Amar Krishnaswamy, MD

Amar Krishnaswamy, MD

Thursday, August 18 - 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. Amar Krishnaswamy, MD answers your questions about valve disease and treatment.

More Information

  • View more information on valve disease, percutaneous interventions.
  • 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.

Non-surgical Treatment for Heart Valve Disease

Traci: What are some nonsurgical treatments for valve care?

Amar_Krishnaswamy,_MD: Most common "non-surgical" or catheter-based valve treatments:

1. For patients with severe aortic valve stenosis:
a. Transcatheter aortic valve replacement (TAVR)

2. For patients with severe mitral valve regurgitation:
a. MitraClip catheter mitral valve repair
b. Transcatheter mitral valve replacement

3. For patients with leakage around a surgical valve:
a. Percutaneous paravalvular leak closure

celiao: What is the non-surgical treatment for mitral valve regurgitation?

Amar_Krishnaswamy,_MD:

2. For patients with severe mitral valve regurgitation:
a. MitraClip catheter mitral valve repair
b. Transcatheter mitral valve replacement

3. For patients with leakage around a surgical valve:
a. percutaneous paravalvular leak closure

sinaihospital: I have heart valve disease, what treatments can I have for this problem, doctors?  I see a cardiologist for this, thank you.

Amar_Krishnaswamy,_MD: There are a number of options that may be available depending on the valve and the type/extent of disease. Some patients require only medicines, some require open heart surgery, and some require catheter-based repairs.

georgefromfla: Are there non-surgical options for aortic valve stenosis?

Amar_Krishnaswamy,_MD: Most commonly transcatheter aortic valve replacement (TAVR) which consists of replacement of the valve using a catheter delivered most commonly via the artery at the top of the thigh (90% of the time at Cleveland Clinic).

mdellafera: The only alternative to severe AS that I know of is surgery. Is there any other alternative?

Amar_Krishnaswamy,_MD: Transcatheter aortic valve replacement, which consists of replacing the aortic valve using a catheter that we deliver via the artery at the top of the thigh in 90% of cases, is an excellent alternative in a number of patients with results that are as good or better than surgery (in properly selected patients).

landey: What are the non-surgical treatments? Curative or Palliative?

Amar_Krishnaswamy,_MD: Some are palliative and some are curative. Depends on the specific valve and the specific procedure. Happy to review with more details.

mfor6046: What are the non-surgical treatments for aortic stenosis?

Amar_Krishnaswamy,_MD: Most commonly transcatheter aortic valve replacement (TAVR) which consists of replacement of the valve using a catheter delivered most commonly via the artery at the top of the thigh (90% of the time at Cleveland Clinic).

McD: Are you close to non-surgical methods of correcting the stenosis in lieu of valve replacement?

Amar_Krishnaswamy,_MD: Are you referring to aortic valve stenosis? Most commonly transcatheter aortic valve replacement (TAVR) which consists of replacement of the valve using a catheter delivered most commonly via the artery at the top of the thigh (90% of the time at Cleveland Clinic).

ckp: Are there any repair options available for a congenital bicuspid aortic valve?

Amar_Krishnaswamy,_MD: It depends on whether you have aortic stenosis or aortic regurgitation. Sometimes, bicuspid regurgitation can be repaired instead of valve replacement.


Transcatheter Aortic Valve Replacement (TAVR)

DMar: Please define TAVR

Moderator: We have a great page on TAVR (Transcatheter aortic valve replacement) - please see my.clevelandclinic.org/services/heart/services/valve-treatment/aortic-valve-disease-percutaneous-interventions.

vieja: I'm wondering if "non-surgical" includes "minimally invasive"? I had open heart for an aortic valve problem 11 years ago and "minimally invasive" valve in a valve surgery a year ago.

Amar_Krishnaswamy,_MD: I am assuming you had valve-in-valve transcatheter AVR? This is considered percutaneous and not surgical. Also not traditionally referred to as minimally invasive. I hope this answers your question.

mparrov: I live in Tucson, AZ. How long would I normally need to stay in Cleveland for this procedure? My aortic valve clearance is down to 3.1.

Amar_Krishnaswamy,_MD: I'm sorry I am not clear about the procedure that you need; we do not usually refer to "aortic valve clearance." Happy to review further.

Moderator: Please contact our Resource Nurses at clevelandclinic.org/heartnurse if you would like to learn more about procedures and length of stay.

