Michael Zhen-Yu Tong, MD
Michael Zhen-Yu Tong, MD

Edward Savage, MD
Edward Savage, MD

Wednesday, February 17, 2016 - Noon


Description

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. Michael Zhen-Yu Tong, MD and Edward Savage, MD from the Sydell and Arnold Miller Family Heart & Vascular Institute in Cleveland and Cleveland Clinic Florida answer your questions.

More Information

  • View more information about heart surgery
  • If you need more information, contact us or call the Miller Family Heart & Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
  • View previous chat transcripts.

Atrial Fibrillation: Maze Procedure

adourian: I have paroxysmal atrial fibrillation (Afib) that lasts about 18 hours and is becoming more frequent, now biweekly. I also have moderate aortic valve stenosis. Other than slowly increasing gradients in the heart, the heart structure and arteries are all ok. I am on blood thinners and am told that Afib itself is rarely fatal and that I should try to hold in there and address the Afib when I have my valve replaced in two to three years if I can deal with it from a lifestyle standpoint. I would like to know when I start to risk this thing called "remodeling" and whether I should worry about it in terms of its impact on the success of a maze/ablation at valve replacement time. Somewhere I read that success rates for maze/ablation is less for those with persistent Afib than for those with paroxysmal Afib. If true, should I be thinking of moving to rhythm medications or an ablation sooner?

Michael_Zhen-Yu_Tong,_MD: The success rate for maze is dependent on many factors. It is true that for patients with persistent atrial fibrillation (Afib) the success rate of a maze is less than that of paroxysmal Afib. It is also true that patients with Afib rarely die from Afib and as long as they are on anticoagulation the risk of stroke is quite low. My recommendation would be that if the gradients across the aortic valve are reasonably high then it may be reasonable to proceed with the surgery replace the aortic valve and performed a maze simultaneously. If the gradients across the aortic valve are still pretty low and then I would recommend seeing in an electrophysiologist doctor (EP) for consideration of a transcatheter ablation or medications.


Valve Surgery

kendellewat: My mitral valve is moderate and I have been told my tricuspid valve is moderate-severe. What are the symptoms for the tricuspid valve? I have SOB that has gotten worse and take a diuretic.

Edward_Savage,_MD: Shortness of breath primarily and later lower extremity swelling. Your cardiologist will have to determine if surgery is indicated. If you are having symptoms, you may want a second opinion.

sweetgirlz: My father, age 72, has had two prior aortic valve surgeries...first about 40 years ago and second one 10 years ago with a bypass too. He is having shortness of breath again and they did a cath - the doctors said that he needs another surgery but it would be very risky. Is there any other options?

Edward_Savage,_MD: I am afraid I cannot answer this question with the information provided. We need to review the catheterization, echocardiogram and his other medical history to provide an opinion. That said we successfully perform operations on patients for the third time with significant patient benefit. There also may be catheter based options but this cannot be determined without a complete assessment.

Michelet: I'm a 44-year-old female, remarkably healthy, BP 95/68, low cholesterol. All blood panels with anemia good, good kidney function, but mild asthma with chronic mucus throat congestion. I have a BAV, I'm 4'11" and 108 lbs. If I need a Bentall procedure am I at higher risk for my size for OHS? I'm worried about bleeding risk and lung risk with mild asthma. How do they control bleeding during surgery as I'm tiny and don't have a lot to lose? Also is my mild lung condition a concern? What do they do to prevent respiratory complications in patients like me?

Michael_Zhen-Yu_Tong,_MD: Dear Ms. Tracy, your size would not be a concern for a Bentall procedure. However, given your size, when we put you on the heart-lung machine for the surgery, your blood will likely get diluted to a certain degree. If you do not have any bleeding disorders, bleeding should not be a major issue for you, however there is a likely chance that you will require blood transfusions either during surgery or afterwards. Your overall risk of surgery and risk of complications should not be any higher than someone else who is taller and heavier. In regards to your asthma, unless you had very severe asthma, this should not be a concern for surgery either. You should see a pulmonologist preoperatively to optimize your asthma treatments for surgery and this would also include performing a pulmonary function test to assess the degree of obstruction you have. After surgery we can give you breathing treatments with bronchodilators to help your breathing. Patients with severe asthma may also benefit from steroids around time of surgery. However if your asthma is mild like you have indicated, this should not be of any concern. We work with many patients with multiple medical conditions and have a team approach to addressing medical issues.

