Patrick Collier, MD, PhD
Patrick Collier, MD, PhD

Edward Soltesz, MD
Edward Soltesz, MD

Tuesday, March 17, 2015 | Noon


Description

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 Dr. Patrick Collier and surgeon Dr. Edward Sotlesz answers questions about treatment options for valve disease.

More Information

  • View more information on valve disease and valve 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.

Diagnostic Testing and Results

jerry56: I am 45 year old male, with bicuspid aortic valve, and AR and AS. Until recently, my echo results were OK (ESD 32 mm, EF 65%, and aortic diameter 32 mm). A year ago, I started swimming four times a week (1,500 yards in about 45 minutes). My fitness level improved, with max oxygen consumption increased from 35 to 50 ml/kg/min. But my recent echo showed one odd change, with max gradient increased from 35 to 72, even though I have no symptoms of severe AS, and feel OK. My cardiologist is not concerned about the gradient change, and thinks that it may be overestimated. He told me that the gradient depends on the stroke volume, which may be higher for two reasons: first, my AR, and second, increased stroke volume due to my recent aerobic training. Just in case, he checked my BNP, and it was OK (around 10 pg/mL). So my cardiologist suggested that I ignore the odd echo result, and continue with my swimming routine as before. Would you agree with his opinion? (and sorry for the long question!)

Patrick_Collier,_MD,_PhD: Gradients are a means to assess valve narrowing but it is true that they are flow dependent (in other words can be affected by other factors other than valve narrowing.) However, they can be overestimated too and need to be put in context with other clinical and valve parameters. From what you describe, it sounds as though your cardiologist has appropriately looked at your overall condition. If you need heart surgery in the future, we would advise you to come to Cleveland Clinic.

RunnInTheForest: Dear Cleveland Clinic:  I'm a 29 year old male with some heart and systemic problems. My question is about when is it wisest to intervene in order to be able to live a long and healthy life as a border-line patient with mild heart failure. My diagnosis is Hypertension (treated with Losartan), COPD(FEV1/FVC 65%), and Chronic rhinitis. Also have borderline Heart failure(EF +/- 55%). Parameters for the heart are: Thickened Interventricular septum(13mm), Left chamber diastole(56 mm), Left chamber systole (43 mm), Left atrium (47 mm). Mild mitral insufficiency, mild tricuspid insufficiency, Pulmonary pressure 20 mHG. Ejection fraction: 55%. Without pulmonary hypertension. Questions: 1) In longstanding hypertension is it wise to do any harder Cardio training, or will it risk to dilate and hypertrophy the ventricle further? 2) I heard some valve-repair techniques comes with complications, what are those?  And is it true you might suffer from some Bundle branch block after Mitral valve repair?

Patrick_Collier,_MD,_PhD: From what you describe, there is no indication for surgery at this time. Elevated blood pressure at age 29 is unusual and secondary causes (such as kidney/endocrine/vascular problems) should be excluded. Equally COPD is unusual at age 29. If you smoke, you are encouraged to stop immediately and we can provide support for you to do this here at Cleveland Clinic. On the basis of what you describe, I would suggest that regular exercise is important for your health. Excessive exercise may make left ventricular hypertrophy more likely – however, the main driver to LVH is more likely to be high blood pressure itself so it is important that this is controlled. Bundle branch block is a conduction abnormality that can be detected by EKG. By itself, it may not necessarily cause symptoms. It is very unlikely after MVR but can certainly occur after other heart surgeries such as AVR or myectomy.

liesel: I am a 76-year old female with two stents in LAD, had MI, had blood clots in my leg due to trauma, have Factor V Leiden-homozygote. I have moderate mitral valve prolapse, heart cath on 6/2013 showed mitral leaflets with 2-3% mitral incompetence. Conclusion of Echo on 11/12/13 said: Mild LV dysfunction. Pulmonary hypertension, moderate. Echo on 12/9/14 said: Hypertrophied LV with mild LV dysfunction. Pulmonary hypertension, mild. After the Echo on 12/9/14 my cardiologist told me that the mitral valve was getting worse and we had to watch it. When I look at the reports, I see that the hypertension is now mild instead of moderate??? So I am confused. Should I be worried? I feel good and live a healthy lifestyle. My question: 1) How do I know when I am getting worse? 2) Are there any medications?

Patrick_Collier,_MD,_PhD: Typical symptoms related to either mitral regurgitation or pulmonary hypertension include shortness of breath and reduced exercise capacity. I would encourage you to report any new symptoms to your cardiologist. The discrepant in the reports relating to pulmonary hypertension severity may most likely relate to inter-test variability. The mitral regurgitation should be followed with echo.

Halelm: I am a 60-year old woman who received the following results from a recent echo test. I'm curious about the amount of exercise that is considered appropriate, and what if anything should I be concerned most with. thank you! • A small circumferential pericardial effusion is present. • Myxomatous degeneration anterior and posterior leaflets mitral valve with mild prolapse and probably moderate regurgitation. • Mild tricuspid regurgitation. • There is borderline mild pulmonary hypertension. • IVC less than 2.0 cm and greater than 50% collapse consistent with RAP pressure of 5 mmHg.

Edward_Soltesz, MD: No; is no indication for surgery based on what I see from the echocardiogram. Moderate exercise should be acceptable.


Symptoms

caidensmommy: 45-year old woman - reason for test saw abnormality on stress test. I have irregular heart beat and will get palpitations for past 15 years, this last one was a doosey.  This is what prompted the trip to a cardio dr...this is the summary as written in report. Summary:
1) The left ventricle cavity size is normal. There is mild global hypokinesis that is most pronounced in the distal and apical septum. The overall LV ejection fraction is estimated to be 50 to 55%. There is normal LV diastolic function.  2) There is mild tricuspid valve regurgitation and the right heart pressures are at the upper limit of normal. Any help if I should be concerned?

Patrick_Collier,_MD,_PhD: An echo is often performed in patients with arrhythmia to carefully assess for the presence of structural heart disease which can impact the prognosis and treatment of such symptoms. If appropriate, we can further investigate subtle abnormalities on echo with more detailed imaging tests such as echo strain, or CMRI. We would be glad to provide a second opinion.


Aortic Valve Disease

heart valve: Hi I have two leaflets and moderate aortic valve regurgitation.  I would like my valve to be repaired, is it possible? If so how long will a repair last?

Patrick_Collier,_MD,_PhD: I believe that you are referring to a bicuspid valve. Generally, surgery is performed only once the aortic valve leak is severe (unless you needed concomitant surgery for an enlarged aorta etc.). Valve repair remains an option for selected patients with bicuspid aortic valves that are leaking on a case-by-case basis depending on the anatomy - particularly if not calcified, or involve prolapse with extra tissue. Likelihood of delaying AVR for 10 years is as high as 90%. Risk of recurrent significant AI is highest in the first year so careful follow-up is necessary.

Kbeer: I have been diagnosed with severe aortic valve problem and the doctors advising that I need a surgery.  But I have no symptoms and they are telling me I need it asp.   Which makes me wonder what should I do? I am limiting my activities and I don't know what is going on.   Please let me know because they are waiting on me to select a day for the surgery.

Patrick_Collier,_MD,_PhD: Surgery may be recommended for severe aortic stenosis despite the lack of symptoms in a number of scenarios including: reduced heart function (LVEF<50%), need for concomitant heart surgery, critical or rapidly progressive valve narrowing with low surgical risk, abnormal exercise test results. We would be glad to provide a second opinion here at Cleveland Clinic.

