Ask the Heart Surgeon - Dr Johnston
Tuesday, February 9, 2010
Douglas Johnston, MD
Staff cardiac surgeon
Sydell and Arnold Miller Family Heart & Vascular Institute
As one of the largest, most experienced cardiac and thoracic surgery groups in the world, and the Cleveland Clinic Cardiovascular Surgery program cares for patients from all 50 states and around the world. Our surgeons offer virtually every type of cardiac surgery including elective or emergency surgery for heart valve disease, aortic aneurysm, coronary artery disease, arrhythmias, heart failure, Marfan syndrome and other less common conditions. Even complex operations, such as second and third bypass operations and aortic and great vessel surgery, are routinely performed at Cleveland Clinic with excellent results. Dr. Johnston, a Cleveland Clinic cardiac surgeon provides answers to your questions about heart surgery during this online chat.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Douglas Johnston, MD a Cleveland Clinic cardiac surgeon. Dr. Johnston, thank you for being here with us today.
Speaker-_Dr__Douglas_Johnston: Thank you for having me today.
General Surgery Questions
maslarj: After surgery, do all of your patients require cardiac rehabilitation?
Speaker-_Dr__Douglas_Johnston: We recommend outpatient cardiac rehabilitation for most patients who have cardiac surgery. Exercise is a very important part of getting better and feeling healthy after surgery. Cardiac rehab provides a way for patients to get monitored exercise and feel comfortable with how much they can do. I recommend it for my patients.
golfgirl: If a patient is out of state and travels to Cleveland for cardiac surgery, do we follow-up with our regular cardiologist after we are released from the Cleveland Clinic?
Speaker-_Dr__Douglas_Johnston: Good question. We will help arrange whatever is most convenient for the patient. It is usually best to have a cardiologist close to home who can see you more often and make adjustments to medications - but we are always happy to see you here back at the Cleveland Clinic.
Chloe: Please explain the types of minimally invasive surgery approaches. I have your hand out and am not sure if the 3-4 inch approach actually go through the sternum as the traditional approach does.
Speaker-_Dr__Douglas_Johnston: For aortic valve disease, we use a 3 - 4 inch incision that does split one half the sternum.
For mitral valve disease, we can use the same incision or an incision on the size of the chest between the ribs that does not split the sternum.
The same incision is not right for every patient - there is no one size fits all.
bill53: How do they decide if someone can have minimally invasive surgery or not?
Speaker-_Dr__Douglas_Johnston: This depends on the type of operation being done, patients other health problems, and to some extent the size and shape of the patients chest. As surgeons, our job is to tailor the right operation and the right incision to the right patient.
ml45: What is beating heart surgery?
Speaker-_Dr__Douglas_Johnston: Beating heart surgery is exactly what it says - it is doing surgery without stopping the heart. This can be done safely in some situations and for some operations. But often, the best and safest approach is to stop the heart to perform the operation.
Chloe: How close to the time of surgery do you require a cardiac catheterization be done?
Speaker-_Dr__Douglas_Johnston: If a patient has had a cardiac catheterization within 6 months of surgery - that is usually adequate. If a patient has new or different symptoms, or worsening heart function - they may need an up-to-date cath.
taylor: I had valve surgery 6 months ago and still have pain in the middle of my chest – is that normal? Should I get checked. It hurts whenever I move.
Speaker-_Dr__Douglas_Johnston: Some patients have soreness for a while after surgery which gets slowly better. Pain at 6 months is unusual and should be checked by your doctor.
CLSTAR: How well does an older patient (over 70 ) do with valve repairs?
Speaker-_Dr__Douglas_Johnston: Older patients can do very well with valve repair as long as the condition of the valve is adequate to perform a good repair
sam01: I was told I have three leaking heart valves? Is that common to have all three that leak? Can they fix all the heart valves?
Speaker-_Dr__Douglas_Johnston: We see a lot of patients with disease in 2 or 3 valves. It is often possible to address all 3. Some may need replacement, others may be repaired.
heather24: I am having a mini-sternotomy to repair my mitral valve at the Cleveland Clinic. Would you be able to describe how the heart-lung machine is hooked-up for this type of surgery?
