Thursday, February 22, 2018
Heart valve disease occurs when one or more of the heart valves do not work correctly and cause the heart to pump harder to circulate the right amount of blood through the body. Left untreated, heart valve disease can reduce a person’s quality of life and become life-threatening. Cardiologist Christine Jellis, MD, PhD and surgeon Douglas Johnston, MD answers questions about treatment options for valve disease.
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- View previous chat transcripts.
Heart Valve Symptoms
magilla: Could you be precise about symptoms of valvular issues and their duration? My cardio guy keeps asking me about my symptoms but it’s not clear to me if my symptoms are related to my valvular disease or I'm just tired as I don't get good sleep. On average about four or five hours per night. I have asked others for feedback on any symptoms I may be experiencing as I don't want to rationalize them away.
Christine Jellis, MD, PhD: Valvular heart disease often presents with non-specific symptoms of fatigue and exertional dyspnea initially. A good way of getting an objective evaluation of your symptoms and exercise capacity is to consider stress testing with concurrent echocardiography. This can be useful in determining the severity of your symptoms and attributable to your valve disease.
Timing of Surgery
litho7: How should a healthy young person with a familial history of required valve surgery and current regurgitation with a slight increase in atrial volume due to malformed valve pace their plans? Is it wise to wait for symptoms to undergo surgery if it seems inevitable? Are innovations around the corner that might make valve repair less invasive in the future?
Christine Jellis, MD, PhD: Currently we would advocate evaluation in a valve center of excellence to determine the severity of your own valve disease. Our current guidelines advocate for surgical intervention in the setting of severe disease and sometimes it is reasonable to operate on asymptomatic people if there is a high chance of repair with low risk of morbidity in the setting of severe mitral regurgitation. We already have minimally invasive techniques and there will all be more likely per-cutaneous innovations in the future.
Minimally Invasive Valve Surgery
ypark416: I am a 68-year-old petite woman, have a severe aortic stenosis with bicuspid valve (AVA = 0.8 cm). I do not have obvious symptoms yet. Should I have surgery now or wait until I have symptoms? Am I a candidate for minimally invasive heart valve replacement or transcatheter surgery? I am 5 feet tall and 98 pounds. I am relatively healthy.
Douglas Johnston, MD: Sometimes symptoms can be very subtle. Including decline in activity or fatigue. There are some echocardiographic findings in addition to the valve area that may be helpful in determining when a patient may have valve surgery. One critical test to see if a patient can have minimally invasive heart surgery is a cardiac catheterization. If there is no CAD, most patients at our institution can have minimally invasive valve surgery.
candy2231: What would prevent someone from having a minimally invasive - not through the breast bone - surgery for aortic valve? My dad is a golfer and needs aortic valve surgery. His surgeon has not offered him this but I read about this surgery on your website. Seems like he could get back to his activities faster if the breast bone is not cut.
Douglas Johnston, MD: If a patient only requires aortic valve replacement and the other valves and coronary arteries are okay, then most patients would qualify for a sternal sparing approach.
kegloff: 1) How is the recovery different between a minimal incision valve surgery and a regular open heart surgery?
2) Can you tell me about the Ozaki valve replacement? Is this an option at the Cleveland Clinic and how successful is this valve replacement?
3) Can you determine the probability of being able to repair the valve vs valve replacement before the surgery?
Douglas Johnston, MD: 1) Minimally invasive surgery results in shorter hospital stay, less need for blood transfusion, less pain and a faster recovery. 2) We are performing the Ozaki valve replacement at Cleveland Clinic - however this cannot be performed through a minimally invasive incision. 3) For a leaky aortic valve, we can often predict how likely a repair is based on preoperative echo.
Jamestown Gal: Has minimally invasive surgery taken the place for open heart surgery for AS?
Douglas Johnston, MD: The benefits of minimally invasive surgery for AS have been demonstrated in multiple studies. Our approach is to use minimally invasive surgery routinely unless there is a reason a larger incision will allow us to do the surgery more completely or more safely.
