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Valve Disease Diagnosis Interventions&Surgery (Drs Svensson&Tuzcu 3 15 12)

Thursday, March 15, 2012 | Noon


Heart valve disease occurs when one or more of the heart valves do not work correctly and cause the heart to pump harder to circulate the right amount of blood through the body. Left untreated, heart valve disease can reduce a person’s quality of life and become life-threatening. Interventional cardiologist, Dr. Murat Tuzcu and cardiac surgeon, Dr. Lars Svensson from the Cleveland Clinic answer your questions about Valve Disease, Diagnosis, Interventions and Surgery.

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Cleveland_Clinic_Host: Welcome to our "Valve Disease, Diagnosis, Interventions and Surgery" online health chat with Dr. Murat Tuzcu and Dr. Lars Georg Svensson. They will be answering a variety of questions on the topic. We are very excited to have them here today! Let's begin with the questions.

Valve Disease – General

adourian: Under what circumstances is a "stentless" tissue valve the preferred replacement option over a "stented" tissue valve?

Dr__Svensson: There are a few reasons to use a stentless valve. Here at the Cleveland Clinic we hardly ever use them and we prefer to use human valves for, for example, infected aortic roots or previous aortic valve replacements.

hs: can you reduce severe regurgitation to mild or moderate with medication?

Dr__Tuzcu: It is not possible to change the severity of valve malfunction if the valve itself is degenerated but sometimes, valve regurgitation is related to factors other than the valve itself. An example of this is the weakened and enlarged heart resulting in leakage of the mitral valve. Therapies aimed at improving heart function may very well reduce mitral regurgitation. Another example is adequate control of blood pressure and optimizing the heart rate may improve severity of aortic regurgitation.

clara: I have mitral regurgitation mild / moderate - tricuspid valve moderate severe - basically I was told they all regurgitation. I have had bypass grafts and the aortic valve replaced. The last 3 years I have had to have 6 stents. My doctor told me that some of my new symptoms could be because of all the valves regurgitating. He also told me that he is concerned because of the need for stents so often. I am somewhat confused with my situation dealing with valves, grafts, and stents. Should I get a second opinion?

Dr__Tuzcu: The combination of multi-valvular heart disease with multi-vessel coronary artery disease creates a very complex medical problem that should be evaluated in an expert center with good multi-disciplinary heart teams.

Hananola: Is life expectancy better with valve repair than with valve replacement? Does valve repair generally lead to normal life expectancy? Please discuss long-term outcomes for both. Thank you.

Dr__Svensson: We recently reported in a study that patients who had aortic valve repairs after 7 years after the operation - their survival was better than aortic valve replacements. The survival was also equivalent to age and gender match US population.

Symptoms of Valve Disease

VickiD: I'm 62 yr old woman, non-smoker, w/moderate aortic stenosis for 1 yr. When I read about symptoms etc., shortness of breath is mentioned. I am experiencing shortness of breath with any exertion, but recover very quickly. I'm not sure when shortness of breath becomes a concern (since I don't have it all the time). I have my follow up at Cleveland Clinic coming up soon.

Dr__Tuzcu: Indeed, shortness of breath is a very important symptom in the evaluation of aortic stenosis. You should bring that up at your next visit to the Cleveland Clinic. You should be prepared to describe the precipitating factors of shortness of breath, such as walking, jogging, climbing stairs or anxiety, if it appears at rest or while sleeping, if it progressed overtime. Your doctor will also ask you if there are any associated symptoms such as palpitations or dizziness.

Diagnostic Testing

jacob: I have had periodic echos to examine the extent of my ventricular stenosis. Is a "stress-echo" either a necessary or desirable additional diagnostic tool?

