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

Edward Savage, MD
Edward Savage, MD

Thursday, February 2, 2017 | Noon


Description:

One of the largest, most experienced cardiac and thoracic surgery groups in the world, Cleveland Clinic’s Department of Thoracic and Cardiovascular Surgery cares for patients from all 50 states and around the world. Surgeons Edward Savage, MD, and Michael Tong, MD answer your questions about heart surgery.

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  • View previous chat transcripts.

Valve Surgery

adourian: For someone who will have a valve replacement short-term and also has periodic self-correcting paroxysmal afib, what do you recommend in addition to replacing the valve? Ablating the PVs? Ablating the atria itself? Removal of the appendage? All of the above? Can everything you suggest be done with a partial sternotomy?

Edward_Savage,_MD: Perform a maze procedure in addition to the valve and part of that is also includes removal of the left atrial appendage (LAA). I am doing this through a mini right thoracotomy approach.

earl359: What tests are done do check to see if you need a heart valve operation? I understand that the aorta is the number one heart valve that goes bad, is that true? Will an EKG pick up a leaking heart valve? My father who is in his 70s about four years ago was told he had a slight leaky heart valve but not to worry about it. Now that five years has passed, what is the odds that it is leaking more than before, do small leaks tend to get worse over few years of time? Thank you for taking my questions.

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: The two most common valves that need repair or replacement are the aortic and mitral valves. EKG will not detect abnormalities. Echo is generally the best test to evaluate for valve dysfunction. Generally, only when the leakage or stenosis (narrowing) becomes severe, is when patients need surgery.

magilla: Cardio Thoracic Surgeon questions:
1. I have heard some TAVR procedures are conducted on cardiac patients in the moderate range. Is that correct? If so is that done at the CC?
2. Will they do a TAVR procedure on patients with an enlarged Aortic root?
3. Because of proximity of the AV node to the Aorta does the TAVR procedure usually end up with a patient requiring a pacemaker?
4. Are other procedures in place or in clinical testing that use minimally invasive techniques such as TAVR for the Tricuspid or Mitral valves?
5. What determines if a Valve needs replaced vs. repaired? Are human cadaver valves used for repair or replacement?
6. What is the current life of valve replacements? Does the patient’s activity help to determine the life?
7. What percentage of patients having open heart surgery gets a transfusion? Can patients bank their own blood to be used in the event a transfusion is required? How soon before surgery should you bank blood?

Edward_Savage,_MD: 1) Yes and yes; 2) It depends on how big the root is - that would need to be evaluated; 3) There is a small incidence of requiring pacemakers after TAVR, but in most cases no; 4) Yes; 5) The decision to repair or replace a valve is based on standard criteria - degree of narrowing or leak. Cadaver valves are not routinely used; 6) Difficult to predict - depends on age, type of valve. Mechanical valves should last a lifetime. Tissue valves do have a finite lifespan. And while patients over 60 are often recommended tissue valves, they will not usually outlive the valve. Second question – no; 7) Depends on the operation - less than 10 percent for low risk and up to 80% with high risk operations. Yes, then bank their own blood unless their heart disease is severe and removing the blood would cause them to get sick.

RayMC: I'm a 69-year-old male with normal dimension for both chambers, moderately calcified aortic valve w/limited aortic opening and PGAV=65mmHg, mild mitral and tricuspid regurgitation. RVSP=32mgHg, LVEF = 70 and normal left ventricular contractility. Would you agree that corrective action on the valve is premature? Would the use of vasodilators be a viable medical therapy? Are there specific vasodilators that you prefer?

Edward_Savage,_MD: We cannot judge whether this is premature based on this information.

magilla: Are heart lung machines used for all open heart surgeries? If so what assurance do patients have that the machines are thoroughly cleaned to prevent cross contamination? Do patients have a choice of the type of surgery they believe makes the most sense to them?

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: Almost all open heart surgeries will require heart lung machine with the exception of TAVR and off pump coronary artery bypass grafting (CABG). Machine is thoroughly cleaned. All the equipment that are in contact with the blood are disposable and a new set is used for each patient.

JRoland: Given the risk that valve surgery can pose to the heart's electrical conduction system, increasing the likelihood that valve surgery patients will need a pacemaker, are there any ongoing developments to help reduce that risk?

Edward_Savage,_MD: The valves are near the conduction system. Although it is not that common for a patient to need a pacemaker after surgery - probably less than 5%.

seamullet2016: Can robotic or minimally invasive surgery be used on an operation for aortic and mitral valve replace or repair?

