Amar Krishnaswamy, MD
Amar Krishnaswamy, MD

Robert Cubeddu, MD
Robert Cubeddu, MD

Thursday, February 23, 2017 – 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. Cleveland Clinic interventional cardiologists Amar Krishnaswamy, MD (Cleveland, OH) and Robert Cubeddu, MD (Weston, FL) answer your questions about the latest non-surgical treatments for heart disease.

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Aortic Valve Disease Treatment – Heart Surgery, Transcatheter Aortic Valve Replacement (TAVR)

macnikkorguy: With a bicuspid aortic valve which shows severe aortic regurgitation on TEE, do I meet the requirements to have a repair or replacement valve surgery done, or ONLY if I had bicuspid aortic stenosis?

Amar Krishnaswamy, MD: The treatment of bicuspid aortic valve disease, whether stenosis or regurgitation, is most often performed via open-heart surgery. In centers such as ours, it is sometimes possible to repair a regurgitant bicuspid aortic valve, something that is not done at most places. However, a final decision on valve repair vs replacement requires a thorough analysis of your imaging.

ashadds: Hello. I am a 26-year-old young man. I have a bicuspid valve and I am totally fine and asymptomatic. My echo parameters recently LVEDD = 5.6 cm, LVESD = 3.6 cm, LVEF = 65 %, IVSD=1.1 LVPWD 1.1, GRADIENT AORTIC VALVE PEAK/MEAN = 62/36 mmHg
Second Opinion = PEAK Gradient = 50mmHg Echo done one day after this diagnosis
When would I require intervention? Can I realistically expect 15 years before I require intervention?

Amar Krishnaswamy, MD: It is difficult to make specific recommendations without seeing you and reviewing your echocardiogram primarily. With the numbers you provide, it is possible you may remain without symptoms for a few years, but waiting 15 years without intervention would be unlikely. Given your age and a bicuspid aortic valve, if/when you develop severe and symptomatic aortic valve stenosis it will be necessary to have an open-heart surgery to replace the valve.

macnikkorguy: Is it possible to replace or repair a bicuspid valve via transcatheter or is that always done via open-heart surgery?

Amar Krishnaswamy, MD: There are many different factors to consider including your age, the specific anatomy of your bicuspid valve, and whether the primary issue is aortic stenosis or aortic regurgitation. Both can be options depending on the specific situation.

cg1217: My question is this: I am a 40-year-old male having surgery on March 7 to replace a bicuspid aorta and 4.95 ascending aorta aneurysm that has grown from 4.4 in 12 months. The surgeon recommended even though it was my decision to replace the valve with a bovine tissue valve instead of a mechanical valve. I have bounced back and forth with the decision, but he seems to think that I possibly could get 20 years out of the valve and a second surgery later would (could) be able to have the TAVR procedure. He thinks I would be happiest in the long run with a tissue valve. That is my plan but I just wanted your opinion because my concern is that if I only get 10 or so years out of the valve I could be looking at multiple surgeries over my lifespan. I am very active and although I have always known I had a bicuspid valve, the aneurysm has just started in the last few years. Thanks for any help.

Robert Cubeddu, MD: This is a tough question in today's world having access to TAVR, and I do understand your doctor's suggestions. The guidelines would however recommend a mechanical valve at your age. Mechanical valves are much more durable. My concern is that at your age, if you get a bovine valve you will likely require a TAVR by age 50-55; then another TAVR 10 years later and so on.... However, the choice of valve is based on many factors and requires a careful discussion between the patient and the surgeon.

macnikkorguy: I am 66 and have severe aortic regurgitation on TEE with a bicuspid aortic valve. Is there any hope that a transcatheter procedure to repair or replace the aortic valve could be done - instead of open heart surgery?

Amar Krishnaswamy, MD: Highly unlikely for pure bicuspid aortic regurgitation to have a good result of catheter valve replacement so this is not something we do except in extreme circumstances for patients with no other hope. Minimally invasive surgery for replacement or repair may be feasible for you, though.

Mark18225: Does Cleveland Clinic (Cleveland, Ohio) perform the TAVR on moderate risk patients? How many TAVRs have been done at your institution? What is your mortality and complication rate? I live in Florida. How do I arrange my care at Cleveland Clinic?

Amar Krishnaswamy, MD: We do TAVR on moderate and high-risk patients commercially. We do TAVR on low-risk patients as part of the PARTNER-3 trial. We did 374 TAVRs in 2016 and have been doing TAVR since 2006 (total cases over 1200). In-hospital mortality in 2016 was 0%.

