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Ask the Heart Surgeon (Dr Soltesz 6 16 10)

Wednesday, June 16, 2010

Edward Soltesz, MD
Staff Cardiac Surgeon
Sydell and Arnold Miller Family Heart & Vascular Institute

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Dr. Soltesz was called into surgery for this chat. Here are the answers to your questions:

Valve Surgery

Ckchaka: Which is a better tissue valve choice for mitral valve replacement, porcine or bovine?

Speaker: Dr. Edward Soltesz: There is no real difference in performance or longevity between porcine and bovine (i.e., pig and cow, respectively) mitral valves. Surgeons may have preferences based on their familiarity with either valve. For instance, I prefer porcine valves in the mitral position and bovine valves in the aortic position.

Kaydee: My Fathers cardiologist has a blanket rule that he does not do open heart surgery on 86 year olds My dad is in very good health other than his mitral valve is very calcified. His doctor says his heart is very strong. Is the procedure you do for repair or possibly replacement of the mitral valve always less invasive than traditional open heart surgery?

Speaker: Dr. Edward Soltesz: Age is only a single factor in determining a patient’s risk of any form of surgery. A patient’s overall medical condition, including his or her other medical problems (e.g., hypertension, peripheral vascular disease, emphysema, etc.), predicts their risk of mortality and complications from heart surgery. For example, a 50 year old male with severe emphysema, hypertension, and diabetes, has a higher risk of dying from a mitral valve repair than a healthy 86 year old male with only hypertension. Minimally invasive approaches are available in most situations.

Roullac: This is another question that I would be pleased to hear your view. I tend to go to bed very late 2.30 - 3.00 am (at times I find myself unable to drop off to sleep as soon as I go to bed, (I tend to take my worries to bed with me and I am unable to switch off). Do you think that this may have a bad effect on my heart. I do sleep for 7.00 or 8.00 hours when I eventually drop off to sleep ( I wake up once during the night to use the restroom).

Speaker: Dr. Edward Soltesz: I do not think your sleep habits would affect your heart. Seven to eight hours of sleep per night seems reasonable. I would consult your regular primary care doctor for some help with your sleep pattern.

Roullac: I had my surgery for Mitral valve repair on the 26th of August 2009 and last week I had my first ECG. test, my heart rate for stage IV for Bruce protocol reached 155 beats, total exercise time 9:19, the expected heart rate target was 166. The result was that I achieved 94% of maximal predictated heart rate. Do you consider this to a good reult or a bad result?

Speaker: Dr. Edward Soltesz: This seems like a good stress response presuming that you had no other abnormalities detected during the protocol.

Manny: What is the recommended procedure to follow for an 89 year old man needing aortic valve replacement? Is a minimally invasive technique possible?

Speaker: Dr. Edward Soltesz: Minimally invasive aortic valve replacement is possible in all ages so long as a concomitant bypass is not required.

Jive203: My 75 year old husband had an aortic valve replacement on 2/9/10 (he also has COPD). He has not gotten his energy back. He says he can't get the breath to blow his nose. Any suggestions?

Speaker: Dr. Edward Soltesz: I would suggest he see his surgeon and cardiologist to be certain that there are no conditions that can be easily treated (e.g., a residual pleural effusion – fluid around the lung – that could easily be drained, etc.).

Roullac: I would like to ask your opinon, is it true that people who have their valves repaired would need to replace them in 10 or 20 years time. I was let to believe that repair should be a lifelong solution? Please clarify. I was told by my surgeon at Cleveland clinic that my surgery, mitral valve repair (sternotomy) was successful, why would I therefore need to have another one in 10 or 20 years time? Forgot to mention that there was some calcification of the base of the posterior leaflet as well as the posterior aspect of the mitral annulus. Would this be a reason to have my valve replaced in 10 years time? Thank you.

Speaker: Dr. Edward Soltesz: Mitral valve repairs for degenerative disease (i.e., myxomatous mitral valves or “floppy” valves) usually are very durable and can last a lifetime. Minor amounts of calcification should not cause any worry. Aortic valve repairs, on the other hand, do not last quite as long.

Roullac: Dr Soltesz I had mitral valve repair (sternotomy) due to severe regurgitation last year in August, I would like to have your advise as to what I could do tomake my incision less noticeable. Is there anything you could recommend.

Speaker: Dr. Edward Soltesz: Scar healing is always a difficult issue since all patients heal differently. There are a number of formulations available over the counter that may help. A plastic surgeon can also be a great source advice.

BP24: How many operations have you done, where you are repairing something and then all of a sudden something unexpected happens?

Speaker: Dr. Edward Soltesz: Conversions from repair to replacement occur in approximately 5% of cases.