Aortic Valve Disease and Surgery
Wdenman: Just in general terms, what would be the surgical approach to repairing an ascending aorta aneurysm, regurgitating aortic valve, and regurgitating mitral valve? Could all issues be addressed at once and how?
Douglas Johnston, MD: All issues can definitely be addressed at once. In general when both the aortic and mitral valves are involved, a conventional sternotomy approach makes the most sense.
okpark: I am a 69-year-old woman, 5 feet tall and 97 pounds. I have bicuspid aorta valves with severe stenosis (AVA - 0.8 cm2; six months ago it was 0.9 cm2). My ascending aorta is 41mm. I do not have clear symptoms yet.
1) Should I have surgery now or wait until having symptoms?
2) What kind of surgery will be best for me - open heart surgery or minimally invasive surgery?
3) What kind of valve will be good for me - mechanical or tissue?
4) When I have valve replacement surgery, should my ascending aorta also be repaired?
Douglas Johnston, MD: American College of CARD recommendations regarding valve choice would suggest at 69 either a mechanical or biological valve is appropriate. That being said, most patients choose a tissue valve for lifestyle reasons. We would routinely review a CT scan to measure accurately the ascending aorta diameter to determine if this should be repaired at the same time. Aortic valve replacement and ascending aorta can be repaired minimally invasively at the same time.
okpark: I'm a 69-year-old woman, have severe aortic stenosis with bicuspids and mild aortic aneurysm (41mm). A cardiologist, who did a catheterization for me on Feb. 14, said that I would need a valve replacement surgery this year. I live in Virginia, but want to have it done at Cleveland Clinic. After surgery, how many follow-up visits I would need with my surgeon at Cleveland Clinic and when? For the second diagnosis, what kind of my cardiac diagnosis information should I send to Cleveland Clinic? Who will review the information, a doctor or a team of doctors?
Christine Jellis, MD, PhD: We have a multidisciplinary team who work together to insure comprehensive preoperative evaluation and post-operative care. Some people will return to Cleveland Clinic four weeks after surgery for routine follow up although we are happy to work with local physicians to coordinate your care. Most patients do like to keep an ongoing relationship with Cleveland Clinic for follow up and review.
limect: With severe aortic stenosis, which started with Lyme disease and exposure to rheumatic fever as a child (slept with sister who had r. fever), what are the chances all valves will need replacing? Only current symptom is shortness of breath but recently had left sided CHF in left ankle, foot and left eye and face?
Christine Jellis, MD, PhD: Typically in patients who have had rheumatic fever, the mitral valve may be involved in addition to aortic valve. I would always advocate for a comprehensive echo to assess each valve on an individual basis. If other valves were adversely affected, they would then be addressed at the time of surgery for your aortic stenosis. Certainly in the setting of severe AS, this can lead to symptoms of cardiac failure although typically it is bilateral.
TWS: 50-year-old male with severe bicuspid aortic stenosis. Scheduled for valve replacement via right mini-thoracotomy on 2/27/18. I see that the 2017 AHA/ACC focused update of Valvular Heart Disease has lowered the age for Bioprosthetic valve consideration to 50. I am leaning toward tissue valve and wondering if at your pioneering institute, you feel strongly one way or another considering the current trends in TAVI as well as blood thinning studies showing benefits for tissue valve implants, and all the other factors. I would like to believe that the current tissue valves will continue to show greater longevity and valve in valve may legitimately be recommended by the time the valve degenerates. 8-15 years? I am a former pro-athlete, active cyclist, etc. - would like to avoid blood thinners if this is a reasonable path to follow. Knowing that future SVR may be necessary. Also, any thoughts on Edwards Resilia tissue or other recommendation to maximize longevity without warfarin.