Dr__Tuzcu: I don't understand what you mean by "ventricular stenosis" but I can answer the role of stress echo in the evaluation in valvular heart disease. In patients with aortic stenosis, if there are symptoms, we do not perform stress test. But it is a useful technique in patients who appear on the surface as if they are asymptomatic. If doctors think they have reduced their activity and controlled level of symptoms through that reduction, a stress test may help to unmask the symptoms in such a patient. Stress echo is useful in evaluation of mitral stenosis to see the change in gradient as well as the change in pressure in the lungs with exercise - allows the doctor to make appropriate treatment decisions.

Caroline8: Hello, I had a mitral valve repair 6 weeks ago for which my latest echocardiography showed 'one drop of leakage' named 'physiologic leakage' (no leakage on my third week echo), is it normal? Should I worry that it can become worse in the future? Thanks!

Dr__Tuzcu: Minimal regurgitation after surgery is not concerning; it is not a sign of future worsening.

Aortic Valve Disease and Treatment

AndreAortic: I am 54 year old Male and have CAD and AS (1.1cm) as of last test. I will have new tests ran next week for updated status. I have no symptoms at this point and feel fine everyday, but know I am getting close to decision time. I wanted to know your thoughts on when I should have the AS Valve Replacement and whether I should get Bovine (Cow) or Mechanical Valve. I am leaning towards Cow valve due to the requirement for daily Coumadin and Blood tests. Thanks!!

Dr__Tuzcu: On this there are extenuating circumstances. We do not like to recommend surgery to patients with aortic stenosis if they have no limitation and no complaints. But if a patient needs open heart surgery for another reason such as coronary artery bypass surgery, then aortic valve that is moderately narrowed and not causing symptoms is also replaced. As far as the type of prosthesis is concerned, many surgeons in the United States prefer using a bioprosthesis such as bovine valve in patients over age 60 or 65. At age 54, it may not be unreasonable to go that route as well - that is something that you should discuss with your cardiologist and surgeon.

AndreAortic: As a follow-up, since I know I am at 1.1cm on my AS, should I go ahead and have the AS Valve Replacement Surgery before symptoms occur and complicate things? Thanks

Dr__Tuzcu: Current guidelines recommend surgery in symptomatic patients unless there are specific extenuating circumstances. Based on this information, I would not recommend prophylactic aortic valve replacement.

James35: Hi. I had my bicuspid valve replaced almost 2 years with an Edwards Magna 27 mm with ThermaFix. Six weeks after surgery the mean and peak gradient were 13.2 and 24.2, max velocity was 2.46, and the valve area by continuity was 3.25 cm2. At my 18 month echo, the mean and peak gradient were 22.0 and 41.0 with a max velocity of 3.2. No valve area was indicated. I know the mean gradient is still normal, but how concerned should I be about the gradient increase at this early stage? If the valve is normally functioning, what causes this? No calcification was indicated, could it happen that early? Thanks!

Dr__Svensson: The failure of biological valves is very age dependent and we would probably wait until you develop symptoms before recommending replacement. If you are particularly elderly and have comorbid disease, you may be a candidate for valve in valve procedure. We have commenced doing that at Cleveland Clinic.

JLK: We understand that the majority of aortic valve replacement at Cleveland Clinic is done with tissue valves. Are the majority of the valves you use stented or stentless? Which type is more durable, and what is your preference?

Dr__Svensson: The majority of valves are stented valves and there is no advantage in terms of durability of stentless valves; indeed, one study has shown worse durability.

acboyd: Does coumadin play a role in the calcification of the aortic valve?

Dr__Tuzcu: Coumadin is used for preventing clot formation in the heart, in the setting of valve disease or prosthetic heart valves. It doesn’t cause calcification.

MattK: I have aortic stenosis (.07 sq cm) Had 4 way by pass 14 yrs ago. Now age 86. Feel OK except tiredness. Need valve replacement, but I don't take blood for religious reasons. Would minimally invasive surgery or TAVR work for me?

Dr__Tuzcu: It is a special condition not to accept blood transfusions; both open heart surgery and TAVR can be considered in selected centers for such a patient. In summary, definite treatment options should not be ruled out before discussing with an expert in the field.

mikeg: what measurement is considered severe aortic stenosis?

