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Valve Disease (Drs Lytle&Savage 2 7 12)

Tuesday, February 7, 2012 - Noon


Cleveland Clinic provides surgical treatment for patients with valve disease. The Department of Cardiothoracic Surgery offers minimally invasive approaches to treat the various conditions of the heart and lungs. Minimally invasive procedures offer less pain and trauma, decreased recovery time, and a lower risk of infection.

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Aortic Valve Disease and Aortic Valve Surgery


Dr__Savage: If the valve has some leak or narrowing with it, it can. However there are many other reasons for poor athletic performance. The problems associated with a leaky or stenotic valve would be shortness of breath or poor endurance. Absolutely - this bicuspid valve has relevance to your current aneurysm. Given its size you should consult with a cardiothoracic surgeon as soon as possible.

adourian: When replacing an aortic valve what are the risks of having a stroke, what causes them and what is done during the operation to insure minimum risk?

Dr__Savage: The risk of stroke is fairly low after aortic valve surgery- probably less than 1 % in most cases. As patients get older the risk may rise. To minimize risk we make sure that all the debris is cleaned out from the valve; we make sure that the aorta itself is free of calcium; and we also do certain things to make sure there is no air in the heart to cause a stroke. In some patients who are at high risk for stroke, we screen them for carotid artery disease, we also aggressively treat heart rhythms which are common after heart surgery called atrial fibrillation which can also cause stroke.

Dr__Lytle: The most common causes of stroke are vascular disease which involves the blood vessels that go to the brain and atrial fibrillation. Identification of that type of vascular disease is important in determining alternative cannulation strategies for the heart lung machine that will decrease that risk of stroke.

adourian: Increased risk of heart attack for those with AS whose pressure gradient is mild, their ejection fraction is normal but they have something called "low flow". What is low flow? Is it part of my echo results or is another testing technique required to determine it?

Dr__Lytle: Low flow refers to a situation where the heart is not pumping much blood around. The combination of "low flow" and a normal ejection fraction is somewhat uncommon. Echo does not measure cardiac output well and to determine whether someone truly has low flow the best strategy is usually heart catheterization.


Dr__Lytle: Yes. Progressive cardiac enlargement if it is caused by a leaking valve is an indication for surgery in order to prevent further enlargement and heart failure from occurring.

Dr__Savage: The risk of reoperation for aortic valve replacement in this situation is generally very low

EricKD: I am a 58 year old female with bicuspid aorta valve. My cardiologist has been tracking leakage with echos over past 3 years. Leakage is progressing and I have a follow-up next year. Very few symptoms to date other than breathlessness climbing stairs. Very active. Am I a candidate for repair or am I too old?

Dr__Lytle: If your breathlessness is caused by your aortic regurgitation (AR) or if your AR is severe enough or your leakage is severe enough - then you should have surgery. Whether or not the valve can be repaired is uncertain but does become less common the older one gets. It is sometimes possible to repair the valve in a 58 year old woman but less common statistically than if you were a 28 year old woman.

One way or another whether the valve is repaired or replaced if you have breathlessness due to leakage of your valve, surgery would be in your best interest.

JohnR: Is there a means for removing pannus from an artificial aortic valve that doesn't involve cracking open the chest? (valve in question is part of an artificial aortic root (marfans) also have an artificial mitral with some pannus, not as bad. Had both valves for about 15 years.) Thanks

Dr__Savage: No. In most cases when there is significant pannus on an artificial valve getting it off surgically is not usually affective and having them replaced is usually the way to resolve the issue. However, if there is pannus on the valve, intervention should be guided by the presence of symptoms. If there are no symptoms and the valve is functioning, then the recommendation is to make sure anticoagulation is adequate to prevent growth of the pannus.

Dr__Lytle: If the patient does have symptoms, or if one or both of the valves are not moving normally then the patient will require surgery.