Douglas Johnston, MD: You have done your homework! The most important thing to remember the difference between mechanical and tissue valves is that most studies have shown no difference in longevity between tissue and mechanical valves even in patients less than age 50. There is no question that tissue valves wear out faster in younger patients. However, in our study of the Perimount valve, a large number of patients had greater than 15 years of valve durability in your age group. The choice of valve is a very individual choice based on patient lifestyle and other factors and deserves a careful discussion with your surgeon and cardiologist.
TWS: As a 50-year-old with severe bicuspid aortic stenosis. I am thinking about evolving technology and how to factor that into current thinking on valve choice and incision approach for upcoming surgery. I would welcome your thoughts on the following:
1) After one surgery through a right anterior mini-thoracotomy, is it feasible to have a second possibly third with the same incision for replacing a worn out prosthesis in the future. I was informed it has risks due to scar tissue and not advisable.
2) Do you believe/feel/think that robotic aortic valve replacement will become a viable option in the future - it seems that the ability to remove the calcified leaflets would have great advantages over placing a valve in valve through a TAVI with the worn-out/calcified leaflets still in place.
3) Do you believe TAVI will be a safe and repeatable option for valve in valve on calcified leaflets in the near future? i.e., 5-10 years.
Douglas Johnston, MD: 1) Currently we don't believe it is safe to perform a reoperation on aortic valve through a right thoracotomy however having a right thoracotomy the first time, makes the second surgery significantly easier. 2) Robotic aortic valve replacement is probably not going to be a routine clinical option in the near future. Because of limitations of the current technology in dealing with calcified leaflets. 3) TAVI is an option for valve in valve reoperation for high risk operations now. However, we don't have any data on long term durability. Our approach is to prepare a patient for either option whether it is redo surgery or TAVI by optimizing our approach to the first operation.
PaulR: How do the aortic valve repair outcomes compare to aortic valve replacements?
Douglas Johnston, MD: Aortic valve repair is an excellent option for patients who have bicuspid aortic valve and regurgitation or patients with trileaflet aortic valves and an enlarged aortic root causing aortic regurgitation. The long term durability of these repairs are very good.
markrj: Today is National Heart Valve Disease Awareness Day. My echo shows calcium buildup on the aortic valve. I have moderate AV regurgitation. What diet or lifestyle modifications can I make that may extend the time until AV repair or replacement?
Christine Jellis, MD, PhD: Unfortunately there is limited evidence for dietary or lifestyle modifications that can halt the progression for degenerative aortic valve disease. However we would always advocate for a healthy lifestyle as we know this has significant beneficial effects on other aspects of cardiovascular health such as coronary artery disease.
Transcatheter Aortic Valve Replacement
genodoc: How close are we to a Transarterial repair of aortic insufficiency similar to TAVR for AS. And, what new treatments are available for single leaflet Aortic Insufficiency. (EF= 45-50%).
Douglas Johnston, MD: Current TAVR devices rely on sealing to the diseased leaflets and annulus of the aortic valve. In some unusual cases of insufficiency TAVR can be used. But the long term outcomes are not known. In some cases where a single leaflet is affected, leaflet repair is possible.
magilla: Can TAVR be used for more than one valve replacement in a single procedure? How soon do you expect TAVR to be available for the rank and file valve replacement patient?
Douglas Johnston, MD: In cases where patients have failing bioprosthetic valves in the aortic and mitral position, TAVR can be used in "valve-in-valve" procedure for both valves. We need more data on outcomes of TAVR in healthy patients before it is more widely available. We are participating in a trial of TAVR in low risk patients.
Jamestown Gal: Is open heart surgery still recommended for this type of procedure? I’m seeing that TAVR is very successful and trials are being done on younger, healthier people. Is this now an option?
Christine Jellis, MD, PhD: There is currently a trial in low risk patients with severe AS which randomizes patients to SAVR with TAVR. We expect the results of this trial to be available over the next few years. However currently, TAVR is not approved for low risk individuals.
pharmerbrad: I am a very active 48-year-old with a leaky bicuspid aortic valve. Regarding valve repair, is the durability of a repair comparable to that of a tissue valve, or is this still unknown? If one elects for a tissue valve with the hope of TAVR down the road, is it possible for a second TAVR, or will space limit that possibility? The TAVR valves appear to be much less robust, and thus less durable, than the regular tissue valves and this concerns me as a long-term option.