Dr__Tuzcu: An aortic valve area of less than 1 cm/2 and a mean gradient of 40 mm/Hg or higher is the cutoff for severe aortic stenosis. Having said that, there are many patients with lower gradients that have severe aortic stenosis. A physician takes into account many data points in deciding what treatment to provide for aortic stenosis in a given patient.

adourian: For an isolated AVR are both a partial sternotomy and a mini-thoractomy viable minimally invasive options and if so, under what circumstances is each approach selected?

Dr__Svensson: We have a large experience now with mini j-incision for aortic valve replacement and exceeds some 3,000 cases. We have shown that pain afterwards, recovery, blood loss, and risk of respiratory problems are reduced with this approach. There is also the cosmetic benefit. We also do minimally invasive repairs of the ascending aorta through this incision. If you look at our web site, you can see videos of the j-incision.

DAVID3352: I had my Aorta heart valve replaced with a St. Jude mechanical valve. I have been on Warfarin for 10 years. Currently I have developed a Thoracic (TAA) aneurysm from the Aortic root to the beginning of the aortic arch. My last reading was a size of 5.0. Would it be better to leave the 10 year old St. Jude valve or put in a new one that is already attached to the Dacron graft tube?? My original natural heart valve was a bi-cuspid. Would it have any influence on the timing of my current plans for heart surgery??

Dr__Svensson: The timing of re-operation for previous aortic valve replacements and aortic root aneurysms is dependent on your age and co-morbidities. Generally, we wait until the aortic root is about 5.3 to 5.5 cm before re-doing it.

PatandMike: I have aortic valve stenosis, and am beginning to have angina. My cardiologist at our local small hospital has scheduled an angiogram for this Monday morning. He said he would put in an un-medicated stent or stents if indicated, and get a very accurate view of the valve opening and gradients. Both right side and left side are scheduled to be done. He also said that the valve could be bad enough to warrant going very soon afterward to a local hospital, or Northwestern hospital for a valve replacement. I really was wanting to go to Cleveland Clinic for any valve replacement (or other major cardiac) surgery. What should I do regarding the test- change it to Cleveland, go ahead, the stenting, second opinion and switch after test (can you use the local test results) to Cleveland. I have not broached the subject of a second opinion or the Cleveland Clinic, yet. Thank you for this valuable chat service!

Dr__Tuzcu: If a patient with aortic stenosis also has severe blockages in the coronary arteries, attention should be paid to the overall picture before deciding upon statin therapy. Because if the patient is in need of aortic valve replacement, recently placed stents may complicate the surgery and perioperative care. We will be happy to have you come into the Cleveland Clinic for evaluation. Nurses in the Heart Resource Center will be happy to assist you, toll free at 866-289-6911.

waleslar1: I have a bicuspid aortic valve. I'm 58. I have a 4.9 aneurysm at the aortic root. A surgeon, that I had a consultation with, told me that he probably would not opt to repair my valve (valve sparring), because I have an ecentric jet and I think the cusps were not going to be easy to fix, or something like that? My valve is leaking moderately, but is not stenotic. I guess my question is: I have United Healthcare Choice coverage; however I live in Florida - How much red tape is involved to have this all done in Cleveland? And, I'm not a rich man by any means. My next CT Scan is in May.

Dr__Svensson: As a general rule, in patients who are younger, such as yourself, we try to repair leaking bicuspid valves as long as there is not too much calcium on the leaflets. The aneurysms are repaired at the same time mostly with a minimally invasive j-incision. We have financial counselors who can help you work through the insurance issues.

E4855: I am 50 years old and I require a aortic valve replacement soon. I am finding it difficult to decide between a mechanical valve vs. a bio-prosthetic valve. What do you recommend for a patient in my age bracket?