Speaker-_Dr__Douglas_Johnston: Sure. With a mini - sternotomy usually one cannula or plastic tube is placed in the aorta to give blood to the body and one tube is placed in each of the vena cava - the big veins that bring blood back from the body so we can do the operation with the heart and lungs resting.
stepharnold: I am scheduled for valve repair/replacement surgery at the Cleveland Clinic on Oct. 26. I would like to know how you determine whether or not to repair vs. replace and what can I expect during recovery.
Speaker-_Dr__Douglas_Johnston: Part of that depends on what valve is being repaired or replaced - but in general if we can repair a valve safely and expect that the repair will be durable, then we will try to repair the valve. Most patients spend a week or less in the hospital and are walking by a day or two after surgery and can return to full activity in 6 to 8 weeks.
roullac: When would a calcified valve need to be replaced after being repaired and there is no regurgitation? What sort of test does one need to have to detect if the calcification is getting worse? Also what are the causes of calcification?
Speaker-_Dr__Douglas_Johnston: The best test to evaluate a valve both for function and calcification is an echocardiogram. If a valve is calcified but not leaking and not narrowed, usually nothing needs to be done about it. The most common cause of calcification is aging.
roullac: How long will it take for the sternum to heal? I have had a Median Sternotomy to repair my Mitral Valve (Severe Regurgitation). Will I be able to consume to my daily activities which is belly dancing in 8 weeks time?
Speaker-_Dr__Douglas_Johnston: Most people can return to full activity 6 to 8 weeks after surgery. The bone returns to 85% of its original strength at this time. Everyone should check with their doctor before returning to full activity.
roullac: Dr. Johnston, I have had sinus tachycardia prior to surgery and it seems I still have sinus tachycardia now and I was told that this is due to my anemia (as I lost quite a bit of blood during surgery). Also I have had a lot of fluid in my right lung post surgery and my doctor has put me on diuretics which seem to work. Can you tell me whether this could affect my repaired my valve and also what would be the maximum beats that my heart should be beating now; I do exercise at the moment but I am able to walk for an hour.
Speaker-_Dr__Douglas_Johnston: In regard to whether it would affect the valve - it is unlikely that any exercise or increase in heart rate would affect the valve - the valve is very durable and would be able to withstand any activity even with athletes. If you have preexisting sinus tachycardia, it may be worthwhile to evaluate with your cardiologist to see if you would benefit from adjusting your medication or a more extensive evaluation.
CLSTAR: Can a very leaky valve cause damage to the heart muscle (like cardiomyophathy)?
Speaker-_Dr__Douglas_Johnston: Very good question. Over time, a leaky valve makes the heart pump more blood than it is supposed to pump - which can make the heart enlarged (dilated) with time. Eventually this can make the heart muscle weak - like a cardiomyopathy.
smithm: I had bypass surgery 6 months ago. After surgery my doctor said my diaphragm has partial paralysis. Does this ever correct itself? Is it dangerous? Is there corrective surgery?
Speaker-_Dr__Douglas_Johnston: In most cases, this is due to a weakness of the phrenic nerve that often gets slowly better over time. In cases where the diaphragm is completely paralyzed, and the patient has severe symptoms, surgery can be done to the diaphragm to improve the lung function.
Mitral Valve Surgery
shones: What's the best course of action for my parachute mitral valve which has a highly calcified posterior leaflet? Repair or replacement? I have read that valvuloplasty can be safely and successfully carried out in patients suffering from regurgitation associated with severe calcification of the mitral apparatus. Am I excluded from mitral repair?
Speaker-_Dr__Douglas_Johnston: The indications for surgery on the mitral valve have to do with how the valve is working (it can be leaky or narrowed), how that is affecting heart function, and in turn a patient's symptoms. In many cases valves with calcification can still be repaired. That depends on the location of the calcium, and whether there is still enough healthy valve tissue to allow the valve to work well after repair.
Your surgeon can often make a good prediction as to whether the valve can be repaired based on your echocardiogram and other preoperative studies. The final determination is made in the operating room.
