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Heart Surgery Webchat Transcript - Dr Sabik

Wednesday, November 5, 2008

Joseph Sabik, MD
Cleveland Clinic cardiac surgeon Chairman of the Department of Thoracic and Cardiovascular Surgery, Miller Family Heart & Vascular Institute Tomsich Family Department of Cardiovascular Medicine

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Cleveland_Clinic_Host: Welcome to our Online Health Chat with live Web chat with Cleveland Clinic cardiac surgeon and Chairman of the Department of Thoracic and Cardiovascular Surgery, Joseph Sabik, MD, as he answers your questions heart surgery, new advancements, research and options for patients suffering with heart diseases. Welcome Dr. Sabik and thank you for being here with us today.

Speaker_-_Dr__Joseph_Sabik: Thank you for having me.


Minimally invasive heart surgery

aortichomograft: Why should my mom "experiment" with endoscopic minimally invasive surgery for her aortic valve, which needs to be replaced, instead of having time tested open chest surgery? It sounds like the only advantage is to avoid cutting the sternum. Also infection, etc. But for the best result, why should she get into robotics?

Speaker_-_Dr__Joseph_Sabik: The benefits of minimally invasive heart surgery are related to less trauma. This has resulted in better hospital outcomes such as better survival and lower complications. Never feel that you are having "experimental surgery." Always go to a center that has experience with minimally invasive surgery. Robotics is one type of minimally invasive heart surgery - there are multiple options.

rickkr: What determines if aortic valve replacement can be done non-invasively?

Speaker_-_Dr__Joseph_Sabik: Most isolated aortic valve operations can be done minimally invasively. If a patient needs other things done to their heart such as other valves replaced or repaired or bypass surgery, then the operation is usually done with a traditional approach not minimally invasively.

WAMPUMM: My cardiologist here in Phoenix stated that I would need the traditional sternotomy. If the surgeon does not do the mini-sternotomy should I come to the CC for a second opinion...also, how soon should I consider having the procedure.

Speaker_-_Dr__Joseph_Sabik: We can surgically treat many heart problems with a minimal invasive approach - this applies to both valve, aortic and coronary artery bypass surgery. We would be happy to review your records and determine if you are a candidate for minimally invasive surgery.

SarahM: Why are there so few options for minimally invasive bypass surgery?

Speaker_-_Dr__Joseph_Sabik: Today there are a lot more options for minimally invasive for bypass surgery. These procedures started being developed over 10 years ago. The technology and surgical techniques have improved such that today many more patients are candidates for minimally invasive bypass surgery. In deciding if you are a candidate for these types of procedures, it is important to go to a center such as the Cleveland Clinic, where surgeons have been involved in these operations for many years and have a large experience.

WAMPUMM: My cardiologist here in Phoenix stated that I would need the traditional sternotomy. If the surgeon does not do the mini-sternotomy should I come to the CC for a second opinion...also, how soon should I consider having the procedure.

Speaker_-_Dr__Joseph_Sabik: We can surgically treat many heart problems with a minimal invasive approach - this applies to both valve, aortic and coronary artery bypass surgery. We would be happy to review your records and determine if you are a candidate for minimally invasive surgery.

SarahM: Why are there so few options for minimally invasive bypass surgery?

Speaker_-_Dr__Joseph_Sabik: Today there are a lot more options for minimally invasive for bypass surgery. These procedures started being developed over 10 years ago. The technology and surgical techniques have improved such that today many more patients are candidates for minimally invasive bypass surgery. In deciding if you are a candidate for these types of procedures, it is important to go to a center such as the Cleveland Clinic, where surgeons have been involved in these operations for many years and have a large experience

kimf: I have Ebstein's Anomaly and have a porcine valve which obviously will have to be replaced several more times. Is there any chance that this may be able to be replaced in a way other than traditional open heart?

Speaker_-_Dr__Joseph_Sabik: There are multiple percutaneous valves being trialed and developed. It is very possible when your valve needs to be re-replaced that it could be done in a less invasive way with one of these valves.


