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Ask the Heart Surgeon (Dr Savage 02 18 14)

Tuesday, February 18, 2014 - Noon


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 surgical procedures, such as minimally invasive and robotically assisted cardiac surgery. Heart Surgeon, Dr. Edward Savage, Cleveland Clinic Florida answers your questions.

More Information

Aorta Surgery

michalos: My proximal aorta has a few relatively large aneurysms (>5.5cm) and I will need repairs pretty soon. I would like to know if there are any relatively noninvasive procedures for repairing such problems. So far as I can determine, it appears that only a standard cut through the sternum is possible. Twenty-three years ago I had a St. Jude mechanical valve implanted to replace a defective bicuspid valve. The mechanical valve still works well but the aorta up to the arch is in poor shape.

Edward_Savage,_MD: Currently there are no non-invasive options with a few exceptions. If you are in good shape traditional surgery is safe and has the best long term outcome.

barbararita: Hello. This is barbararita ...I missed a chat about heart disease but I have registered for Feb.18th. I have recently been diagnosed with a 4.9 aortic aneurysm in the beginning of November... I will be followed in Late March by my heart Dr. in Jupiter Fl....What is Cleveland's protocol for heart surgery for such an aneurysm? Also where can I be seen in Palm beach Gardens for an appt....Thank-you Barbararita

Edward_Savage,_MD: The current protocol for an aneurysm of 4.9 cm depends on what type of aortic valve the patient has. If three leaflets, we generally wait until the aorta is 5.5 cm unless the patient has symptoms. If the valve congenitally has two leaflets, we base the decision of surgery on the height of the patient - these patients generally rupture at a lower size aneurysm. All locations - To see a cardiologist, you would need to be seen at the West Palm Beach location, to see a surgeon, you'd need to be seen at the Florida main campus in Weston, but it's not too far of a drive.

joshdilo: How do you diagnose Aortic Dissection?

Edward_Savage,_MD: Most patients who present with aortic dissections come to the emergency room with acute back pain - the quickest way to diagnose this is with CT scan with intravenous contrast dye. In most cases, this gives us the diagnosis - if there is still a question we do a TEE which is an ultrasound of the heart using a probe that goes down the throat.

RVer: Had Hemmashield Stent on Thoracic Aortal Aneurysm Ascending in 2009 at St. Luke's Hosp. in Houston, TX. I have another Thoracic aortal aneurysm on the Descending. In Oct. 2013, it was 3.8 cm, in Jan. 2014 it is 4.4 cm. Dr. F has considered me as too high a risk for his surgery. His office is sending CT scans to Dr. K for possible specialized stent. Do you have a possible or alternative fix/solution for this?

Edward_Savage,_MD: We really need more information to answer this question. I suggest the stents may be the best alternative if your doctor feels you are at high risk for surgery.

jkm8870: I have an ascending aortic aneurysm, 4.2 cm, with a bicuspid aortic valve. If my valve continues to be ok and my aneurysm grows, can I just get the aneurysm fixed? I really don't want to have a mechanical valve. Also, is there any physical activity besides heavy lifting that I should not be doing? I am going to Walt Disney in the summer. I was told not to ride roller coasters or anything jerky. Can I ride rides that spin around or just drop?

Edward_Savage,_MD: Yes - if your valve is normal, all we do is fix the aneurysm.

asgalian: A recent transthoracic echocardiogram noted an atherosclerotic abdominal aorta. Is this condition reversible with prolonged use of statins to lower cholesterol levels? What is the significance of a calcified ascending aorta which is also enlarged?

Edward_Savage,_MD: Statins will not reverse the condition - but may stabilize it. It is difficult to answer the second question without more information about the size and other medical issues.

JorgeP: Hi doctor. I had a David's procedure for an aortic aneurysm with Dr. Svensson at the CC on 10/24/13. Results so far have been incredibly good. My question is will all the stuff they did to me affect my life expectancy?