Debmol: I have significantly prolapsed anterior and posterior mitral valve leaflets with 2 broad jets of regurgitation (1 directed ant. and 1 post.) Does this TEE finding increase the likelihood of a bileaflet repair? If so, should this type of repair be done in a specialized center vs. community hospital?
Speaker-_Dr__Douglas_Johnston: Based on your description, your valve likely has bileaflet prolapse. In many of these cases, both the anterior and posterior leaflets must be addressed to achieve a successful repair. The probability of having a successful repair does depend on the level of experience of the surgeon and the center where the surgery is done. Most surgeons would agree that this is better seen at a specialized center with a large experience with complex mitral valve repair.
Debmol: Are there specific things a patient approaching a mitral valve repair should do or not do preoperatively to prepare for surgery (i.e. diet,exercise, etc.)?
Speaker-_Dr__Douglas_Johnston: Patients who do the best after heart surgery are those who are active and lead healthy lifestyles beforehand. A healthy diet and careful exercise as recommended by your doctor are the best preparation.
golfgirl: I am 40 and have had mitral valve prolapse since I was 12 without symptoms. Last year after a sports injury, I was diagnosed with POTS, fibromyalgia, autoimmune disease and now need mitral valve repair surgery due to regurgitation and am symptomatic. Could the autoimmune disease have caused the MVP to worsen? Could POTS get better after surgery?
Speaker-_Dr__Douglas_Johnston: The causes of MVP and degeneration are not well defined. It is a very common disease with a number of possible causes. If part of the tachycardia is related to the heart function because of the mitral valve regurgitation this may get better but in many cases - these are two separate problems.
butterfly34: When they do mitral valve repair can they repair the papillary muscles and how do they do that?
Speaker-_Dr__Douglas_Johnston: In the case of papillary muscle rupture due to a heart attack, often the valve cannot be repaired and needs to be replaced. There is some repair techniques for elective repair which involve reconstructing the connection of the valve to the papillary muscle.
shones: I live on the west coast and need to have mitral valve repair/replacement. Where in northern California would you recommend I have this done?
Speaker-_Dr__Douglas_Johnston: I am not familiar with the particular outcomes of any hospital in that area. We would be happy to see you here for this problem - as we do have numerous patients that come from out of state for heart surgery.
lilie: What percentage of mitral valve surgeries can be done minimally invasive and are they as successful?
Speaker-_Dr__Douglas_Johnston: We have looked at this very closely. A high percentage of mitral valve surgery can be done through minimally invasive incisions as long as the patient does not require other procedures at the same time. Minimally invasive mitral valve surgery is just as successful as surgery by median sternotomy.
Chloe: Following mitral valve repair, how many times is a patient routinely seen by the surgeon after discharge?
Speaker-_Dr__Douglas_Johnston: In most cases, patients come back for one postoperative visit in the Clinic to look at their incision and insure they are doing well after surgery. After that patients are followed by their cardiologists.
Chloe: How are patients requiring mitral valve surgery assigned to a specific surgeon? Do they need to have a name in mind when calling or are they assigned based on the type of lesion they have?
Speaker-_Dr__Douglas_Johnston: Patients do not have to have a particular doctor in mind. All of our surgeons do mitral valve surgery as it is one of the most common problems we operate on. In some cases a particular surgeon may become involved because of an unusual lesion.
Aortic Valve Surgery
carrie: My father has heart failure and enlarged heart. He has aortic stenosis and atrial fibrillation. If he has heart surgery to cure the aortic stenosis – can the other things improve? What are the risks of surgery. My dad is 68 years old.
Speaker-_Dr__Douglas_Johnston: If the enlarged heart is because of the aortic stenosis, then fixing the valve may allow the heart to return to a normal size with time. We can often do a procedure called a MAZE to address the atrial fibrillation at the time of valve replacement. I would say, the risk of surgery depend mostly on a patients other health problems not on age alone. 68 is young for many of our patients having aortic valve surgery.
Bungle75: Is an AVA of .96cm2 and a mean gradient of 48mmHg (up from 32mmHg) with chest tightness a cause for AVR/ I am a 51 yr old fit male. Thank you.