Edward_Savage,_MD: Yes. - Not robotic but minimally invasive.

seamullet2016: I am a 69-year-old male with the following diagnosis. Normal LA size, intact septum; Mitral annular calcification, moderate-severe MS (mean gradient 5 mmHg; MVA = 1.3 cm2), moderate-severe MR; LVH, normal systolic function, possible diastolic dysfunction; AV not optimally visualized but severe AS by gradients (peak = 57, mean = 36 mmHg, AVA = 1.0 cm2), trace AI; Mild enlargement of ascending aorta; Normal RA and RV sizes, trace TR; No pericardial effusion.

He is having some SOB, but not as much or severe as in the recent past. He is aware of the irregular heart beating, but there is no shortness of breath or light headedness with the palpitations. What are the options for surgery?

Edward_Savage,_MD: You will probably need open surgery to replace both valves but we need more information to determine the timing. We would be happy to review your records.


Aortic Valve

lookingforinfo: A 15-year-old diagnosed with trivial aortic regurgitation. Heart and aortic valve structurally normal. No murmur/syndrome/disease, nothing abnormal present. No restrictions and follow-up in two years. Can patient outgrow this problem? Can this be the patient's normal or physiological or pathological or will nothing further will develop? AR is seen in four-way views on echo. I'm finding this is rare in children and if a child has it, it is never an isolated lesion. Is that true? No family history of heart disease/syndrome. Heart structural normal. No bicuspid valve. Patient's doctor thinks the AR may resolve spontaneously. Is that possible? Can this progress from trivial to worse, if her heart structure is normal? Do you agree with spontaneous resolve? An athlete, high-level competition, works out with weights. The doctor said no disease is present and doesn't classify this as a disease. How can this happen? Is rare to have without disease present and the heart is structurally normal? Thank you.

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: Trivial aortic regurgitation should not cause any problems and the risk of progression is very low. He or she should get an echo perhaps every five years unless he or she develops shortness of breath. I agree that I would really classify this as disease.

bgard: I had aortic valve replacement (bovine) in Aug. 2016 and was exposed to the m.chimaera bacteria because my hospital used the Sorin 3T HCU during my surgery. I have some symptoms of bacterial infection - I developed bronchitis (which I have never had before), I have minor levels of night sweats, and my energy level is a little lower than normal. No fever. I want to be tested for the bacterial infection but no doctors I've asked are willing to do so in the absence of more severe symptoms. Will a blood or tissue culture test positive for m. chimaera in the absence of symptoms?

Edward_Savage,_MD: You should consult with an infectious disease specialist.

mkaer1940: I have been told that I have mild aortic valve stenosis. What are my treatment options, and when should I consider surgical intervention?

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: No Treatment is needed at this time until the valve narrowing becomes severe or when symptoms of shortness of breath or syncope develop.

lionel: I am a 57-year-old male and will require surgery in the short-medium term to replace a leaky (moderate) bicuspid aortic valve and possibly repair of the aortic root and ascending aorta. The thing that worries me the most is getting a better understanding of how the heart is restarted after cardio-pulmonary bypass. How is this done and what are the risks that the heart cannot be restarted? Lionel

Edward_Savage,_MD: It restarts on its own once we re-perfuse it with blood. It almost never does not start - nothing to worry about.

cg1217: My question is this, I have a BAV that has been followed since birth. I am 40 years old, last year a CT scan showed 4.4 ascending aorta dilation, (13 months later) CT without contrast repeated last week and showed 4.9 dilation. (Repeated without contrast to make sure lung nodule was not changing). Echo repeated and showed six month difference in valve from 20% gradient to 27% gradient. I am 240lbs, 5'11. I have no symptoms except sometimes short of breath but I am very active. I am scheduled to see my cardiologist later in February. I have always been told surgery would come one day, is now the time I need to have it done?

Edward_Savage, _MD: I cannot really answer this based on the information you provided, but clearly you need to be monitored closely.

davidl: I had an aortic valve replacement in January 2013 performed by Dr. Savage. I was wondering how long the valve should last and will I need another replacement.

Edward_Savage,_MD: This valve should hopefully last you the rest of your life.

mkaer1940: I've been diagnosed as having aortic valve stenosis. When should I consider valve replacement? And tell me about the options available at Cleveland Clinic.