Dr__Svensson: My recommendations are based on a patient's level of activity, profession, and co-morbidities. Another factor is a patient's tolerance for a repeat operation. In our hands, the risk of death for repeat operations is 1.9 to 2.1%. If you are a very active person, and do not wish to take a blood thinner, than I think it would be reasonable to have a biological valve.

Annied54: Status Post Ross Procedure 2002 with evidence of graft failures; Severe Aortic Insufficiency; Moderate to Severe Pulmonic Insufficiency; Pulmonic Stenosis, moderate, also contributing, with a 20 mm peak-to peak gradient; Mildly enlarged left ventricle; 3/6 Systolic murmur and diastolic murmur; and Dilated Aortic Root. (Proximal Ascending Aorta dilated to 4.7 cm)Early RV failure; Mild tricuspid regurgitation is present; Normal Coronary arteries. What repairs procedures are my options? Also, what do surgeons do when scar tissue on the atrium and ventricle have adhered to the back side of the sternum

Dr__Svensson: We have largely stopped doing Ross Procedures because two valves being at risk and do more Ross reversals than primary Ross's. The procedure is dependent on what the pre-operative testing shows.

LAM62: It is so hard to know when it is "time" to have surgery. I have a bicuspid aortic valve. I had a coarctation repair at age 11. My numbers are in the moderate to severe range (.08 cm2 area, gradient of 37, 3.6-3.7 ascending aorta size....don't remember peak velocity). I'll go weeks of feeling normal but then I'll have days of difficulty breathing, light headedness, weakness, and even chest pain. Should the numbers be the definitive, primary basis for making the surgery decision? Is it normal to feel mostly fine for days/weeks and then not so great?

Dr__Svensson: The timing of surgery is so very dependent on when patients become symptomatic from aortic valve stenosis.

barlow: What are the chances that a patient who needs an aortic valve replacement can have minimally invasive, not open heart surgery?

Dr__Svensson: We routinely do all aortic valves minimally invasively using a J-incision. Check our videos on our website for additional information.

alexm: I have bicuspid aortic valve with fused right and non-coronary leaflets (R-N). I would like to ask you two questions. First, does the R-N spatial orientation results in different clinical prognosis compared, for example, with the more common fusion of right and left leaflets (R-L)? Second, are there any particular risks in the disease progression (such as aortic dissection, for example) that patients with R-N fusion should be careful about?

Dr__Svensson: Generally, the left-right fusions are easier to repair. The risk of dissection is dependent on your aortic size. We use a formula dividing your cross sectional area in square centimeters by your height in meters, and if that exceeds 10, we recommend surgery.

LAM62: I have been told that minimally invasive aortic repair procedures are for people who aren't good surgical candidates. I've been told since I am young (49) and healthy and in need of a mechanical valve that I'm not a candidate for a minimally invasive procedure because the full sternotomy is the better surgery. Is there an option for a young healthy person that doesn't require an 8-10" incision in the middle of my chest? And the need for blood thinners for the rest of my life?

Dr__Svensson: We do all patients' operations for routine aortic valve replacements and ascending aortic replacements with a mini-invasive incision irrespective of age or comorbidity. Our results show this is a better operation for most patients.

dhbrown: Both as a mechanical engineer and a likely near term patient (52, active, cyclist, bicuspid, moderate leak, 4.6 cm) I am very interested in the potential availability of near term technological upgrades like the valveXchange valve. Is it likely to be available by 2013 in the US?

Dr__Svensson: We are currently rolling out a trial for the valve exchange valve in Europe. It probably will not be available in the United States until 2014, if all goes well.

Zoro: Is there any difference in replacing the procedure for replacing an aortic valve if the patient has marfans?

Dr__Svensson: For most patients with Marfans needing valve surgery, we do the modified David Re-implantation operation. This is the standard operation we do for tall patients who have root aneurysm.