Palooka1480: I was diagnosed to have two leaking valves. I read catheterization procedure my cardiologist told me I wasn't a candidate for that procedure. I went home back to sitting on the couch and waiting for God to call me. I made up my mind to go forward with the procedure. My cardiologist was right. Nothing they could do for me. Are there any other procedures available, even experimental? I realize I'm an old man (90 in Jan.) but I'm a fighter. Respectfully submitted

Amar_Krishnaswamy,_MD: There may be options for catheter-based treatment of your heart valve condition, but I would need more specifics (and imaging studies to review) to better advise you. We'd be happy to see you at Cleveland Clinic.

ckp: Do any non-surgical treatments exist for bicuspid aortic valves other than TAVR? If not, when will TAVR be available for non-high risk patients? How long does TAVR last before re-surgery is needed?

Amar_Krishnaswamy,_MD: There are some differences in how a bicuspid valve can be classified -- some are amenable to TAVR, while others are not. If the valve is "congenitally bicuspid" then currently TAVR is not the preferred option but may be performed if surgery is simply infeasible. If the valve is "functionally bicuspid" then TAVR may be reasonable. We currently perform TAVR for intermediate- and low-risk patients at Cleveland Clinic as part of clinical trials, though whether you need TAVR and whether you would qualify for one of these trials would, of course, require a detailed review of your specific case.

Rsinistro : What are the risks for an elderly heart patient at Cleveland Clinic that come with non-invasive valve care?

Amar_Krishnaswamy,_MD: The risks are highly dependent on the specific valve treatment/procedure that you need. Happy to answer further with more details.

Julip: Are there studies of the use of TAVR on low-risk patients and, if so, when will the results be published?

Amar_Krishnaswamy,_MD: Currently, TAVR has demonstrated equivalent or better results than surgical AVR in inoperable, high-, and intermediate-risk patients. Given this data, we have commenced the trial of TAVR in low-risk patients (PARTNER III) which randomizes low-risk patients 50/50 between SAVR and TAVR using the Edwards SAPIEN-3 valve. Data will not be available for a few years.

farmgirl: Not sure if TAVR falls under non-surgical or not. If a person needs an aortic and mitral valve replacement but is not a surgical candidate for open heart surgery, would the TAVR procedure give the heart some relief even though the mitral valve is also operating poorly? The patient is an 81-year-old female with no swelling in legs or episodes of passing out. She is in good physical condition except for the valves which cause her fatigue and occasional shortness of breath on exertion. Her only other medical concern is anemia which she has been dealing with since she was a young woman. Thank you for your input.

Amar_Krishnaswamy,_MD: There are circumstances in which TAVR alone may be beneficial even with mitral valve problems, but I would need to review the specific details/imaging to understand whether it would be beneficial in the case to which you are referring.

Julip: Can afib be addressed when using TAVR?

Amar_Krishnaswamy,_MD: Afib is an electrical disturbance that may or more often may not resolve with TAVR. For patients undergoing TAVR who are intolerant of blood thinners used to prevent stroke due to Afib, we often close the left-atrial appendage using the WATCHMAN device (procedure done at a different time). This WATCHMAN does not treat the Afib, just reduces the stroke risk for patients who cannot safely take blood thinners.

mparrov: Can we send you our cardiologists report on AVI and see if you can treat with TAVR?

Amar_Krishnaswamy,_MD: Cleveland Clinic has a formal process for us to review outside files. You can contact the resource center for more information by clevelandclinic.org/heartnurse.

Mwi250: If breast cancer radiation appears to be a factor in my severe aortic valve stenosis, will the calcium deposits form again after a TAVR and if so what can be done?

Amar_Krishnaswamy,_MD: Calcification and scarring from radiation is a challenge, and may be a factor even after surgical or transcatheter AVR. Nevertheless, if you aortic valve stenosis is severe and you are symptomatic, then the best step forward is to have the valve replacement by one of the above methods. If the valve re-narrows in the future due to calcium deposition, then re-replacement may be necessary but could probably be accomplished by TAVR (whether or not the first valve was done by surgery or TAVR).

mdellafera: I have heard that people who are small physically are not great candidates for TAVR. Is that true?

Amar_Krishnaswamy,_MD: Body size is less relevant than the size of the aortic valve and size of the leg arteries as assessed by CT scanning. Small and large people can benefit equally from TAVR.

Moderator: We only have about 5 minutes left in this chat for today. Our physicians are busy answering a few more questions, and we apologize if we were unable to get to your question today.

DavidS: What is the failure rate for TAVR? And is another TAVR procedure the solution?