Edward_Soltesz, MD: New data suggests that irreversible changes to the heart muscle begin in many patients before symptoms occur. Aortic valve replacement surgery can be often be performed minimally invasively with mortality rates lower than 0.4%. Since the risk of sudden cardiac death in asymptomatic patients with severe aortic stenosis is about 1%/year, surgery is the lower risk option. Additionally, many patients with severe aortic stenosis actually have symptoms but not realize them. Family members and friends usually say that such patients have “slowed down” or get more fatigued toward the end of the day. This is very apparent to many so called “asymptomatic” patients after surgery – they report having much more energy and feeling better overall.

adourian: The results of my last echo showed a continuing reduction of my valve area and it is now .8; but my peak velocity is considered mild at 3.17. My question centers on that peak velocity reading. I have read that when the echo reading for peak velocity gets to 4, you risk heart failure. Others say that at that point you should have a stress test to determine peak velocity and a 5 during that test is the critical level. Can you help me better understand if/when I should be doing a stress test and whether these levels I have just described are correct?

Patrick_Collier,_MD,_PhD: I believe you are speaking about aortic stenosis. We have a number of echo parameters to assess aortic valve severity. Severe aortic stenosis is typically defined by echo as a valve area of less than 1 and a peak velocity of greater than 4. In your case, these values are discrepant and I would urge you to discuss further with your cardiologist. The presence or absence of symptoms is a key parameter to decide need for aortic valve surgery. In the absence of symptoms, stress testing can be useful to help in that decision making process also. Stress testing can also help assess how the echo parameters may change in response to increased flow across the valve and therefore, provides utility when resting parameters are discrepant.

adourian: Is cardiac catheterization typically done on all patients before final surgical decisions are made on AS? What is the value of using a TEE, when is it done and why?

Patrick_Collier,_MD,_PhD: Yes. Cardiac cath is done to assess the need for concomitant bypass surgery, generally in all patients. TEE is routinely done perioperatively to guide the surgeon and assess the postoperative outcome. On occasion, a TEE is done in the preoperative setting, to confirm aortic valve stenosis severity and/or assess other valve lesions.

abu63122: I was diagnosed with AS due to bicuspid AV. I have been taking calcium supplements (1000-1200mg) daily for about 25 years since my late forties. Both the cardiologist and gynecologist said there is no link between the supplementation and the stenosis. Do you agree? Thank you.

Patrick_Collier,_MD,_PhD: This is a controversial topic. We do not recommend routine calcium supplementation for patients with aortic valve disease. However, for patients who need calcium supplementation for osteoporosis or other indications, as recommended by their physicians, calcium/vitamin D supplementations are appropriate.

Adourian: Have asymptomatic AS and had a stress test several years ago which was normal in all measurements. Have been having yearly echos and last one showed peak velocity(VMAX) at 3.31. I understand that peak velocity reads differently during stress testing. At what point should I be considering another stress test?

Edward_Soltesz, MD: We have a number of echo parameters to assess aortic valve severity. Severe aortic stenosis is typically defined by echo as a valve area of less than 1.0cm2 and a peak velocity of greater than 4 m/s. The presence or absence of symptoms is a key parameter to decide need for aortic valve surgery. In the absence of symptoms, stress testing can be useful to help in that decision making process also. Stress testing can also help assess how the echo parameters may change in response to increased flow across the valve. During a stress echocardiogram in an asymptomatic patient, the development of symptoms or certain EKG or echo changes would suggest the need for valve replacement. I would recommend continued echocardiographic follow-up with your cardiologist and a possible stress echocardiogram if you remain asymptomatic but develop severe aortic stenosis.

Buddyandcooper: I have a bicuspid valve approaching 4 with mild stenosis. Does this always mean most likely it will get worse to the point of needing surgery? Do I have any other options other than open heart surgery something much less invasive even if I had to go through it again down the road?

Edward_Soltesz, MD: I presume you mean you have severe aortic regurgitation with mild stenosis in the setting of a bicuspid valve. Surgery is performed when the aortic valve leak is severe, either in the presence of symptoms or in select cases, when symptoms are absent. With bicuspid aortic valve, it is important to know what size your aorta is as sometimes there is a need to repair this also. It is difficult to know when you will need surgery, but the likelihood is high that you will eventually come to an operation. At present, percutaneous valves (TAVR) are not indicated for patients with severe bicuspid aortic valve insufficiency. You would certainly be a candidate for a minimally invasive surgical approach.

maxmisty741: Possible to approximate onset of symptoms in asymptomatic patients with severe aortic stenosis ?

Edward_Soltesz, MD: The onset of symptoms cannot be easily predicted. New data suggests that irreversible changes to the heart muscle begin in many patients before symptoms occur. Aortic valve replacement surgery can be often be performed minimally invasively with mortality rates lower than 0.4%. Since the risk of sudden cardiac death in asymptomatic patients with severe aortic stenosis is about 1%/year, surgery is the lower risk option. Additionally, many patients with severe aortic stenosis actually have symptoms but not realize them. Family members and friends usually say that such patients have “slowed down” or get more fatigued toward the end of the day. This is very apparent to many so called “asymptomatic” patients after surgery – they report having much more energy and feeling better overall.

Dwayne: I'm 71, 5'11.5" and weight 230. I've been diagnosed with Aortic valve stenosis. My cardiologist suggested close monitoring with Stress tests and Echo's within the time frames allowed. When I exercise or climb stairs up two floors, I experience shortness of breath. At what point should I stop and rest? Am I in danger of a heart attack with physical exertion?

Edward_Soltesz, MD: Surgery may be recommended for severe aortic stenosis when patients develop symptoms or in a number of scenarios when patients do not yet have symptoms including: reduced heart function (LVEF<50%), need for concomitant heart surgery, critical or rapidly progressive valve narrowing with low surgical risk, abnormal exercise test results. If you are having symptoms, you should inform your cardiologist. We would be glad to provide a second opinion here at Cleveland Clinic.

DanielleH: I'm a 68-year old male with aortic stenosis: Asymptomatic. low surgical risk, exercise echo one year ago was OK; current echo numbers: Jet Velocity=5.2, Mean Gradient = 65.9, Valve Area = .7 - .87. Ejection Fraction = 65-75%. Should I have surgery in the next six months?

Edward_Soltesz, MD: Based on the echocardiographic parameters you listed, I would likely recommend aortic valve replacement surgery soon. I would be happy to arrange a consultation.


Aortic Valve Surgery

Heart54: I am 60, going to have AVR for bicuspid valve. Just can't decide tissue or mechanical. I am a carpenter, work with saws, etc. had a stomach bleed issue 10 years ago due to aspirin use. Would mechanical not be a good choice? Cardiologist thinks because of my age mechanical is the way to go. Are the new lower dose blood thinner mechanical valve (OXL) a good choice if I go mechanical. If I have tissue valve which would you suggest and by the time I would need it replaced would it be risky because of my age. I am very slim and fit and am in excellent health.

Edward_Soltesz, MD: As you are well aware, there are two types of valves: mechanical valves and bioprosthetic valves. Mechanical valves are made totally of mechanical parts that are tolerated well by the body. The bileaflet valve is used most often. It consists of two carbon leaflets in a ring covered with polyester knit fabric. Mechanical valves are very durable and do not wear-out. The disadvantage is that patients need to take life-long blood thinners (Coumadin) that can cause excessive bleeding after trauma and rarely can cause spontaneous bleeding. The On-X mechanical valve may be somewhat different and require lower doses of blood thinners. Preliminary results from a clinical study show the all-carbon On-X valve (On-X Life Technologies, Austin, TX) is safe with lower levels of anticoagulant therapy than normally prescribed to patients with other mechanical aortic valves.

On the other hand, bioprosthetic (tissue) vales are excellent replacement valves because they do not require blood thinners. Unfortunately, these valves wear out anywhere between 5-20 years after implantation. The lifespan of a tissue valve is partially related to the age of the patient at implant; tissue valves last longer in older (>60 year old) patients. Recent studies on certain tissue valves, however, suggest that these valves may last longer than previously thought. Newer generation valves, such as the St. Jude Trifecta valve, appear to have very low initial mean gradients after implantation suggesting that they will last considerably longer. Once a patient’s tissue valve degenerates, another procedure (operative or catheter-based) will be required to re-replace the aortic valve.