PaulfromPA: My father had an aortic valve replacement a few months ago. He went for his follow up and appears to have a pretty big leak around the valve. Will he require surgery again? Is there something that can be done without surgery to fix the leak?

Edward_Savage,_MD: If he can tolerate it, the most definitive approach is to re-replace it if the leak is significant. Sometimes the interventional cardiologists can "plug" the hole but this is usually reserved for higher risk surgical patients.

DGiessen68: I understand that everyone will react to and recover from open heart surgery differently, but from your experience, do patients who regularly engage in cardio and strength training deal with the physical stress of surgery better and have an easier recovery? I know that I will need OHS in the next few years for my BAVD and I exercise fairly regularly now, but I’m wondering if I need to work harder on building up my cardio and physical endurance as if I’m training for an event?

Edward_Savage,_MD: If you are physically active and able to perform moderately strenuous activity, that should be adequate. Any extra training probably won't increase the benefit but can't hurt! I am a big advocate of aerobic and strength training.

nailivic: I had an aortic valve replacement 3-1/2 years ago with a pericardial tissue valve. Recently my cardiologist has detected a heart murmur. Does that mean the replacement valve is calcifying or defective? If so, does it shorten the life of the valve from the estimated 10 to 12 years? Thank you.

Michael_Zhen-Yu_Tong,_MD: A murmur across a prosthetic valve is very common and does not necessarily mean that the valve is dysfunctional. Normal functioning valves can also have a murmur across depending on the size of the valve and the type of valve. I think it would be reasonable for you to have an echo to evaluate the pressure gradients across the valve and to assess whether or not there is any leakage around the valve. This would be the most accurate way to monitor the valve. An echo should also be repeated on an annual basis to evaluate the valve for proper function.

MareyMack: Due to rheumatic fever as child, mitral valve replacement Oct. 1991 at age 35 with St Jude valve (serial#418278 model 29M-101) and numbers are still very strong. My heart doc mentioned in December that he can now use a valve on my next replacement that requires no Coumadin and monthly bloodwork. However, last month in a Q&A with heart doc here, the answer was that I could NOT use a synthetic valve because I have had a mechanical valve; that another mechanical valve would need to be used. I am absolutely content with Cleveland Clinic answer outweighing my own heart doc words however, I am very much interested in knowing the details of why. I want to be able to take this to my own heart doctor and have him understand this. Thank you for these sessions!

Edward_Savage,_MD: If your valve is fine, no operation is necessary. If you needed your aortic valve, I would recommend a mechanical valve since you are on warfarin and tolerating it with few problems. At age sixty, if you needed your mitral re-replaced, I would probably recommend a mechanical valve since a tissue valve is likely to wear out. At age seventy, I would probably recommend a tissue valve. Again this is one surgeon’s opinion, others might differ.

DGiessen68: I have BAVD and currently show mild calcification, mild aortic regurgitation and dilation of the mid ascending aorta at 43mm. What are my options regarding repair versus replacement of the valve?

Edward_Savage,_MD: No surgery is indicated now and may never be necessary. The options can only be address based on the status of the valve when surgery is necessary. The current recommendation is for surgery if your aortic reaches 5.5 cm, or at a smaller size if there is rapid growth or a family history of aneurysms.

starfish89: I had valve surgery two weeks ago. I just found out I have a cracked tooth. Can I get it fixed - or too soon?

Edward_Savage,_MD: You should consult your dentist and surgeon regarding this.

shones: I am a 35-year-old male that was born with Shones complex. In 2009, my native mitral valve was replaced with a bovine valve. However, the heart surgeon did not order a pre-op heart cath nor did he read Complications in Surgery by Mulholland & Doherty. Thus, he occluded my circumflex artery during surgery. I suffered an infraction the cause of which was not discovered until five days later. At that time two stents were inserted at the point of occlusion. My question is how will this issue effect my chances in the future for a successful valve revision when the time comes?

Edward_Savage,_MD: Probably no effect but this cannot be truly answered without detailed review of your anatomy.

