Tuesday, August 18, 2015 - 12 Noon
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 Milind Desai, MD and surgeon Jose Navia, MD answers questions about treatment options for valve disease. Welcome to those who joined us from the Alliance for Aging Research www.LivingwithValveDisease.org.
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- View previous chat transcripts.
Symptoms of Valve Disease
laumya: I have a St. Jude Valve Model 19A-101 implanted 1992, after a valvuloplasty done six years earlier did not hold. I recently had a triple rule out CT Scan where nitroglycerin and a beta blocker were administered. My mean gradient was reported as 44. Can these meds cause gradient to increase? I was always told it should be between 30 and 40, do I have cause for concern? I am an active individual, walk daily and play tennis 3-5 times per week, could lose 10-20 pounds however. I was experiencing chest discomfort but I’ve also had a productive cough since February, which is large reason for discomfort depending on how often I am coughing. If needed who would I see at Cleveland Clinic Weston Florida? Thank you. Hoping not for a third open hear operation.
Milind_Desai,_MD: This is an old valve from 1992 and your gradients have progressively gotten worse. If you are beginning to have these symptoms - shortness of breath and cough - you need to be evaluated at an experienced center. You can start with an echo and evaluation. It is a third redo operation, so you can begin with an evaluation at Weston with Dr. Asher or Dr. Navarro.
Diagnostic Testing and Follow up
sinaihospital: I have heart valve disease also hypertensive heart disease. How often must I have a stress echo, a stress test blood test, and an ekg from my cardiologist? Thank you doctors for your advice.
Milind_Desai,_MD: It depends upon your symptoms and change in symptoms. If you have no symptoms, you need an annual exam to make sure everything is all right. In terms of testing, in a patient with no symptoms and no clinical changes, it is recommend every three years. However, having said that, if there is change in symptoms (new symptoms) you should have testing more frequently.
Calcified Heart Valve
claranorene: One of my heart valves was replaced in 2012 and three others were repaired because of calcium deposits. Should I avoid calcium in my diet, or be taking meds to prevent future calcium from forming in my valves again?
Milind_Desai,_MD: No data to say dietary calcium has contributed to this. There is no evidence that there are medications to prevent calcium deposits on valve. We do not have any medication to remove the calcium on the valve.
wps123: My aorta valve keeps getting clogged with calcium and needing to be replaced. How to prevent this?
Milind_Desai,_MD: Risk factor modification - this is similar to coronary artery disease and includes blood pressure control, diabetes control, cholesterol control, weight control, etc.
HeidiM: I am 19 years old with a bicuspid aortic valve. No symptoms or any issues. Have started to get palpitations. Could the palpitations be from the valve or other reasons?
Milind_Desai,_MD: I would check the valve to make sure it is not deteriorating. But if it is not getting worse, it could be from many other causes. Follow up with an echocardiogram.
jerry56: I am a 47-year-old male, with bicuspid aortic valve, and AR and AS. My echo results are generally OK (ESD 33 mm, EDD 50 mm, EF 72%, aortic diameter 32 mm). But when I started swimming recently, my maximum pressure gradient has increased from 35 to 60 mmHg. My cardiologist explains the gradient increase by the effect of exercise (namely, the increase in stroke volume that biases the gradient upward). Just in case, my cardiologist checked my aortic valve area and BNP, and both turned out normal (valve area: 1.4 squared centimeters, BNP: 10 pg/mL). So he suggested that I ignore the odd echo result, and continue with my swimming routine. I have two questions. First, would you agree with my cardiologist’s opinion? Second, is there any other additional check for the true severity of AS in my case, in addition the valve area and BNP? Thank you very much for sharing your expertise!
Milind_Desai,_MD: Normally when you exercise, the gradient will increase. The important thing is do you have symptoms? If you have symptoms, you need an evaluation and echo. If you do not have symptoms, then you would need periodic follow up - I would recommend within a year of the last study.
jerry56: In BAV patients, CT and MRI are recommended to assess the size of aorta. I have two questions. In your opinion, which of these two tests is the best for routine evaluation of BAV patients? Second, if aorta is not enlarged, how frequently the aortic size needs to be evaluated by CT (or MRI)?
Milind_Desai,_MD: CT has many spatial resolution but it comes with radiation. MRI has no radiation. So - if you are past the age of 50, I would go with CT. Under age of 45 - 50, would go with MRI. If it is normal, then every three years or so.
aroland: Is this a congenital disease?
Milind_Desai,_MD: Bicuspid valve is congenital.
abbie07: Male, 73. Moderate mitral valve regurgitation and severe tricuspid valve regurgitation. My Dr. says keep BP down and I have. That is all. What do you think?
Milind_Desai,_MD: A lot of times moderate may not be moderate - can be worse than or not as bad as reported. We would like to first see the echo and then see the patient to evaluate.
fifi80: In general, how long do people with severe mitral regurgitation live a normal life without having to have surgery?