JRB: Male age 54, nonsmoker, cholesterol 147, normal blood pressure, normal height/weight, athletic, all other parameters normal... Except: Diagnosed Aortic Valve Stenosis (severe) Dec 23rd 2011, no serious symptoms yet, Echocardiogram did not indicate problem with aortic root or aortic aneurysm... Question => Am I possible candidate for "Minimal Invasive" or "mini thoracotomy" approach, and if so, what surgeon(s) at Cleveland Clinic specialize in this approach to aortic valve replacement...?? Not referring to "non-invasive" percutaneous TAVI...., I'm referring to "minimal invasive" or "mini thoracotomy"...

Dr__Lytle: The "mini invasive" or "mini sternotomy" approach to aortic valve replacement was developed at Cleveland Clinic and there are at least 6 CC surgeons with extensive experience with this approach. It is likely you would be a candidate for this type of surgery as long as you do not have coronary artery disease.

Dr__Savage: We also have experience with this approach in Florida.

erica: Homographic valves. What are the advantages and disadvantages? How hard are they to get? Is there a waiting list?

Dr__Lytle: Homograft aortic valves have 2 distinct advantages: In situations of valve infections it appears that re-infection is less common when homograft valves are used. And in some situations homograft valves are more efficient than standard valves. The problem with homograft valves is that they wear out and they do not appear to last longer than standard tissue valves. Also, when a patient does need a reoperation, that reoperation can be more difficult to do. That is why homograft aortic valve replacement has not become standard. However, in those situations, particularly involving infection they can be a very good choice. There is no waiting list but many institutions do not carry homograft valves.

Sept14: It's my understanding that more and more patients are advised to opt for tissue valve replacement of a native bicuspid valve, at a younger and younger age. To what extent are you able to estimate tissue valve longevity in younger patients when so much of the valve manufacturer data and studies evaluate the 65 and up age group, or sometimes just a broad 65 and under age group? Are you able to give any estimate for tissue valve longevity in younger age groups (say age 25, 35, 45, and 55) based on patient experience at the Cleveland Clinic?

Dr__Lytle: This is a long discussion, if you would like to discuss this - feel free to call or see our website on tissue valves.

dukefan55: I am a 56yo female with a bicuspid Aortic valve area of 1cm and an ascending aortic aneurysm of 4.4 cm.I have very visible pulses in my neck and would like to know could this be from my heart condition?

Dr__Savage: Patients with aortic aneurysms can have generalized vascular abnormalities which can lead to lengthening and prominence of blood vessels.  These blood vessels can develop aneurysms or redundancies which would protrude and move when the heart ejects blood. This could be what she is seeing in her neck.  Unless these represent aneurysms, which is unusual, they are probably of no consequence.  Pulses in the neck can be visible from other cardiac problems including tricuspid valve regurgitation and she should consult with her doctor in this regard.  She should be sure to make sure her blood pressure is controlled.

Sept14: What is the Cleveland Clinic preferred type of mechanical valve for aortic valve replacement and why? Or does it depend on certain circumstances? 

Dr__Savage:  (Bruce will have to answer for the main campus)  All approved valves have a similar safety and efficacy profile.  I use the Medtronic ATS Medical Valve because I find it easier to implant is patients with a small aorta.

ZIMMNC:  I have recently had a valve replacement using a pig valve. When I should need another surgery in the next 10-15 years what procedures are typically used? 

Dr__Savage: When and if a pig valve will fail cannot be determined absolutely.  The younger you are the faster they tend to fail.  Also mitral replacement valves fail faster than aortic replacement valves.  Some fail early for unknown reasons.  In general tissue valves tend to have a low failure rate for about 8-10 years, after that the failure rate begins to accelerate.  This does not mean that all valves will require re-replacement at 10-15 years.  Currently, the treatment is repeat surgery and replacement with a new valve.  In the future it may be possible to put a transcather "valve in valve" but the role of this approach is not know at this time.  It should be noted that the risk of elective reoperation to replace a failed aortic valve is very low.  For mitral the risk is somewhat higher.'

LMC:  How do you chose what type of valve to use for replacement? 