Aorta surgery

karlamcadam: My question is in regard to Aorta expansion. Five years ago I had open heart by pass surgery. Then, my aorta was measured at 5.0 cm, recently I had a CTA test that showed the aorta is now 5.6cm. I was told that I am not a candidate for aorta surgery because of the proximity of the by-passes to the aorta. That the risk of aorta surgery was too high compared to living with the enlarged aorta. Have there been any new developments is this area?

Speaker_-_Dr__Joseph_Sabik: You obviously have a complicated heart condition. These problems are often handled by surgeons with experience in both heart reoperations and aortic surgery. We perform these types of procedures at the Cleveland Clinic and are commonly referred patients just like yourself. We would be happy to review your records and offer an opinion.

nevio: Dear mister Sabik my mother (age 67)chest CT-scan demonstrated enlargement aneurisms of the descending thoracic aorta (diameter 6,92 cm).She did resection aneurism ascending aorta and arch of aorta 31/07/2003.The aorta is replaced with a fabric substitute (inter vascular artificial limb diameter 23 mm).What are the chances for a operation in your clinic?

Speaker_-_Dr__Joseph_Sabik: Every patient has to be evaluated to determine their suitability for surgery. However your mother has a large descending thoracic aortic aneurysm that clearly meets the size criteria for surgery. These procedures can be performed open with a standard approach or endovascularly with an endovascular graft. One of aorta surgeons would be able to evaluate her to determine the best way to treat her aneurysm.

martinjstahl: I have a thoracic aneurysm and two leaking valves. Is there any chance that in the future you will be able to repair the thoracic aneurysm non-invasively, as I understand that you can repair an aortic aneurysm non-invasively? Are there any new techniques that are available that reduces the mortality rate for the operation? What is the success rate? How long does the operation for the valves and the thoracic take? Why would the CC be a good place to have the operation? At what cm (5.5?) do you recommend that the operation take place? Which is more accurate: a CAT or MRI?

Speaker_-_Dr__Joseph_Sabik: Whether a thoracic aortic aneurysm can be repaired endovascularly depends on its location and anatomy. So - today we can repair many thoracic aortic aneurysms minimally invasively. 

In terms of size, size is not the only important factor - although it is a very important one in deciding when to have your aneurysm repaired. Other important factors include a family history of aortic aneurysm or sudden death and whether the aneurysm is symptomatic.

Aortic aneurysm surgery is a specialized field of cardiovascular surgery. Best results are obtained in centers with large experience. The Cleveland Clinic has one of the largest experiences in the treatment of aortic aneurysms.


Aortic valve surgery

emilyej: I am a healthy 56 yr old female who had a stenotic aortic valve replaced with a homograph valve five years ago. It has been moderately/severely leaking for the past three yrs. My understanding is that the eventual replacement cannot be done as a minimally-invasive procedure due to the tricky nature of removing a homograph valve. What kind of valve would likely be used to replace it, and would the incision need to be as long as my current scar (8 1/2")?

Speaker_-_Dr__Joseph_Sabik: It is probably safest to perform the aortic valve reoperation through a standard cardiac surgery incision. As to the type of valve - this is dependent on patient preference and co-morbidities.

WAMPUMM_2: I am 85 y/o M with aortic stenosis x 15yrs, Asymptomatic, Echo q6mo, recent .8-.6?Is AVR inevitable; traditional or minimal sternotomy?

Speaker_-_Dr__Joseph_Sabik: Your valve is severely stenotic and in the near future I would expect you would require an aortic valve replacement. If you only need your aortic valve replaced - I would suggest being evaluated for a mini-sternotomy

rickkr: What determines if aortic valve replacement can be done non-invasively?

Speaker_-_Dr__Joseph_Sabik: Most isolated aortic valve operations can be done minimally invasively. If a patient needs other things done to their heart such as other valves replaced or repaired or bypass surgery, then the operation is usually done with a traditional approach not minimally invasively.

seanrip1: I had aortic valve and aortic root replacement in mid-August. I'm 60, a male, and very active. How long might my bovine valve last before I need a replacement? What symptoms should I watch for? How often should I have an echocardiogram?