Edward_Savage,_MD: In general if patients are asymptomatic - we only do surgery to improve their life expectancy. If they are symptomatic we also improve life expectancy.

asgalian: What is the best way to assess the extent of calcification or atherosclerosis for the aorta? Echocardiograms make note of but do not address the extent of the damage.

Edward_Savage,_MD: In general, we don't care about the extent of calcification or atherosclerosis - what we care about is the diameter of the aorta - best way to assess that is probably a cat scan.

Aortic Valve Surgery

BobD: I am a healthy 67 year old male with aortic stenosis and need surgery in one-two years. What is your long term success rate and mortality rate for the robotic vs. standard valve replacement surgery? Thank You

Edward_Savage,_MD: Currently the aortic valve is not being replaced robotically. Our isolated aortic valve replacements are performed through small incisions and our mortality is extremely low and success rate very high.

kingo595: Hi, I’ve been told I need an aortic valve replacement what will happen to me?

Edward_Savage,_MD: If you need an aortic valve replacement and you have symptoms and you have a leaky or stenotic valve then aortic valve replacement will improve your symptoms and life expectancy.

PistolPete: I had a bi-cuspid aortic valve replaced with a bovine valve. I am 71 and at some point expect the valve will need to be replaced again. From what I read there is a new experimental procedure that inserts a new valve over the existing valve avoiding splitting the chest open making it much easier on an older patient. How successful is this procedure and can it be done on a person who already had a valve replacement ? How long does the new valve last?

Edward_Savage,_MD: It is being done this way for selected patients however the percutaneous valves are not approved for this use in the US at this time. We have no information on durability at this time.

mridder: What is the most current information on the progress of TAVR procedures? Specifically, how are the guidelines evolving for what patient can qualify for a TAVR procedure and what are the latest outcomes comparison data when compared to traditional AVR procedures? Finally, do you have any data on valve-within-valve procedures where TAVR is being used to replace an existing (failing) artificial valve?

Edward_Savage,_MD: Currently TAVR is being used for very high risk patients - patients who are not considered for traditional surgery. The outcomes have been similar to traditional aortic valve replacement. The guidelines may extend to other less risky patients but have not done so yet. Valve in valve is being used in an experimental basis and the data is not in yet.

peppertree: Are there any medical procedures to remove the calcification on an aorta valve, such as ultrasound, etc., without open heart surgery? What if any ways are there to slow, stop, or regress the stenosis? I am already doing diet, exercise, statin, and blood pressure treatment. There are articles recommending supplements that may help.

Edward_Savage,_MD: It sounds like you are doing everything that has been recommended to slow the progression of the stenosis. There are probably congenital aspects of the disease that you cannot control. The only treatment is surgical replacement of the valve at this time. Removal of the calcification of the valve was tried years ago but had poor outcomes.

fjpor: I had an Aortic Valve replaced in 1988 in Norfolk, VA at which time they put in an Allograft. I had bicuspid valve congenital defect and was at acute aortic insufficiency, which had not been diagnosed until that time at age 49.Now the valve is leaking and I have heard different answers as to whether or not minimally invasive surgery is an option for replacement of said valve. The surgeon who did my husband's bypass indicated that heart surgeons are not really happy about having to replace allograft type valves because of all the work, so I don't know what I am looking at. At age 74 - not too distant to 75 - I'm not really sure I am amenable to ANY surgery but if I do, I want all the information I can gather just as I did what will be 26 years ago come September 15th of this year.