The decision to choose a mechanical or tissue valve is based on a number of factors. Importantly, a patient’s survival (i.e., how long the patient is expected to live) is not impacted by which valve is chosen. The risks of life-long Coumadin effectively equal the added risks of repeat surgery. If patients are involved in heavy manual labor where injury is a risk, then patients often opt for tissue valves with the understanding that they will need one or two reoperations in their lifetimes. Other patients who have significant anxiety surrounding hospital stays and operations may opt for a mechanical valve so as to not require a reoperation. Human valves (otherwise called homografts) are reserved for situations where valves are infected (endocarditis). These valves do not require blood thinners, but unfortunately, do not last as long as bioprosthetic valves. Therefore, this would not be a good option for you. I would be pleased to review your case in detail in order to recommend a valve.

DanielleH: Please explain the current estimates for using tissue replacement valve for aortic valve replacement: are there different tissue options? Is bovine best? I'm 68 in otherwise good health, but need valve replaced. I get bloody noses and don't really want to be on blood thinner rest of life.

Edward_Soltesz, MD: See previous answer: In general, there are three types of bioprosthetic tissue valves: homografts, bovine pericardial valves, and porcine valves. Homografts are human cadaver valves that require no blood thinners or other specific medicines and last about 15-20 years. Homografts become very calcified and develop severe leakage as they begin to fail. Bovine pericardial valves are bioprosthetic valves whose leaflets are constructed with bovine pericardium. These valves last 15-20+ years and develop progressive calcification of the valve leaflets. Porcine aortic valves have leaflets made of porcine tissue and typically last 15-20 years as well. These valves, however, typically develop sudden tearing of a leaflet that leads to rapid development of severe aortic regurgitation. We favor using bovine pericardial valves in the aortic position and porcine valves in the mitral position. We reserve aortic valve homografts for infected aortic valves as they are very resistant to re-infection.

DanielleH: Why are the estimates for bovine valves so huge: 12 - 20 years? Can you recommend any research papers that discuss this in more detail? If I need to have a bovine valve re-operation 10 years from now, would you expect that to be done with a minimally invasive procedure? Where is the research/FDA approval on this?

Edward_Soltesz, MD: We recently published our 25 year results of bioprosthetic aortic valve replacement in 12,000+ patients. The rate of structural valve deterioration (SVD) – that is, the need to have a re-operation because the tissue valve has “worn out” – is surprisingly low even for young patients (<60 years old). The actual rate of reoperation for SVD was 9% at 20 years.

Currently, there is FDA approval for TAVR in certain inoperable or high risk patients for traditional surgical AVR. Such valves include: Edwards SAPIEN Nov 2011 (PARTNER IB COHORT); Jun 2012 (PARTNER I A COHORT) Medtronic CoreValve Jan 2014 (CoreValve Extreme Risk Trial) Edwards SAPIEN XT Jun 2014 (PARTNER II COHORT) TAVR is indicated for the treatment of patients with severe symptomatic calcified native aortic valve stenosis who have been examined by a heart team and found to be inoperable or at high risk for traditional open heart surgery, and in whom existing comorbidities would not preclude the expected benefit from the procedure. Such devices are contraindicated for patients who cannot tolerate anticoagulation/antiplatelet therapy. The heart team must include an experienced cardiac surgeon and a cardiologist. Here at Cleveland Clinic, our TAVR team continues to have excellent results with outcomes available on our website.

Anthric: Eventually I will need an aortic live tissue valve replacement. Is a limited invasive procedure available for me and, if so, is it as effective as an open chest procedure? I'm 74 years old. How long is recovery time with aortic valve replacement and what limitations and post-operative symptoms will I experience?

Edward_Soltesz, MD: Aortic valve replacement can be performed with excellent results and exceedingly low risk. If you do not need other heart valve or bypass surgery, this can be done minimally invasively. Most of the time, you stay the night in the ICU and then get three - four more days in a step-down unit before going home. Postoperatively, you should be feeling quite well in a few weeks and back to all your activities very soon after surgery. I would be happy to review your case and provide even more details based on your particular situation.

Frankathy: I am a 78-year old formerly healthy male. I had aortic valve replacement on 1/7/2015 and have had continuing issues with excessive fluid buildup and SOB. I had a TEE procedure on 3/13/2015 which revealed "significant" leakage and several minor leaks around the valve. What are my options regarding timing and urgency for the proper corrective procedure? Cleveland Clinic is out of my insurance network, would you direct me to the appropriate place to make other arrangements.

Patrick_Collier,_MD,_PhD: We would gladly offer advice from our financial counselors regarding insurance issues. Sometimes, surgery is not always necessary - medicines or perhaps less invasive approaches may be an option. The other option - you can contact our nurses and we will put you in contact with Cleveland Clinic alumni in your area. www.clevelandclinic.org/heartnurse.

Edward_Soltesz, MD: I would be happy to review your case. There are many options for you. I would be happy to provide a second opinion.

adourian: How much time is one typically on the heart/lung machine during a "j" incision aortic valve replacement vs. one where a sternotomy is used? I also understand that the j approach delivers significantly improved outcomes that a sternotomy. Is this true and why?

Patrick_Collier,_MD,_PhD: The time spent on the heart lung machine does depend on the particular type of surgery being performed, the complexity of the surgery and patient factors; more so than the specific surgical incision. A smaller incision results in more rapid recovery and generally less patient discomfort.

Edward_Soltesz, MD: Minimally invasive aortic valve replacement surgery has been performed by us at Cleveland Clinic since 1997 through an upper hemisternotomy J incision. The duration of the operation (including cardiopulmonary bypass times) is equivalent to full sternotomy. Recently, we have advanced further in minimally invasive aortic valve replacement surgery and have evolved to a minimally invasive right anterior thoracotomy approach. In this surgery, we make a 6cm incision between the 2nd and 3rd ribs; we do not disturb the sternum. Cardiopulmonary bypass times are similar with this approach too. Importantly, unlike other centers, we place you on the heart lung machine through the ascending aorta, not the groin vessels which can increase stroke rates. I would be happy to provide a second opinion and see if you are a candidate for a right anterior thoracotomy AVR.

Mike_i: Hi, I am 38-year old and I have an aortic bicuspid with 60% regurgitation. I would like to have details regarding the aortic valve reparation eligibility criteria, the costs of this surgery and the medical documents I would have to present in order for this surgical solution to be assessed. Thank you kindly!

Patrick_Collier,_MD,_PhD: Aortic valve surgery is indicated in symptomatic patients with severe aortic regurgitation. Also for asymptomatic patients with severe aortic regurgitation in selected cases – with reduced heart function (LVEF <50%); excessive heart dilation (LVEDD >65mm) especially if low risk; or both (LVESD >50mm); or need for concomitant heart surgery (important to assess aortic size in Bicuspid aortic valve disease). Past medical records would be helpful but all necessary pre-operative testing can be arranged here at the Clinic. We have financial counselors here that would be delighted to discuss insurance/cost issues. Please contact our Heart and Vascular Institute Resource Nurses - who can help you with the process www.clevelandclinic.org/heartnurse.

Edward_Soltesz, MD: We would be happy to review your case and determine your eligibility for aortic valve repair. Most likely, this can be done minimally invasively. I would be happy to review your case.

Frankathy: I am a 78-year old male who was in very good health and asymptomatic prior to surgery. I had an increasing aortic stenosis issue which was addressed in Jan. I had an aortic valve replaced on 1/7/15. Since then I have had three visits to the ER and two hospitalizations for plural effusion, it took two visits to convince them that I was drowning from the inside. In these recurring visits they have only treated the symptoms and the recurring problem is no better. I am out of energy and appear to be out of options other than to plan periodic visits to have fluid removed from my system. I have the hospital record of all lab tests, X-rays, and several echocardiograms.

