Per Wierup, MD, PhD
Per Wierup, MD, PhD

Friday, May 25, 2018 | Noon


As one of the largest, most experienced cardiac and thoracic surgery groups in the world, our surgeons offer virtually every type of cardiac surgery. We specialize in very complex cases as well as groundbreaking surgical procedures, such as minimally invasive and robotically assisted cardiac surgery. Dr. Per Wierup answers your questions about heart surgery.

More Information

  • View more information about heart surgery.
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  • View previous chat transcripts.

Aortic Valve Surgery

dixitworld: I had BAV replaced eight years ago with ATS Valve. Currently 31 years of age. Sep. 2015 Echo showed 4.7cm ascending aorta aneurysm and Dec. 2017 Echo showed 5.1cm aneurysm. First time had CTA in Dec. 2017 showed 5.2cm ascending aorta aneurysm and 4.4 aortic root. Started with beta blockers since Dec. 2017. Had Echo at your clinic in April and still showed 5.2cm. Surgeon at your center has asked bentall procedure within six months, even though my mechanical valve is working fine. Other surgeon at other hospital proposes to wait till 5.5cm. Other surgeon also proposed to retain existing mechanical valve but CC surgeon informs bentall procedure is best so will remove existing valve also. I am 5'8" and 76kg weight. Recommendation for surgery without second CTA or checking growth and replacing working mechanical valve. Can't my aorta growth stop with beta blockers starting this year only? I live in California and too much depressed.

Per Wierup, MD, PhD: In your case, with history of BAV, we know very well that there is an increase of aneurysm formation and subsequent rupture of the aorta. There is still a debate whether the cut off should be 5.0 or 5.5 cm. However, it is more important to note that your aorta seems to be growing and I would strongly advise you to have a repeat surgery which ideally should be a Bentall procedure to minimize risk for future aortic rupture. Although a big operation, this is routine for us and the patients do very well. Contact your surgeon's office if you have questions - we are happy to help you.

Grandpa75: I have had aortic valve replacement four times over the last 48 years. Born with congenital stenosis in 1943, I had homograft valves in 1970 and 1987. In 1999, I had a bovine valve and developed endocarditis which required another homograft in early 2000. After 18 years of good health I know that my current valve is showing some regurgitation and I may need another. My question is whether a 5th valve replacement is even possible. Has Cleveland Clinic had any success in performing such a surgery? My third and fourth surgeries were done at Cleveland Clinic and I am grateful for the last 18 years. Thanks again.

Per Wierup, MD, PhD: Thank you very much. We are actually receiving a substantial number of patients with your history and we are performing even the 5th time reoperation for degenerated homografts. It is a complex surgery but we do many of them with good results. Please send in your records should you require a consultation.

poona: My very active Dad, 84 years old, has severe Aortic Stenosis and has been referred to CC to have HVR. He does not qualify for TAVR because of his great overall health and vitality....just needs a valve. His only symptom is fatigue. He is very interested in you performing a minimally invasive procedure over a sternotomy or partial sternotomy, but not if the success rate is not as high. With the best outcome for your patient in mind, can you tell me how you determine when you recommend minimally invasive over open heart? What is a "typical" minimally invasive aortic valve replacement consist of in terms of incisions and recovery time vs sternotomy?

Per Wierup, MD, PhD: We typically perform minimally invasive aortic valve replacement either through a partial sternotomy or small right thoracotomy incision. The decision on which approach to be used is made after reviewing the whole patient.

poona: Which procedure would you recommend for a patient who has an isolated aortic valve replacement surgery need?

Per Wierup, MD, PhD: Our primary approach is a minimally invasive aortic valve replacement.

poona: Why is minimally invasive aortic heart valve replacement better than traditional open heart if best outcome for the patient is always the goal?

Per Wierup, MD, PhD: Both minimally invasive and traditional sternotomy have excellent and equal long term result. However, with minimally invasive approach, there is less bleeding, pain and a quicker recovery.

poona: How much longer does minimally invasive aortic heart valve replacement surgery take compared to the sternotomy method? Approximately how long will the surgery take?

Per Wierup, MD, PhD: The minimally invasive approach takes about 10-20% longer. Who is a good candidate for aortic repair instead of replacement?

Per Wierup, MD, PhD: Typically if you have an aortic valve leak, you are more likely to be a good candidate for aortic valve repair.

GaryfromCHI: Can I ask you if you have had heart surgery in the past, is there ever a way to do a mini invasive procedure not through the breast bone to treat a future surgery. For example I had bypass surgery when I was 40 and recently found my aortic valve is getting bad - and will need a valve in my future. Do they have to crack the sternum?