Edward_Savage,_MD: If you reach the point where you need surgery to replace the valve, at this time the only option is re-operative surgery. Minimally invasive is often referred to based on size of incision. In general if this surgery is redone - most surgeons prefer a full incision. In either case we still use the heart lung bypass machine during surgery. At Cleveland Clinic, our surgeons are very comfortable in performing this type of surgery. My only suggestion is not to wait until you are very symptomatic and you start to have significant functional decline. We would be happy to evaluate your husband.

svrsap: Your valuable guidance and suggestion/advice on this. Is Valve Replacement really MANDATORY? If Yes, What would be the best/right choice of valve (How Can I choose which is the right Qualified VALVE). Risk factors and success, any ref would you like to recommend, so that I can perform surgery (if required) in Hyderabad INDIA. Diagnosis: K/C/O Degenerative AVD, Severe AS, Mild TR/MRS/p CT CAG- Normal Coronaries, Calcium Score of "Orange Information: CATHER USED: 5F-OptitorqueLMCANormal LAD Type III Vessel, Normal DIAGONALD1, D2 - Normal LCXNon Dominant System, Normal OMs:OM1, OM2-Fair Sized vessel Normal. OM3- Large Vessel Normal. PCA Dominant System, Normal. PDA and PLVB-Normal. LV ANGIONot Done. Severe AS on Echo. CATH DIAGNOSIS Normal Major Epicaridal Coronary Arteries. CATH ADVICEAortic Valve Replacement.LMCANormalLADType III Vessel, NormalDIAGONALD1, D2 - NormalLCXNon Dominant System, NormalOMs:OM1, OM2-Fair Sized vessel Normal. OM3- Large Vessel Normal.PCADominant System, Normal. PDA and PLVB-Normal.LV ANGIONot Done. Severe AS on Echo. CATH DIAGNOSISNormal Major Epicaridal Coronary Arteries. CATH ADVICEAortic Valve Replacement. LEFT HEART CATH AORTIC=120 LV=300 GRADIENT=180 mmHg Advised: THERE ARE NO BLOCKS, BUT TO GO FOR AORTIC VALVE REPLEMENT, based on this can you advise me on right selection of valve.

Edward_Savage,_MD: In general the current recommendation for aortic valve if you are 60 - 65 or greater to have a prosthetic valve from a pig or porcine or cow - bovine or pig pericardium. If you are younger than 60 the current recommendation is to have a mechanical valve.

kahuna8: SUBJECT CARDIO CATHERIZATION (CC) - I have an appt. with heart surgeon Mar 31 for a consultation, anticipating Aortic Valve Replacement 6 - 12 months. TWO QUESTIONS 1) How long are the results of CC valid; 6 months, 12 months, or it depends on circumstances? 2) How important is it that I get the CC before the interview, or better to wait just prior to surgery? Male 77years, Valve 0.9, Gradient 54, no symptoms, overall health very good. Thank you.

Edward_Savage,_MD: The cardiac cath results are often adequate for six months as long as there is no significant coronary artery disease. If the arteries are completely normal, then often I think a year is ok. Do not have the cath performed until it is before the surgery unless there is another indication for the cardiac cath.

dorrcorp: Male, age 76, 5' 7", 200 pounds, work part-time at Chamber of Commerce. Cholesterol 110 (40 mg/day Simvastatin, 600 mg Welchol, 1500 mg Niaspan). 7 angioplasties, most recently 2005. No heart damage; blockages removed; carry Nitrostat, never used it. 20 mg Zestril; 60 mg Isosorbide; 75 mg Plavix; 200 Metropolol; 32 mg Atac and Diabetic (non-insulin, controlled by diet and 5 mg Glyburide daily; typical blood sugar reading before breakfast 100-115). Kidney disease (stenosis); kidneys operating about 45% capacity. Diagnosed by annual echo 3.5 years ago as clinical candidate for aortic valve replacement. But cardiologist (I see him twice a year) has been putting it off because I feel so incredibly good, have none of the three main warning signals—chest pain, increased heavy breathing, dizziness. Question 1) Am I candidate for NON-INVASIVE aortic valve replacement? Question 2) If so, what NON-INVASIVE procedures are best option for me; pros and cons of each; recovery time for each?