KennethOH: Can you talk about the TAVR procedure - is it under anesthesia or is it under sedation?

Robert Cubeddu, MD: In most instances TAVR can be performed under sedation without the need for general anesthesia.

Shawn55: What is the recovery and follow up like if you have a TAVR procedure. I am kind of far from Cleveland Clinic and wonder how often I would need to return after this.

Amar Krishnaswamy, MD: You usually spend two days in the hospital. If possible, we have you stay in Cleveland for a few days thereafter to make sure you are feeling well before you return home if you are coming from a distance. Follow-up can be either at Cleveland Clinic or with your local cardiologist.

Belinda35: My husband has aortic stenosis with a 1cm opening.  He has history of heart attack several years ago with a 35% EF. Would he be a TAVR candidate?

Robert Cubeddu, MD: It would be advisable to review his echo carefully. If the valve is not severely stenotic then perhaps no need to replace the valve just yet. Surveillance echo every year is recommended.

Linney: Doctors do you do any percutaneous non-surgical procedures for aortic stenosis?

Robert Cubeddu, MD: Yes we do. A large portion of our patients with aortic stenosis are now being treated with TAVR = transcatheter aortic valve replacement. This novel procedure eliminates the need for open heart surgery to replace the aortic valve.

RalphCo: How do you decide if a patient is a TAVR candidate vs. open heart surgery? Sounds like TAVR would be much better. I am 55 years old requiring aortic valve replacement and hoping I don't have to have surgery.

Amar Krishnaswamy, MD: The decision requires a careful review of your imaging, comorbidities, etc., to see if the TAVR is an option in the first place. If it is anatomically feasible, then the decision for TAVR vs surgery (SAVR) is based on your degree of operative risk. TAVR is only approved for patients at medium or high operative risk by the FDA. If considered low-risk, you would need to enroll in a clinical trial (PARTNER-3) which randomizes patients 50/50 between TAVR and SAVR. At your young age, I would be concerned that you have a bicuspid aortic valve, which is generally not anatomically feasible for TAVR.

Pat: If I come from a distance for a TAVR, how long do I need to stay in Cleveland after the procedure?

Robert Cubeddu, MD: The average length of stay in the hospital after TAVR is approximately 2-3 days. Additional days may be required and will depend on procedural outcomes and patient recovery.


Mitral Valve Disease Treatment: Heart Surgery, MitraClip, Balloon Valvuloplasty, TMVR

TIMMY: OHS 4/15/2015 mitral valve replacement, Maze procedure and tricuspid repair at the Cleveland Clinic. I am doing very well thanks to Dr. Gillinov and his staff. My question: Since the mitral valve will not last forever, what progress is being made on the TMVR for repair or replacement? Timmy

Robert Cubeddu, MD: Considerable progress being made at the time. There are ongoing studies and procedures looking at TMVR for patients like yourself. There is a good chance this may become available to you in the future if need necessary.

lorkay: Hello. What is the current recommendation for mitral valve prolapse intervention combined with AFib? What is the current recommendation for mitral valve prolapse?

Amar Krishnaswamy, MD: I'm not certain about the question. If severe mitral valve regurgitation due to prolapse, along with atrial fibrillation (afib), then at Cleveland Clinic we tend to favor mitral valve repair surgery with ablation at the same time of the valve surgery and closure of the left atrial appendage.

If mitral valve prolapse without severe valve regurgitation, then surgery may not be necessary though treatment of the AFib may be warranted either with medicines, anticoagulation, ablation via catheter, or some combination of all of these.

lorkay: Hello. What is the current recommendation for mitral valve prolapse with a concurrent diagnosis of Paroxysmal Atrial Fibrillation? Ablation #1 failed and am now on Sotalol and Pradaxa which is keeping me in sinus rhythm most of the time. My EF is back up to ~50% when in sinus rhythm.

Amar Krishnaswamy, MD: If severe mitral valve regurgitation due to prolapse, along with atrial fibrillation, then at Cleveland Clinic we tend to favor mitral valve repair surgery with ablation at the same time of the valve surgery and closure of the left atrial appendage.

If mitral valve prolapse without severe valve regurgitation, then surgery may not be necessary though treatment of the AFib may be warranted either with medicines, anticoagulation, ablation via catheter, or some combination of all of these.

Melissa: Does the clinic accept or require a TEE procedure results from a patient's home cardiologist prior to appointment for a mitraclip, or would Cleveland Clinic need to perform their own TEE?