Edward_Savage,_MD: Surgery is usually performed when patients have symptoms although there are rare times when a patient does not have symptoms when surgery is recommended. This usually occurs with an abnormal BP response on a stress test or if the valve is very, very tight. All options are available at the Cleveland Clinic based on your medical needs.

dsivyer: 59-year-old male, Aortic valve replacement May 2011. Edwards 23mm pericardial tissue valve. Values showing signs of narrowing. 2.5 - 3. Some shortness of breath with exercise. Patient obese but active and normal heart function otherwise. How complex is re surgery and what are the mortality rates or risks of re do surgery compared to 1st time surgery. Has TAVR advanced at all since 2011 where it may be as good an option as conventional AVR surgery? I may have moderate patient-prosthesis mismatch. If this is the case what are your thoughts on aortic root enlargement to accommodate a large prosthesis? Thank you for your time.

Edward_Savage,_MD: Re-surgery complexity depends on the patient and case - but most often the second case is not more difficult than the first and mortality is low If you already have patient-prosthesis mismatch, that can get worse if the TAVR valve is placed in that valve. If you have patient prosthesis mismatch, aortic root replacement in a second operation is a reasonable option - however you would need to be evaluated. All of this have to be evaluated on an individual basis .

DGiessen68: (48m here with BAVD) what is the quietest artificial valve on the market or coming to market? I've heard good things about the On-X...but I'm worried that any amount of "clicking" I hear will…I’m not sure how I would handle it.

Edward_Savage,_MD: I don’t really know which is the quietist - most do not make much noise and most patients tune it out and do not hear it. It is not a huge complaint in most patients.

Marie21: I'm a 42-year-old female, 5 ft. 2 in, 174 pounds, good health other than ascending aortic aneurysm of 4.4 cm as measured last year by MRI. Also have a BAV that is stable and in good shape with no symptoms. I've been lifting 7 pound weights and doing high repetitions (100 reps for each arm). Is this reasonable weight lifting given the aneurysm I have or should I stop doing this? Don't want to suffer a dissection.

Edward_Savage,_MD: It is reasonable to do light weight lifting, no quick movements or straining.

Bill1952: Lot of good stuff on this chat. Little confused about the 5.cm vs. 5.5 cm surgery threshold. In some of the answers so far, I have seen both 5 cm. and 5.5 cm as the surgery/wait threshold.

Edward_Savage,_MD: 5.5 cm is the threshold for most patients. If you have significant AI, 5 cm is the recommended size. If you have certain congenital diseases that weaken the aorta, sometimes surgery is performed at smaller sizes.

Bill1952: Thanks. What is significant "AI"? Also, any radiation concerns with annual CT to monitor size of aneurysm?

Edward_Savage,_MD: Significant aortic insufficiency has a very precise definition based on echocardiogram evaluation. There is some radiation concern with yearly CT but the risk is low.

cg1217: I sent this question in so you may get it twice, I have been followed for bicuspid aorta since a child, several years ago I was diagnosed with dilation of ascending aorta, last year Cy scan measured 4.4, this month on a Ct repeat without contrast for another issue (lung nodule) the Dr sent over I needs to see my cardiologist because it had grown to 4.9. I am 240, 5"11 and 40 years old. With it growing that much in 13 months will I need surgery now? I meet with my cardiologist on the 14th and she is meeting with surgeon to discuss. Just wondering g what you thought?

Edward_Savage,_MD: That is worrisome however sometimes the difference in measurements are not true size differences but difference in techniques during evaluation. The most important thing would be for the surgeon to review the films to determine the severity of growth. It definitely requires follow up.

books825: My aortic valve was replaced at CC in June 2016. I now have atrial flutter. Would ablation be advisable to convert my heartbeat back to sinus rhythm? I am 85 years old; BP 105/55; BMI of 24.

Edward_Savage,_MD: We cannot make that decision for you - this is a discussion with your cardiologist. You may want to consider seeing an electrophysiologist - a heart rhythm specialist .


Mitral Valve

Promenade205: I have been told by my cardiologist that I have mitral valve pro-lapse. How do I know when and if I need surgery to replace the valve and how would the procedure be done? Open up the chest or go in between ribs? Thanks.