Amar_Krishnaswamy,_MD: The overall risk of stroke for TAVR in most patients is around 1% and mortality is around 1%. Some patients, of course, may present a higher risk. It is rare for a TAVR to not work once it is placed, but there may be a circumstance under which another TAVR needs to be placed if that happens. Our assumptions based on bench-top testing and some clinical data is that the TAVR valves should last 10-15 years, similar to valves placed surgically. If the TAVR eventually fails over time, another TAVR procedure would probably be feasible.


Transcatheter Aortic Valve Replacement (TAVR) – Aortic Insufficiency

genodoc: How close are we to doing TAVR for Aortic Insufficiency?? At what point is valve replacement indicated in AI with no symptoms, full exercise capability w/o SOB?

Amar_Krishnaswamy,_MD: Currently, TAVR is not being used for "pure" aortic regurgitation (AR) because the valves do not sit well without significant calcification that causes aortic stenosis. For patients with AR and without symptoms, it is important to carefully analyze a number of parameters including left ventricular function and left ventricular size -- any decrease in function or increase in size could signal the need for surgery even without symptoms.


Transcatheter Aortic Valve Replacement (TAVR) – Previous Valve Replacement

Violinda: I was wondering if this discussion will also be applicable to a patient that has already had an Aortic valve replacement (Lotus valve w/ pacemaker) but still has valve leakage and calcification build up again? Will the non-surgical techniques discussed be OK for a patient who's already had a TAVR procedure but has residual lingering problems? Thank you in advance.

Amar_Krishnaswamy,_MD: In order to understand whether treatment of the valve leakage is necessary, it is important to understand the extent of the leakage, whether the leakage is through the Lotus valve or beside it ("paravalvular leakage"), and if the leakage is severe whether there are clinical symptoms. Treatment may include medicines, surgery, or percutaneous closure of a paravalvular leakage.

graypatt: I am a 53-year-old male that had an aortic valve replacement 15 years ago. Although the valve is operating well there is some narrowing, and it will have to be replaced eventually. I have read there have been great advances in arthroscopic heart valve replacements, and wondered if I would be a candidate in the future?

Amar_Krishnaswamy,_MD: For patients with bioprosthetic aortic valve failure, we can perform valve-in-valve transcatheter aortic valve replacement which consists of placing a new aortic valve within the failed surgical valve. The approach is either via the leg (most common as long as the leg artery is large enough) or the chest. This procedure currently is only approved by the US FDA for patients considered at high risk for undergoing routine cardiac surgery. Also, this procedure cannot be performed for patients with a mechanical aortic valve replacement.

drdicklac: I have an Edwards bovine prosthetic aortic valve, 23 mm, in 2009 for treatment of congenital bicuspid aortic valve insufficiency, which now has developed dysfunction resulting in severe 3-4+ aortic insufficiency, including a paravalvular leak component, which is presently asymptomatic. I am 67 years old, with apparent nonproteinuric CKD. Repeat open aortic valve replacement surgery was initially proposed as a treatment of choice when clinically indicated. However, TAVR has now been recommended instead of open heart valve replacement surgery. How many "valves-in-a-valve" have been done (transcatheter aortic valve replacement) with a bioprosthetic vs. native valve? Thank you.

Amar_Krishnaswamy,_MD: There is a large worldwide and Cleveland Clinic experience in TAVR for native valves and valve-in-valve. The decision of whether surgery or TAVR is best for valve-in-valve in a specific patient is dependent on a thorough analysis of the patient and imaging. Either option could be the "best choice" for you depending on the above analysis.


Surgical Aortic Valve Replacement (SAVR) vs. TAVR

Mwi250: (1) Please discuss the stroke and mortality percentages of the TAVR procedure vs. an aortic valve transplant, and (2) Having received my cumulative lifetime limitations of radiation during cancer treatments, I am interested if these procedures can be done through ultrasound and MRI imaging thereby bypassing further radiation morbidity issues.

Amar_Krishnaswamy,_MD: The relative benefits and risks of TAVR vs. surgical AVR (SAVR) depend highly on patient-specific factors. In broad terms, for patients considered high-risk or medium-risk for going through open-heart surgery, large clinical trials demonstrate SAVR and TAVR are relatively similar for these risks of mortality and stroke, though TAVR performed via the leg (transfemoral) may actually be slightly safer in the most recent trial in intermediate risk patients. Radiation exposure with TAVR is quite minimal, and cannot be avoided -- it must be done under X-ray and we also must do a CT scan prior to the procedure for planning. We do both SAVR and TAVR on many patients here at Cleveland Clinic with prior radiation treatment for cancer and would be happy to review your case.