Transcatheter Aortic Valve Replacement (TAVR)

Matthew: At last week's web chat I asked about a TAVR. The doctor said there were several anatomic and physiologic requirements that needed to be met before he could tell me I could have the TAVR replacement. Can you tell me what these requirements are? Is this surgery covered by Medicare? Is it a better option for an 87 yr old man with .07

Dr__Tuzcu: TAVR is approved by FDA for patients with severe symptomatic aortic valve narrowing who are deemed to be not suitable for surgical aortic valve replacement. At age 87, if you have no other serious medical issues, it is unlikely that you will be unsuitable for surgery. Having said that, that determination can only be done after comprehensive evaluation.

adourian: Given the long term possibilities of percutaneous valves for older patients does it factor into what type of tissue replacement valve is selected the first time around for an otherwise healthy 75 year old?

Dr__Svensson: As far as valve replacements and those most suitable for valve-in-valve, the only ones that we avoid are stentless valves because data has shown that for valve-in-valve procedures the risk is higher.

adourian: Other than percutaneous valves what other promising advances do you see on the horizon for tissue valves?

Dr__Svensson: I presume that by percutaneous valves, you mean ones put in through the groin. There are a lot of new developments in valve types both for open surgery, different approaches, and also different valves. For example, we are working on new trans-apical approaches for mitral valves; we are doing a number of mini-transaortic valves, and transvenous mitral valves.

Cleve: What factors determine whether OHS or percutaneous or catheter procedures are most appropriate to repair/replace my torn implanted tissue aortic valve please?

Dr__Tuzcu: Currently, there is no FDA approved technique to replace a degenerated prosthetic valve percutaneously. However, there is a research registry that enrolls patients who are extremely high risk for a repeat open heart surgery. If your doctor thinks that your risk for open heart surgery is very high, you can be evaluated for a percutaneous valve replacement.

einstein: update status of trans femoral aortic valve insertion,plz.. when will it be used in younger, healthier patients? also plz update your experience with aortic valve repair for aortic insufficiency in bicuspid valve. thanx . bill

Dr__Svensson: As far as using transfemoral aortic valves in younger patients, the biggest problem has been that even in the older patients, the risk of stroke is 3 times higher for transfemoral approach compared to open aortic valve replacement (4.6 % vs. 1.4%) so for the moment, it is unlikely that the FDA will approve TAVR for lower risk patients. As far as bicuspid valve repair, we have done approximately 770 patients and the ten year durability in our last study was 91%. I expect that the 20 year durability will be about 80-85%.

Sept14: Hello. I'm aware that transcatheter aortic valve replacement was approved relatively recently by the FDA, but is only for high risk patients. Has transcatheter aortic valve replacement been done in lower risk patient groups elsewhere in the world, and if so, have results been better? Have these types of valves been in use long enough to give any reasonable indication on expected longevity of the valve? Thank you.

Dr__Svensson: At this time, we have no long term information on the durability of TAVR. The likelihood is that it will be similar to current biological valves.

Mitral and/or Tricuspid Valve Disease and treatment

Cruiser500: I have no symptoms but both Echo cardiograms & TEE's indicate MV prolapse with moderate to severe regurgitation. Am I at risk of Heart failure? Should I be having some signs of distress? Should I wait for symptoms before going ahead with Mitral Valve Repair surgery? I understand from my cardiologist that if I have heart failure, even if the mitral valve is repaired, the damage to the heart from heart failure cannot be repaired. How can I be certain when to have the surgery?

Dr__Svensson: We usually recommend mitral valve repair when mitral valve regurgitation is severe, or symptomatic, or there is evidence of left ventricular dysfunction.

aquarious207: If a person knows they have a valve problem, how long can they live with it? What would happen if the mitral value closes up?