Per Wierup, MD, PhD: We don't crack the sternum, we do open it with care. Depending on your age and co-morbidities – there are options such as TAVR to consider. Please send in your records and we can determine the options for you.

ArnoldN: I had aortic valve surgery last year – aortic valve and recently they found the stitching around the valve is not holding. What do they do now? Replace the valve? I am wondering if I can come to Cleveland Clinic – would I go through surgery again for this? Is there a way to restitch without re-opening the chest? If I need a new valve what would they use? I have a mechanical valve now.

Per Wierup, MD, PhD: It sounds like you certainly need to be evaluated. Having a partially loose valve carries multiple risks. Depending upon your specific condition, we can either treat it with a catheter based approach or with removal of the old prosthesis and insertion of a new valve of the type depending on your preference.

Aorta Surgery

Phillyguy: There seems to be high success rates for thoracic ascending aortic aneurysm surgery. Why don't they choose to perform surgery sooner (less than 4.5cm) in order to save people from catastrophic ruptures?

Per Wierup, MD, PhD: The reason for performing aneurysm surgery is to prevent ruptures. There is a large amount of evidence showing that below 4.5 cm the risk of rupture is extremely low. However, certain conditions do exist where we elect to perform surgery even below the size of 4.5. Please send your information and we can evaluate you.

Mitral Valve Surgery

mcdhal: My friend, 78 years old, has multiple heart problems: Severe mitral annular calcification, so much so that they cannot implant a valve. Aortic valve calcification. Coronary insufficiency of at least two arteries and very poorly controlled arterial fibrillation.

He has been told that there is nothing surgically or percutaneously that can be done for him. I am suggesting a second opinion. He is trusting his cardiologist and not seeking a second opinion. Is there a chance that other doctors might do something more to help him. His life is very limited now with constant fatigue. If so, what are some possibilities? Karen

Per Wierup, MD, PhD: Severe mitral annular calcification is a surgical challenge and in a few cases, it is impossible to perform surgery. However, we perform many surgeries on patients with severe mitral annular calcification and your friend should definitely ask for a second opinion.

KellyE: If one has antiphospholipid syndrome and needs mitral valve surgery, what are the problems related to that? Are there things to consider about the surgery?

Per Wierup, MD, PhD: Antiphospholipid syndrome increases the risk for blood clots. We have had many patients with this syndrome and we are very experienced with the care of these patients and dealing with this condition.

WesK: I had surgery five years ago on my leaking mitral valve and my tricuspid valve. Now my mitral is leaking again – very short of breath. Wondering if there are mini-invasive options available.

Per Wierup, MD, PhD: A repeated mitral valve repair is a surgical challenge, however, preferable. We prefer a good exposure in order to achieve optimal results.

Char: I have a history of Hodgkin’s with radiation to the chest and now need valve surgery. Is that something that can be done with the robot? Mitral valve surgery?

Per Wierup, MD, PhD: Heart surgery after radiation is a surgical challenge and we are referred many of these patients from throughout the US. The robotic approach is not the safest in this case.

Augustine: My mom is 90 with severe annular calcification of the mitral valve, mitral stenosis. Needs heart surgery. Can you talk about heart surgery in an older person? Is it safe? What about the heart- lung machine? I have heard that can cause problems in the elderly? Do you do catheter procedures for the mitral valve - for stenosis?

Per Wierup, MD, PhD: We do perform surgery in 90-year-old patients; and also in patients with severe annular calcification of the mitral valve. Both situations are challenging and the combination of them, is quite risky. Sometimes, a catheter procedure might help.

Multiple Valve Surgery

kara47: I just found out I need TWO valves replaced. Is that unusual. I am 47 years old and very scared. Is that risky?

Per Wierup, MD, PhD: It is not uncommon that the patient need multiple valve surgery. We do more than 1,000 of these each year with excellent results. The risk is not based upon the number of valves involved.

NohaR: My mother needs an aortic valve and a mitral valve replacement - she is 80 years old and had coronary bypass surgery when she was 70. Is it possible to do both through a catheter - is 80 too old for heart surgery?

Per Wierup, MD, PhD: 80 is not too old for surgery - we do many patients who are much older. Generally catheter based treatments treat the aortic valve, and if you need both, surgery is the preferred strategy.

Coronary Artery Bypass Surgery

BooneT: Had five bypass grafts four years ago, and then two years ago had my 3rd heart attack. At that time I had a stent put in the blocked vein graft. Now I have a blockage at the end of my LIMA - will I need surgery again to fix this?

Per Wierup, MD, PhD: We need to look at your films and medical records to determine if surgery is needed.

