Deborah Kwon, MD
Deborah Kwon, MD

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

Thursday, December 24, 2017

More Information

Aortic Valve Disease

MLJ: I am a 57-year-old male with well compensated moderate Aortic Valve incompetence. Results of my recent echo: Normal LV size - LV volume 130mls; overall low normal systolic function. EJ-54, LVFS-27; No evidence of LV hypertrophy or regional wall abnormalities; Impaired relaxation pattern of LV diastolic filling; Normal RV and systolic function; Left atrium mildly dilated (23cm2); Normal RA; Aortic Valve - mild sclerosis but no stenosis, PPG 12mmHg, 2-3/4 regurgitation. LVOFT SV - 125ml. Indexed 62ml/m2. Mild dilatation of aortic root and AA - 41mm; Normal PA systolic pressure. Questions (1) I see my cardiologist in a year to monitor LV function etc. He does not think I will need a new valve in short-medium term or may be not at all? Should I be concerned about my EF level of 54? Earlier this year it was 53 and with a stress echo it was 62. In June last year it was 66. What accounts for these EF variations? (2) Is impaired relaxation pattern of LV diastolic filling common with AR?

Deborah Kwon MD: There can be some variation of EF due to inter-observer variability up to 5% - so the variation in your EF numbers are within the same range. You could have a cardiac MRI for more precise quantification of EF and LV size - and this study could also provide further quantification of the aortic regurgitation. Cardiac MRI is considered the gold standard of LV EF and LV size. Impaired relaxation can be seen with AR but it is not a parameter we use to grade the severity of the leak.

run4him: 54-year-old male with BAV, moderately high stenosis who passes out during running, but NOT during bicycling. Why the different responses in my body to the same level of exertion?

Deborah Kwon MD: That is actually not the same level of exertion. Running is a higher level of exertion than cycling. If you have stenosis and passing out with running, we would recommend avoiding this activity and being evaluated for valve surgery.

Farmlover: Dear Doctors, Thank you so very much for your time and patience to answer questions! Is it normal for people in their middle age to have ‘mild regurgitation” of mitral valve, pulmonary valve, tricuspid valve and NO regurgitation of a sclerotic trileaflet OR bicuspid valve? In other words, could already established sclerotization of aortic valve point toward development of future stenosis? Are they physiologically "sclerotic" at middle age, in patients you see? (I am middle aged, structurally healthy heart, with an aneurysm of ascending Aorta, whereby it was/ is still unclear whether I have a trileaflet OR bicuspid aortic valve, could not be seen on echo yet. My echo result corresponds with my question). THANK YOU AGAIN SO MUCH!

Deborah Kwon MD: Having mild regurgitation (leak) in any of your valves can be considered in normal range. Having a sclerotic aortic valve could put you at risk for developing AS in the future.

Aortic Valve Surgery

crsrts: Does getting a minimally invasive aortic valve replacement make a second open heart surgery easier for the surgeon due to less tissue scarring from the first surgery? Is the risk of complications (i.e. bleeding) the same if one has two sternotomy incisions vs a thoracotomy approach, followed by a full sternotomy?

Per Wierup MD, PhD: In general, having a primary operation minimally invasive makes it much easier going in the second time and diminishes the risks during the re-operation. All risks are less if the first operation was a minimally invasive surgery.

STEVEJ: When a bioprosthetic (bovine) aortic valve begins to fail, can it be removed and replaced via catheter? Or is it more accepted to keep the bioprosthetic valve in place and insert a TAVR within it (valve in valve)?

Deborah Kwon MD: If you are low surgical risk, we recommend that your valve is removed and replaced surgical. The bovine valves can never be removed via catheter. If you are intermediate or high surgical risk, TAVR within your bioprosthetic valve would be an acceptable way to treat bioprosthetic valve disease.

Pka: After replacement of an aortic valve with a bioprosthetic valve, how long before the heart is fully healed from the surgery? If I decide to have a modified MAZE 4 lesion set and LAA ligation to correct paroxysmal afib how long before those are fully healed?

Per Wierup MD, PhD: Safely would be two months.