Dr__Tuzcu: The answer to that question depends upon the type of valve problem and the severity. For example, if you have a severe aortic stenosis with symptoms, that is a problem that needs to be addressed in a very timely fashion. On the other hand, chronic aortic regurgitation can be managed conservatively for years, even decades. As far as the mitral valve closing up is concerned, symptoms of shortness of breath, sense of palpitation due to rapid irregular heart rhythm (atrial fibrillation) and elevation of pressures in the lungs are the major concerns. If none of these is present, patient is usually treated conservatively even if the mitral valve is significantly narrowed.

xinxin: My mom is 63 year old with moderate to severe rheumatic mitral stenosis (valve area 1.17 cm^2), and moderate aortic valve regurgitation, and she needs to have a valve surgery, I want to ask what is the usual waiting time at CC? Thanks

Dr__Tuzcu: We are able to provide same day appointment for clinical evaluation and surgery can be scheduled within weeks.

pjackson: If you have systolic anterior motion does that automatically always mean you have HCM?

Dr__Tuzcu: Having systolic anterior motion of the mitral valve does not necessarily mean that you have HCM. Sometimes this condition can be due to different geometric alignment of various parts of the heart. For example, a different location of one of the papillary muscles may be very well lead to systolic anterior motion.

hosmer26: Does the clinic repair or replace the mitral and tricuspid valves without chest surgery?

Dr__Svensson: We have a very large experience now with both robotic and mini-thoracotomy repair of the mitral and tricuspid valves. For the foreseeable future, except for inoperable patients, this is the preferable approach.

Dr__Tuzcu: Currently, there is no improved technique for non-surgical repair or replacement of mitral and tricuspid replacement in the United States. There are scientific studies going on that test the safety and effectiveness of repairing leaking mitral valves with a clip that is inserted through the leg vein in the groin. On the other hand, mitral valve and tricuspid valve are repaired very effectively and safely through a small incision or through small holes with the help of a robot. Experienced surgeons in high volume centers such as Cleveland Clinic have demonstrated that these procedures can be done with an extremely high safety record in a very effective manner.

shikama: 1. Mechanical or biological mitral valve replacement for 69 year old healthy woman? I hear that in the case of cow's valve, it's life may be less than 10 years. Assuming 8 years, I may be faced with 3 surgeries, 1st: now; 2nd at age

Dr__Svensson: For a 69 year old, we would recommend a cow valve because you do not need to be on a blood thinner and in addition, the risk of needing another operation in the next 12 years is about 5%.

shikama: Continuing question 2: 2nd surgery at age 77 & 3rd at 85. What's your opinion? 4. I understand right chest surgery has more risks, and takes longer than mid chest surgery. What is your recommendation regarding the right chest method for valve replacement not repair? For your information, this 69 year old healthy woman has moderate stenosis mitral valve with calcification. If mechanical valve is chosen, what are the risks and inconvenience of life-time use of Coumadin?

Dr__Svensson: When we looked at this issue, we found the risk of death for re-operations was the same by the mediastinum or right thoracotomy, however, the risk of stroke was higher with a right thoracotomy. If you have atrial fibrillation, then you will need to have a mechanical valve.

nysubway12: If I was found to have mild valve regurgitation in one valve then the following year I had 2 leaking valves , do you think at some time I will need an operation for it. triglycerides #65 HDL IS 50 HDL RATIO 3.50 LDL 112 THOSE WERE THE BLOOD READING IN OCT 2010

Dr__Svensson: It sounds like you should wait until you either develop symptoms or your heart shows evidence of deterioration before having surgery.

Mitral Clip

BettyH: What type of instructions do you give your patients that are discharged after a Mitral clip procedure?

Dr__Tuzcu: The instructions differ depending upon the patient characteristics. If the patient has heart failure, weakened heart muscle, instructions are very different than a patient who had mitral clip for degenerative mitral valve disease. The common instructions for all of them are related to the medications such as aspirin and clopidogrel and avoidance of strenuous activities in the first week.


LeeBAV: Hello. Are there any medications, vitamins, etc that have been reasonably identified to potentially delay calcification of either a native bicuspid aortic valve or a bioprosthetic replacement? I've read about a few things such as statins and Vitamin K2 or Vitamin K supplements...what would be your recommendations on these or any others I haven't mentioned? Ok to take, but may not work or best not to take at all? Thanks so much!