Edward_Savage,_MD: For a patient without symptoms, we will often do a stress echo to see if the patient in fact does need surgery. For a patient like you in seemingly good health, you would receive traditional heart surgery.

zman949: I have a bi-cuspid aortic valve that is going to need replaced. I am 56 years old, and am in good health. Do you think it’s possible to have the minimal invasive surgery to replace my valve, and would you recommend a tissue or mechanical valve. Thanks

Edward_Savage,_MD: If by minimally invasive surgery you mean a limited sternotomy - the answer is yes. If you are in good health, you are not a canddiate for interventional TAVR procedure. The choice of valve is individualized and requires a discussion with your doctor. If you are 60 or younger a mechanical valve is suggested but some patient opts for a biologic valve. The benefit of mechancial valve is durability however you need to take blood thinners lifelong - the advantage of a tissue valve is that you do not have to take a blood thinner however if you are below age 60 and live to your 80s there is a good chance the valve will wear out and will need to be replaced.

fjpor: Had aortic valve replaced in 1988 - bicuspid congenital defect leading to acute aortic insufficiency, they used an allovalve. Now leaking - moderate aortic insufficiency. Now 74 years of age. Any minimally invasive options open for me? My husband's cardiac surgeon seemed to be put off by thought of having to replace such an old allograft as they are a "lot of work". Any suggestions?

Edward_Savage,_MD: Moderate aortic insufficiency is not necessarily an indication for surgery at this time - there are other parameters that would need to be evaluated. If it is necessary it can be done and we have experience in doing it.

fjpor: Have already submitted question about replacement of almost 26 year old allograft aortic valve using minimally invasive procedures. Also, what is new in aortic valve replacements now that were not available in 1988 when I had my valve replaced.

Edward_Savage,_MD: 1) We really don’t use allograft valves anymore. We found they are no more durable than currently used bioprosthetic valves. 2) Current bioprosthetic valves are currently more durable than those used in 1988. 3) Some new mechanical valves may not need as much anticoagulation as the older mechanical valves.

fjpor: If I wanted to get a second opinion at one of your Florida facilities, which one is closest to me living in the central Florida area near Gainesville, FL?

Edward_Savage,_MD: You need to go to Weston - it is a long but easy drive - we would be happy to see you. 1.877.463.2010.

SantaFePair: Is the reliability of TAVR reaching the point that it is almost as safe as thoracic surgery for otherwise healthy patients?

Edward_Savage,_MD: It is too early to fully evaluate the applicability of TAVR for patients who are most appropriately treated with surgical valve replacement. We don t have enough long term information about durability of these valves.

SantaFePair: For an otherwise healthy patient undergoing traditional aortic valve replacement, what is the risk of cognitive impairment? Also, stroke?

Edward_Savage,_MD: The risk of cognitive impairment or stroke is dependent on age and the presence or absence of vascular disease. The patient who is otherwise healthy the risk of prolonged cognitive impairment and stroke is very low.

davidl: How long is an aortic valve (pig) going to last. I have heard that they last for up to 20 years...

Edward_Savage,_MD: They can last forever - what happens with pig valves is that around 8 - 10 years we see an acceleration of failures - however this does not mean your valve will fail.

DRD: I have aortic stenosis and need my valve replaced. What are your success rates of the J-incision vs standard open heart procedure?

Edward_Savage,_MD: Same results - I do all isolated aortic valve replacements with j incision and also do some aortic aneurysms through that incision too.

Aortic Valve and Aorta

michalos: I am going to have surgery replacing my mechanical aortic valve (which I have had for 23 years and is still ok) and the proximal aorta (new valve and ascending aorta). I understand the procedure involves dropping my temperature considerably and would like a bit more information about how that works. Can you describe the procedure a bit for me? Among all the other questions I put to my surgeon, I neglected this one. My surgeon is Dr. Michael Moon, who I understand was in your first group of Fellows around 2006/7.