Patrick_Collier,_MD,_PhD: Recurrent pleural effusions can occasionally occur post-operatively. Our medical and surgical teams have particular expertise in addressing this issue – a procedure such as a pleurodesis may help to prevent recurrent pleural effusions. A second opinion is available here.

zman949: I had my aortic valve replaced at Cleveland clinic about three months ago with the minimal invasive surgery. I have just finished cardio rehab, and am doing well. I have three questions for you. 1) Is it normal for your heart rate and blood pressure to be a little higher after surgery, and if so should it settle down? 2) What is the recommendation for amount of baby aspirins someone should take after surgery? 3) How long after surgery could someone get a massage or go see a chiropractor?

Patrick_Collier,_MD,_PhD: Heart rate and blood pressure are affected by many things. Sometimes they can be elevated post operatively in the setting of pain or discomfort. At this stage, however, we would expect that any such pain or discomfort has resolved and would recommend you visit your cardiologist if you have further concerns about either blood pressure or heart rate. The recommendation for anti-platelet therapy vary on a patient to patient basis, depending on specific factors, including type of surgery, concomitant factors, and bleeding risk. Again, we would recommend you discuss this with your cardiologist who would gladly further advise. Generally massage therapy is not contraindicated post operatively, however, we would caution against any aggressive manipulations particularly while post-operative wounds are healing.

Pstrand: I was diagnosed with abiotrophia defectiva in November of 2014. Had two months of rocephin iv tx. I have an aortic aneurysm, and replacement bovine valve of nine years is deteriorating. Would this combination indicate use of homograft vs. prosthetic?

Edward_Soltesz, MD: This organism is notorious for destruction of tissue valves and has a 20% relapse rate following antibiotic treatment. I would recommend surgery with a homograft replacement soon. We have extensive experience with endocarditis and perform more surgeries for endocarditis than anywhere else. I would be happy to review your case.

avalverepair: I am 69. Over 10 years my blood pressure has gone up. In 2007 I had a first attack of A Fib while taking many meds. After tests doctors diagnosed that I have mild to severe case of aortic regurgitation. I was on many medications including a blood thinner. Since 2007, I had only three attacks of Afib. Recently I was told that my aortic valve has only two petals instead of usual three (birth defect). My cardiologist, who routinely monitors me (echocardiograms) & advises that eventually I will need surgery. I take six to seven meds twice a day. My question is when I need a surgery, would it be for valve repair or replacement, what kind of valve, and what is the best place to get it done? Should I expect complete correction of this condition and recovery after this kind of surgery? Or could I somehow manage this condition through drugs by the end of my life? If surgery is the only solution, do I need to wait until I am really old for getting it done? Can I get 2nd opinion through Cleveland Clinic? Cost?

Patrick_Collier,_MD,_PhD: When do I need surgery - generally surgery is performed when the aortic valve leak is severe, either in the presence of symptoms or in select cases, when symptoms are absent, repair or replacement - repair of bicuspid aortic valve is possible but generally only when the valve is not calcified (making valve repair less likely when you get older) and the anatomy is appropriate or in situations where the leak is mainly due to a dilated aortic root and again the anatomy is appropriate. Aortic valve replacement is also an operation with excellent outcomes and we would be glad to discuss repair or replacement in your specific case further. With bicuspid aortic valve, it is important to know what size your aorta is as sometimes, there is a need to repair this also. We check your coronary arteries with a heart catheterization to assess the need for bypass as well. Your cardiologist will advise you on the need and timing of surgery and we would be glad to offer a second opinion. Please reach out to our resource center clevelandclinic.org/heartnurse.

Edward_Soltesz, MD: I would be happy to provide a second opinion on your case.

avalverepair: Thank you for answering my question! Just a follow up regarding taking calcium supplement. I read in one of the answers you discourage taking it if person is suffering from aortic valve issues. I do take it as well as vitamin D3. Should I stop taking calcium?

Patrick_Collier,_MD,_PhD: We would advise you to not to stop taking your calcium supplements without discussing further with your own doctor. To clarify, if a patient has an appropriate indication for calcium supplementation, it is recommended they continue such medication even if they have aortic valve issues at the current time. What we discourage is routine calcium supplementation, self-prescribed in the clinical scenario above.

abu63122: With regard to aortic valve replacement, is a midline incision the preferred method over the incision between the ribs, if so, why is this? I'm concerned about the scarring with the midline, but wonder whether it is harder to access the valve by going in the side. Does recovery through the side incision present more possible complications i.e. not regaining normal muscle use?

Edward_Soltesz, MD: Minimally invasive aortic valve replacement surgery has been performed by us at Cleveland Clinic since 1997 through an upper hemisternotomy J incision. The duration of the operation (including cardiopulmonary bypass times) is equivalent to full sternotomy. Recently, we have advanced further in minimally invasive aortic valve replacement surgery and have evolved to a minimally invasive right anterior thoracotomy (between the ribs—the “side approach”) approach. In this surgery, we make a 6cm incision between the 2nd and 3rd ribs; we do not disturb the sternum. Cardiopulmonary bypass times are similar with this approach too. Importantly, unlike other centers, we place you on the heart lung machine through the ascending aorta, not the groin vessels which can increase stroke rates. We have seen less pain and faster recovery with this approach. This approach actually allows excellent valve visualization. I would be happy to provide a second opinion and see if you are a candidate for a right anterior thoracotomy AVR.

Stan6M: I have had aortic valve surgery in Aug 2013. I had a lot of calcium and had to use a 21 bovine valve. Can I get an in-valve later.

Edward_Soltesz, MD: The present technology is limited, but devices are in the pipeline to provide this option in the future.

MTrainer: I am 60 with bicuspid valve, mean gradient is 46; no symptoms; feel great have been told looking at surgery in the next few months. I am carpenter and use saws should this be reason to go tissue and not mechanical?

Edward_Soltesz, MD: Yes. I would recommend a bioprosthetic valve in your situation. This can more than likely be done minimally invasively if you have no other concomitant operations (e.g., bypasses). I would be happy to see you in consult.

PriorityBob: In November of 2014, a Cleveland Clinic physician replaced my aortic valve, repaired my mitral valve, performed the Maze procedure on me, and implanted a pacemaker. I am 68 years old, and am now exercising 5-6 days per week, feel great, and have lots of energy just four months after surgery. Thanks to the team at the Clinic for your good work. Life is great !!!

Patrick_Collier,_MD,_PhD: Thank you for your note. Glad you are doing so well!


Transcatheter aortic valve replacement (TAVR or TAVI)

mikenewcan: What is the status of the FDA testing of the non-invasive percutaneous method of aortic valve replacement? Is FDA approval expected in the near future?

Patrick_Collier,_MD,_PhD: Currently, there is FDA approval for TAVR in certain inoperable or high risk patients for traditional surgical AVR. Such valves include: Edwards SAPIEN Nov 2011 (PARTNER IB COHORT); Jun 2012 (PARTNER I A COHORT) Medtronic CoreValve Jan 2014 (CoreValve Extreme Risk Trial) Edwards SAPIEN XT Jun 2014 (PARTNER II COHORT) TAVR is indicated for the treatment of patients with severe symptomatic calcified native aortic valve stenosis who have been examined by a heart team and found to be inoperable or at high risk for traditional open heart surgery, and in whom existing comorbidities would not preclude the expected benefit from the procedure. Such devices are contraindicated for patients who cannot tolerate anticoagulation/antiplatelet therapy. The heart team must include an experienced cardiac surgeon and a cardiologist. Here at Cleveland Clinic, our TAVR team continues to have excellent results with outcomes available on our website.

kbarnettvk: Can a Stent Valve be used to replace a cow or pig valve that is exhibiting stenosis in March 2015? If not, will this be an option in the future? Thank you.

Patrick_Collier,_MD,_PhD: I believe that you are referring to valve in valve TAVR (where an aortic valve can be inserted like a stent procedure to open up an aortic valve prosthesis that has narrowed). Currently, this valve in valve technique remains a potential option for selected “inoperable” patients only. As this technology continues to advance, this may well be available to more patients in the future.