IWSteve: 68-year-old male with severe aortic regurgitation - former competitive athlete. Discovered in Feb. 2013 during a routine physical. Echos indicate my atrial chamber is now severely dilated. Ejection factor has decreased to 55. Taking Lisinopril with BP 125/55. Am I correct in that the protocol for recommending surgery is to wait until there is sufficient damage to the heart? I am more than ready at this point.

Edward_Savage,_MD: I cannot answer this without additional information. Surgical timing for severe aortic regurgitation is dependent the presence of symptoms, or the size of the left ventricle not the atrium. If your ventricle is severely dilated surgery may be indicated.

kathyV: With mechanical valves, can one use fish oil instead of Coumadin? And if not, why can we not use the newer anticoagulants that don’t require monitoring?

Edward_Savage,_MD: No to fish oil. The newer anticoagulants have been tested with mechanical valves and were not as effective as warfarin so the FDA has not approved them for use.

Nama4: I am 70, and have been told I have a leaky aortic valve. An echo done eight months ago was apparently ok. The doctor did not suggest when/if I should have this checked again. I am in good health and can walk twenty minutes 3x week on a treadmill without difficulty, but at times if I run up or down the steps, my HR goes to 150+ BPM as measured by a finger pulse ox device. It comes back down pretty quickly. I am not overweight. Will I just know when I need to do something? My 82-year-old brother had his valve replaced a year ago.

Edward_Savage,_MD: I would need to know how "leaky" your valve is. A mild leak may never progress. For mild leaks the general follow-up recommendation is an echo in three years unless symptoms develop. If the leak is worse, you need to follow up with your cardiologist for advice.

MaggieA: Who is not a candidate for minimally invasive aortic valve replacement? If you have it, minimally invasive, does it affect the outcome of surgery?

Edward_Savage,_MD: Most patients with isolated valve disease are candidates. If other procedures need to be done such as bypass grafts, then they may not be. The outcomes are usually the same, some minimally invasive patients recover faster.

jamaica: If you need aortic valve surgery and mitral valve surgery - can it be done minimally invasive? Is there an age limit?

Edward_Savage,_MD: Yes, this can be done with minimally invasive, and no, there is not an age limit.

Shawna22: My doctor told me that they rarely repair the tricuspid valve or they don't repair it until severe. My symptoms are getting worse and I think I need another opinion. If my valve is failing what is the preferred surgery - repair or replacement? Can they do it minimally invasively? Are there catheter treatments instead?

Edward_Savage,_MD: If you are having symptoms this should be addressed. Traditionally cardiologists have waited too long to refer patients until they reach the point where the risk is high. The choice is to repair if possible, if not then to replace the valve. I do all these isolated tricuspid valve procedures through a mini right thoracotomy approach. There are no catheter-based treatments.

vennidel: If you have an On-X mechanical valve, do you still need to be on Coumadin?

Edward_Savage,_MD: Yes. However, for a valve in the aortic position, after two months the target INR is lower (1.5-2), then for other mechanical valves (2.5-3.5) The mitral position requires full anticoagulation.

mamaD: If someone needs an aortic valve replacement but their aortic valve is unusually small, can they still have a tissue valve replacement or must they have a mechanical valve?

Edward_Savage,_MD: In most cases yes, it may require enlarging the annulus and root.

Bernard: I currently have a homograph aortic valve. It's been in about 11 years. I've been told eventually it will need to be replaced. I'm an active healthy 60 year old male. I'm not on blood thinners. If I had to have it replaced today, what are my options?

Edward_Savage,_MD: You may never need this valve replaced. Your options include a redo homograft, mechanical or tissue valve. A percutaneous valve may also be an option.

animallover28: Sorry about this other question. Is TAVR still not as safe as open heart. Or have problems been minimizing?

Michael_Zhen-Yu_Tong,_MD: Currently TAVR is reserved for patients who are considered too high risk for open heart surgery. The main concerns, however, is the question of durability. Depending on your age, we want the valve to last as long as possible, and currently we do not have reliable long-term data on the durability of TAVR valves. If you are reasonably healthy, then opened surgery is still the best option for you. However if your risk of surgery is too high, then TAVR may be an alternative. Whether you are a candidate for TAVR also depends on some other anatomic and technical factors that will need to be assessed prior to surgery.


Valve and Maze Surgery

adourian: When you do a maze/ablation to address Afib at the time of an aortic valve replacement, is a "J" partial sternotomy the clinic's procedure of choice or do you need to do a full sternotomy? What procedure (atriclip, sutures) does the clinic use with regard to closing the atrial appendage?