Edward_Savage,_MD: It sounds like you have an enlarged aorta - if this extends up to the part of the aorta which is the arch, where the vessels to the brain come off - we often have to cool your blood down to about 60 degrees F to slow the circulation so we can attach the graft to the vessels - the cool temperature helps protect your brain during this procedure.

michalos: Can you tell me roughly what percentages of people who have received mechanical valves have to have repair and/or replacement a second time or more? Is the prognosis following a second replacement after 23 years any better, worse or the same? I received my first valve at 55 and am now 78. the valve works fine but the ascending aorta is severely compromised (about 6.5-7.5 cm). I will have surgery for repair but wonder about risks and life after repair?

Edward_Savage,_MD: The prognosis after a second replacement is going to be determine by your physical status and the degree of difficulty of your second operation. In general the risk of a second operation is not that much higher than the first operation - if you are with a surgeon who has experience with reoperations. Regarding the surgery for ascending aortic aneurysm - the risk is higher than the first time you had surgery since you are older although once you received a successful repair you should be able to return to a normal life.

xdwl: Hello, I have a few questions on my aortic regurgitation. I was diagnosed with HCM ten years ago. I did not have any AR before septal myectomy which was done in 2012. Trace AR was detected in one week post-surgery, then mild AR in three months, and mid-moderate AR in 15 months post-surgery. AR seems progressing. 1) My AR occurred just after the surgery. Would myectomy cause AR? 2) Although the myectomy well eliminated the obstruction in my LVOT. I developed a new symptom since the sixth week post-surgery: chronic chest discomfort (stuffy chest), which is not associated with exertion. NYHA II. Bp 95/60mmHg. LVOT gradient 20mmHg. Coronary angiography normal. MRI found my ascending aorta 50mm. So, my doctor thinks this aortic aneurysm may cause my feeling of stuffy chest. I would like to get your advice -- would a 50mm aneurysm OR mid-mod AR can be associated with my chest discomfort symptom? Thank you for taking the time to answer my question!

Edward_Savage,_MD: It is difficult to attribute chest discomfort to this although it is certainly possible. We would need to evaluate you more closely and have more information. If you do have significant aortic valve leak and enlarged aorta - usually if we see a 50 mm aneurysm with moderately severe - severe regurgitation -we would recommend surgery at that time - you may need another surgery. It is difficult to know what to attribute the aortic regurgitation to - without all the details we really cannot comment on this.

jkm8870: I am 43, good health. I have a bicuspid aortic valve with aneurysm of 4.2-4.3 cm. I was diagnosed two years ago. I am 5'7" and healthy weight. I do get mid back pain b/w my shoulder blades. Should this be a concern? It feels deep like a strain or pull, but is not. If my valve works ok and my aneurysm grows, can I just get the aneurysm fixed? I do have pain sometimes upon exertion and am scared to do more high intensity aerobic activity. My b/p is good too. Should I still be on low dose metoprolol. My b/p today was 117/86 and hr of 76.

Edward_Savage,_MD: In general mid back pain that is intermittent is probably not related to the aneurysm. Yes you can get the aneurysm fixed if the valve is fine. Yes you should still be on low dose metoprolol.

Mitral Valve

JuneLa: If one chooses watchful waiting for mitral valve repair rather than early surgery, might the mitral valve with myxomatous disease deteriorate while waiting, thus making surgery more complex?

Edward_Savage,_MD: If you choose watchful waiting rather than early surgery, you can lose significant heart function. It can increase the risk of the operation and reduce the long term survival time after surgery.

JuneLa: Thank you for addressing my question, but perhaps I wasn't clear enough. I understand the implications on the heart function of choosing watchful waiting, but what I really want to know is will there be further degeneration of the valve itself thereby reducing the chances that the valve can be repaired rather than replaced.

Edward_Savage,_MD: In general, waiting should not further damage the valve. The results of likely having the valve repaired should be similar.