Speaker-_Dr__Douglas_Johnston: Yes. Aortic valve area of less than 1 cm is considered severe and along with your symptoms most cardiologist and surgeons would recommend aortic valve replacement based on national guidelines.
golfgirl: Prior to valve repair, would you order a CT angio to ensure that there is no plaque in the aortic valve?
Speaker-_Dr__Douglas_Johnston: We use CT scan before surgery mainly in the case of previous heart surgery to look at how best to do the operation safely. A cardiac catheterization would probably be necessary before valve surgery.
McKim: I've been diagnosed with severely leaking aortic valve implanted 7 years ago and ascending aorta of 5.0. After an angiogram, the local surgeon suggests that because my coronary arteries could be located very close to the heart he is inclined to only replace the valve and leave the aorta alone. I feel like this isn't the best solution as the ascending aorta is likely to need attention in the near future. Are there options at the Cleveland Clinic not afforded my by the local surgeon?
Speaker-_Dr__Douglas_Johnston: If I understand correctly, you have had a previous aortic valve replacement and now need another operation on your aortic valve. In general we would replace the ascending aorta when it is 5 cm in diameter and the patient needs surgery for another reason. I or one of my colleagues would be happy to review your case and discuss surgical options
trippstreet: New York Times had front page article in the business section on experiment AVR with balloon technique. Any thoughts on this for the future and can it be used for a second AVR?
Speaker-_Dr__Douglas_Johnston: It is a very exciting technique - and we are involved in the very same study that was published in the NYT article. I think this technique holds a lot of promise for the future and one of the populations that may benefit the most may be patients with a previous valve replacement. For the moment - however this technique remains experimental.
jillian99: My mom needs aortic valve surgery but it is a surprise. She never had symptoms. Is that common? How do they know she needs the surgery – her doctor told her after an exam.
Speaker-_Dr__Douglas_Johnston: In general, we make that evaluation after looking at how narrow the valve is on an echocardiogram, looking at the heart function and talking to the patient about how they are doing. Many patients have mild symptoms and limit their activity so they feel better so this is a very common way for patients to present.
Tricuspid Valve Surgery
tric_v: Are there any minimally invasive or catheter based procedures to fix the tricuspid valve?
Speaker-_Dr__Douglas_Johnston: Interesting question - we have developed a few experimental techniques to fix problems with the tricuspid valve with a catheter. These are still very early in their development. However - it is often possible to do minimally invasive surgery for the tricuspid valve.
sevyressag: I'm hoping to go to one of the Cleveland Clinics for tricuspid evaluation. Does it matter if it's the one in Cleveland or one of the Florida clinics?
Speaker-_Dr__Douglas_Johnston: We have a very collegial relationship with the Florida Clinic - if it would be better for you be evaluated in Florida - we would be happy to evaluate your records and films in Cleveland.
asdf: What options are there for tricuspid valve disease – can the valve be repaired with a small incision – what about with the robot?
Speaker-_Dr__Douglas_Johnston: In many patients robotic approaches are possible for tricuspid valve repair.
CLSTAR: I once had a dr. tell me that you can almost live without the tricuspid valve. How important is it to repair or replace?
Speaker-_Dr__Douglas_Johnston: It is true that patients can do very well with a badly leaking tricuspid valve as long as the rest of the heart is healthy. Repair or replacement is necessary when patients have severe symptoms or the right side of the heart begins to fail.
sevyressag: Is there an age limit for a heart transplant? Also can a person with a pacemaker swallow a camera to diagnose where intestinal bleeding is coming from?
Speaker-_Dr__Douglas_Johnston: Age limit for transplant - age is one of many factors considered by a committee of cardiologists, surgeons and other care givers in deciding when someone can have a transplant. Regarding the camera and pacemaker - I would think so but I am not sure - you should discuss your questions with the cardiologist who put in your pacemaker.