Michael_Zhen-Yu_Tong,_MD: When we perform an aortic valve replacement the incision that we use is typically a mini J incision. Sometimes we can perform the procedure through an even smaller incision on the right side of the chest without going through the sternum. However if a maze procedure is also needed simultaneously, we would need to do a full sternotomy to be able to access all parts of the heart to perform the maze. In regards to the left atrial appendage there is some variability from surgeon to surgeon. Some use a clip. I like to staple the appendage and completely amputate it. The results are equivalents and it's a matter of what the surgeon feels most comfortable with.

adourian: I have paroxysmal Afib that lasts about 18 hours and is becoming more frequent, now biweekly. I also have moderate aortic valve stenosis. Other than slowly increasing gradients in the heart, the heart structure and arteries are all ok. I am on blood thinners and am told that Afib itself is rarely fatal and that I should try to hold in there and address the Afib when I have my valve replaced in two to three years if I can deal with it from a lifestyle standpoint. I would like to know when I start to risk this thing called "remodeling" and whether I should worry about it in terms of its impact on the success of a maze/ablation at valve replacement time. Somewhere I read that success rates for maze/ablation is less for those with persistent Afib than for those with paroxysmal Afib. If true, should I be thinking of moving to rhythm medications or an ablation sooner?

Michael_Zhen-Yu_Tong,_MD: The success rate for maze is dependent on many factors. It is true that for patients with persistent atrial fibrillation (Afib) the success rate of a maze is less than that of paroxysmal Afib. It is also true that patients with Afib rarely die from Afib and as long as they are on anticoagulation the risk of stroke is quite low. My recommendation would be that if the gradients across the aortic valve are reasonably high then it may be reasonable to proceed with the surgery replace the aortic valve and performed a maze simultaneously. If the gradients across the aortic valve are still pretty low and then I would recommend seeing in an electrophysiologist doctor (EP) for consideration of a transcatheter ablation or medications.


Valve Surgery and Bypass Surgery

maxmisty741: I need aortic valve replacement and a single bypass. Can these combined procedures be done using the minimum invasive technique ?

Edward_Savage,_MD: The right coronary artery can be bypass along with aortic valve replacement with a mini upper sternotomy approach. The other vessels cannot be reached through this incision. However, on some patients, I have had the cardiologists stent the artery then a month later I have performed a minimally invasive valve procedure.

tedoster: I need coronary artery bypass surgery and mitral valve repair. I assume I can have both surgeries at the same time? Does one or the other impact the results of the surgery? Is it more risky to have two surgeries at the same time? Is the recovery any different?

Edward_Savage,_MD: They should be done at the same time. The risk is slightly higher, the recovery is the same.


Coronary Artery Bypass Surgery

carl1962: I have diabetes. I had a stent put in three years ago for a blocked artery and my artery clogged again. Had two stents last year. I am now having symptoms again. I am having a cath next week. When do you consider bypass surgery vs. stent? I really do not want to undergo surgery but would it last longer?

Edward_Savage,_MD: If the stent has repeatedly stenosis, surgery may be a better option.

Dodger1: I am a 67-year-old male with some angina during exertion (exercise). I am able to manage the angina quite well and are physically active. I have had bypass and a later stent and take four heart melds. My doctor suspects the angina may be due to some blockages in small arteries. Can small vessel disease be seen/detected with a cath (or other means) and can it be repaired somehow? Thank you very much for your help.

Edward_Savage,_MD: Yes it can be seen by a cath. Disease in small vessels is best treated with medication.

tracymax: My dad has had many stents over the years. he is currently being evaluated for bypass surgery as he keeps reclogging his arteries. During his initial appointment, the doctor said sometimes if there are too many stents they can't bypass it.  Is that true? Can there be too many stents for bypass surgery?  He had a cath this week and I am going with him to his appointment on Friday. Are there any questions we should ask?

Edward_Savage,_MD: Theoretically yes, but usually bypass is possible. The surgeon usually has a standard overview talk that will cover the most important issues.

ronnieL: What is the less invasive bypass surgery available anything with laser or robotic, can you provide more information for someone who is considering bypass but without being too invasive and who would be a candidate for this type of surgery.