DGiessen68: Is there a procedure (Bentall, Ross, etc.) and valve (Edwards, Perceval, Inspiris, etc.) that is gaining momentum as the best option to have done on someone with a BAV and aneurysm? Is there something on the horizon that shows great promise? I’m 49 with a 4.6cm aneurysm and trying to keep informed on my options within the next few years. Thank you!

Per Wierup MD, PhD: As of now, depending on how the valve looks we either recommend a Bentall procedure or a remodeling technique where we resect the aneurysm but repair the valve.

ecash: What does a "survival benefit" mean when stated that there is a 15 year survival benefit with an aortic mechanical valve? Does this apply to all aortic mechanical valves?

Per Wierup MD, PhD: There is no shown survival benefit for mechanical valve vs. bioprosthesis.

Nama4: My 50-year-old seemingly-robust son has a 4.4 ascending arch aneurysm and moderate aortic valve leaking. Is he likely to need open-chest surgery?

Per Wierup MD, PhD: Yes - he should be monitored closely to determine whether his aneurysm is increasing or his aortic valve leakage progresses. Minimally invasive surgery may be an option for him in the future.

golfer70: When my aortic heart valve wears out, bovine, do you replace now with open heart or while beating.

Per Wierup MD, PhD: If the patient is healthy we recommend open replacement of the valve. This is not performed on a beating heart.

Aortic Valve Treatment – Non-Surgery (TAVR)

golfer70: I am a 70-year-old male, I had a bovine aortic valve replacement in 2005, how long can I expect that to last and what symptoms should I be watching for to worry about. I do see a cardiologist yearly. Any suggestions on how to help it last longer?

Deborah Kwon MD: Maintain a heart healthy diet, keep your blood pressure in good control and engage in regular cardiovascular exercise and maintain a healthy weight.

NYgal: When someone is being evaluated for TAVR, what makes them high or moderate risk vs. low risk? My dad is being considered for PARTNER 3 because he is low risk - but wondered what would push him to moderate risk?

Deborah Kwon MD: There is a variety of things that can increase your risk such as age, pulmonary function, kidney function, liver function, frailty and the exercise capacity. I would consider it a blessing that your father is considered low risk - this means he is healthy other than his valve disease and should have a good result with either surgical aortic valve replacement or TAVR.

rbgarden1: I'm a post radiation female with multiple stents to the upper area of the chest and carotids. My aortic valve has also been affected and will need a valve replacement. My doctors said I am not a candidate for open heart surgery. Was wondering about the new procedure through the femoral artery as a possibility. I am an active 71-year-old.

Per Wierup MD, PhD: Certainly you should be evaluated for a transfemoral TAVR procedure.

Shelby20: I am 44-year-old female with Turner Syndrome... I have a bicuspid aortic Valve and a mild coarctation. I had surgery to replace my ascending aorta due to enlargement two years ago at Cleveland Clinic. With a coarctation, although mild, what is the possibility of a valve replacement through TAVR?

Deborah Kwon MD: Given your young age, should you need aortic valve surgery within the next 10-15 years, it would be advisable that the valve be surgically replaced if you are otherwise healthy. If TAVR is recommended because of other comorbidities, CT scan would be obtained to determine the size of the coarctation to see if it is large enough to accommodate the catheter.

Valve Disease – Medical Management

earl359: I was wondering if you could please comment about any new medications that would help to heal a leaky heart valve. I understand that there are many different types of medications for various forms of heart problems, but was just wondering if there are any specific ones that would be given for someone who has heart valve problems. Thank you.

Deborah Kwon MD: There are certain cardiac medications that may be helpful for medical management of heart valve problems, but they are dependent on which valve is leaking. For instance, with mitral regurgitation, the goal would be reducing blood pressure and after load reduction. And for aortic regurgitation we would want to reduce the blood pressure but not reduce the heart rate. Therefore, your specific questions would be best answered by your cardiologist who knows you best.

Bunny 1: What type of medical treatment can I get for an aortic heart valve leak or any other valve, besides a transplant?