Dr__Savage: The choice of valve is based on multiple factors: age, other illnesses, desire to avoid blood thinners.  For the aortic position the recommendation from the American Heart Association is for a tissue valve if over 60 and mechanical if younger.  For the mitral position, a tissue valve if over 70 and mechanical if younger.  However, many surgeons are putting tissue valves in younger patients.  The choice of valve is a personal decision and requires a detailed discussion of the pros and cons with the surgeon. 

ddavis: I apologize to you if my English is flawed. Daniel D wrote from Caracas, Venezuela, and I have 55 years. It is a pleasure to welcome you and hope you are well. Recently, after making all assessments, preliminarily diagnosed me a severe symptomatic valvular stenosis with effort angina FC II, peak gradient 116, 54 mm Hg half.The doctors tell me I should replace the aortic valve through a surgery to open heart.I wonder if there is a minimally invasive type of Surgery for the intervention of aortic valve replacement and that steps would have to advance. Thanks Doctor and I hope your comments

Dr__Savage:For you the best choice is surgical aortic valve replacement which can be safely performed through a minimally invasive incision with a mortality risk close to 0%.

Transcatheter Aortic Valve Replacement

Robert_S: Have mild valve disorder which is monitored annually with echo and carotid artery sonogram. At some point will require treatment. Hoped to wait for minimally invasive surgery but in prior chats this appears to be only for high risk patients. Is this likely to change? If so what is likely time frame?

Dr__Lytle: If by mini invasive surgery - you mean a catheter born valve, the reason it is used for high risk patients at this point in time is because the mini-invasive nature of that operation would theoretically have the most benefit for high risk patients. Catheter born valve replacement has its own risks that are specific to that type of procedure, including what may be an increased risk of stroke. Another possible disadvantage of catheter born valves is that the valve longevity is completely unknown and a further disadvantage is that the seating of the valve is sometimes more difficult with a catheter leading to leak around the valve.

At the present time, the use of catheter born valves is being studied with randomized trials of high risk patients because logic would seem to indicate that the advantages are greatest for that group. in fact, we don't yet know whether there is an advantage or a disadvantage for high risk patients or for low risk patients or for whom the advantage really exists. That is why studies are being performed to find out what the advantages may be. Catheter born valve are not the only less invasive strategies for valve replacement.

Dr__Savage: In current surgical replacement - the risks are so low it is difficult to show an advantage for other strategies.

ehbrod: My mom recently died. She had severe aortic stenosis and also needed some replacement stents. She was 90 years old. She had a valvoplasty and seemed to be doing well. We were hoping she would be a candidate for noninvasive aortic valve replacement. Is there ever a situation where a cardiac patient is left without treatment in a hospital and treated for all the side effect problems of lying in bed too long?

Dr__Savage: Not knowing the situation it is difficult to address this - I would say that when your mother was sick, these valves were probably not approved. They may or may not have been approved for a TAVR. There are times when a patient may not be a candidate because they are so debilitated due to other medical problems.

NaomiH: Who qualifies to have a transvascular aortic valve replacement? Does an 87 year old patient qualify by virtue of age alone? How risky is open heart valve replacement for an 87 year old woman?

Dr__Savage: This is a difficult question to answer because some 87 year old people are healthier than younger patients. Age is not really the indicator for type of valve replacement. Current criteria for TAVR is not being a candidate for surgical replacement.

Candidacy for surgical replacement is affected by other medical problems (such as lung or kidney function); level of overall functioning of the patient, history of prior heart surgery. Many patients are very healthy going into the operation and very healthy after.

Dr__Lytle: At the present time to be a candidate for TAVR, a patient does not need to be inoperable but they need to score a certain risk score and this takes a very detailed evaluation. For many patients in their 80s, standard aortic valve replacement is a very safe procedure.

Mitral Valve Disease and Surgery

nutzy: could be recommended a mitral valve repair in case of rheumatic heart disease, or the only solution is replacement?

Dr__Savage: Some valves damaged by rheumatic disease can be repaired but many require replacement. If the valve is repaired, the repairs tend to be less durable because of progression of the rheumatic disease. The decision for repair must be individualized.

jb1371: Consider an asymptomatic patient with moderate mitral valve regurgitation. What surveillance measures do you recommend to identify the time when a valve repair should be considered?