Speaker_-_Dr__Joseph_Sabik: Today's tissue valves are much better than ones from a generation ago. Our belief is that many of these valves will last 15 to 20 years. Symptoms such as shortness of breath or chest pain might be due to failure of the tissue valve. Your cardiologist will be the best person to monitor your valve. He or she may decide to do echocardiograms once a year as needed.

mkedje: I am a 55 year old male with aortic stenosis. The valve area is 1.2 cm2 and the aortic root is 4.5 cm. My cardiologist recently told me that the Mayo Clinic is recommending surgery at 0.9 cm2 instead of 0.7 cm2. And if the aortic root is enlarged, surgery should be performed when the area reaches 1.1 cm2 instead of 0.9. What are you feeling about this recommendation?

Speaker_-_Dr__Joseph_Sabik: The timing of surgery needs to be individualized. Although all of your cardiologists' comments may be appropriate, one size probably does not fit all.

bulsmith1: I am a 35 yo male that had the Ross Procedure and repair of an ascending aortic aneurysm repaired at CCF in 2000. Recovery has been uneventful until approximately 3 years ago. There was a new aneurysm discovered in the ascending aorta measuring 5.0cm. Is it appropriate to continue to monitor the aneurysm or is it time for another OHS?

Speaker_-_Dr__Joseph_Sabik: The timing of surgery needs to be individualized. It is probably appropriate to contact your surgeon and get them involved in your care.


Mitral valve surgery

qizzynob: September, 2007, I had a mitral valve repair-2 chordae shortened w/ a ring on top. When I left the hospital, my records show minimal leakage. However, w/ each new echo, the leakage is greater. My last one in August showed "moderate" leakage. Will it automatically progress to severe leakage again, and then I will be a candidate for re-repair, or does it sometimes reach a level (like moderate), then not get any worse? If I do need another surgery, do they again try a repair, or replace it? After the surgery, I was on life support for a week, and in the hospital for a month (my right heart wouldn't start when I came off the machine), so I really do not want to consider another surgery if not absolutely necessary. I've begun to "cough" again, especially when lying down, and the shortness of breath on exertion is increasing. I'm not having this done again in Charlotte, and read where Cleveland Clinic was the place to go.

Speaker_-_Dr__Joseph_Sabik: None of us are smart enough to predict the future. Hopefully your valve leakage will not progress and you will not require further surgery. However, if your leakage does progress and you develop recurrent symptoms and your heart strength weakens, I completely agree with you that it will be important for you to go to a center such as the Cleveland Clinic that specializes in mitral valve repair surgery. I think with greater experience the more likely that your valve can be re-repaired if it fails.

KH252NC: I need to mitral valve repair and maze procedure for atrial fib. Surgeon wants to do robotic mitral valve repair and cryomaze for afib. Is this the recommended surgery for treatment for both conditions. does Cleveland Clinic do both procedures at same time and is cryomaze most effective and safest.

Speaker_-_Dr__Joseph_Sabik: There are many ways to treat mitral valve disease and atrial fibrillation. Robotic repair is one of them. There are no guidelines to suggest that any of the approaches is recommended over the other. The importance is to have the care individualized to the patient so that it is the best option for that patient.

KH252NC: When a patient has shown an anaphylactic allergy to Heparin, how are alternative substitutes for Heparin determined when a patient needs surgery for Mitral Valve repair and a CryoMaze procedure for Atrial Fibrillation?

Speaker_-_Dr__Joseph_Sabik: When a patient has a heparin allergy, we have other medicines we can use to thin the blood so that the heart lung machine can be used safely. Bivalirudin is the drug we use today in patients with heparin allergies at the Cleveland Clinic and can be used to have a mitral valve repair and cryomaze.

jazajaz: Dr. Sabik, For one with severe mitral valve leakage (ejection fraction of 65) and moderate tricuspid valve leakage, when would be the best timing for any valve repair?

Speaker_-_Dr__Joseph_Sabik: The most common indications for mitral valve surgery are:

  • the development of symptoms such as shortness of breath
  • decrease in heart function
  • and - rise in the blood pressure in the lungs.

Recent studies have suggested that when patients have what is called a flail leaflet, that early surgery results in better survival.

jazajaz: Does severe mitral valve leakage indicate a flail leaflet?