Multiple Valve Surgery

Aktoothfairy: My father, who is 83 yrs. young is currently waiting to hear from University of Washington to see if he's a candidate for the TAVR procedure and maybe a mitral valve replacement. For the past six weeks, his cardiologists have him on a continuous pump of Dobutamine. What is most frustrating for him and us is the doctors in Anchorage CAN NOT come to a decision of what exactly the necessary treatment. He is not a candidate for open heart surgery. In 2013, he did have a pace maker/defibrillator placed due to Afib, he continued to have Afib after so they performed the ablation and he did not recover well from that procedure. Later, the electrical Dr. said to a fellow Dr. that my father wasn't ever really in Afib but he displayed the symptoms so they took the chance. One doctor states he should stay on the Dobutamine due to less risks of stroke. One doctor states its aortic stenosis. Another said it was the mitral valve leaking. My father thinks the TAVR is the answer. What is needed for a second opinion.

Edward_Savage,_MD: It is difficult to make an assessment with the information you provided. In general TAVR is only used for patients with significant stenosis. If there is significant leaking, this would not be an option. If there is some leaking from the mitral valve with significant stenosis of the aortic valve, TAVR may be an option. It would be helpful to know why he is not a candidate for OHS and who made that determination. If he really is 83 years "young" maybe a second opinion would be appropriate.

tracyrw: Hello Doctor, my name is Tracy W. I'm 51 and getting ready to have heart surgery on March 4th and I just want to see what advise could you give me about being depressed. Is this normal? I just want to say that my surgery is very complex with a sub aorta membrane and regurgitation of the aorta , and with the mitral valve and now I have congestive heart failure I want to know if that's normal too.

Edward_Savage,_MD: Yes it is normal to be depressed and in fact it is not unusual to have depression after heart surgery - usually knowing this is enough to get through this - but sometimes patients need to be treated for depression. If you do not have a history of clinical depression, most patients get through this and are able to get back to their normal - non-depressed state.

Myectomy and Valve – HCM

xdwl: Hello, I am a 56 year old female with HCM, had septal myectomy in Sep. 2012. My symptoms much improved. But a few new problems found in my recent follow up:1) My ascending aorta was 44mm pre-surgery. But recent MRI and Echo showed ascending aorta 49-50mm, Aorta Size Index is 3.02 now. I would like to ask, should I have aorta surgery now? What is the size of an aneurysm indicating for surgery? 2) My MRI also found some HCM residual problems: basal septum 9mm, MID SEPTUM 17mm. PAPILLARY muscles mildly prominent and apically displaced. My echo and stress echo were still OK: LVOT gradient 20mmHg. No change with Amyl Nitrite or exercise. No SAM. Mild MR, Mild to moderate AR. I feel stuffy chest sometimes, which is not associated with exertion. NYHA II. My question is that, if I will have surgery on my aneurysm and AR now or in the future, should the surgeon also do anything in my 17 mm MID SEPTUM and PAPILLARY to correct HCM residual problem? Thank you very much!

Edward_Savage,_MD: 1) If your valve had three leaflets and normal, the size recommendations would be 5.5 cm. If your valve was bicuspid or abnormal we would operate on a lower size based on height relative to the related area of the valve. 2) it is difficult to answer this question - this would require further evaluation of your tests and medical exam.

lizhemler: I am a 58 year old female. I had a myectomy and mitral valve repair at UCLA in July 2013. I had a severe regurgitation and my obstruction was around 120-180 before the surgery. About eight weeks after surgery, the regurgitation was declared 'mild' and the obstruction was around 20. Now, six months after the surgery, I am having symptoms like I had before the surgery (sob, tiredness). My cardiologist did another stress echo and said that my regurgitation is still 'mild' but the obstruction is back to where it was prior to surgery. He put me on 25ml of metropolol but I have not noticed any difference except I am more tired. I have very low blood pressure to begin with (90/60) and he doesn't want to raise the dose. My questions are these: How could this (the obstruction returning) happen after a seemingly successful surgery? Could this be because I am still healing from the surgery? I'm so tired. Will things get better?