Robert Cubeddu, MD: If the TEE images are provided and forwarded to the Cleveland Clinic in advance, the physicians can then review the images and determine if there is a chance you will qualify for mitraclip. You will however need to be seen by a doctor before any procedure is scheduled or performed.

Jamess5: Same question as Pat, if a person comes from some distance for a Mitraclip procedure, how long will they expect to stay in the hospital at Cleveland?

Amar Krishnaswamy, MD: We usually do our MitraClip procedures on Wednesdays, and patients leave the hospital on Thursday morning if they are feeling well and the procedure is uneventful. It would be reasonable to leave Cleveland on Friday if the post-procedural course is uncomplicated.

Consult: Balloon replacement of mitral valve for stenosis vs. minimally invasive surgery for mitral valve stenosis. Which has the least amount of risk and the better outcome, and the better percentage of patient's leaving the hospital?

Robert Cubeddu, MD: Balloon replacement of the mitral valve for mitral stenosis remains unapproved and is considered off-label. Surgery is still the preferred option for mitral valve replacement. Balloon valvuloplasty on the other hand may be a suitable option for you; this will depend however on the etiology of your mitral stenosis and mitral valve anatomy.

Sangupta: My mother is 65 years old. Is percutaneous mitral balloon valvuloplasty safe considering her age. She has leaky valve, hypertension and short of breath.

Robert Cubeddu, MD: Mitral balloon valvuloplasty is an approved procedure for rheumatic mitral stenosis. In your question you raise the point that she has a "leaky" valve; valvuloplasty is not used nor recommended for leaky valves.

Schmidty266: Yes, I'm currently a patient of Dr Niebauer at the Cleveland and have mild mitral value regurgitation and its being watched. I have high blood pressure, on meds for it plus Inderal for the palpitations.  I have bad dizziness on med for it, shortness of breath walking short distance, other symptoms. I'm wondering, should I see a surgeon who actually deals with this type of valve problem, being treatment does not seem to be working and I don't know what to do.  If I just keep letting my Dr. watchful waiting or to see a mitral valve Dr.

Amar Krishnaswamy, MD: It is hard to attribute your symptoms to only mild MV regurgitation. On the other hand, it is possible that your echoes so far have not demonstrated the full degree of your MV regurgitation or there is another reason for your shortness of breath. Since Dr Niebauer is an electrophysiologist, it may be beneficial to seek consultation with a cardiologist who has expertise in valve disease, though not a cardiac surgeon at this time.


Aortic Disease and Mitral Disease Treatment

Jamess5: How many TAVR procedures and Mitraclip procedures are performed at the Cleveland Clinic each year and what are the 1, 3, 5 year success rates for these procedures?

Amar Krishnaswamy, MD: In 2016, we did 374 transcatheter AVR procedures. There was 0% in-hospital mortality. We did approximately 60 MitraClip procedures and also had 0% in-hospital mortality.1-, 3-, 5- year survival rates are not available at this time, but are also less relevant when discussing procedural success since these longer-term numbers require us to also factor in patient co-morbidities.

akka: Risk factors for open heart vs. mitral-and aorta-clip surgery. Recuperation time for both. Percentage of mitral and aortic-clip surgery that goes in a few months to open heart surgery. I have no diabetes, have high HDL, very low cholesterol and triglycerides; I have lung sarcoidosis, irregular heartbeat with pace-maker for bradycardia, and 25 mg of beta blocker day. Would I be a good candidate for open-heart surgery? Because I do not want to be clipped only to come back again for open-heart surgery in a few months. Thanks.

Amar Krishnaswamy, MD: Generally, you are in the hospital for two days after transcatheter aortic valve replacement. Generally, you are in the hospital for one day after MitraClip mitral valve repair. I cannot comment on the feasibility or necessity or benefit of either of these procedures for you without reviewing your imaging and meeting you in person.

akka:  How do you determine who should get open-heart surgery and who mitral- and aortic- clip surgery?

Amar Krishnaswamy, MD: With respect to catheter-based treatments, the clip is for the mitral valve and valve replacement is for the aortic valve. The decision is based upon review of the patient, the patient's imaging, an assessment of the patient's risk factors, and then a final conclusion of what is in the best interests of the patient with regard to expected benefits vs risks.


Tricuspid Valve Disease Treatment

lacy433: I had my tricuspid valve replaced with a pig valve 03/2009. My surgeon put a pacemaker lead right thru the middle of the new valve. In 2015, I am told the new valve is failing and he wants to do surgery again. I get a 2nd opinion this time, and we are watching and waiting. I've already had two open heart surgeries. How would you handle this situation? I don't necessarily want another invasive surgery.