Douglas Johnston, MD: At least out to 10 years a good aortic valve repair is as durable as a tissue valve or maybe a little better. Some aortic valve repairs last for a very long time although this is difficult to predict since a number of patients with valve repair will eventually need reoperation because the valve becomes narrow. You are correct that there are some questions about TAVR valve durability - however we should have answers to those questions by the time you would need a valve in valve TAVR down the road. It is important to note that even reoperative aortic valve replacement for a failed bio-prosthesis can be done with extremely low risk. Less than 1% at Cleveland Clinic.
TWS: It is great to know that reoperative risk is low at Cleveland Clinic! That said, do you have any thoughts on the choice of bioprosthesis today to maximize potential TAVI in the future? The latest valves are designed for expansion - perhaps the data is still inconclusive and do you believe that is a significant benefit in design to maximize TAVR success in the future?
Douglas Johnston, MD: The jury is still out on whether there is a "best" bio-prosthetic valve to allow for future TAVR, as the anatomy is fairly complex and the decision making really needs to be tailored to each patient. We are very active in research in this area.
Mitral Valve Disease and Surgery
RaymondM: My wife Nancy has mitral valve regurgitation diagnosed as medium to severe by Cleveland Clinic. The heat team did not want to give her a surgical fix. What should we do now? She is athletic and has no symptoms.
Christine Jellis, MD, PhD: As she has moderate to severe disease and currently asymptomatic it would be reasonable to continue ongoing monitoring. They would usually plan to do this in our Valvular Heart Disease Center with clinical review and echocardiography in six months.
BradFisher: I am a 46-year-old male that has been diagnosed with moderate plus mitral valve regurgitation. I am asymptomatic. I exercise quite often and recently had a stress test where I was on the treadmill for 15 minutes and stopped when my heart rate was at 161. Doctor felt good about the results. Anyway, do you recommend any exercise restrictions based on this limited data? When I work out (I use a heart monitor) should I try and have my heart rate go past 161, should I stay at the 85% threshold (152) or do something else? Also, would you recommend a beta blocker in my situation?
Christine Jellis, MD, PhD: Typically in the setting of mitral regurgitation we would not put restrictions on exercise. Most exercise programs will target achieving a HR of 75% during aerobic exercise. A beta blocker would not be routinely recommended unless you have a history of arrhythmia in the context of your mitral valve disease.
mkelly901b: Hi! What's on the horizon, or just over the horizon, for sufferers of functional mitral regurgitation?
Christine Jellis, MD, PhD: Every case of functional mitral regurgitation should be reviewed on its own merits as this may be addressed if the patient is having open heart surgery to address coronary artery disease. There are some other per-cutaneous options in research trials to look at treating functional mitral regurgitation however these are still in development.
Byoin: Is it common for a person who has had successful mitral valve repair surgery (to address severe mitral valve regurgitation) to experience a drop in his/her left ventricle ejection fraction percentage? Is this because a sonographer performing an echocardiogram - pre-surgery - cannot distinguish between blood flowing in the wrong direction (i.e., back into the left atrium) vs. blood flowing in the right direction out of the left ventricle, such that the reading is artificially high? How does one treat this if, post-surgery, the ejection fraction is below the low end of the normal range (i.e., 50%)?
Christine Jellis, MD, PhD: Sometimes we do observe a reduction in LV EF post operatively - this can be due to numerous factors. However, we often see an improvement in cardiac function over subsequent months postoperative with restoration of a normal or near normal EF. It is important to insure that you have adequate post-operative follow up so that pharmacological therapy can be optimized to assist with LV remodeling.
dl021318: What is the long-term durability of the Cosgrove ring for mitral valve repair? I had mine in 1996 and wonder outcomes.