Per Wierup MD, PhD: Ace inhibitors lower the systemic blood pressure and may in some degree reduce the leaky valve.

sinaihospital: I have heart valve disease since 2004. How often must I have a stress echo, a stress test, an EKG, and blood tests from my cardiologist? Do I have to get an okay from my cardiologist before having surgery or having major tests, doctors? Thank you for your advice.

Deborah Kwon MD: It depends on the severity of the heart valve disease. Mild range - every three years unless a change in symptoms; however if in Mod range, that may justify yearly testing. Because it is not clear what the severity of your valve disease is, it would be advisable to contact your cardiologist before having surgery.

Pharmacist: Hello! What is the relationships between heart valve and high coronary artery calcium score? Does high CAC score has effect on cardiac valve? Please give me the guideline for treating that case? Or how to prevent valve disease.

Deborah Kwon MD: Currently there is not a correlation between high coronary artery calcium artery score and heart disease. A high CAC demonstrates you have coronary artery disease and the same treatment and preventative measures are also beneficial in preventing valve disease.

Mitral Valve Surgery

Dischgla: Three questions; thank you both in advance!
(1) With dx of mod mv regurg left vent, eject fraction =.55%, all else normal, age 73 female--at what point is it best to request a second opinion--before surgery is recommended or just after? (2) What are contraindications for repair of mv prolapse and regurgitation with myxomatous degeneration of leaflet? For minimally invasive repair options? (3) Before surgery, what types of exercise are recommended and to be avoided?

Deborah Kwon MD: This depends a lot on if you are having symptoms now. Mod MR in itself is not an indication for surgery; although some patients can develop more MR with exercise or it may not be well seen with traditional transthoracic echocardiography. So - if you are not having any symptoms, then it may be okay to be followed with traditional echo. But if you are having symptoms it may be best to have more testing to determine if there is more significant MR that has not been yet identified.

Per Wierup MD, PhD: When there is an indication for MV surgery, there is no contraindication for MV repair which in most patients is more beneficial than MV replacement. We perform a lot of robotic assisted MV surgery and patients who are interested in this are routinely evaluated for this possibility.

shones: I'm 37 years old and was born with Shones Syndrome. My Mitral valve was replaced at Stanford in 2009. Included in my stay at Stanford, two stents five days after valve replacement were inserted into my Circumflex artery due to the fact the surgeon occluded that artery during replacement surgery. My research leads me to the conclusion that during the past 20 to 30 years there has been no medical advancement in the area of Mitral valve repair/replacement. Why not? Since I received a Bovine valve I will have to have that replaced at some point in the future.

Per Wierup MD, PhD: There has been tremendous improvement in treatment for mitral valve disease. Very likely you received a bovine valve to avoid the complications associated with the necessary anticoagulation for mechanical valves. You are correct, your bovine valve will likely need to be replaced in the future, but there is great biological variability as to when it will be required.

Dischgla: How often does pericardial effusion occur after mitral valve surgery (which I am expected to have within the next year or so)? My good friend had two severe occurrences of effusion, requiring emergency hospitalization each time, three weeks after mitral valve repair. This happened over 10 years ago in Texas.

Per Wierup MD, PhD: It is common to have a small pericardial effusion that requires monitoring after surgery. Pericardial effusion that needs treatment is in the range of 1-2%.

Dischgla: What are the criteria for determining if minimally invasive mitral valve surgery is an option for the patient? What are the criteria for determining whether repair is an option versus replacement of the mitral valve?

Per Wierup MD, PhD: There are several criteria including cardiac function, respiratory function, and whether or not you have atherosclerotic disease of the aorta. We routinely evaluate for possible minimally invasive mitral surgery.

MomTheBomb: Can mitral valve be repaired without using contrast dye?

Deborah Kwon MD: All patients who have to have their MV repaired or replaced must have a cardiac cath or CT - an assessment of their coronary arteries which requires contrast dye.