Edward_Soltesz, MD: While a valve-in-valve procedure may seem attractive, this approach is still reserved for very high risk patients since the complications and risks of the procedure are still higher than traditional preoperative heart surgery. Today, a reoperation to re-replace a valve can be done with extremely low risk; in fact, the fact that the surgery is a re-operation does not actually add risk in and of itself. I would be happy to review your case and discuss further.

kahuna8: Your best estimate of when a STS Score of 2.73 will qualify for a TAVR? PARTNER IIA results - when do you expect? Thank you.

Patrick_Collier,_MD,_PhD: For the foreseeable future, TAVR is unlikely to be recommended for low risk patients because standard or traditional aortic valve surgery can be done at very low risk. However, the technology continues to advance and we await future developments.

richmond: I have calc. heart valve that needs replacing- has to be transcatheter aortic valve- when will Edwards Sapien 3 be available for someone like me? 86 years old- have Emphysema- Bronchitis- Carotid buildup [about 45- 50 I think]- Abdominal Aneurysm [Moderate- unchanged]

Patrick_Collier,_MD,_PhD: For patients who are deemed high risk or inoperable, with regards to a surgical AVR, the Edwards Sapien and XT valves are currently FDA approved and have been shown to have very good outcomes. The S3 valve is currently being studied and we wait these data.

Edward_Soltesz, MD: You may be a candidate for a minimally invasive right anterior thoracotomy aortic valve replacement. This approach is exceedingly safe and low risk. I would be happy to review and provide a second opinion.

Quahogbay: I am 79, I have valve Aortic stenosis. They tell me it is a classic "murmur". Last echo reading was around "40". This condition was first found in 1996. Had Echo treadmill, was 1 year ago, was taken to my max and had no symptoms, wasn't out of breath, and felt normal. Had double bypass in 1992, using mammary arteries and also have a AAA @ 3.5 mm's which hasn't changed since found in 2013. Last blood work, 2/27/15... HDL-79 LDL-55 TOTAL CHOL -144, all other hematology & basic metabolic panel within normal ranges. Question: Am I a candidate for a non-invasive valve replacement? If so, what would be my next step? Paul H

Edward_Soltesz, MD: Without reviewing your whole medical history, I cannot conclusively determine whether you would be a candidate for TAVR. However, based on what you say, I suspect you would not be considered high risk enough and therefore not a candidate for TAVR. More than likely you would be a very low risk candidate for surgery. We would be happy to review your case and provide the answer.

LJK123: My husband age 90, had a 4way by pass 15 yrs. ago. Currently he was told he needs TAVR aorta valve replacement. (at stage 7 when checked 2 years ago). Tests show his arteries are to narrow to use groin method, and his valve is enlarged.. Transapical approach was suggested. How is this approach working? Is there much blood loss? How long does it last?

Edward_Soltesz, MD: Transapical approach is idea for high-risk patients with limited access. Increasing experience with this approach has resulted in improved outcomes. There is typically very little blood loss. We do not have data on TAVR valve longevity at this point, but I would expect the durability to be very good.


Bicuspid Aortic Valve and Aorta Disease

JoeS: Thirty-seven, male, entered ER for heart pals on 1/1/15, first time A-fib, reverted on own with med overnight. B4 release, echo done and revealed bicuspid aortic valve and about 5 cm ascending aortic aneurysm. No other health problems, no prior surgeries, saw 2 surgeons and gave 80/85% chance of repair as there is no calcification. Excuse the French, but scared &*$%less of open heart surgery, but understand I need it to repair aneurysm anyway. Can't swallow being on Coumadin with a mechanical or multiple reoperations with tissue. Do I have any other options if repair is not possible to fix this once and not have to live it every day or decade? Also, how many repairs and replacement should a surgeon have done him or herself to be top tier?

Edward_Soltesz, MD: Depending on the size of your aortic root, you will likely require either an aortic valve repair plus ascending aortic replacement or a modified David’s re-implantation procedure (otherwise known as a valve-sparing root replacement) with concomitant valve repair if needed. The David procedure is ideal for patients who have an aortic root and ascending aortic aneurysm who also have a leaky aortic valve that is repairable. The aortic root is the waist-like area of the ascending aorta just above the aortic valve The ability to repair bicuspid valves is still excellent at hospitals that perform a high volume of these surgeries. There is no specific number of cases that makes a surgeon or hospital facile with these techniques, but typically large-volume aortic centers have good experience. I would specifically ask about the volume of aortic valve repairs. If your valve is repaired with minimal residual leakage or stenosis, then you should have very good longevity (freedom from need for reoperation >90% at 20 years). If your valve cannot be repaired, then it would have to be replaced with either a bioprosthetic valve (tissue) or mechanical valve. There is no difference in survival between valve choices. Survival overall should be close to age- and sex-matched controls in the general population. Some younger patients elect a tissue valve first for lifestyle reasons; if the valve lasts long, then a reoperation with another tissue valve is certainly an option. On the other hand, if the valve does not have good durability, then the second operation would be a mechanical valve. There are many choices and approaches. A minimally invasive approach is likely an option for you. This approach makes the second operation easier and safer.

I would be more than happy to provide a second opinion. At Cleveland Clinic, we have the largest aortic and mitral valve repair experience in the US. with outstanding outcomes.


Mitral Valve Disease

Bobo1942: Why wait so long to treat mitral valve disease?

Patrick_Collier,_MD,_PhD: In more recent times, the vogue is to treat mitral valve disease earlier and earlier. Even - before the patient has symptoms in some cases. This is because surgery can be done at low risk and long term outcomes are better with earlier surgery. However, we do not generally treat mitral valve disease surgically until the leak is severe and having adverse effect on either heart function or heart size; or symptoms develop.

Edward_Soltesz, MD: In general, the decision to undergo surgery must balance the risk of surgery vs. watchful waiting. Open heart surgery has become very safe over the past five years, and many doctors are now questioning the age-old thresholds for operations that were based on decades old operative risk. For instance, during the years 2011-2013, our mitral valve repair mortality was 0%.

svetlomir_2000: Is it possible strenuous exercises to cause Mitral regurgitation and MVP? Does the MV annulus change when the heart`s cavities change (as a result of sport in case of “athlete heart”)? Thank you very much for your answer.

Patrick_Collier,_MD,_PhD: MVP is a common disorder where there may be excessive tissue/thickening of the mitral valve and can be associated with leak of the mitral valve. If supporting chords to the mitral valve rupture, this can be associated with more significant leak or MR which may or may not be associated with symptoms. There is currently not a predictable way to avoid such an event. Typically, we do not exercise restrict patients with MVP or MR as the risk of sudden cardiac death is considered very low. One advantage of stress echo which we have a lot of experience with here at Cleveland Clinic is the ability to detect (in rare cases) severe mitral regurgitation with exercise that was not at all as impressive on a resting echo - stretching of the mitral annulus with exercise is a possible mechanism in such a scenario.

John1960: Hi - 53 year old male. Had MVP with mild regurgitation entire life. Only symptom until last year was skipped beats/palpitations. Have mild hypertension controlled with 5 mg lisinopril. Murmur more pronounced in 2014 so had battery of tests. Echo showed the regurgitation progressed from mild to moderate. Left ventricle went from 55mm (2012) to 57 mm. I'm 6 ft., 175 lbs., run 20 to 25 miles a week (6,000 miles in 5 years), rest pulse 44 - 54. In 2014 wore holter monitor and had nuclear stress test (no issues). Concern: skipped beats more prevalent, sometimes get PACs (never before 2012). Question: while I can do 3 to 4 miles at 7 mph daily without effort, concerned that enlarging to 57 mm is result of moderate regurgitation. Should I consider surgery to fix prolapse with the 57 mm ventricle? How much of enlargement could be just a normal reaction to all my running? Don't really want surgery, but don't want to wait and end up damaging the left ventricle.