Douglas Johnston, MD: Long-term durability is based both on the ring and how the leaflets are repaired. We looked at how many patients were free of severe regurgitation at 10 years and more than 90% of patients still had a valve that is working well. In your case an echocardiogram would be the best test to see how well the valve is working.
Dischgla: Where does one turn to research which surgeons and hospitals have the most experience with, and best outcomes from, mitral valve repair and replacement? Thank you.
Douglas Johnston, MD: The Society of Thoracic Surgeons (STS) reports a star rating for programs performing valve and coronary surgery based on the safety of those procedures compared to hospitals across the country.
Dischgla: Regarding timing for second opinions for mitral valve repair/replacement: after my cardiologist refers me to a surgeon or before? Right now I'm on the cusp for referral, being seen every six months.
Christine Jellis, MD, PhD: If you are considering potential mitral valve surgery in the near future it is always reasonable to seek a surgical consultation to enable you to look at all available options.
virgi: I had Mitral Clip installed July 2017. I have recovered very well. Are there any restrictions for lifting, or exercise?
Christine Jellis, MD, PhD: Typically post mitral clip there are no significant restrictions to physical activity for this duration after the procedure.
normaneon: I have had mitral valve regurgitation for many years, also A-fib and an ejection fraction now down to 42. I have gone to a seminar on the MitralClip. The speaker recommended this and I asked my cardiologist and all he said was I might be a good candidate. Being a new procedure do you recommend it?
Christine Jellis, MD, PhD: evaluation for mitral valve clip needs to be comprehensive and take into account the cause of mitral regurgitation and anatomy of the valve and heart. In the right circumstance it can be an extremely useful technique for treatment of mitral regurgitation and a procedure we perform regularly at Cleveland Clinic. We would be happy to evaluate you on an individual basis to determine if you would be a suitable candidate.
Post Heart Surgery
adourian: Dr. Johnston, thank you for your skills in early Oct. in replacing my aortic valve, removing the LAA and performing a modified MAZE. I went into surgery with a resting heart rate of 60 and came out with an 85. I understand that this is normal while my system rebuilds its red cells and volume post-surgery. Traveled back to clinic for two month follow-up and EKG/ECHO/CBC all normal. Tests back home have shown CT chest PE and x-ray normal except for "slight bibasilar atelectasis", "a mild amount of pericardial fluid inferiorly and laterally on right" and "small right and minimal left pleural effusions." No presence of pulmonary embolism. I have been in aerobic conditioning for three months and resting HR remains in high 80s. Is it just a question of time before my heart responds to fitness training and resting HR drops or could MAZE, LBBB or some other factor be effecting a permanently higher rate? Also what can I expect with the LBBB over time?
Douglas Johnston, MD: How heart rate responds after surgery is different from patient to patient and depends on the medications you are on particularly for blood pressure. It may take a few months for the heart rate to settle down to what the final heart rate will be. LBBB is something you would want to watch with serial EKGs but based on your normal echo may not have any impact over time. Glad you are exercising. Keep up the good work.
davidn: Hi, I had an aortic valve replacement in 2015 (biological valve). The surgery damaged the AV nodes and required a pacemaker. I am currently 100% paced. Are there any new treatments that offer hope of restoring AV function? Thanks.
Christine Jellis, MD, PhD: Unfortunately the need for pacing can occur after aortic valve replacement surgery however there are always new pacemaker innovations. We would encourage you to follow up with a pacemaker clinic or EP cardiologist to make sure your pacemaker settings are optimized. At this time the options for restoring nodal function are limited.
Types of Replacement Valves: Biologic Valve vs. Mechanical Valve Replacement
Wdenman: I heard that the use of mechanical valves is going to diminish due to the new technologies that make it easier to replace a tissue valve when it wears out? Any thoughts on this?