Speaker_-_Dr__Joseph_Sabik: Not necessarily.


Stents and bypass surgery

jpstan650: how many stents can be inserted before open heart surgery is warranted. Can aneurysms within the coronary arteries be corrected with open heart surgery.

Speaker_-_Dr__Joseph_Sabik: The more stents the less likely that bypass surgery can be performed effectively if needed. You never want to have something that limits your options down the road - stent use should be used judiciously so that in case you ever need surgery - that option is still there.

Most coronary artery aneurysms do not need to be treated at the time of surgery unless there are important blockages associated with them. Occasionally a coronary artery becomes very large and can cause complications - these can be treated surgically.


Bypass surgery

oldieforsure: I am 75 years old with family history of coronary thrombosis at early age. Father passed away at age 35 and brother at age 52. I have had three MI's, quadruple by-pass in 1992 and recent (Dec 2003) angiogram shows three venous grafts are occluded. My cardiologist says surgery is no longer an option. I walk two miles daily and have ejection fraction of 45%. I have mild nocturnal angina controlled by Nitro patch. Toprol XL 25mg, Aspirin 81mg, Vytorin 10/80mg and 1500mg Nicain daily are my meds. I leave my patch on until after my morning walk. My lungs are good, do not smoke, but find myself winded walking up one flight of stairs. I have completed the 35 hours of EECP (early 2004). What are my options

Speaker_-_Dr__Joseph_Sabik: In my experience, patients are often told that surgery is not an option. However, surgeons with experience particularly with reoperations know how to perform surgery in patients with complicated conditions. I would not say that surgery is not feasible without a proper evaluation. The importance is to compare the risks of surgery with its benefits - that would be an important part of the evaluation. We would be happy to review your records.

cm: For Left Main Stenosis, is it better to try first with Stent and then go for CABG?

Speaker_-_Dr__Joseph_Sabik: The present American Heart Association/American College of Cardiology guidelines still recommend that coronary artery bypass surgery be performed for patients with important left main coronary artery stenosis.

cm: Thank you for your clarification but if we prefer to go with the left main stent does the Cleveland clinic perform the left main stent

Speaker_-_Dr__Joseph_Sabik: We do left main coronary artery stenting, however, I still suggest you consult both a surgeon and an interventional cardiologist before deciding on which way to proceed.

quilterlynn: What does research or your personal experience tell you about new graft procedure on a patient whose former graft has failed (clogged up)?

Speaker_-_Dr__Joseph_Sabik: In a recent study we performed at the Cleveland Clinic on coronary artery bypass surgery reoperations, we found the risk for patients undergoing reoperations to be similar to those patients undergoing primary surgery.

namllits2002: what is the criteria for using the beating heart technique in bypass surgery

Speaker_-_Dr__Joseph_Sabik: If your operation can be done as effectively and safely off-pump as on-pump, then off-pump surgery is an appropriate method of performing the operation. Important factors to consider are the extent of disease in the coronary arteries; left ventricular function; and patient co-morbidities.

clara: I had bypass surgery 2 years ago, and the grafts are filling up. Also I have very small arteries that can't be stented. The angina symptoms have be getting worse, and I was told to go to the ER if I think I am having a heart attack. They did not use the mammary arteries incase I would need them later. I am confused what direction to go. The individual that did the grafts told me he had to go into the other leg, because the vein was so small.

Speaker_-_Dr__Joseph_Sabik: It sounds like to me it would be appropriate for you to at least consult a surgeon who is experienced at reoperative coronary surgery. We have a process to review records and provide a surgical opinion. If you need more information, chat online with a nurse from our website or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.

clara: My grandmother had bypass surgery and they used the veins in her legs. I thought the arteries were better. How do they decide what to use?

Speaker_-_Dr__Joseph_Sabik: The best thing we have to use to do bypass grafts is the arteries inside the chest wall - called the internal mammary arteries. Often, bypass surgery is performed using at least one of the internal mammary arteries and the saphenous veins from the legs. In appropriate candidates, both internal thoracic arteries and other arterial grafts may be used as opposed to using the vein from the leg.