Jose_Navia,_MD: I would recommend that for severe mitral regurgitation you have a repair. Emerging data shows that early repair is better than waiting because you preserve left ventricular function.
Aortic and Mitral Valve Surgery
SandraK: If I am 82 years old, but have been very active, is it possible to go through aortic and mitral surgery?
Milind_Desai,_MD: Yes - everybody is different, but age is only a number. We would need to see your medical records and evaluate you.
liesel: I am a 76-year-old female with two stents in LAD, had MI, also suffer from occasional high pulse A-Fib episodes. I have moderate mitral valve prolapse. Echo on 12/9/14 said: Hypertrophied LV with mild LV dysfunction. Pulmonary hypertension, mild. I exercise five days a week and eat a heart healthy diet. Lately I have been waking up around 4 a.m. and have difficulty breathing while in the laying down position. If I get up and walk around or sit, the breathing gets better. My question: Could the breathing difficulties be a result of the mitral regurgitation? My next question: I heard that with the minimally invasive mitral valve repair surgery (through the side) the recovery is supposed to be more painful and problematic than the conventional open heart surgery? Would you have any statistics on that?
Milind_Desai,_MD: You need a thorough recent evaluation to see if things have changed with your heart valve. Yes - minimally invasive surgery provides a shorter recovery time and less trauma and is available to be considered in your case. Our average length of stay for minimally invasive surgery is four - five days and recovery is about four weeks. Robotic surgery would be shorter.
Okiegal: If I have had prior aortic valve surgery, and now my mitral valve is leaking and I need valve surgery, does that prevent me from having robotic mitral or minimally invasive mitral valve surgery?
Milind_Desai,_MD: In general, yes, it would prevent robotic or minimally invasive mitral valve surgery.
Trykkergirl: Should I have mitral or other valve repair prior to severe rating, like when leaks are moderate? Do you ever operate on people with mild leaks, if they have mild leaks in three valves?
Milind_Desai,_MD: No - we do not do mitral valve repair prior to severe rating. We do not operate on people with mild leaks.
coloradosun: My sister has been recently treated for endocarditis with IV - she is completing her IV therapy. She has severe mitral valve prolapse and requires heart surgery to fix. How long after her IV therapy is surgery possible? What does this mean for her recovery and going through surgery?
Jose_Navia,_MD: Six weeks for sure and then the risk for surgery is basically the same. In some cases, we may choose to do surgery earlier but it depends on the situation.
RonnieR: I need mitral valve surgery. Is it usually done minimally invasive? I have read that repair is better but how long do repairs last and do people who have a repair have a normal lifespan and normal activities?
Jose_Navia,_MD: Most of the mitral valve surgery we try to do minimally invasive unless there are some factors that prevent this. Most experienced heart valve centers do this. Repair is the preferred option if possible and lifespan and other outcomes are good.
fifi80: Hello I am a 34-year-old female. When I was 19, I was told I had mitral valve prolapse. Over the years my regurgitation has been mild to moderate. Last month I went for my routine echo and now the regurgitation is severe. My cardiologist says my EF is 65% and none of the chambers have been affected. She says there is no emergency. But everything I read from the internet says that once it is "severe" surgery is required?
Milind_Desai,_MD: Elective mitral valve repair would be an option in your case at an experienced center that can guarantee a more than 90% success rate for surgery. This can be achieved minimally invasive or robotically assisted.
mvpr: Good Morning! What is your criteria for determining when to perform mitral valve repair for prolapse with regurgitation? Also, do you recommend Enzyme CoQ10 to your mitral valve patients? Your expertise is greatly appreciated.
Jose_Navia,_MD: It has to be severe mitral regurgitation and symptomatic. In some cases we operate before symptoms present but your cardiologist should be able to with that evaluation. We do not recommend CoQ10.
rbrannan: I would like to get my mitral and tricuspid valves repaired, but at my age I don't think I can tolerate a full sternotomy. Are there any recent MIS procedures that will permit valve repairs for someone that has under gone a triple CABG? Thanks.
Jose_Navia,_MD: Yes. Minimally invasive right thoracotomy could be an option, or lower sternotomy to approach the mitral and tricuspid valve through the lower portion of the heart. We would be happy to evaluate you.
Eddie PK: If I have mitral and tricuspid regurgitation, shortness of breath, afib - how do you know when you are ready for surgery? Will they repair both valves at same time? Can it be done mini?
Jose_Navia,_MD: It can be repaired/replaced at the same time. Both can be done mini with same incision. A clinical evaluation will decide readiness.
Transcatheter aortic valve replacement (TAVR)
Mominlex: My mother received recent results and the decision that she is not a candidate for TAVR at the University of Kentucky. From these results, can you identify the reason she might have been rejected and do you see any reason to pursue additional opinions?