Edward_Savage,_MD: If you have just MVP and no leak you may not have anything to worry about - the timing of surgery is based on symptoms and degree of leak. If it is isolated to the valves it can be performed through the ribs.

dddepas: I do have a heart condition. I have a mechanical mitral valve done in 2010. My current age is 49. Currently on Blood thinner. Also, I am on beta blocker 12. 5 dose 3x a day because I have been having my veins have pulsation in my neck. Breathing fine, but some days I get short of breath. Looking for a 2nd opinion. Thank you.

Edward_Savage,_MD: We cannot evaluate you in this forum. You should call and make an appointment. We would be happy to see you. You should be seen by a cardiologist.

johnmd: How many mitral valves have you operated on- repaired or replaced? What is your criteria for surgery in a patient with 3+ M I, no P H or remodeling of the LA or LV?

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: I operate on around 50 mitral valves a year either in isolation or in combination with other valves, aorta or coronary bypass. I would wait until one of the following happens, worsening of the mitral insufficiency to 4+, development of symptoms, enlargement of the left ventricle, decreased ejection fraction, development of atrial fibrillation or pulmonary hypertension.

dricke: I have a bad mitral valve from rheumatic fever. It was not discovered for 40 years until I had a really serious afib attack. That was when I was 58. I am now 68 and wondering if delaying valve replacement or repair is the current best practice. I'm concerned that I will not be able to handle the surgery as well if I wait too long. I am NOT symptomatic as no shortness of breath, no swelling, and exercise daily by walking about 5 miles. I'm concerned the heart may enlarge, the afib become unmanageable, and of course a concern of clotting. I take and handle warfarin very nicely. I never miss the goals. I need no other medications. I see a cardiologist twice a year and my internist knows his way around the heart quite well too and I see him twice a year. Any new recommendations in the pipeline now? Thank you for this wonderful service that helps alleviate so much concern. Dennis

Edward_Savage,_MD: It would be helpful to know if it is a tight valve or leaky valve, Generally speaking - Unless the valve leak is severe we would not do anything if you are not symptomatic. This is the same for a tight valve.

pettijohn: How long should a repaired mitral valve last?

Edward_Savage,_MD: In most cases, the rest of your life.

Promenade205: Is a heart catheterization necessary to determine if a mitral valve needs replacing?

Edward_Savage,_MD: No - it is based on the echocardiogram usually - but if you are going to have surgery a heart cath will be necessary if you are over age 40.

Johnmd: What surgical approach are you using for pure mitral valve insufficiency?

Edward_Savage,_MD: I am personally using a mini right thoracotomy approach. Some people are using a mini upper sternotomy or robotically assisted.

johnmd: What are your criteria for operating on mitral valve regurgitation?

Edward_Savage,_MD: Severe MR; presence of symptoms is an absolute indication. Relative indications include reparability of the valve, ventricular dilatation, episodes of atrial fibrillation, or signs of developing pulmonary hypertension.

Promenade205: I have a - fib in addition to MVP. Are they related and one cause the other? Does that affect whether I need valve replacement or not?

Edward_Savage,_MD: Yes they are related and it does play a role in the evaluation of timing for valve surgery.

johnmd: Describe in detail what you mean by minimally invasive surgery for, say mitral valve insufficiency. Thank you.

Edward_Savage,_MD: Surgery is performed through a small incision through the ribs - 4th intercostal space. We have information on our website as well. And I am happy to see you.


Aortic Aneurysm

randjenn: I have ascending aortic aneurysm measured by CT at 4.9 on last three sessions, 5.1 on one. How often would you recommend the CT scan at this point? I am experiencing chronic fatigue and occasional chest pressure on left side. Is this normal at this stage? Doctor initially advised surgery but then walked back after test last year at this time when no change was found. Is it normal to have long-term static condition without growth?

Edward_Savage,_MD: You scan have long term static condition without growth. I cannot really recommend timing of CT scan without more information and review of medical history.

IAS: HI, Can you interpret this for me on my CT cardiac scan report. What is the actual size of my ectasia? "There is an ectasia of the ascending thoracic aorta which measures 3.9 x 3.7cm above the aortic valve plane. At the level of the proximal arch it measures 3.7cm and in the distal arch measures 2.8cm." Would you define my aorta as aneurysmal at this size? I am a healthy 54 year old male, 5 11, 170lbs and my calcium score can back ALL 0's. There are 4 measurements, so I am not sure what the actual size is. Thank you so much!