Coronary Artery Bypass Surgery (CABG)
Raju: My mom, 60yrs old is diagnosed with triple vessel disease with severe disease of thin caliber RCA and intermediate disease of LAD with strong TMT. Since she has type2 diabetes, she is currently advised on medicines & diet. Right artery is 90%clogged. Is she a candidate for Bypass surgery CABG?. Please advise.
Speaker-_Dr__Douglas_Johnston: There are two primary reasons for us to perform CABG surgery: to prolong life and to improve symptoms. Patients who have coronary disease in all 3 vessels or in the left main coronary artery are likely to live longer with CABG surgery than with medical treatment. Some patients with other combinations of coronary narrowings may benefit from CABG for treatment of chest pain symptoms or to improve survival. I would encourage you to have your mother's catheterization film reviewed by our cardiologists and surgeons to help answer that question.
456kingsley: I was told I need bypass surgery but it can’t be done with a small incision – why can valve surgery be done with the mini but bypass cannot?
Speaker-_Dr__Douglas_Johnston: Good question. To do good bypass surgery, we often need to move the heart around and get access to many parts of the heart, which requires a larger incision.
clara: I think I deleted this, so I am putting it in again. I had 2 bypass/ aortic valve 3 yrs. ago. The next yr, the grafts had filled up 50%. Four months ago they put a stent in the posterior descending artery - 90% blocked. the left anterior artery had progressed to 50% obstructed by diffuse blockage. The distal circumflex is 80% obstructed by diffuse disease, and the right posterolateral segment is 30% obstructed by a single discrete lesion. The grafts have increased 50%. I was unable to finish the question. He said that the LAD was not treated, and it is unclear why no mammary artery was used. He said that it was unclear why I was incompletely revascularized but nothing could be done about it. Is there anything that can be done if the diffuse blockage continues? I know that the disease has progressed.
Speaker-_Dr__Douglas_Johnston: Progression of coronary artery disease after surgery is a problem that requires a very careful evaluation - looking at not only where the disease is - but the condition of those parts of the heart fed by those arteries. This is something that deserves a very careful evaluation by both a cardiologist and surgeon to see if any further intervention is needed or would be beneficial.
aaron23: A month ago I had minimally invasive bypass surgery. I was out of the hospital in 3 days – I am able to walk and do things – but I have a terrible cough – I don’t really cough anything up but the cough is irritating and constant. It happens all day long. Is this normal after surgery? What causes it? How long will it last?
Speaker-_Dr__Douglas_Johnston: It is not normal to have a constant cough after surgery and that certainly should be checked. Sometimes a small amount of blood or fluid around the lung can cause irritation and coughing.
BM32: My dad has left main trunk disease and needs bypass surgery but he also has pulmonary fibrosis. Does that increase the risk of surgery?
Speaker-_Dr__Douglas_Johnston: Lung disease does increase the risk for surgery - how much increase in risk depends on how well the lungs function and this can be answered by a pulmonary function test. This requires a close conversation between surgeon and pulmonologist.
jimb: I had a heart catheterization and I have blockages in my LAD. My doctor wants me to have bypass surgery because of the location of the blockages – but my wife thinks I should get a second opinion to make sure I should have surgery vs. having a stent. What is the difference – why would someone have bypass surgery over a stent? Am I missing something?
Speaker-_Dr__Douglas_Johnston: Great question. There are a lot of studies on this issue. The reasons to do bypass surgery are to prolong someone’s life or make someone’s life better. For blockages in the LAD, in certain locations, bypass surgery leads to better survival than stenting.
borger: Are there any new treatments for constrictive pericarditis being used now or in the future?
Speaker-_Dr__Douglas_Johnston: For people who have pericardial disease that is active - meaning they have inflammation - we have new ways to diagnose and evaluate the disease with MRI which can guide treatment. For those people who have had the disease for a long time, we are active in considering surgery pericardiectomy as an option.
Hypertrophic Cardiomyopathy (HCM)
BrooksK: I have obstructive Hypertrophic Cardiomyopathy (HCM) and am being seen at CCF. How does one determine when the conditions/symptoms are bad enough to warrant surgery. I'm a 61-year-old, white male and was much more active before going a drug regimen that helps with HCM symptoms but seems to have a whole raft of side effects. Is it wise to have surgery to correct the heart's structure before I'm "too old"?