Mitral Valve Treatment – Non-Surgery

MomTheBomb: My husband is a 68-year-old diabetic who has been diagnosed with Cardiomyopathy. He had a heart attack in September of 2016 and was subsequently told that he had "mild to moderate" Mitral-valve Regurgitation, which now has been upgraded as "moderate to severe". We were told that he may consider Mitral valve repair, however, his kidney creatinine is 2.67 and his cardiologist was concerned that the contrast dye from the catheterization could kill his kidneys. He is able to function fairly normally throughout the day but he is getting tired more than usual and is not sleeping well because of difficulty breathing. He had been exercising 2-3 times a week, but not lately. We were wondering if there is a way to repair the valve without using contrast dye and without open heart surgery, where his chest would be opened, because of the damage to his heart caused by the heart attack. If such surgery is not an option, what other options are there to improve the situation?

Per Wierup MD, PhD: The obvious alternative is MitraClip which we do here at Cleveland Clinic.

Mitral – Tricuspid Disease

calliemaddie: Can mitral and tricuspid valve repair be done through minimal invasive surgery? If not, why. Thank you.

Per Wierup MD, PhD: We offer robotic heart surgery for a mitral and tricuspid valve heart surgery.

Zulu: I am 63, have Mitral/Tricuspid Valve disease, moderate leakage w/regurgitation, not severe enough for surgery yet, per cardiologist. I have shortness of breath, chest pains, abnormal ECG, Syncope, tiredness, am on supplemental oxygen (concentrator) when at rest. I also have May Thurner Syndrome/chronic venous insufficiency, per Cleveland Clinic Vascular Surgeon, need multiple stenting above and below the groin area, and will be on blood thinners. I am immunodeficient. Questions: 1) Risks of blood thinners and heart surgery? 2) Additional demand on heart when saphenous veins are performing as normally as possible after stenting? I have been informed by vascular surgeons that a person "can live without a leg, not without a heart". With these complications, or other complications, patients have should the heart surgery be the priority? How do we know the Cardiothoracic surgeon is taking into consideration the entire condition of the patient? Thank you both.

Per Wierup MD, PhD: Cardiac surgery is very complicated - we are always taking in the total picture of the patient. Your history and symptoms sound quite complex - it would be best to have a complete evaluation by a cardiologist at Cleveland Clinic who would work with the vascular surgeon and cardiac surgeon to plan your care.

Heart Valve Surgery

STEVEJ: I am a 57-year-old male and have had a mitral valve repair at Cleveland Clinic in Oct. 2014 and an aortic valve replacement in Colorado Springs in Aug. 2017. As I live in Colorado Springs at an elevation of 6000 feet, can the elevation adversely impact my long-term prognosis? My heart beats much harder here than at lower elevations. Also, are there known genetic markers for valve failures? All common causes of valve disease have been ruled out in my case; I've never smoked or been overweight, have no cardiovascular disease, and have exercised regularly throughout my life. Thank you.

Deborah Kwon MD: There is less oxygen at a higher altitude which can result in symptoms such as shortness of breath or palpitations. This has not been shown to adversely impact your long term outcome. Currently there is active research looking at genetic markers for valve disease. Some genes have been identified but there is still a lot more work that needs to be done.

earl359: Does Cleveland Clinic regularly do heart valve surgery on older people on Medicare? With all of the different changes that some hospitals are doing in my area, I am just wondering if an older person could feel confident that they would receive these types of procedures if and when needed. The other question I have is why do so many doctors, and other news magazine types of outlets, always not recommend things like aortic ultrasound screenings? I forget what magazine it was, but they had a list of things to avoid and aortic screening was one of them, and I just couldn't understand why they would take the time to do that? If anything I would think that it would be the opposite? Thank you.

Per Wierup MD, PhD: We perform a lot of surgery in elderly patients - when necessary.

Deborah Kwon MD: When community based screenings are performed, we do not always know the quality of the screen, so it is always best to go through your physician for testing and screening. For instance, the community screen may cause alarm for an abnormal finding or give you false reassurance if the test is not of good quality and interpreted correctly.

Pka: In addition to antiplatelet medication for the rest of my life what temporary medications are recommended after bioprosthetic valve replacement surgery along with modified MAZE for paroxysmal afib and for how long will I be on those meds?