Michael_Zhen-Yu_Tong,_MD: The "whether or not" a minimally invasive surgery is possible depends on the location of your blockages and how many bypasses are going to be needed. While we do not use lasers, minimally invasive bypass surgery through a small incision on the left side of the chest is possible and certain patient's with or without the use of the robot. We will need to evaluate you coronary anatomy, fully assess whether or not you’re a candidate for minimally invasive coronary artery bypass surgery.


Aorta Surgery

Nama4: My 48-year-old son's ascending arch aortic aneurysm is now at 4.5 cm, having grown .1 cm since it was diagnosed a year ago. I keep hoping for new and better techniques before he has to have surgery. I read that at St. Luke's-Roosevelt Aneurysm Center they are now operating on ascending arch aneurysms with a less invasive method than splitting the entire chest. Are you doing that at CC? Will that approach become more common?

Michael_Zhen-Yu_Tong,_MD: The general recommendation for isolated ascending aortic aneurysm is to proceed with the repair at around 5.5 cm. However, if patients have a connective tissue disorder such as Marfan or Ehlos Danlos syndrome; or have a family history of aortic dissection or a bicuspid aortic valve, then the recommendation may be to proceed when the aorta smaller. The standard approach for ascending aortic aneurysm is through a sternotomy, however in many patients, we can replace the ascending aorta through a mini J incision in the chest; with an incision about 8-10 cm as long as the aneurysm is mainly limited to his ascending aorta. Prior to surgery he would need to be assessed whether or not he has any valvular disease or if he has any coronary disease and if he does have these issues then surgery will likely need to be addressed through a full sternotomy. There are stents that can be used for aneurysms however the stents typically are used in the abdomen. The results of stents in the ascending aorta is still very experimental and currently only reserved for the highest risk patients, such as those in poor health or the elderly, and would not be recommended for somebody his age as they will likely not be durable.

iriverman: I'm 70 years old and have a 4.1cm ascending aortic aneurysm that has been stable for two years. I sometimes am involved in moving heavier objects, such as furniture, and need to know what is a reasonable weight that I can lift without possibly causing further aneurysm enlargement? Thanks so very much.

Edward_Savage,_MD: I don't really give patients weight limits. I tell them to be rational and cautious with no swift jerky movements. Lift but don't strain.

Angelgabriel: I had an aortic arch graft two years ago and currently have a decending aorta aneurysm of 6.4cm and an abdominal aneurysm of 4.8cm. I have been told there is a new stent for this condition which the FDA has yet to approve. Do you have any additional information about this?

Michael_Zhen-Yu_Tong,_MD: Yes, these would be called fenestrated or branched grafts. These grafts are not approved yet by the FDA for commercial use but are available under what's called an investigational device exemption. We have so far implanted more than 1,000 of these grafts. What determines whether or not you would be a candidate for one of the stent grafts is the anatomy of your aorta and your other medical factors. Generally these grafts are custom made based on your exact aortic and measurements on CT scan. There is a delay of generally around two months for these grafts to be manufactured and shipped. To determine whether or not you are a candidate for this type of surgery, please feel free to contact us and we can do a formal evaluation.

RVer: I had an ascending thoracic aneurysm repaired in 2009 at St. Luke's Episcopal in Houston, TX. That was complicated by a double by-pass. I also have another ascending thoracic aneurysm just at the carotids and I have an abdominal aneurysm at the juncture of the kidneys. Both are 4.1 cm. I am 73 years old and in pretty good health- 5'3" and 128 lbs.- former smoker (8 years ago). I have had a mastectomy, a ureter exchange every four months (due to scar tissue from the heart surgery-retroperitoneal fibrosis)-, and I have wet macular degeneration (I get the shot monthly). I exercise daily and am fairly active. I am also a candidate for Repatha. I've been told that these aneurysms are inoperable. What are your methods for correcting this?

Michael_Zhen-Yu_Tong,_MD: Based on your description I do not see any obvious contraindications for repeat surgery should one be needed. Having said that, the size of your aneurysms are not large enough that surgery is needed at this point. However I would recommend close follow-up with annual CT scans to monitor for any changes in the size of the aneurysm. Typically the recommendation for aneurysm of the aorta is around 5-1/2 cm however every patient's threshold is different depending on other factors such as whether or not they have connective tissue disorder. Based on your description I do not see any clear reasons why surgery would not be possible but we will need to fully evaluate your records and your images to be able to make that determination.