Speaker-_Dr__Douglas_Johnston: Surgery for HCM is indicated when the ventricular septum of the heart becomes thick enough that it partially blocks the flow of blood from the heart under some conditions. In these cases the mitral valve may also become involved and begin to leak. Your doctors can help decide whether the anatomy of your heart would benefit from surgery. Timing of surgery is a matter of weighing the risks and benefits for an individual patient, which includes considerations of age, physical condition, and other important factors. Having a candid discussion with your doctors regarding your concerns about timing of surgery is very important.
Congenital Heart Disease Surgery
dvraju: My son Nikhil 9years old had a VSD from his birth, very small hole 3mm. He used to take medication when he was a toddler but now he is going on a regular visit with cardiologist who is monitoring him every year for progress. His hold has not been closed and we get feedback from doctor indicating we don’t have to do invasive surgery if VSD is not affecting his growth. My question is at what point do we need to consider surgery as an option to fix VSD?. THANKS in advance.
Speaker-_Dr__Douglas_Johnston: Surgery for a small VSD in an older patient - meaning not a baby - is something that needs to be individualized to the patient and requires a careful discussion with a pediatric cardiologist and heart surgeon. I would encourage you to raise this question with your son's cardiologist.
General Cardiovascular Questions
reprobatus_max: I am an insulin-dependent diabetic (mellitus, type 2) for 20 years (insulin started 5 years ago). My primary care provider, an internal medicine MD, tests my heart with sensitive CRP, occasional stress tests, and lipid panels. I have no CVD symptoms but want to know what other testing can be done to check for onset of or progression of CVD? I have severe DDD, spondylosis, foraminal and central canal stenosis of thoracolumbar spines and am retired due to severe, unremitting pain in back and lower extremities. Am I going to have to wait for a CVA or MI before more aggressive testing can be conducted? Do you have difficulty getting HMOs to cover preventive testing when patient like me is in a very high-risk category? Thank You.
Speaker-_Dr__Douglas_Johnston: Non-invasive screening tests are an important first step in evaluating the risk of cardiovascular disease. Exercise stress testing is an important part of this, though it can be difficult to get an accurate result in patients with mobility problems or difficulty achieving maximal heart rate. Usually the next step after a positive stress test would be a cardiac catheterization. In some cases, this may be performed when the suspicion of coronary disease is high but other tests are negative.
Because of heart disease is such a common problem and is still the number one killer in the United States, most insurance will cover testing as recommended by the guidelines published by the American Heart Association and American College of Cardiology.
fevvay57: I HAVE A MITRAL VALVE PROLAPSE. I JUST FINISHED 6 WEEKS OF CHEMO, AND 7 WEEKS OF RADIATION BECAUSE OF HEAD/NECK CANCER. I CAN'T EAT, AND CAN'T DRINK MUCH WITHOUT THROWING UP. I HAVE LOST 31 LBS. DURING ALL THIS. WHAT, IF ANYTHING, COULD THIS BE DOING TO MY HEART?
Speaker-_Dr__Douglas_Johnston: Some chemotherapy drugs can affect the function of the heart. That said, mitral valve prolapse is a very common condition which most often would not be made worse by your cancer or treatment. An echocardiogram would help answer that question, but it is likely your heart is not affected. Best of luck in the remainder of your treatment and recovery.
dvraju: I have seen healthy people with no prior medical issues, collapsing & dying of heart issues. Is there a proactive way of doing echo cardiogram or MRI for adults more than 40 yrs old to check for healthy heart rather than conventional annual check up's. THANKS in Advance.
Speaker-_Dr__Douglas_Johnston: Unfortunately there is no perfect screening test. The best prevention is a healthy diet, exercise, avoidance of smoking and regular check ups with your medical doctor.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Johnston is now over. If you have additional questions, please go to clevelandclinic.org/health/livepersonchat to chat online with a health educator.
Thank you again Dr. Johnston for taking the time to answer our questions about heart surgery today.
Speaker-_Dr__Douglas_Johnston: Thank you for having me today.
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