Jose_Navia,_MD: We are more than happy to review your mother's records and provide an opinion through the eConsult system to give you a second opinion - or we can see her here.
MarkC: My father was a candidate for TAVR but requires a large valve due to a large aortic root. Can you please tell me the largest valve on the market today and what is being done for people requiring large aortic valves?
Jose_Navia,_MD: Thirty-one is the largest one that we can use.
Mechanical and Biologic Heart Valves
gatorfrog: Thank you for your time. My husband has a titanium aortic heart valve. He has had it for 12 years and was told it would last for his lifetime. Is that possible? And, also, he has been having issues with swelling in his feet and ankles and some left shoulder pain. Could these issues be related to his heart and should he see his cardiologist. The last time we saw him (the doctor), he indicated that he didn't think they were cardiac related, but it seems like it would be. Thank you for any help.
Milind_Desai,_MD: The mechanical valve can last a lifetime, but the problems could be related to many associated things such as fibrosis around the valve, thrombosis and other issues. Make sure your INR is in normal range. He should see a cardiologist for a follow up evaluation. All patients after valve surgery should be seen at least once a year.
Marv: As I understand it, there are currently two valve manufacturers offering both mechanical and animal tissue aortic valves. Which manufacturer and which valves do the cardiac surgeons at Cleveland Clinic use the most?
Jose_Navia,_MD: There are advantages and disadvantages to both types of valves. Typically mechanical valves last longer but it requires anticoagulation lifelong. On the contrary, tissue valves do not last the entire life but it has a positive impact on not requiring anticoagulation lifelong. When the tissue valve deteriorates it can possibly be replaced percutaneously.
Bobby: When choosing a valve for valve surgery - are there any issues with MRI in the future?
Jose_Navia,_MD: No - all patients with valve replacements can have MRI.
After Valve Surgery
ShirleyM: My husband had valve surgery and has had afib after surgery. He is now three weeks past and still on his medications. How long will he need to be on this? Is there a time when he can come off those medications? How do they know it is gone, if the afib is being treated by the pills?
Milind_Desai,_MD: Every patient is different. The only way of knowing if the afib is coming back is to take the patient off the medications and see if it comes back. We usually evaluate the patients at six weeks post op to see the status.
Shannon62: Can you talk about antibiotics before dental work. They have made the requirements much more lenient and I was taking antibiotics for a long time. Then my primary said I didn't need them any more - but when I called my surgeon, he said he still suggests it. What do you think? Have a mitral valve repair with a ring in place.
Jose_Navia,_MD: Yes - you should take antibiotics with dental procedures, even a teeth cleaning.
hughesrl7: Caucasian, male, age 69, good health. I had a mitral valve repaired in 2004 and my most recent cardiac echo reported moderate mitral valve regurgitation. Does this mean I might need another repair (or replacement)? Not sure I want to go through that again! Any new alternatives? Thanks, Richard.
Milind_Desai,_MD: I would do serial monitoring with echo. Once it gets to severe and clinical symptoms such as shortness of breath, fatigue become present, then evaluation for surgery is warranted. Alternatives - not right now. But potentially in the future, there may percutaneous approaches. We are currently investigating this option - it will be in the future.
jacksmommy: I am a 44-year-old woman. I had mitral valve replacement eight years ago, and I have a bovine valve. I also had 2 TIAs within minutes of each other almost three years after surgery. Would I be a candidate for minimally invasive surgery when my bovine valve deteriorates? What is the average longevity for a bovine valve in a young patient? I've found it difficult to find information on patients younger than 60.
Jose_Navia,_MD: Assuming you had a mini-sternotomy or a mini-thoracotomy. Potentially no for minimally invasive follow-up. We can repeat a mini-thoracotomy. For younger than 60 years, the average longevity is about 10 - 12 years.
Experienced Heart Center
Marv: You've used the term "experienced center" several times. Can you define such a center or list some parameters, please?
Jose_Navia,_MD: This term is generally based on outcomes, the variety of patients, quality of care, the risks of procedures and availability of multiple treatment options for cardiovascular disease.
Trykkergirl: After getting Afib found in Sept of '13, age 68, I was in it for about six months, cardiologist didn't attempt sinus rhythm. I was proactive and finally got Flecainide (found good electrophysiologist) 100mg twice daily and normal sinus rhythm before scheduled electrical conversion procedure March of '14. Two 30 minute episodes since, took extra flecainide and lisinopril HCTZ and normal sinus rhythm right away. Lucky. After Afib diagnosis was told after Echo, I had mild mitral valve, aortic valve and tricuspid valve leaks, mild diastolic dysfunction, EF of 60-65% with normal left ventricular size, all thickness, and contractility. Mild left atrial enlargement, mild aortic valve thickening, mild tricuspid leak w RV systolic pressure at 37mmHg, no pericardial effusion. Heart cath 06 '15 (false positive chemical stress test for CAD, he said my arteries have no plaque) showed NO mitral valve insufficiency. Strange. Lots SOB on exertion. I exercise. Obese, Venus insufficiency. Valve surgery?