Dr__Savage: There are two types of surveillance. Self and by your physician. Self surveillance means that you watch for any change in symptoms or reduction in functional status. Surveillance by the physician will be by repeated echocardiography every 6 months to 1 year to look for evidence of worsening leak or enlargement of the heart chambers.

Heart Surgery Questions

fixedvalve: Hello, what are the advantages of " off pump " heart valve surgery ? No " pump head " symptoms ? Or maybe other advantages?

Dr__Savage: Off pump valve surgery is really addressing the catheter valve however this can branch to the concept to off pump coronary surgery. Long term the studies for bypass surgery have not really shown better outcomes with off pump or without it.

Dr__Lytle: There are small number of patients that put them at a particularly high risk of stroke where off pump may put them at an advantage. But for the general patient population it has not been possible to demonstrate a clear advantage.

Jana: Must be always perform to ensure breathing intubation during surgery, or just use an oxygen mask? I am afraid namely intubation. Thanks for your answer.

Dr__Lytle: IF your question is about open heart surgery, the standard strategy during heart surgery is to secure the airway with endotracheal intubation. Many patients are afraid of this part of the procedure before the operation. However, in fact, that bothers almost no one.

Katrina: Can you talk about valve surgery for someone who had prior radiation exposure?

Dr__Lytle: Post radiation heart disease is the most complex and difficult problem adults have. Radiation affects all heart structures including the heart muscle and the understanding of whether the valve disease is severe enough to be causing the problems and to indicate surgery is very complex. If surgery is indicated, the operations are difficult. There is no short answer to this question. If a patient has had prior radiation and heart disease they should seek out an institution such as ours that has extensive experience with this problem and be willing to get more than one opinion about what the best course of action is.

quilter: I have been told I need a mitral valve replacement and have restricted arteries. but no useful arteries for bypass

Dr__Lytle: I am not certain what your question is but I would suggest a second opinion.

Nancy2: Hi, I am a 53 year old woman who was diagnosed with moderate-severe mitral regurgitation about 2 months ago. I am asymptomatic although I do have palpitations that my cardiologist says are not related to my valve problem. I have had an ECHO, Stress test, EKG, & a Stress ECHO. My next appt is in mid March. My question is....when my cardiologist refers me to a surgeon, how do I get statistics on the number of valve repairs the surgeon has done and their long term outcome? Is there a website or organization that tracks this data? Can I get the information directly from the hospital? I have never 'shopped around' for a surgeon. I'm a little uncomfortable asking for this information. Any help would be appreciated. Thanks!

Dr__Savage: You should not be uncomfortable asking for this information as these are very important questions.

There is not really a national website - there is the Society for Thoracic Surgery (STS) website which lists outcomes, but the information is not available to the general public. The hospital will probably not be able to give you that information either. Here are some steps to take:

  • First ask your cardiologist about the surgeon and the surgeon’s experience.
  • Then - talk to the surgeon. Ask questions such as: How comfortable are you with this procedure? What is the number of valves you have repaired vs. replaced? 
  • If you are not getting answers, ask another surgeon.

For example I had a patient who I performed mitral valve repair on and the first surgeon they went to only offered valve replacement not repair.

Dr__Lytle: Dr. Savage is correct. The patient should not be reluctant to ask for information. The doctor is working for the patient not the other way around. At the Cleveland Clinic we have extensive data regarding all surgeons and operations in regard to short term outcomes. We do not have long term outcomes according to surgeon. This is in part, due to patient privacy issues. But, the patient has the time to investigate the options in a very detailed way and should be perfectly comfortable in doing so.

clara: I hope I am not sending this twice, but my computer did seem to send it last night. I have had bypass replacing the aortic and bypass. Since that I have had 6 stents - all my major arteries are stented. I have now been told that I have moderate mitral valve regurgitation and the tricuspid valve is moderate / severe. I have started to have lightheaded symptoms at times and SOB. I was told to call if I get more symptoms. 

Dr__Savage: You need to follow up with your doctor.