Patrick_Collier,_MD,_PhD: Generally surgery is deferred until the mitral regurgitation is severe. 55 - 57 mm may not represent a real change but may be test variability. I would encourage regular follow-up with your cardiologist and we would happy to offer a second opinion.

Koreanaca: I am a 42-year old female of Korean descent. I was diagnosed with Lupus about 2.5 years ago. In July 2014, I had chest pains and a hard time breathing ... I was diagnosed with severe mitral valve regurgitation and heart failure. I was immediately put on daily Lasix diuretic medication (I am currently on 40 mg/day), and upon my subsequent return for an examination in September 2014, my cardiac surgeon noticed a marked improvement in my heart functions, with no evidence of heart failure, and with less mitral insufficiency. So now, we are on a waiting/monitoring regimen, with check-ups every six months (or sooner if needed). I realize that I will have to undergo heart surgery at some point, and have a couple of questions: 1) My cardiac surgeon says that when the time comes, I will most likely need to have the valve replaced (rather than repaired). Are there any minimally invasive techniques for mitral valve replacement, or is open-heart surgery the only option?

Edward_Soltesz, MD: Unfortunately, this is a difficult question to answer without seeing the echocardiogram. I would be happy to review your case and offer an opinion. You can contact our nurses and we can assist you. www.clevelandclinic.org/heartnurse.

Koreanaca: 2) Will the lupus (currently under control with 10 mg/day of prednisone, and anti-malaria medication) pose any major threats having heart surgery? And will having lupus have any bearing on whether to choose a mechanical or bioprosthetic valve?

Edward_Soltesz, MD: Patients with Lupus are at an increased risk of heart surgery due to a host of other medical problems they usually have. I typically recommend bioprosthetic valves in such patients.


Mitral Valve Surgery

barryvan: We have all heard the positives, but what are the negative aspects of opting for a minimally invasive procedure for mitral valve repair?

Patrick_Collier,_MD,_PhD: Minimally invasive mitral valve repair does not confer additional risks over and above traditional approaches. This procedure requires stringent preoperative testing to identify suitable candidates, and limits any unexpected findings for the surgeon.

Edward_Soltesz, MD: The first rule of minimally invasive surgery is that is must be performed with equal or lower risk than traditional surgery. We have stringently maintained this philosophy in our practice over the past 35 years.

rnbd: Mitral valve regurgitation. I understand that a newer procedure is to put a clip in place to repair/help repair the valve. How does this work? Can it be done with non-invasive surgery, or would it require open chest? I have scaring from open chest bypass surgery in early 2011.

Patrick_Collier,_MD,_PhD: E-clip is a relatively safe non-invasive procedure that is approved for use in certain patients with mitral leak. It is reserved for use in selected patients who are turned down for conventional MV surgery. It is important to state that most patients (even those who have had prior open heart surgery) remain candidates for conventional MV surgery which can still be done very safely here at Cleveland Clinic - in fact, one third of CT surgeries done here involve patients that have had prior surgery - such patients obtain the most benefit from the surgical expertise that the Clinic can provide.

Edward_Soltesz, MD: Re-operative heart surgery today is extremely safe and effective. In fact, since 2002, a re-operation does not add risk to the surgery. The risks associated with surgery stem from underlying medical issues. I would be happy to review your case.

Jesse N Ricardo: Dear webinar doctors, I am a fairly healthy 80-year-old male. How do I manage asymptomatic (3+ ejection fraction 55 to 60) serious mitral valve prolapse and regurgitation? It was diagnosed by adult echocardiographic doppler report a couple of years ago locally and at Cleveland Clinic. At the time, both local and Cleveland Clinic's doctors and surgeons were upset with me for electing not to have surgery. Currently no one is willing to follow up, seem to have forgotten and/or maybe given up on me. How do I manage "watchful waiting"? I am taking an 81 low dose aspirin in the morning and in the evening. Thanking you in advance for some clarification.

Patrick_Collier,_MD,_PhD: We would be delighted to offer an appointment to reconnect and discuss matters further.

Edward_Soltesz, MD: I would advise calling us and scheduling an appointment. My office can help establish this immediately.

quilting: When having a mitral l valve replacement what is the difference between a pig valve and a mechanical valve. What are the pros and cons?

Patrick_Collier,_MD,_PhD: Overall survival similar with tissue vs. mechanical valves. Decision is a personal one made together with the cardiac surgeon. Mechanical valve: Pros - more durable Cons - need for anticoagulation with warfarin which carries a major bleeding risk of up to 1% per year; excludes the possibility of a future valve-in-valve percutaneous option. Tissue valve: Pros - may not need anticoagulation; includes the possibility of a future valve-in-valve percutaneous option. Cons - need for re-operation in typically 12-20 yrs. (or occasionally sooner) although this can be done at Cleveland Clinic relatively safely.

Edward_Soltesz, MD: We recently published our 25 year results of bioprosthetic aortic valve replacement in 12,000+ patients. The rate of structural valve deterioration (SVD) – that is, the need to have a re-operation because the tissue valve has “worn out” – is surprisingly low even for young patients (<60 years old). The actual rate of reoperation for SVD was 9% at 20 years. Importantly, there is no difference in survival across all ages between valve types.

quilting: I need to have my mitral valve replaced. I also have a recently kidney transplant what are the chances of losing the kidney. I also have diabetes and antiphospholipid syndrome what are my chances of surviving this surgery.

Edward_Soltesz, MD: We now know that cardiac surgery is very well tolerated in patients with previous kidney transplants. The chance of graft failure (that is, losing the kidney) is very low. Antiphospholipid antibody syndrome affects coagulation factors and care must be taken before, during, and after surgery to prevent excessive bleeding as well as clotting. We minimize periods of  "no anticoagulation," use special laboratory tests to monitor the degree of blood thinning during cardiopulmonary bypass, and re-institute postoperative anticoagulant therapy to a targeted INR of 2.0 to 3.0 quickly after surgery. Although I do not know all your medical details, I would suspect that your risk of mortality and/or complications is still very low.

rclin13: I have moderate-severe eccentric mitral valve regurgitation with two MR jets, posteriorly and anteriorly. Does having both posteriorly and anteriorly MR jets complicate repair surgery and whether minimally invasive repair can still be performed?

Patrick_Collier,_MD,_PhD: From what you describe, repair of your mitral valve may involve a little more complexity than standard. However, this does not exclude minimally invasive repair. I would suggest having a surgical review here and coming to Cleveland Clinic for surgery. We are happy to assist you.

Edward_Soltesz, MD: Minimally invasive surgery can still be performed. I would be happy to review and provide a second opinion.

Barryvan: What doctors (in addition to Marc Gillinov) at Cleveland Clinic are proficient in mitral valve repair?

Edward_Soltesz, MD: Just about all surgeons at Cleveland Clinic routinely perform mitral valve repair surgery. The excellent outcomes of our group speak to the collective experience of the entire team.

Macondel: I am a 73 year old female. I had mitral valve repair surgery in 2001. My last Echocardiogram on 09/29/14 detected the following:

  • Left ventricle size is normal, wall thickness is normal.
  • Left ventricular systolic function is now-normal with an EF between 50-55%.
  • Left Atrium is mildly enlarged by A4C volume.
  • Right ventricle is moderately enlarged (3.8-4.1 cm).
  • Right atrium is mildly enlarged
  • Aortic valve is trileaflet and mildly thickened.
  • Mild aortic valve sclerosis without stenosis.
  • Moderate-to-severe aortic regurgitation with normal descending aortic flow.
  • Moderate mitral regurgitation is present .. mitral ring annuloplasty is in place.
  • Moderate tricuspid and pulmonic regurgitation present.
  • Normal AO Root, Arch and Descending AO.

My cardiologist is planning on another echo in June It appears to me that I am facing heart surgery again. With these symptoms, can you tell me what my chances are for success and what the surgery might entail.