Christine Jellis, MD, PhD: Already we are seeing a trend in patients preferring a bioprosthetic valve due to lifestyle factors and ability to avoid long term anti-coagulation. The option of valve in valve TAVR in the future will also likely impact on patient's choice of a bio-prosthetic valve during their initial surgery. The importance of discussion with your cardiologist and cardiac surgeon preoperatively is emphasized so that the correct prosthesis can be chosen for you.
Jamestown Gal: I’m due to have a biological valve replacement in the near future - I currently have two flaps on my valve. Will they replace it with a normal three flap valve?
Douglas Johnston, MD: It sounds like you have a bicuspid aortic valve. This is a very common reason to need an aortic valve replacement. If you receive a tissue valve, all of those have three leaflets. Mechanical valves have two.
adourian: Dr. Johnston, I understand that the older one is when their aortic valve is replaced by a bioprothesis like the Perimount 2700 that you used for me the longer it will last. Are there any studies that have identified what the causal factors are?
Douglas Johnston, MD: The reasons why a biologic valve may fail earlier than normal have to do with age; younger patients have shorter durability on average. And - the other factor is the relationship between valve size and the size of the patient. Valves that are more efficient tend to last longer.
charlesa: I am in need of a pulmonic valve and revision of my pulmonary artery. What types of options are available?
Douglas Johnston, MD: Sounds like maybe your pulmonary valve was repaired as part of a congenital heart operation? Fortunately there are a lot of options for this situation. Some of which require reoperative heart surgery and some of which can be done with a catheter. I would suggest reviewing your studies with a surgeon and cardiologist who are familiar with adult congenital heart operations.
brenda 6: Are you doing trials yet on the Navigate valve? My mom is 75 years old with severe tricuspid valve regurgitation . She is in good health otherwise.
Douglas Johnston, MD: We expect that the Navigate valve will be in clinical trials in the United States soon, although the timing is always unpredictable. Our physicians would be happy to evaluate your mother's case and provide some further detail.
Heart Surgery – General
magilla: Do you have someone at CC that specifically address questions concerning morbidity and what is being done to reduce patient risk concerning the issue? Here in Arizona they have these computer driven machines that look like R2D2 from Star Wars. Honor Health in our area has some of these specifically to control mobidity issues. The name of the machine is called Xenix. My understanding is they are used in OR's, ICU's, ER’s and patient rooms to eliminated contagion. They emit high intensity ultraviolet light that kills contagion such as superbugs.
Christine Jellis, MD, PhD: Cleveland Clinic prides itself on being a leader in facilities management and we have some of the lowest rates of infection for heart surgery in the country. Our state of the art operating rooms have multiple capabilities for addressing infection control and this is a priority for all our patients.
Necblake: I have a question about viral myocarditis. I am not sure if this chat is able to answer it though.
Christine Jellis, MD, PhD: We have a large practice looking after patients with myocarditis and would be happy to assist you but it is not within the scope of the discussion today.
Sunaid9193: Hello, I’m a 24-year-old male. Back in 2014, one day I woke up to this pain in my chest. I thought it'll go away in a few days but it didn’t. After three days, I still have the pain. I went for a checkup. They said your BP was 180/something I don’t remember but it was high. The doc got my ECG done and he put me on propranolol. But that didn’t solve the problem. After that, one doc put me on NSAIDs thinking might be a muscle inflammation. Since then it has been four years and I still feel the pain in my chest. And all this time I’ve been doing ECGs and echos. I did my exercise tolerance test too. Only once in the beginning they diagnosed pericardial effusion, after which they put me on aspirin for a month. It relieved the pain a little bit but it’s still there and along that I’ve been starting to develop sexual problems too. Do you think they are not able to diagnose my real problem? Because they say your heart is fine according to the tests. I’m a chronic smoker, smoking since 8 years old. Would be obliged if guided on this thanks.
Douglas Johnston, MD: The fact that you had a pericardial effusion and your symptoms are related to chest pain suggest that your pericardium may be driving your symptoms. We deal with this condition quite often, and it is often difficult to diagnose - we would recommend you be seen by a center of excellence for pericardial disease.
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.