Edward_Savage,_MD: It is difficult to know - presumably you had a successful result - it is possible the valve is obstructing the outflow tract. We would need to evaluate your medical records and test results to provide you with an answer to your important questions.

Coronary Artery Disease – Bypass Surgery

mgaax: I had triple bypass in 2001. Have there been any studies as to length of that surgery lasting? My cholesterol numbers are wonderful. I eat right and exercise daily I’m now 68 years old. Your opinion on this is welcomed. Thank you.

Edward_Savage,_MD: Patients after bypass surgery can have excellent outcomes after surgery - I cannot predict when you may have failure or outcomes but sounds like you are doing great and doing all the right things.

mymiddheart: I had CABG x2 (age 50) with left internal mammary artery and saphenous vein graft on anterior descending and I am post-operative at 14 yrs. Doing very well (65 yrs. this year, good weight, blood pressure and I am active) but showing some diastolic dysfunction Grade ll on left ventricle with latest echocardiogram this year. Question: What percentage of women with my history receive stents and what percentage need to have open surgery for a second time? Would this dysfunction preclude any heart intervention if I need it?

Edward_Savage,_MD: The use of stents and surgery is really dependent upon the anatomy of blockages and what will work best for the particular patient. This dysfunction would not preclude any heart intervention if you needed it.

amir33: Hi, I just found out today my grandma has a heart disease that she needs a surgery for. I don't know what you call it in English but one of her vein in her heart is not working properly and she needs an immediate surgery that has a 50/50 percent chance of living. Can you please tell me what the disease is and whether she will have a good chance of survival or not.

Edward_Savage,_MD: It is very difficult to answer this question because we don't know the details of her disease process. It is not clear of why they said she has a 50-50 chance of living - in general most patients who are very stable at the time of needing surgery have a very good chance of survival.

Motherneedsinformation: My son is 35. Has a brief history of hypertension. His father had a five way bypass at 40. Had chest pain for a while he went to the ED. Had angioplasty (was too small to place stent) had another 90% blockage but nothing done for it. Was informed he waited too long and had permanent damage to tip of heart. Put on plavix and bp meds. Dc'd after two days. Two weeks later having same chest pain went back to ED. Admitted and had a stress test. Meds were doubled sent home the following day. States he signed form stating he still had chest pain when dc'd. Three days after discharge, Dr. states he didn't have my son’s phone number and needs another cath. Dr. states he has plaque/calcification throughout. Artery that had angioplasty now completely blocked but building collateral circulation. A stent was placed in the 90% blockage. Has two more that are 40% blocked. Feels he is too young for a bypass and they are only good for ten years. I feel that my son needs a second opinion. Any advice appreciated. Thank You!

Edward_Savage,_MD: It is difficult based on information provided to give you more information or advice, but from the info you provided, it sounds like he does not need bypass at this time. However if you want a second opinion, I suggest you go to a local cardiologist or if he wants to come to Cleveland Clinic, we would be happy to see him.

kym712: My doctor said that if I will not take my medication I might end up having a bypass operation. Is my 2D echo result life threatening? This is my 2D echo result: Interpretation: doppler: normal mitral tricuspid E/A ratios normal pulmonary artery pressure 2D ECHO: Normal left ventricular geometry (left ventricular mass index = 71 g/m2; relative wall thickness = 0.37) with mild hypokinesia of the anterior interventricular septum and anterior left ventricular free wall from base to apex Normal right ventricular dimension with adequate wall motion and contractility Normal left atrial dimension with normal left atrial volume index (19 ml/m2) Normal right atrial dimension Structurally normal mitral valve, aortic valve, tricuspid valve and pulmonic valve with good opening and closing motion Normal main pulmonary artery and aortic root dimension CONCLUSION: Normal left ventricular geometry with mild segmental wall motion abnormality; ejection fraction = 70%; E/E1 = 6.

Edward_Savage,_MD: No. Your 2D echo is not life threatening - it does reflect mild wall motion abnormalities which may reflect coronary artery disease - these need to be followed up with your cardiologist.

khum77: Hello, I would like to ask best treatment for total proximal occlusion.Thanks.