Edward_Soltesz, MD: The need for re-operative surgery is dependent on a number of factors including whether or not you are having symptoms. Surgery would be well tolerated and likely involve replacement of your aortic and mitral valves and repair of your tricuspid valve. This is a relatively low risk surgery. I would be happy to provide a more detailed second opinion.

Rnbd: I had a major heart attack, January 2011 (age 69), resulting in 4 bypasses. Subsequent echos have shown severe regurgitation with the mitral valve. I don't know the numbers. I was at CC last August for a repair, but Dr. Soltesz told us the leaking problem was with the heart muscle pulling the valve apart, vis. a problem with the vanes. I did an echo stress, and was sent home. Now I'm hearing about a mitral valve clip. Is this something I should consider? If so, would it require open chest surgery, or could it be done robotically?

Edward_Soltesz, MD: I would be happy to review a more recent echocardiogram. Please call my office. You may also be a candidate for a mitral valve clip. This is performed through the femoral vein with catheters and does not require the robot or open surgery.


Tricuspid Valve Disease

js121499: My 15 yr. old daughter was diagnosed with a leaking tricuspid valve. She did not have this 18 months ago. She was also diagnosed with a pituitary tumor or lesion, her Neuro surgeon said they don't know what it is and has a history of a positive ana. Again, I am told none of this means anything, but she feels ill and always winded. What would cause a sudden leaking tricuspid valve, and are their systemic illnesses that can cause this. She does have a history of pten mutation and gross resection of cerebellar mass. Her Cardiologist said the valve is leaking more than they normally see. I feel like no one is trying to help her or look for the underlying cause.

Patrick_Collier,_MD,_PhD: The severity of the tricuspid valve leak is important to clarify here. Trivial or mild leaks of the tricuspid valve are common. Even with a structurally normal tricuspid valve, the degree of leak can vary from one study to another depending on a person’s fluid volume status – if someone has edema or extra fluid (which can happen in the setting of some pituitary conditions or some inflammatory/rheumatological conditions), the degree of tricuspid regurgitation may be more. Most often, such a situation would be improved with diuretic medication. We would be very willing to provide a second opinion anytime if you wish.

islamG: What are the selection criteria for patients to be a candidate to percutaneous tricuspid valve replacement especially in patients with advanced right heart failure with systemic congestion?

Patrick_Collier,_MD,_PhD: Although percutaneous tricuspid valve replacement has been performed here in highly selected cases if approved on compassionate grounds, it is not a standard operation. Medical therapy remains first line therapy to deal with systemic congestion associated with advanced right heart failure. Cardiologists here at the Clinic have particular expertise in managing such patients and can often avoid the need for open heart surgery. For selected patients that are medically-resistant, surgeons at the Clinic have particular expertise in doing isolated tricuspid valve surgery (sometimes even off pump) in selected cases.

cdmeg3657: I have severe tricuspid valve leakage. Have been told by my heart doctor that nothing can be done to fix this problem. What options do I have? Thank you.

Edward_Soltesz, MD: There are multiple options for tricuspid valve regurgitation ranging from medicine to surgery. I would be happy to provide a second opinion.


Multiple Valve Disease

ArturoSA: My wife is 65 years old. Born in Mexico, she had rheumatic fever as a child and developed mitral valve stenosis. She had two open-heart surgeries in Mexico. A third one, performed in San Antonio, implanted the Bjork Schiley valve. Now she has aortic valve stenosis and her tricuspid is bad also. I know you are experts in TAVR, but the question is: Can you fix both aortic and tricuspid valves via minimally invasive surgery? And if so, can they both be fixed in one procedure? My wife dreads another open-heart surgery and has been "coping" with congestive heart failure for two years. Can you help? We can give you all the contacts to get her medical records and tests.

Patrick_Collier,_MD,_PhD: Your wife's heart condition is complex. We believe a center such as Cleveland Clinic can offer her the best opinion to address her situation and we would recommend a formal consultation. If you decide to send your records or come in for a visit, our team can help you out. Please contact our Heart Resource Center at heartcenter@ccf.org or 866.289.6911.

Edward_Soltesz, MD: Your wife’s condition is similar to many we deal with on a daily basis here. I would be happy to review her case.

xdwl: 57 yrs. female with HCM. Underwent septal myectomy in Sep. 2012. LVOT obstruction has been eliminated. I had mild MR before myectomy. Post myectomy, my MR progress and become moderate (2+). In addition, I developed AR (1+-2+) and ascending aorta dilation (4.7cm). My LA and LV dimension also changed comparing with the echo in 20 mos. ago; LA Diameter from 4.0 to 4.7 cm; LA Volume from 34 to 38 ml/M2; LV ID (diastole) from 4.3 to 5.4 cm; EF from 76 to 65. No LVOT obstruction. MRI: mildly thickened anterior mitral valve leaflet. I feel mild SOB when take a walk sometimes, but most of the time I can still travel around. 1) Can MR be a complication post-myectomy since the surgeon excised my thickening part of septum down through to apex; release the adhesion of anterior papillary muscle; excise abnormal myocardium bundles in mitral valve and ventricle wall. 2) When should I undergo MR/AR surgery? What is the likelihood of MR recurrence post valve surgery? Thank you very much!

Patrick_Collier,_MD,_PhD: From what you state, there is no surgical indication at this time. We would recommend continued surveillance in particular of your MR and dilated aorta with at least annual cardiology review (or sooner if any concern).

Edward_Soltesz, MD: While you do not have an absolute indication for surgery now, you will need very close follow-up of your aortic and mitral valves as well as your aorta. If your aortic valve is bicuspid, then we would recommend surgery sooner since we usually define a threshold of 4.5-5.0cm for aortic replacement in such patients.


Aorta Disease

strelaw: I have been diagnosed with an ascending thoracic aortic aneurysm (4.7 cm) and have been told that although I do not need surgery now that the only option available is open heart surgery. I was previously told by my cardiologist and internist (who did not then know the location of the aneurysm) that the procedure would involve entering my body through the groin rather than open heart. Do you know if it is possible to treat my condition in a less invasive way then open heart surgery? Thank you.

Patrick_Collier,_MD,_PhD: The standard operation to fix a dilated ascending aorta is ascending aorta repair and is generally performed via a mini-invasive technique involving a mini-sternotomy involving a 6cm incision in the upper sternum. This surgery can be done at very low risk. Isolated repair is recommended once the aorta is over 5.5cm but in certain circumstances (connective tissue disease, family history of dissection, etc.) may be recommended at lower dimensions.

Strelaw: I am a 63 year old male who was recently diagnosed with an ascending thoracic aortic aneurysm (4.7 cm) and have been advised that the only option is open heart surgery with a claycon graft. While the doctor is suggesting that I have an annual MRI and does not suggest surgery until the aneurysm increases to 5.0 cm, I am wondering if there an option to make the repair without open heart surgery?

Edward_Soltesz, MD: Aortic aneurysms occur due to defective tissue. The only treatment is replacement of the involved aortic segment with a graft (Dacron, etc.) or endovascular stenting. Both accomplish the same result: exclusion of the involved segment from the circulation and blood pressure. Repairing the aorta (for instance by excising a portion of it) leads to recurrence.


Atrial Fibrillation

heartvalve: I had heart surgery in June 2014. I also was diagnosed with atrial fibrillation prior to the surgery and was put on a warfarin drug to prevent a stroke. I still had atrial fibrillation after the surgery so my cardiologist shocked the heart into regular rhythm. My cardiologist recommended that I stay on warfarin. I have had several ekgs since the shock treatment and all showed normal heart rhythm. Can I stop taking warfarin, and if so when?