Aorta and Valve Surgery

mariearc2015: I am 83 years old, I have moderate aortic insufficiency, moderate mitral regurgitation, Mai of my lungs and an aortic ascending aneurysm 5.3.Is there any less invasive procedure than open heart surgery to repair my aneurysm at Cleveland Clinic? Thank you, Marie

Edward_Savage,_MD: I usually repair isolated ascending aortic aneurysms via a mini upper sternotomy however realize this still requires the heart lung machine and stopping the heart. It is basically the same operation but through a smaller incision. This would also depend on whether other procedures needed to be done.

mariearc2015: In a previous question I asked about a less invasive repair of my aortic aneurysm 5.3. I failed to mention that I have one kidney, I was a donor for my son. Does this make a difference? Thank you ,Marie

Edward_Savage,_MD: If your creatinine is normal then the absence of a kidney should not matter.

bobbyW: I have a bicuspid aortic valve and my aorta measures 4.5. The valve stenosis is moderate. Do I wait for the aorta to get to 5 or the stenosis to get to severe before surgery? Is it one or the other - or both? When should I be evaluated?

Edward_Savage,_MD: Wait till the ascending aorta is 5-5.5 cm or the aortic stenosis is severe and symptomatic. You should be followed regularly by a cardiologist.

Dondon: I would like to thank Dr. Tong for taking care of my heart problems. In Nov. of 2014, I was flown from New Mexico to Cleveland Clinic to have my aortic valve (bicuspid) replaced, and an aneurysm (5.7 cm) to the ascending portion of my aorta repaired. Dr. Tong was my surgeon, and he and his team did a fine job. I have pretty much recovered fully with no problems. I'm an avid cyclist (35+ years) and was told pre-surgery that in time, I would return to a normal lifestyle. A week ago was day 365 for me getting back on the road on my bike. The rides started off at 3 - 5 miles at less than a 6 mph pace. I eventually built my endurance up and completed a metric century ride for my 1-year after surgery goal. This rehab and recovery on the bike was all done at a heart rate of 70% or less of my max HR, and I ended my first year of biking on the road with 5,300+ miles. Thank you again, Dr. Tong, for giving me the opportunity to continue my normal lifestyle.

Michael_Zhen-Yu_Tong,_MD: So happy you are doing well. Congratulations on your century ride!


Subaortic Stenosis

ideatrics: Hello Doctors - I am a 62-year-old male with membranous subaortic stenosis and I am wondering if I need surgery. My recent echo showed "severe septal left ventricular hypertrophy" It indicated that there is a "sub aortic membrane causing LVOT obstruction". Peak LVOT gradient was 53 mm Hg and mean was 32 mm Hg. It also indicated "mild left atrial enlargement". I have also had atrial flutter and atrial fibrillation that was treated with ablation about two years ago. I am starting to have some episodes of high heart rate again. Could the obstruction be causing the Afib? Should I be evaluated for resection surgery? Thank you.

Michael_Zhen-Yu_Tong,_MD: I think it would be reasonable for you to be evaluated for a myectomy surgery - where part of the hypertrophied muscle is cut out. Your gradients are fairly elevated. I don't know if these were done in the setting of a stress test, however if these are your resting gradients, then your stress gradients may be even higher. It is possible that the obstruction is causing increased pressure in the left atrium leading to the atrial fibrillation and the maze procedure can also be considered at the time of your surgery.


Low Ejection Fraction - Heart Failure

xdwl: Hi, Doctor, I heard LVAD can be used for later stage of HF with reduced EF. How about HF with preserved EF? Will LVAD be equally beneficial for HF with preserved EF as well? Since these patients' EF may still be normal, what is the indication for them to have LVAD? Is it more common for them need to have both RVAD and LVAD? Thank you very much!

Edward_Savage,_MD: There are various indications for LVAD based on the functional status with heart failure. Heart failure has to be pretty severe before LVAD is indicated. Most patients with preserved EF do not need and LVAD. The only exception is intractable arrhythmias.