Edward_Savage, _MD: The measurements are taken at different places. It would have to be evaluated on an individual basis.

jamesofoakton: I have a mild aneurysmal dilation of the ascending thoracic aorta measuring with 5 x 4.5cm at the level of the right pulmonary artery. The descending thoracic artery measures 2.6cm at the same level. No evidence of thoracic aorta dissection. Coronary artery calcification is normal. Normal origins of the coronary arteries. No pericardial effusion. Normal heart size .Age 83. Generally very good health, excellent vitals, all blood tests are in the normal range. Please, your observations, recommendations. Thank you Kindly.

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: If you’re in good health, you should be able to tolerate the surgery to replace the aorta. The general recommendation is to replace the aorta once it reaches 5 cm. I would recommend replacing your aorta.

4.3ascending: Would a patient ever expect to experience pain associated with an ascending aortic aneurysm without a dissection or rupture? If so, what could potentially cause that pain?

Edward_Savage,_MD: There can be some pain but it is a difficult pain to describe - can be a pressure in the chest - but one of the reasons we repair aneurysms at a certain size is because the pain they have is often unreliable and unfortunately the first pain they have in most cases is when it ruptures or dissects.

bgard: I have an aneurysm in the ascending aorta. Found by accident when having a CT for unrelated issue. Measurement is 4.0cm. I had an AVR mid 2016 due to aortic stenosis (born with bicuspid valve). What do you recommend re: timing for continual checking of measurement? I am a 62 year old woman, 5'4", normal weight, good BP, excellent health.

Edward_Savage,_MD: I would suggest following with yearly CT scans and if stable for 2 - 3 years I stretch it out to every 2 years or so. It may never change in size.

manus0142: DOB: 4/17/48; Ross procedure in March, 1998; Currently have ascending aortic aneurysm at 5.6cm (last CT scan in July, 2016) I am interested in knowing what Cleveland Clinic's approach is relative to the repair. Do you have to redo the two valves along with the aneurysm repair? Can the aneurysm be repaired via minimal invasive methods such as the keyhole surgery? Trying to look at best and lowest risk options. Thanks, Jim

Edward_Savage,_MD: In general I would do these through a full sternotomy and if it is possible to spare the valve by doing root replacement because it is likely that the part of the aorta that was replaced is aneurysmal - this is a known problem with Ross procedure. IF your aneurysm is 5.6 cm it probably needs to be fixed. We would be happy to evaluate you.

brian042167: In 1994 I had two open heart surgeries to repair an ascending aortic dissection just above the root into the arch and had a St. Jude valve put in. I now have been told my aortic root is enlarged to 6.6 cm and surgery is needed but is stable. My blood pressure is good as is my over all health. I take metoprolol succinate 50mg two times a day and warfarin 4mg 1 daily and clozepam 2 times daily. Protime is in range and all other blood tests are good. The St. Jude valve is working properly. I want to learn about what operative procedures are available for my condition to determine the best options that will provide the best outcome. Have been informed surgery is required within the next couple of months. Sincerely Brian.

Edward_Savage,_MD: You sound like you need an aortic root replacement - we would need to evaluate you more fully. We have a process to send in records. Please contact us.

iriverman: I'm 71, 6ft., 210lbs. Good health other than 4.1cm thoracic aortic aneurysm discovered 1-1/2 years ago. Have had CT every 6 months to monitor. Taking 50mg Losartan to maintain blood pressure below 120/80 range. Is it reasonable to continue daily physical activities, moderate exercise, and lifting various objects not exceeding 100lbs. (1/2 body weight). I'm concerned about dilation or rupture.

Edward_Savage,_MD: Yes.

Bill1952: Based on echo, a 3.9 cm aneurysm in my ascending artery. CT scan confirmed but at 4.3 cm. Follow up for another echo 1 year from the first echo to determine rate of growth. My questions: 1. would the CT results show the shape of the aneurysm? I understand that can impact treatment decision. 2. Should my follow up be an echo, as opposed to a CT scan? 3. To determine rate of growth I assume the repeat echo would be compared to the first echo? 4. I have a tricuspid valve, and I hope that if I need surgery I can keep it/repair it. Would my CT show if that is an option? 5.. Finally, at what point should I consult a surgeon to get an opinion or at least confirm my game plan, as prescribed by my heart doctor. Currently, my game plan is (a) blood pressure meds; and (b) watchful waiting. I am 65, 6.1 inch, 170 lbs, exercise regularly, average BP of 127/80, Resting Heart rate of 55 bpm, and no other health issues. My heart doctor is at Johns Hopkins. Thanks for your devotion to heart care.