Coronary Artery Bypass Surgery

Applegate: I'm male age 81. Had MI '81, CABGx5 '82, Redo CABGx3 '94, no stents. Annual cardiolite stress tests OK. Active for age on zocor & atenolol. Added aggrexox & keppra after small stroke'06 & GM seizure'07. Some recent angina so had angiogram 2/10. Showed severe CAD w/ all old vein grafts either lost or degenerated & 60-90% occluded. Only one new vein bypass to PDA & one new LIMA bypass to LAD still patent. Normal ventricular function, EF60%. Now on aggressive medical therapy. Imdur 60mg & 8lmg aspirin added. Angina better. No more surgery or stent recommended. QUESTIONS: When if ever would you consider such intervention.? If not, why not? Risks? Other options? Thanks!

Speaker: Dr. Edward Soltesz: In patients with previous coronary bypasses and a patent LITA-LAD bypass graft, re-operation to perform more bypasses will usually only afford improved control of angina but not improved survival. Re-operation is indicated in the setting of a patent LITA-LAD bypass when patients have severe angina uncontrollable with medicine and when a considerable amount of the heart muscle has poor blood supply. These difficult medical and surgical decisions require close collaboration between cardiologists and cardiac surgeons. There are many options available for your situation: reoperation, stents, and medical therapy, as well as a combination of the three. I would recommend seeing an experienced cardiac surgeon who specializes in coronary reoperations to more fully review your case.

Peppy: Why do so many women have strokes after bypass surgery? I know of several women and one died within the month. This is frightening.

Speaker: Dr. Edward Soltesz: There is no known difference between the rates of stroke in women and men following bypass surgery. The overall risk of stroke following bypass surgery (and any surgery, for that matter) is related to coexistent medical conditions that increase the risk of cerebrovascular disease (e.g., diabetes, hypertension, high cholesterol, previous strokes, etc.)

Fran: When a coronary artery is bypassed, what happens to the native artery over time?

Speaker: Dr. Edward Soltesz: A coronary bypass is performed by creating a small opening in the native coronary artery and attaching the bypass to that opening. Theoretically, blood flows out of the bypass and both up and down the native coronary artery. The native coronary artery remains intact.

General Questions

BP24: I am highly considering a career as a cardiac surgeon, however I am curious to how much schooling involved?

Speaker: Dr. Edward Soltesz: Schooling includes: 4 years of college with a premedical concentration, 4 years of medical school, 5 years of general surgery residency, and 3 years of cardiac surgery residency/fellowship at minimum (=16 years after high school). Most cardiac surgeons also spent 2 years in research and 1-2 years in additional sub-specialization fellowship (=20 years after high school).

Peppy: What is optimal medical therapy? Is there a diet to prevent the progression of atherosclerosis and heart surgery?

Speaker: Dr. Edward Soltesz: Optimal medical therapy depends on the condition. For coronary artery disease, for example, appropriate use of a statin drug, aspirin, and a beta-blocker would be considered “optimal medical therapy.” A variety of balanced diet plans are available to help fight heart disease; the American Heart Association Diet is an excellent start.

Peppy: What can a patient do if they cannot tolerate statins after having been stented?

Q11: Intolerance of statin drugs should be discussed with your primary care doctor or cardiologist. There are other medications available if you specifically need medication control of high cholesterol.

Peppy: Do some heart meds cause high glucose readings? How can the patient prevent this effect and still comply with his/her medical therapy?

Speaker: Dr. Edward Soltesz: There should not be any heart medications that elevate glucose levels just by themselves. I would consult your primary care doctor or cardiologist if you are noticing high glucose levels.

BP24: What is the toughest aspect of being a heart surgeon?

Speaker: Dr. Edward Soltesz: The toughest part of being a heart surgeon is knowing what you have power over and what you don’t. Modern cardiac surgery has given us amazing new opportunities. Understanding their limits is the difficult part.

Peppy: It seems that there is not a mortality benefit with surgery say over medical therapy in the latest research published in Time and Newsweek over the past couple years. Could you comment?

Speaker: Dr. Edward Soltesz: A mortality benefit exists for most all indicated operations. Unfortunately, I am not sure what particular situation you are speaking of.

FastAl: I never complain when my doctor is called away like this. He would do the same for me if I were in need. Best wishes to him and his patient! Later-

Speaker: Dr. Edward Soltesz: Thank you. Patient did well.

Clara: What can be done with a distal circumflex that can't be stented, because it would require the stent to be bent.?

Speaker: Dr. Edward Soltesz: The options are : surgical bypass, catheter-based stenting, or medical therapy. Unfortunately, without seeing the actual catheterization and interviewing the patient to determine the degree of symptoms, it is difficult to say what is the best course of treatment.

Roullac:I read that by using tea tree oil I could get rid of a small keloid scar which I have as a result of my sternotmy (August 2009). Would you recommend using tea tree oil? Would Ibe able to see good results by using it? Can I use it now or shall I wait for a few more months, it is not a year yet since I had my surgery?

Speaker: Dr. Edward Soltesz: Tea tree oil has limited antibacterial and antiviral properties. I do not know of any peer-reviewed research or publication that supports its use for the healing of keloid scars. For such situations, I always recommend my patients see a plastic surgeon.

Reviewed: 06/10

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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