Wangshousan: Over 20 years ago, I had a severe heart attack. The middle artery had block out completely. I had no chance to do bypass or stent. So front muscle of my heart was dead. Down the road the left artery somewhat also partially blocked, so I was put one stent in it. Recently the right side artery was blocked 80%, so doctors put two stents in it. Since first heart attack, I am taking all kinds medications, last 20 years I never stopped them. My LVT is about 35% for last 10-15 years, since then this figure did not change lot. The QRS duration of my EKG is about 106ms. It did not change too much neither. For one year, my breath is getting shortened.
My questions are:
1. From long term point of view, what should I do to prevent HF or any severe problem of my heart?
2. Are there surgery procedures which will improve my heart condition?
3. Any research(s) going on, as a volunteer I could join it or them such as stem cell injection, gene therapy, etc.
4. Any suggestion(s)?

Michael_Zhen-Yu_Tong,_MD: Dear Mr. Wang. Given the recurrence of shortness of breath, I would advise repeating your left heart cath and repeating an echo to evaluate whether or not there are any new problems with the heart. If there is valvular disease or if there are new blockages in the arteries then treatment may help your symptoms. If there are no new blockages in your arteries and there are no new valve problems - then it would be important to make sure that you are on proper medications. These may include a type of medication called an ACE inhibitor, a beta blocker, a diuretic such as Lasix, and sometimes spironolactone. These medications can improve your heart failure symptoms and decrease the rate of worsening. Your EKG did not show a wide QRS therefore a cardiac resynchronization therapy will probably not be beneficial to you. It is also important to ensure that your lungs are healthy as well. With an ejection fraction around 35%, you probably do not need advanced therapies such as a mechanical device or transplant at this time. In the future however if your heart failure continues to worsen these may be an option for you. At present we do have the study for stem cell injection however this is done at the time of a mechanical device implant and in your situation your heart is not bad enough to be considered for this therapy. Patients with heart failure are more challenging to advise on a forum such as this because each patient's situation is very different. There are a lot of factors that go into deciding what is the best treatment option for an individual patient. If you would like a more comprehensive evaluation of your heart condition and the best treatment option for you, I encourage you to contact us or heart failure cardiology specialists.


Calcium and Heart

shoe-in2: I have a lot of calcium apparently. My test results have showed calcified aorta - and also I will need mitral valve surgery due to mitral valve stenosis and calcium on my valve. My first question is 1) Will that affect the surgery that I have? and 2) Why do I have so much calcium? Is there something I should be doing to prevent more? What about after I have my surgery - is that an issue?

Edward_Savage,_MD: We would have to review the CT scan to see where the calcium is this could impact the conduct of the operation. Calcium deposition in the aorta can be associated with age, smoking, obesity, and heredity. It is difficult to say why you have it.


General Questions

gerryo: I have had three stress tests that confirmed a lack of oxygen in the lower heart. My cardiologist says there is nothing medically that can be done. He prescribed Metopolol to take twice a day. But my breathing seems to be getting more difficult. I have a sleep apnea machine to sleep. But nothing to help during the day. I am 54 and male. Any suggestions?

Edward_Savage,_MD: If you are obese, consider weight loss. You may have to consult with a pulmonologist to see if it is from your heart or lungs. An exercise program may be helpful. Consider a second cardiologist opinion.

giacomina: My daughter, Anna ,age 24, died in her sleep 17 months ago. She was extremely healthy and fit, but did have a fainting episode 8 months prior to her death. An emergency room visit at that time (she had never fainted before, so we went to the ER) concluded with a diagnosis of "dehydration" and "anxiety". Her autopsy report states "mitral valve prolapse" as the cause of death. After obtaining her records, I noted on the ER report her EKG was abnormal the first time - "long QT rhythms" were found. A second EKG was normal. We were never told of the abnormal EKG, even though we were in the ER all night. My daughter was monitored through the night. I still do not feel as if we know what caused her death. Can you shed some light on my daughter’s death? Thank you

Michael_Zhen-Yu_Tong,_MD: I am very sorry to hear about your loss. It is really difficult to know what the cause might be - the mitral valve prolapse never leads to sudden death. In young patients who are otherwise healthy who have sudden death; it may be related to an abnormal heart rhythm but this would be only a guess. Autopsies can often determine the causes of death however if somebody has a cardiac arrest from an abnormal heart rhythm this may or may not be detectable from an autopsy. I am again very sorry for your loss.

Reviewed 02/16

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.