Mwi250: What are the stroke and mortality percentages of aortic valve transplant vs. TAVR procedure?

Amar_Krishnaswamy,_MD: The relative benefits and risks of TAVR vs. surgical AVR (SAVR) depend highly on patient-specific factors. In broad terms, for patients considered high-risk or medium-risk for going through open-heart surgery, large clinical trials demonstrate SAVR and TAVR are relatively similar for these risks of mortality and stroke, though TAVR performed via the leg (transfemoral) may actually be slightly safer in the most recent trial in intermediate risk patients.

Kisboros: Sorry for the dummy question: how do you determine if one has to have open-heart surgery or transcatheter procedure in advance?

Amar_Krishnaswamy,_MD: No question is dumb when concerning your health! The decision for surgical valve vs. transcatheter valve procedure depends on a number of factors: 1) Clinical situation and other conditions; 2) Imaging to demonstrate the feasibility of surgery vs. catheter vs. one or the other; 3) Sometimes patient-specific preferences; 4) Sometimes FDA-decisions on the approved indications.


Transcatheter Mitral Valve Replacement (TMVR) and MitraClip

2girls: Can you talk about indications for mitraclip and then TMVR?

Amar_Krishnaswamy,_MD: We perform the MitraClip for patients with degenerative mitral regurgitation who are considered high-risk for going through open-heart surgery. For patients with functional mitral regurgitation, the MitraClip is only available in the US as part of a clinical trial called COAPT that randomizes patients between the MitraClip and continued medical therapy. For these patients, we may be able to enroll in a trial of TMVR based on very specific clinical and anatomic criteria, which would not require randomization and would thereby provide a new valve treatment if possible. It is more rare to consider TMVR for patients with degenerative mitral regurgitation since the MitraClip is available, but not out of the question if it would be a better treatment.

farmgirl: The procedure I was referring to is where they use the MAC to hold the replacement mitral valve.

Amar_Krishnaswamy,_MD: So-called "valve-in-MAC" for severe mitral stenosis due to MAC, consisting of placing a TAVR prosthesis in the MAC, is not an approved procedure. It is performed by us at Cleveland Clinic and worldwide in a limited capacity and in very specific cases. It is a very high-risk procedure and should be reserved for patients who are severely limited by their mitral stenosis and have no surgical option for mitral valve replacement. The newer transcatheter mitral valve replacement devices are not used for patients with MAC.

roxi: I have had mitral valve repair with an annuloplasty ring. Does this preclude non-surgical repairs if required?

Amar_Krishnaswamy,_MD: Rarely, recurrent mitral valve stenosis or regurgitation after prior mitral valve ring may be treated by placing a transcatheter aortic valve prosthesis inside the MV ring. This is not an approved procedure and is extremely high risk. More commonly, patients require redo cardiac surgery.


More than one Valve

gabbyme3: I have a heart murmur.  My echocardiogram procedure showed diffuse thickening of the aortic valve cusps with reduced excursion. Mitral valve thickened  (plaque 50%). Could this lead to a heart attack or stroke? Thank you for taking my question.

Amar_Krishnaswamy,_MD: Heart attack and stroke have a number of different risk factors, and your doctor should work with you to optimize the control of these including diet, exercise, cholesterol, blood pressure, etc. Having thickening of the aortic valve just demonstrates that you should optimize your risk factors as above. If the aortic valve disease is severe and you have symptoms as a result, then treating this with surgery or a transcatheter procedure may be necessary.


Symptoms

gd1822: For the past six years I have had intermittent and random attacks of chest pain/pressure, some shortness of breath, and pain down my left arm. There does not seem to be a trigger, the attacks are short-lasting, and I can relieve them, usually, by deep breathing and resting. My diagnoses have ranged from GRD, emphysema, angina, and small vessel disease.

Current diagnosis is:
IHSS (idiopathic hypertrophic subaortic stenosis) Apr-12-2016 –
Active Bradycardia Mar-18-2016 –
Active Obstructive sleep apnea syndrome Jan-28-2016 –
Active Chest pain, unspecified type Jan-28-2016 –
Active Hypertensive heart disease without CHF
I am taking losartan, ranexa, verapamil, and metoprolol. I have had some relief, although the attacks still occur and are unpredictable. My blood pressure is also depressed, ranging in the mid-40s.
If these symptoms are typical of any conditions treated at the Institute what is a typical treatment plan; where can I get further information?

Amar_Krishnaswamy,_MD: There are a number of different possible causes of your symptoms. Devising a treatment plan would require a further review of your specific case and imaging.

Reviewed: 08/16

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.