312mk: I had breast cancer 10 years ago with radiation and chemotherapy. I am a very active woman, eat right, but ended up with a heart attack – my doctor said I need bypass surgery. I have a few questions: 1. Did the cancer have something to do with getting heart disease? 2. Someone told me it could be a problem having heart surgery because I had chemo and radiation – is that true? 3. Are there minimally invasive options?

Speaker_-_Dr__Joseph_Sabik: I don't know of any relationship between cancer and development of heart disease. Unfortunately, there may be relationships between the treatment of cancer and the development of heart disease.

Depending on the anatomy of your coronary artery disease, a minimally invasive approach may be an excellent option for you

Russ: My dad had bypass surgery 3 weeks ago and then left the hospital with medications to control an irregular heart beat – is that common?

Speaker_-_Dr__Joseph_Sabik: I believe your father developed atrial fibrillation. This is a common irregular rhythm after heart surgery and in the vast majority of patients, by two months, they no longer have the abnormal rhythm.

maryn: I have another question for Dr Sabik, I am not sure which arteries have to be bypassed, my cardiologist said the main left trunk & the left side., in addition to valve repair/replacement for the aortic & mitral valve. would I be a candidate for off-pump surgery?

Speaker_-_Dr__Joseph_Sabik: No. Since your heart valves have to be operated on, we need to perform your surgery with the assistance of cardiopulmonary bypass.


Myectomy

sassydeborah: I am about to have a myectomy. Can you explain this procedure?

Speaker_-_Dr__Joseph_Sabik: In some people, the muscle of the heart gets very thick and obstructs the blood leaving the heart. To relieve this obstruction, this muscle is excised.


Adult congenital heart disease surgery

Super_Dave_2: I am a 45 year old male facing heart surgery due to birth defects. Aortic Valve and stem replacement, Patch hole next to Aortic valve, repair hole between 2 bottom chambers, possible pace maker. I am a brain aneurism survivor from 1989 and a neurologist cleared me for use of low dose coumadin. Q: Is a mechanical valve my best bet and is there a fix that would not require coumadin?

Speaker_-_Dr__Joseph_Sabik: Your case is very complicated. It would be difficult to do it justice with the amount of information we have - we would be happy to evaluate your case further to provide you with an appointment. We have excellent surgeons who specialize in adult congenital heart disease.


Diagnostic Testing

charlesho: I have three stents and an angioplasty. How can I determine the status of my coronary arteries

Speaker_-_Dr__Joseph_Sabik: Non-invasive methods include one of the many types of stress tests, although these do not give an anatomical picture of your coronary anatomy, they provide physiologic information as to whether the blood flow to your heart is adequate in meeting demands when you exert yourself. Some of the new high speed CT scans can also give anatomical descriptions of your coronary anatomy. A left heart cath would be an invasive way of imaging your coronary arteries and would give the best information. However, this test is usually reserved for patients with recurrent symptoms or positive stress tests.

jazajaz: Can a flail leaflet be determined from an echocardiogram?

Speaker_-_Dr__Joseph_Sabik: Often it can.

jazajaz: How is blood pressure in the lungs determined?

Speaker_-_Dr__Joseph_Sabik: A noninvasive method is with an echocardiogram. An invasive method involves a right heart catheterization.

jazajaz: Is blood pressure in the lungs different from the usual reading for blood pressure?

Speaker_-_Dr__Joseph_Sabik: Yes.


Complicated Medical Care

jraea52: My husband is 52 yrs old and has been dealing with an arrhythmia for six years. He has had several ablation surgeries with no success. His most recent surgery resulted in having to put in a pacemaker due to severing the electrical path between the upper and lower chambers. He also has hemachromatosis that he has had several flabotomies for. is there a surgeon that may specialize in multiple conditions. His HR averages 295 bpm in the past 174 days and his blood pressure is low and he is exhausted all the time.

Speaker_-_Dr__Joseph_Sabik: Since he has multiple medical problems - it will be important to go to a center that has expertise in all of these problems so he will get the care he needs to have an uneventful surgery and recovery.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sabik is now over. Thank you again Dr. Sabik, for taking the time to answer our questions today. 

Speaker_-_Dr__Joseph_Sabik: Thank you for having me today.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 11/08

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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