic participates with most major medical insurance programs. See for information on insurance plans accepted by the Cleveland Clinic. Coverage limitations are dependent on individual group contracts. Therefore, you should contact your insurance provider directly to learn the specifics of your coverage at the Cleveland Clinic. Your insurance representative is the best person to inform you of the level of coverage you will have as a patient here.


kowens526: The Pradaxa manufacturer advertises their drug is for patients who have Atrial Fibrillation without valve problems. What happens when Pradaxa is given to a patient who's A-Fib is caused by a Mitral Valve problem?

Dr_Lytle: That strategy has not been tested with a trial. If the mitral valve problem is a native mitral valve our assumption is that there probably is no difference in outcomes.

If is a prosthetic mitral valve that is a poorly understood situation.

sarczar: Is there a natural-supplement alternative to aspirin after AVR surgery? I have gout attacks and also so not want the side affect of internal bleeding caused by aspirin. I was thinking a Vitamin E and fish oil combination?

Dr_Lytle: Not that we are aware of.

kowens526: Tests prior to a scheduled Ablation in June revealed a blood clot that has not dissolved even after changing from Warfarin to Pradaxa five weeks ago. An August TEE showed the clot still there and a third TEE November 17th showed the clot has grown. There is Mitral Valve scarring from childhood Rheumatic Fever. Any suggestions for dissolving or removing the clot to allow the Ablation?

Dr_Lytle: Your question is a difficult one to answer because there is no information about how severe the mitral valve problem is. If the mitral valve dysfunction is severe, the best solution to this problem would be to have an operation to repair or replace the mitral valve, treat the atrial fibrillation with ablation, and remove the clot. If the mitral valve is not severely abnormal, continued treatment with anticoagulants probably is the best approach until there is evidence that the clot is not there. We would be glad to review the details of your situation should you wish.

Atrial Fibrillation

fstoner: After having quadruple bypass surgery last December, along with the Maze procedure, I was left with continuous controlled Afib. Cardioversion did not hold and I was told that any medications had worse side effects than the Afib. I exercise 3 times a week, eat low fat and low salt, maintain proper weight, blood pressure and cholesterol. What impact will this Afib have on my longevity?

Dr_Lytle: In most studies of cardiac conditions, the presence of atrial fibrillation has either a negative impact on life expectancy or no impact. You did not state your age and it sounds as though you are exercising and maintaining a good life style right now. In individual cases people may live to a very long life expectancy in the presence of atrial fibrillation and further treatment, I think, would relate to your age, general health, and how much the atrial fibrillation bothers you. Further procedures to attempt to treat the atrial fibrillation are possible but if you are doing well it is not necessarily the case that they have to be employed.


hjdt: I had mitral valve repair with the titanium ring the minimal invasive about 17 months ago. hospitalized 5 times after with pleural and pericarditis, a-fib and 3 conversions, have been on prednisone for high inflammation levels and every time try to wean off the inflammation returns and I crash for a few days. Is this common and can it still be what they have been calling post cardiotomy syndrome? I am also diabetic. I am also having fluttering mostly when I go to bed and early mornings. Thanks

Dr_Lytle: Your experience is not common, but it sounds like you do have post cardiotomy syndrome, although it sounds like this is a much more vexing problem in your situation than it usually is. It sounds as though appropriate initial treatments have been instituted but unfortunately unsuccessfully. We would be happy to review your situation should you wish.

Stem Cell Therapy

Vone: Does the Cleveland Clinic perform stem cell surgery for cardiac repair?

Dr_Lytle: At the present time stem cell treatments are investigational procedures and the Cleveland Clinic has been involved in some trials of stem cells. However, we have no open trials at this particular time. In this country, however, stem cell treatments are the subject of trials at the present time. See to search on stem cell studies.

Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again for taking the time to answer our questions about heart surgery.

Dr_Lytle: Thanks for having me today.

Reviewed: 11/11

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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