Patrick_Collier,_MD,_PhD: Excellent question. Stroke can be a devastating event for a patient and coumadin is very effective at reducing the risk associated with AF, a heart rhythm disorder associated with fast irregular heart beat and an increased risk of clotting type stroke. AF can occur particularly in the first few months after surgery even in patients who don’t have it pre-op. Patients should report symptoms such as palpitations and if suspected get an EKG to assess for AF. However, AF can sometimes be silent in which case, prolonged heart monitoring may be required to detect it – this may be necessary in patients that remain at high risk of stroke. The decision to stop warfarin in your case has to be individualized and I would encourage you to discuss further with your cardiologist. For patients that have AF prior to surgery, some are recommended to have MAZE or ablative therapy to reduce the burden of AF post-op. A paper on this topic was published in the NEJM this week by Dr. Marc Gillinov. Removing the left atrial appendage can be performed to reduce the risk of clotting type stroke.

Trykkergirl: Female, 70, Afib eight months last yr., normal since March. Had a 15 min bout of Afib last Thurs, got normal taking my metoprolol 25 and Flecainide 100 which was due in anyway. Took deep breaths. BP 142/105, pulse 108. Came out of Afib heart rate normal in an hour. Could feel Afib this time (didn't know what felt like when in it happened before). Typical heart rate 112/68 pulse 58 or so.  Questions: What is safe highest heart rate I should get when exercising (I ride bicycles)? Must I go back on Warfarin (have PDP, can’t afford novel drugs) because of this short Afib incident? Not in Afib now and take aspirin. I HATE eating so unhealthy on warfarin, despise that drug. Never could get good INR. PLEASE NO!!! HR is elevated on inclines when riding, breathing is more labored exercising and in general, more swelling in legs too -also have VI).. have mild/moderate mitral valve leak, mild aortic and tricuspid regurgitation. See my tiny town cardio Thurs, but trust you more.

Patrick_Collier,_MD,_PhD: Atrial fibrillation is a complex condition that requires a very individualized approach - we have very excellent electrophysiology doctors who would be more than willing to offer you a second opinion.

Trykkergirl: Can lack of sleep night before total exhaustion, bring on few minutes of Afib in mild-moderate heart valve disease patient?

Edward_Soltesz, MD: I’m sure it can.

Pettijohn: What is the relationship of long-term atrial fibrillation and mitral valve regurgitation (severe) and implications, if any, for valve repair/replacement?

Edward_Soltesz, MD: Patients with structural valve disease (such as mitral regurgitation) and atrial fibrillation benefit from a concomitant Maze Procedure. This procedure creates lines of ablation in the left atrium and removes the left atrial appendage, the source of most strokes in patients with atrial fibrillation. The success of the Maze procedure nears 80%.


Valve Surgery – General

AnnS: 1) Why does the minimally invasive valve surgery have higher death as well as stroke risks than the traditional open heart approach, and what are the risk rates? 2) What is the main cause for the higher stroke rate with minimally invasive valve surgery and what other significant risks are there for the minimally invasive approach? For more complex surgery involving not only mitral valve but also tricuspid valve plus maze, how would the risk increase?

Edward_Soltesz, MD: In our experience, minimally invasive surgery has similar or lower mortality and stroke rates compared to conventional surgery. On the other hand, percutaneous valve replacement (TAVR) does have higher risks. This is due to the overall higher risk patients undergoing TAVR procedures as well as the approach. In surgical aortic valve replacement (both standard as well as minimally invasive), the calcified leaflets are removed and all small pieces of calcium are cleaned out before the new valve is sutured in place. In TAVR procedures, the valve is expanded within the calcified valve, pushing aside and compressing the calcified leaflets. There is usually minimal increased risk with the addition of a tricuspid valve repair and/or Maze to a mitral valve repair. I would be more than happy to review your specific situation and provide a risk estimate.

DanielleH: Two questions: 1) One cardiologist told me that a bovine valve can last 20-30 years. From all other sources the number was 10-15 years, What the latest information on this? 2) I'm asymptomatic, but my Mean gradient is 65.0, my jet velocity is 5.1, my valve area is .87, and my ejection fraction is 65-75%: Should I have surgery immediately, in the next six months, or wait for symptoms?

Patrick_Collier,_MD,_PhD: Most patients can expect to get 12- 20 years out of a bovine valve, unfortunately, some valves deteriorate before this time and thus the need for regular follow-up. We recommend you discuss timing of surgery with your cardiologist. Stress testing, BNP and/or strain assessment may be helpful. We would be glad to offer you a second opinion.

Edward_Soltesz, MD: Newer bovine pericardial valves will likely last longer than 20 years. The main predictor of structural valve deterioration (SVD, or the valve “wearing out”) is the mean gradient postoperatively. The latest generation valves have mean gradients around 5mmHg after implantation. Based on our data from 12,000+ patients, this would predict a very long lasting valve. Your echocardiogram would suggest to me you may need surgery soon. I would be happy to review your case and provide a second opinion.

DanielleH: Two questions: 1) Are there different types of tissue valves? What are they? What's the best or longest lasting one for a 68 year old? 2) When should an angiogram happen - how long before surgery? Is two months fine?

Edward_Soltesz, MD: In general, there are three types of bioprosthetic tissue valves: homografts, bovine pericardial valves, and porcine valves. Homografts are human cadaver valves that require no blood thinners or other specific medicines and last about 15-20 years. Homografts become very calcified and develop severe leakage as they begin to fail. Bovine pericardial valves are bioprosthetic valves whose leaflets are constructed with bovine pericardium. These valves last 15-20+ years and develop progressive calcification of the valve leaflets. Porcine aortic valves have leaflets made of porcine tissue and typically last 15-20 years as well. These valves, however, typically develop sudden tearing of a leaflet that leads to rapid development of severe aortic regurgitation. We favor using bovine pericardial valves in the aortic position and porcine valves in the mitral position. We reserve aortic valve homografts for infected aortic valves as they are very resistant to re-infection.

RobertW: what is the expected time before a bovine aortic valve needs to be repaired or replaced?

Edward_Soltesz, MD: We recently published our 25 year results of bioprosthetic aortic valve replacement in 12,000+ patients. The rate of structural valve deterioration (SVD) – that is, the need to have a re-operation because the tissue valve has “worn out” – is surprisingly low even for young patients (<60 years old). The actual rate of reoperation for SVD was 9% at 20 years. Age is a factor: bioprosthetic valves last longer in older patients.

Bullskis: How long after discharge can patient travel by air?

Patrick_Collier,_MD,_PhD: Generally patients who are traveling here from out of state can fly safely once discharged from the hospital as we assess for potential issues, such as the presence of pneumothorax before discharge.

WALTERBLASS: Would you please discuss the likelihood of arrhythmia's in the minimally invasive procedure, as against trans-sternal ? A French cardiologist who examined me three years ago said that his experience was that minimally invasive procedure produced MORE arrhythmia's than the trans sternal. Was that just him, the experience then, or still true? Thank you!

Patrick_Collier,_MD,_PhD: The likelihood of arrhythmias is very much dependent on patient factors, including indication for surgery, presence or absence of preoperative arrhythmia, degree of atrial dilation over and above the surgical approach per se. Our experience is that we do not find an increased risk of arrhythmia with a minimally invasive approach.

Edward_Soltesz, MD: Our data would suggest the opposite: minimally invasive approaches tend to reduce postoperative arrhythmias since there is less pericardial inflammation.

Halelm: Is there a right point (age, health, etc.) to consider various treatment options?

Edward_Soltesz, MD: Yes. It is important to have an active dialogue with your doctors about all this.

Quilting: After surgery how long are you in the hospital. how long do you have to stay in Cleveland after.

Edward_Soltesz, MD: This all depends on the surgery. For a minimally invasive mitral repair or aortic valve replacement, you can expect to stay in patient for 3-5 days and remain in Cleveland (at a hotel for instance) for 1-2 more days. For more complex aortic surgery, this may be extended to 7-10 days total.

heartvalve: What has been your experience of valve repair using an Annuloplasty Ring?

Edward_Soltesz, MD: Valve repair is extremely durable when done in the correct situation by experienced surgeons.

Reviewed: 03/15

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