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: Echo is usually not the most reliable test to evaluate for aortic diameter. CT or MRI is much more accurate in measuring the size of the aorta and are the modalities of choice for follow-up for aortic aneurysm. The CT also can determine the extent of the aneurysm whether it involves the root, ascending aorta, arch. That will determine the extent of the aortic replacement. If the aortic valve have normal leaflets, then it will not need to be replaced at the time of surgery. Your game plan good. I would recommend seeing a surgeon when the aorta reaches 4.5 cm with the goal of replacing when it reaches 5 cm. I would also avoid heavy lifting. Any lifting that requires you to strain to the point where you are holding your breath.

randall: With a thoracic aneurysm, what is the criteria for which surgery is less risk than maintenance? If at 4.9 cm for two consecutive tests six months apart, how often should a CT-scan be scheduled to measure progress of maintenance and potential danger? Are there any other alternative remedies to surgery for this condition being researched at this time?

Edward_Savage,_MD: For an ascending aneurysm the criteria is 5.5 cm but there are situations when it would be operated on at a smaller size. I cannot tell you how often to have a CT scan without more info on your medical history. Yes - but none done clinically at this time.

carmenc: I have a 5.25 cm upper thoracic ascending aneurysm. I am 62 years of age in good health, 5-10 " 215lb male and will need surgery. I read that Cleveland clinic has an endovascular procedure that may be an option for me instead of the traditional open chest / Dacron graph surgical procedure.

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: In the ascending aorta, a stent graft may be used in salvage situations where risk of surgery is too high. The durability of the repair with stent graft in the ascending aorta is unclear and would not be recommended in your situation. Depending on the extent of your aneurysm, it may be repairable through a small incision. (8-10 cm).

nodule: I am a very healthy 54 year old male, 5 11, 170lbs and was recently diagnosed with 3.7cm thoracic ascending aneurysm at the arch from a calcium CT scan I did voluntarily. No bicuspid valve or other issues. My blood pressure is averaging optimally at around 120/80. Never smoked, don’t drink or use drugs. Test result for calcium was all 0's. I have two questions. Is it to my advantage that my arteries are clear of plaque? In your experience, how long have you seen a person's aneurysm remain stable, or only grow extremely slowly? I had an echo ultrasound to check my abdominal area and all is normal. The technician told me he has patients whose aneurysms have remained stable for over 20 years.

Edward_Savage,_MD: 3.7 is not excessively large and this may actually be your aortic size. We would need to look at your scan to see if this is normal for you or if it looks aneurysmal before making a determination.

Verne: I have a 4.8 cm aneurysm ascending thoracic diagnosed 7 years ago. I'm 79. How often should I have CT scans?

Edward_Savage,_MD: I cannot answer this based on this information - timing is individualized based on many parameters.

Marie21: I have an ascending aortic aneurysm measured at 4.4 cm by MRI last year. I am a 5 ft. 2in. tall female with a weight of 174 pounds. I also have a bicuspid aortic valve that is still in good shape. My Cardiologist will only consider absolute aortic size regarding when to have surgery on the aneurysm and he is insisting on following the current guideline of 5.5 cm. I've read that measuring body size relative to aortic size is more accurate for predicting when to consider surgery. Since I am a shorter, smaller person would I need to consider surgery on my aneurysm sooner than 5.5 cm?

Edward_Savage,_MD: You ask a reasonable and controversial question. In general the recommendation your cardiologist is following is 5.5 cm - that may change for patients that have certain connective tissue conditions. The fact that you have a bicuspid valve, we may consider performing your surgery at a smaller size. For bicuspid valves we sometimes use the aortic area to height ratio and if that ratio is over 10 we may consider surgery For you -you would reach that point at about 4.5 cm. It may be worthwhile to consult a surgeon for another opinion.

nodule: Is blood pressure control the most important thing one can do to slow growth of small thoracic ascending aneurysm of 3.9cm? 54-year-old male, 5' 11" 170, optimal pressure always seems to be UNDER 120/85. Thank you.

Edward_Savage,_MD: Yes.

ALTHEA45417: I was diagnosed with the following: RADIOLOGIST IMPRESSION: 1. Right coronary artery dominant system. Patent right coronary artery. Patent left main coronary artery. The left main coronary artery arises more posteriorly than normal from the left coronary cusp. Patent left anterior descending coronary artery. Patent left circumflex coronary artery. 2. Left ejection fraction of 50.78%. 3. Calcium score is 0. 4. Dilated proximal ascending thoracic aorta at 5.5 cm, just superior to the sinus of Valsalva Do I need surgery to correct my ascending thoracic aorta. I was diagnosed with the following: Issues Addressed Ascending aorta enlargement ( ) LVH (left ventricular hypertrophy) Non-rheumatic aortic valve.