Deborah Kwon MD: After MAZE, we recommend Coumadin for 3-6 months and then you would wear a heart monitor to determine whether you have paroxysmal afib. If there is no evidence of paroxysmal afib, then the Coumadin can be discontinued.

Jed: Are there restrictions on travelling by air after valve replacement surgery?

Per Wierup MD, PhD: We have many patients that fly home - we have no restrictions but it is always wise to contact your airline.

adourian: Do clinic heart surgeons leave the pericardium open or do they close it after open heart surgery and why?

Per Wierup MD, PhD: We have to leave it partially open because all hearts get a little swollen after heart surgery. If we close the pericardium we will create a tamponade, meaning that the heart is squeezed in the sac and has a hard time to fill and pump the blood.

adourian: What is the probability that after a sternotomy with closure by sternal wires the wires can break, and is there a way to assess how probable it is for me by having an MRI or a cat? Would like to know that when I pick up skiing again that I am not putting myself at risk.

Per Wierup MD, PhD: I assume from your question that you have already undergone open heart surgery. There is a less than 1% risk of having the wires fracture or the bone itself. However, after two months the sternum has healed and there is no risk any more.

Temp2011: Let's say you know someone that had to have a valve replacement and died because of an infection in the new valve and was complaining about it for a long time and they dismissed it. How can you make sure you don't have to have a heart valve replacement done and you end up dying?

Per Wierup MD, PhD: You have to get a cardiology evaluation regarding your heart condition.

Bunny 1: I take 2000 mg. of antibiotics before dental procedures. One doctor tells me to take it and another says it is not required. What is the medically correct answer?

Deborah Kwon MD: Antibiotic prophylaxis before dental procedures is recommended in patients who have had valve surgery or prior history of endocarditis. The guidelines were changed over the past several years, which may account for differences in practice. I would suggest you follow your cardiologist’s recommendations. You can print a wallet card.

Aortic Aneurysm Surgery

EJER: What is the length in inches of the incision for an aortic aneurysm repair if the heart valve does not have to be replaced?

Per Wierup MD, PhD: If it is an ascending aortic aneurysm (which is the most common), that operation can be performed minimally invasive with a partial opening of the sternal bone. The incision would be about four inches.

golfer70: I am a 70-year-old male, I had a bovine heart valve put in in 2005. How long should that last?

Per Wierup MD, PhD: There is a great biological variability and there is difference between aortic and mitral position in the longevity of the valve. I assume that you were 58 when you received your bovine heart valve. The normal range then would be 8-15 years.

EJER: What is the risk of death during/following surgery for repair of aortic aneurysm, assuming patient is otherwise in good health?

Per Wierup MD, PhD: Less than 1% at Cleveland Clinic.

EJER: How likely in a one-year time period would be dissection of a 5.2 cm aortic aneurysm?

Deborah Kwon MD: A 5.2 cm aortic aneurysm should be evaluated. This depends on many factors such as if he has a bicuspid aortic valve or connective tissue disorders such as Marfan

Alcohol Related Heart Disease

Innova: How long it will take to cure alcohol related heart problem after quitting alcohol. I am having dizziness and pounding heart on the next day of drinking. So i quit alcohol. But even after four months of stopping alcohol intake, dizziness and pounding heart is present in few days. Please let me know the reason behind this.

Deborah Kwon MD: The alcohol toxicity affecting the heart can be variable from patient to patient. Your symptoms are concerning for possible atrial fibrillation - I would recommend getting an EKG and/or Holter monitor as well as an echocardiogram to further assess your cardiac condition.

Diagnostic Testing

earl359: A week ago, my 72-year-old mother had an Aortic Ultrasound Screening done, and this morning she woke up and found that her hand has pinkish-red color spots on it on her small fingers area on the palm of her hand. also on her other hand is a few other similar spots on the palm area of her hand, so my first question is do you think that the ultrasound may have somehow caused the redness spots like that on her hand? Thank you.

Deborah Kwon MD: Ultrasound is obtained using sound waves on the chest and is very non-invasive. It is very unlikely that the red spots are related to the ultrasound. She should be evaluated by her local doctor.

Reviewed: 12/17

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