Surgery with Low Ejection Fraction

Petey: My uncle needs an open heart surgery – he needs mitral valve and coronary artery bypass surgery. He is 54 years old and had a heart attack – he has heart efficiency is 25%. Is heart surgery possible?

Per Wierup, MD, PhD: Yes. It might be life-saving in his case.

Robotic Heart Surgery

vincentS: I am not understanding when a robot can be used for surgery and when it cannot. How does the surgeon decide when the robot can be used?

Per Wierup, MD, PhD: The robot is typically used for isolated mitral valve repairs. We cannot use a robot if the patient has too much leakage in his aortic valve or if there is calcifications in his aorta. All our mitral patients are being evaluated for possible robot approach.

Barbie: I need surgery on my mitral valve and my tricuspid valve. Can this be done with robotically assisted surgery?

Per Wierup, MD, PhD: Yes it can but it depends on the type of lesion you have on your valves. It would need to be evaluated and you are welcome to send in records.

Heart Tumor

FloWI: My brother has a tumor in his heart. The left atrium. What is the process to have that removed? Is this a type a cancer that requires additional treatment? He told me he needs heart surgery.

Per Wierup, MD, PhD: Most of the times, it is not cancer. But, we do recommend surgery since there is a risk that part of the tumor can dislodge and cause a stroke. We prefer to remove it using the robotic approach.

Sub-Aortic Membrane

Yan1704645: Hi Doctor. Thank you so much for giving me the opportunity. My 10-year-old son had a surgery in China in 2013 to remove the membrane under aortic valve. But it might be due to the close proximity to the Aortic valve. It did have a residue in the surgery, so now the membrane has grown back. My son has no symptoms at all at the moment. I would like to ask 1) Is there any way to stop it from growing? If he is very symptomatic, is there better treatment to remove the membrane clean? What is the probability for the membrane to regrow? 2) How to decide when is necessary for a surgery? When PG max is more than 70 mmHg? If surgery is necessary, is there any new technology like mini-surgery or minimally invasive for removing it from aortic valve other than ordinary surgery? 3) What I'm concerned about most is that if the membrane keeps growing after another surgery? Does my son have to have surgery repeatedly at every five years, or at eight years, ten years? Are there similar patients before? 4) Can you recommend a doctor who is professional for this case In case of another? Thank you so much.

Per Wierup, MD, PhD: Thank you very much. Subaortic membrane has a tendency to re-occur. The way the membrane is removed is strongly related to re-growth. We operate on this quite often and with excellent results.

Travel after heart surgery

George: If i need a valve surgery and bypass surgery and want to come to Cleveland Clinic, how long do I need to wait before I fly home?

Also – if I have surgery in June – would I feel up to taking a longer flight in September to Europe? Is that safe?

Per Wierup, MD, PhD: Our patients typically stay in the hotel for two days after being discharged from Cleveland Clinic. At that point, they are having a checkup in the outpatient clinic before flying home. There should not be any problems in flying to Europe two months after surgery.

Pain after heart surgery

FenceGuy: Five years ago, just before my 53rd birthday, I had a triple heart bypass surgery. I have had pain constantly since the open heart surgical procedure. My left upper chest in one exact spot hurts so bad I can’t stand a shirt to touch my chest. Unfortunately I am left handed and am limited in many activities. I have been back my cardiothoracic surgeon here in Lancaster, Pa. I have been to a neurologist and had an MRI series done, the orthopedic surgeon. The only thing that helps a little and is short lived is a heavy course of oral steroids. I have been on 1000mg of Gabapentin 3x/day TID. I would give anything to be able to do normal activities like throwing a ball, tennis etc.

Per Wierup, MD, PhD: Since it seems related to the wound, I would suggest to have your sternal wires removed and also having an evaluation to see whether you have unstable healing of your sternal bone. Always after any type of bypass surgery, your cardiologist needs to evaluate you to make sure you don't have ischemia in your heart.

Emergency Stroke Transport

earl359: Does Cleveland Clinic still do hospital-to-hospital emergency transports for heart attacks and major strokes? I live near Youngstown, and it was in the news about two weeks ago about how there was a huge delay because an emergency chopper landed at our small airport and the gate was locked, and the fire chief didn't have the key to get in, and so it raised a question in my mind why they didn't transport directly from the hospitals rooftops? Do they do that anymore? And if it would be a good idea for a stroke person to be taken by ground ambulance to Cleveland Clinic from my home (100 miles). My reasoning being that Cleveland is a comprehensive stroke center and that proper treatment there would be worth the drive time because the ambulance could provide medical treatment on the way?

Per Wierup, MD, PhD: Yes, of course we do emergency transport.

Reviewed: 05/18

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.