Dr__Tuzcu: Observational studies suggested that statins may slow the progression of aortic stenosis, but randomized clinical trials failed to support this suggestion. Currently, there is no good medical treatment that slows the progression of aortic stenosis. Adhering to healthy living standards would be my best recommendation.

jillrn: Male, Caucasian, 67. 71", 220, active. BP well controlled at home, but a cuff reactor. Based on an echocardiogram performed about a year ago, I was diagnosed with mild Aortic Stenosis (~1.64cm) - asymptomatic, murmur barely discernable by auscultation. Echo was otherwise normal with no enlargement and an ejection fraction of 55%. I have read that one eight-year study by Dr. Philippe Piarot presented at the Canadian Cardiovascular Congress, found that administration of Angiotensin-receptor blockers seemed to slow the progress of AS considerably. Although ACE inhibitors seemed to have some effect, it was not as pronounced. I am currently taking 40 mg of lisinopril/da for hypertension with only a mild occasional cough. Would it be advisable to consider switching to an ARB? Any other medical interventions? One additional question. Would earlier intervention provide an opportunity for repair of the valve rather than replacement and what are the percentages in an otherwise healthy individual?

Dr__Tuzcu: There is no firm proof that any medical therapy delays the progression of aortic stenosis. Having said that, optimal control of blood pressure with ACE inhibitors and control of high cholesterol with statins are advisable in patients with aortic stenosis. Prophylactic aortic valve replacement surgery in moderate aortic stenosis with no symptoms is not advisable.

tucson: I am diagnosed with severe aortic stenosis and a very high heart calcium score. I am asymptomatic and am physically very active. I realize I will need an aortic valve replacement in the future but wonder if there is anything I can do to control/reduce my calcium score in the meantime. I also wonder what is the optimal point for my valve replacement.

Dr__Svensson: There is no good proof that either diet or statins reduce the risk of calcification. Supplemental calcium may increase the risk.


FredL: Just had surgery for replacement of stenotic aortic valve. I am 71 years old and a competitive cyclist. What is the normal recovery before one can resume strenuous aerobic activity?

Dr__Tuzcu: The full recovery from open heart surgery takes about 8 weeks. We also like our patients to undergo cardiac rehabilitation. After the initial portion of the recovery is completed, for strenuous aerobic activity such as cycling, you should consult with your cardiologist and then get in shape to get back up to elevated levels of cycling.

Heart Rhythm and Rate and valve disease

xinxin_1: I have mitral valve stenosis and aortic valve regurgitation, I am taking beta blockers to control my rate, now my heart rate is around 43-48 range, is that normal? (by the way, my heart rate was about 55-60) Thanks

Dr__Tuzcu: Heart rate in low 40's is not a big problem in itself, as long as you do not have symptoms due to the low heart rate such as dizziness, lightheadedness or fatigue. Slow heart rate is very helpful in the setting of mitral stenosis as it allows ample time for the blood in the left atrium flow into the left ventricle through the narrow mitral valve. On the other hand, if the aortic valve regurgitation is moderate or severe, slow heart rate may not be very good as it increases the time for regurgitation to occur. You should ask these questions to your physician - address specific questions pertinent to your condition.

Aortic Aneurysm

Kim: Hello, a few years ago I found out that I had a thoracic aortic aneurysm and was referred to Dr. Svensson. My size was 4.5cm. At that time, he didn't think I needed to be seen. Last year I was evaluated at Mayo Clinic and found out I also have a bicuspid aortic valve and they resized my aneurysm at 4.3cm and said I needed to be checked annually. I wanted to know if there is a cardiologist in Louisville, KY that you recommend and with the 2 conditions that were hard to detect initially, if I should be evaluated at Cleveland Clinic.

Dr__Svensson: I don't know any cardiologists in Louisville. I recommend you find a cardiologist at the Mayo Clinic or Cleveland Clinic that you can see regularly/every year. We'd be happy to see you here.

Reviewed: 03/12

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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