Jose_Navia,_MD: Valve surgery - not yet. However, follow up with your cardiologist for regular visits.
hoagie0013: How hard is it to image valve problem. I have had arrhythmia problems for 11 yrs. I have had four ablations over last five yrs. and still am having mainly episodes of tach. and some episodes of a-fib. Heart seems to want to stay in sinus but keeps kicking out; very weird that this can happen for weeks and then one morning I awake and my heart is beating like it did when I was 10 yrs. old. They tell me I have excitable heart cells but I’m not buying that because if they were excitable wouldn't they be excitable always. I have had testing done for valve disease and have found mitral valve has small leak. Is it possible the doctors are overlooking valve problems? Could a small mitral valve leak cause the problems I am describing? I am at the point of having av node ablated. This is something I really don't want to do but it is getting to the point that I have no choice. Please give me your thoughts on my situation. Thank you.
Jose_Navia,_MD: You need an echo to see what the quantification of the MR; Also an electrophysiology opinion at an experienced center - certainly before you contemplate av node ablation.
claranorene: I am an active 65-year-old female (5'8", 150lbs). In 2012 I had to have my mitral valve replaced with a bovine valve. At that time I was told the valve would probably only last for 10 yrs. Now, I hear they don't like to replace the valve because of scar tissue. Is it possible to have it replaced when it starts to fail? I also have a problem with Afib. controlled by a pacemaker, diltiazem, Tikosyn, metoprolol, potassium, magnesium, warfarin, vit c, and fish oil. Is there anything I can do to stop Afib. The meds usually do an Ok job of keeping it controlled but, I hate taking so much meds. They tried stopping the Afib when I had surg. but it didn't work.
Milind_Desai,_MD: You should see an electrophysiologist to see if atrial fibrillation ablation is an option.
Pacemaker: I have a two-lead St. Jude's pacemaker that was placed on the right side of my heart in 2011. However, the left side of my heart is not circulating blood from my feet like it should, according to my cardiologist. As a result, blood is pooling under my skin on both legs from my ankles to my calf. My cardiologist performed a venous ablation procedure on both legs in 2014, to improve blood flow to my feet. A month ago, my PCP referred me to a vein specialist. The specialist performed a blood pressure test on my arms and ankles and said blood flow to my feet was adequate. The only recommendation doctors have given me, thus far, is to take a fluid pill and wear support stockings. The discoloration has continued, however. I also have painful neuropathy to my feet and osteoarthritis but no diabetes. Any suggestions from you? Should I discuss with my cardiologist adding a pacemaker lead to the left side of my heart? Thank you. (P.S. I am 72 years of age.)
Jose_Navia,_MD: It sounds like you need a very good evaluation by a heart failure cardiologist at an experienced center such as Cleveland Clinic.
Non- Valve Related Questions
Deepak: I have pain, left side of chest, two - three years including shoulder, arm, left hand last three fingers and the left. Symptoms have changed over a period of time. I have consulted the topmost cardiologist here and they say that it is not related to heart. ECG and Stress echo test many times, Holter, EMG test, CT Scan and X-ray of chest, Cervical X-ray, MRI Brain and Angiogram all normal. I have also done the CT Coronary Angiogram on 29 November 2012, where in the calcium score was zero, with an conclusion that Type III LAD with right dominant system and a calcium score of zero and right coronary artery is arising from the left coronary sinus and has an interarterial course coursing between the aorta and pulmonary artery. All the doctors say that this is since birth so you don't have to worry as this is not related to heart. I would just like to understand that is the conclusion mentioned in the CT angio report is a sign of concern for me. Doctors say that it is a muscular pain but I am very concern about my health.
Milind_Desai,_MD: This patient has an interarterial coronary anomaly which in some cases, is associated with that outcome and is considered to be a dangerous form of that anomaly (life threatening). I would recommend you get evaluated at an experienced center for surgical correction. Sometimes, surgery is an option to treat this.
godhelp23: Hi, around one month ago I started feel nausea. Even the thought of food makes a sense of vomiting. I go to doctor and he gave me some medicines and that solve my problems. Also he suggested me for abdomen ultrasound in which I was diagnosed with multiple hyperechoic nonshadowing foci in my pancreas. After one month, doctor stopped my all drugs and said everything is alright but after two - three days of stopping drugs, I again feel like nausea and stomach discomfort. I am very scared of some incurable disease if it goes untreated, please experts suggest me.
Milind_Desai,_MD: You need a good internal medicine doctor who will look at the big picture and provide testing and provide you with alternatives for treatments.
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