Activity and Lifestyle after Heart Surgery

Shannon-S: I had AVR in June 2010. On a recent scan (last month), they discovered mild mitral AND tricuspid valve insufficiency. I spoke with my surgeon who says it will never be a problem. My questions are: 1. Is there ANYTHING I can do, dietary or otherwise, to SLOW DOWN the progression of the valves' insufficiency? 2. I have read that WEIGHT TRAINING can be a factor. do you think that, with intermediate lifting, a 'stretch' stress factor can be put on the valves? Should I stop doing this activity? 3. Do you have a general time frame that regurgitation goes from mild to moderate to severe? I am 60 years old. MANY THANKS for ANY info you can give me on how to stop this from happening! I am very frightened about having to go thru this again.

Dr__Savage: You can relax. To say that this will never be a problem, a little absolute - but it is unlikely it will be a problem.

  • Follow up closely with your doctor and control high blood pressure hat you may have; 
  • Stop smoking; 
  • Weight training is probably speculative if it were a factor. I would recommend no heavy weight training - however moderate weight so that one is not stressing oneself would be beneficial.

It may never progress from mild to mod to severe. It would depend on intrinsic disease of the valve and we cannot predict that time frame.

WilliamP: Where do I find exercise programs for older people with valve replacement. I am on my 2nd aortic tissue valve, am 76 and in good shape (bmi>25). I do aerobic exercise 3 times a week for up to an hour. Avg. HR of 122 to 130 with a max of 145. I roughly follow the Polar heart rate training basics but is there a better source?

Dr__Lytle: It sounds as though your exercise program is pretty good. Aerobic exercise three times a week and getting your heart rate to the levels you describe is a good idea. I would continue to do that as well as keeping an active lifestyle.

Dr__Savage: Cardiac rehabilitation programs may be available as a resource to you. You can contact your local program and they may be able to make recommendations.

WmB: -I had minimal invasive mitral valve surgery on 9-1-11 and I have two questions: 1. Do I need to take my premed for dental work? 2. when can resume heavy lifting such as weights? Thanks, Bill

Dr__Lytle: I assume, you are referring to antibiotic prophylaxis and it is my opinion that you should take antibiotics before dental work if you had valve repair or replacement lifelong.

In regard to heavy lifting, we believe aerobic exercise should be the first type of exercise done after mitral valve surgery and if someone is going to lift weights, they should only begin to do so only after they have regained a pretty good aerobic exercise level.

Dr__Savage: I agree with the guidelines for antibiotic prophylaxis stated by Dr. Lytle even though the AHA guidelines may be contrary to this.


adourian: New news on not taking aspirin unless one has already had a "cardiovascular event". Is aortic stenosis considered an "event" in this context? What is your advice to patients regarding daily consumption of 85mm aspirin if their only problem is AS?

Dr__Lytle: That probably is a good idea as long as the patient does not have any history of bleeding problems that would contraindicate taking aspirin.

Valve Disease

kicker03: Are there any acceptable medical/medicine treatments vs. surgical for valve disease?

Dr__Savage: Most medical treatments for valvular heart disease focus on high blood pressure treatment. While this may improve symptoms it is not clear that medical therapy will delay or prevent complications. When surgery is indicated, there is not medical substitute.

Undiagnosed Heart Disease

Jana: I am 17 years old, I am girl and already a few days my heart palpitations. Do not get stressed, do not drink any alcohol, and do not smoke. This may indicate a heart pounding heart disease? In the four years I was sent to they echocardiography without cardiac problems only preventive pediatrician that due to my hydrocephalus exclude hypoplastic heart syndrome. This syndrome was excluded by echocardiography. So what would it be? Heart disease? If it was this, what is the treatment? Even add that whenever it starts, I'm hot, I have red face and short of breath. The same occurs even at the slightest exertion, and yet it is also out of breath. It means a heart defect?

Dr__Savage: This does not necessarily mean a heart defect. It may be another problem that influences the heart - for example - hyperhydrosis syndrome. The way to answer this would be to first see an electrophysiologist and start there if you are having problems with heart beat.

Dr__Lytle: You could be having a rhythm disturbance and the way to discover that is with a 24 hour monitor.

Reviewed: 02/12

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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