Edward_Savage,_MD: If it is truly 5.5 cm then surgery is required.

Bill1952: I read that the shape of the aneurysm is relevant to surgery decision. Fusiform vs. irregular. Would a CT scan show you the shape?

Edward_Savage,_MD: Yes - the CT scan will show you the shape.


Coronary Artery Bypass Surgery

Soprano08: I had a quad bypass 12 years ago. How has the operation improved since that time and what are the alternatives now to new grafts?

Edward_Savage,_MD: The operation is basically the same - we are probably using more arterial grafts at this time - rather than saphenous vein grafts


Cardiac Surgery

Purdue 90: I had open heart surgery in June 2015 (age 48). Since my surgery, I have experienced severe pain in the left mid back (near scapula) region. The pain is consistent but the intensity changes. There is no activity that makes the pain worse/better. I have tried heat/cold wraps, OTC pain meds, rest, neuromuscular therapy and manipulative therapy. I exercised/weights before surgery and have returned to an exercise routine. I also do yoga, light weights and stretch. My recent MRI showed 2 Tarlov cysts on the spine (T9T10) (T10T11), no other problems were noted. I would like to identify the cause so that I can possible end the daily pain. QUESTIONS; Due to the open heart procedure, what other conditions (muscular, skeletal, neurological) could be causing this pain? Do you have any advice on treating this pain? Could you recommend a CC department who could help me? Thank you for your time.

Edward_Savage,_MD: This pain could be related to your surgery due to the spreading of your chest during surgery. Usually this gets better over time. For patients like you, whose pain has not diminished, you should see a medical bone specialist (usually in orthopedics) first to be evaluated.

magilla: What should patients do to protect themselves from cross microbial contamination before and after surgery? I’m thinking in terms of MRSA, C-diff, Staff and blood infections like Sepsis. Does it make sense for patients to get inoculations to protect themselves from flu, pneumonia, tetanus and so forth? How soon before procedures should they do these things? Are cardiac patients allowed to bring their own medication and vitamin supplements into the hospital? Does CC provide information about their rating regarding microbial contamination?

Michael_Zhen-Yu_Tong,_MD,_MBA,_FRCSC: What should patients do to protect themselves from cross microbial contamination before and after surgery? I’m thinking in terms of MRSA, C-diff, Staff and blood infections like Sepsis.

Best thing a patient can do is to ensure that have their sugars under control if they are diabetic. Patients will be given scrubs to clean themselves the day before surgery. If patient are colonized with MRSA, they will be given treatment for it prior to surgery. Best way to avoid cdiff is to avoid taking unnecessary antibiotics.

Does it make sense for patients to get inoculations to protect themselves from flu, pneumonia, tetanus and so forth? How soon before procedures should they do these things? Vaccination is always recommended for overall heath but will generally not provide any protection against surgical infections, therefore there’s no recommended time frame.

Are cardiac patients allowed to bring their own medication and vitamin supplements into the hospital? Generally, we will provide medications. If patient would like to use medications or supplements that is not on our formulation, patients can take their own as long as they don’t interfere with other medications and they are approved by the treating physician.

Does CC provide information about their rating regarding microbial contamination? You can find our information and data about ratings here.

bgard: What can you tell me about m. chimaera? Specifically, is there a reliable test to diagnose this bacterial infection if a person is asymptomatic? I was exposed to the bacteria Aug. 2016 during OHS and was informed of the exposure by the hospital where surgery was conducted.

Edward_Savage,_MD: Here you go - my.clevelandclinic.org/departments/heart/about/news/livanova-heater-cooler . This page has important information and links you will find helpful.

JRoland: How is the role of the cardiothoracic surgeon changing as interventional cardiology expands what is possible with catheter-based procedures?

Edward_Savage,_MD: What is emerging over time is that the cardiologists and surgeons are working together in a cooperative fashion to offer the best procedure to fit the patient.

pettijohn: What is a subdural hematoma? Is it a result of surgery? How is it resolved?

Edward_Savage,_MD: Subdural hematoma is in the brain. Usually this is due to trauma.

Reviewed 02/17

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