Edward_Savage,_MD: There is no best treatment for total proximal occlusion - for some patients no treatment is necessary. However, if you are having symptoms or you have a large area of the heart at risk by stress test - a treatment may be needed. Sometimes it can be opened by catheters and stented however many cannot and will require bypass surgery.

Subclavian Artery

jessiduhon: I am 30 years old and was diagnosed with a right sided aortic arch with abberrant left subclavian artery ten years ago. The left subclavaian artery causes a significant posterior impression on the posterior thoracic esophagus. My symptoms seem to be getting worse. Like my throat is closing. I have read you guys are the best and I was wondering what information you might have for me or direct me where I should go from here? Thanks so much!

Edward_Savage,_MD: An anomalous left subclavian is usually asymptomatic. If you are truly having symptoms and have diagnostic studies to evaluate you, then repair can be considered. We would be happy to evaluate you.

Atrial Fibrillation and Left Atrial Appendage Closure

kahuna8: Left Atrial Appendage Closure (LAAC). I am male, 77, no symptoms, facing aortic valve replacement in the next year. Echo - 0.9 valve area, 54 mean gradient, ejection fraction 74%. AFIB (not diagnosed) seems to be a common problem. I am an "all in type" - my study suggests that having a LAAC in conjunction with AOV replacement is the way to go. Thank you for your comment.

Edward_Savage,_MD: It is only indicated for patients with proven atrial fibrillation. These are not prophylactically placed.

Heart Failure – LVAD

Virginiawagyu: I am 83 years old and have 20 ejection Fraction and 16.3 Vo2 consumption. Would I be eligible for an LVAD?

Edward_Savage,_MD: Possibly, but we need a lot more information - you would need to be formally evaluated.

Atrial Septal Defect – ASD Closure

irishuk: It is mentioned on the page about robotic assisted surgery that it can be done if the person is an "appropriate candidate". In relation to ASD closure, what would be the circumstances where a person would/wouldn't be suitable. I understand TOE and Angiogram would be used as a diagnostic. What could be found with these to rule someone out of being able to have robotic assisted.

Edward_Savage,_MD: Candidacy for robotic ASD closure would be dependent on the type of ASD. Presence of other associated cardiac abnormalities that may need to be addressed, and size of the patient.

Pericardial Disease Surgery

JAD: I am a 75 yr. old female diagnosed one year ago with constrictive heart disease (pericarditis) and restrictive lung disease from having radiation 50 yrs. ago. At that time, doctors thought I had a malignancy and gave me radiation treatments. When I did not improve, I had surgery and a teratoma tumor was removed from the mediastinum. My phrenic nerve was injured in surgery and I am short of breath. I am currently taking Hydrochlorothiazide 25mg and Klor-con M20 and low sodium diet. I have to make a decision about surgery but my concern is the Phrenic nerve being injured and my age. What is your opinion?

Edward_Savage,_MD: If you are very symptomatic, the surgery can help. If we know in advance which phrenic nerve is damaged, damage to the other can be avoided.

raymore: I am scheduled to have a sternotomy (paricardiectomy). What things can I do to help a better recovery from this surgery? I live 1000 miles away, would you advise returning home by auto or by airplane?

Edward_Savage,_MD: Make sure you are in good nutrition, continue to exercise as best you can, exercise on a daily basis as best you can. If you live 1000 miles away - I would plan to do that drive over a 4 - 5 day period but the best way to travel is probably by airplane.

davidl: Thanks Dr. are the best!

fjpor: Thank you, Dr. Savage for your informative and helpful information. This is a great adjunct to regular medical care locally and next best thing to 2nd opinion.

Edward_Savage,_MD: Thank you.

Reviewed: 02/14

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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Call a Heart & Vascular Nurse locally 216.445.9288 or toll-free 866.289.6911.

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