Robert Cubeddu, MD: Tough scenario, and I understand how you feel. This would depend on other factors. If you feel well and are not in any significant heart failure, watchful waiting seems very reasonable.

Shaina: 72-year-old female with 8-year-old failed tricuspid bio prosthesis. Are you performing valve-in-valve percutaneous tricuspid valve replacement?

Amar Krishnaswamy, MD: This is considered an off-label procedure, meaning that it is not FDA-approved. However, if a patient has a degenerated TV and is not a candidate for re-operation, then we do sometimes offer the procedure (which we have done a number of times) in specific clinical situations after careful review.


Heart Valve Treatment - General

cg1217: I had another question: Do any younger patients (40-50) choose a tissue valve? The reason I ask is b/c I am within two weeks before surgery and my concern of the mechanical valve is the need for procedures while on blood thinner. For instance, minor procedures and being on blood thinners, how do patients stay healthy if they needed a procedure and had to come off a blood thinners while waiting. Would there be problems with the valve?

Amar Krishnaswamy, MD: This is a very specific question and truly requires an in-depth conversation with you about the particular risks and benefits. Most patients below the age of 60 years routinely receive a mechanical valve, though there are exceptions. Most mechanical valves tend to last 25-30 years, so you may be looking at another valve replacement at that point via open-heart surgery. Bioprosthetic valves tend to last around 15 years, and can be replaced at that point either via a transcatheter procedure or via another open-heart surgery. The choice of valve is based on many factors and requires a careful discussion between the patient and the surgeon. At the present time, we don't tend to favor catheter-valve replacement of a failed surgical valve for patients at a young age (i.e. < 65 years old or so).

ashadds: What options does CC offer for a younger patient besides a mechanical valve? What options offer an optimal choice?

Amar Krishnaswamy, MD: It is difficult to answer this question without knowing the specific valve issue/location/etc. Some valve disorders can be treated with valve repair rather than replacement, and these procedures are not often done outside of large centers such as ours.

macnikkorguy: I was recently diagnosed as having a bicuspid aortic valve with severe aortic regurgitation via a TEE. Your on-line materials that I have seen reference aortic valve repair or valve replacement as treatments for valvular stenosis, but not specifically for BAVD. Are aortic valve repair and replacement also suggested treatments for BAVD? A recent standard echocardiogram measured my ejection fraction at 55-60%. I also have a patent foramen ovale and bi-directional shunting - predominately left to right. Would it make sense to repair the patent foramen ovale at the same time that my aortic valve repair or replacement is addressed? Thank You!

Amar Krishnaswamy, MD: The treatment of bicuspid aortic valve disease, whether stenosis or regurgitation, is most often performed via open-heart surgery. In centers such as ours, it is sometimes possible to repair a regurgitant bicuspid aortic valve, something that is not done at most places. However, a final decision on valve repair vs replacement requires a thorough analysis of your imaging.

akka: What are the complications in open-heart valve replacement surgeries? Clip surgeries?

Amar Krishnaswamy, MD: The general complications of either include: stroke, difficulty from weaning from the ventilator, or death. The specific risks for a given patient depend on a number of factors that requires an in-depth analysis of you, your imaging, and your co-morbid conditions.


Septal Defects

GHH: My brother had a hole in the heart from a small age, but parents found out at the age of 20. Then he did the surgery at the age of 25. Now he is 32. But he doesn't have any complications now. But will there be any complications in the future? What would be his life span? Will he live up to 60 /65? Should we do an echo test every six months? Please advise me... Thanks.

Robert Cubeddu, MD: If the hole in the heart was taken care of effectively, there is a chance he will not require any further intervention as an adult. It is advisable however that he follow-up with a cardiologist to confirm that all is good at this time. Periodic echocardiograms may be necessary.

Pannu: Is any other treatment available for VSD instead of open heart surgery?

Robert Cubeddu, MD: Certainly, this will depend on the type of VSD. In some instances the VSD may close with the use of a catheter and a special plug without having to perform open heart surgery.


Heart Valve Disease

Mitral Valve Disease

mankmm: I have significant MVP with bi-leaflet thickening "likely secondary to myxomatous degeneration". Why do the symptoms of shortness of breath and palpitations come and go, seemingly randomly (for periods varying anywhere from hours to weeks at a time)?

Amar Krishnaswamy, MD: It is difficult to give you a proper answer without reviewing your imaging. If your MV prolapse is causing severe mitral valve regurgitation, the degree of regurgitation can vary somewhat based on blood pressure, level of activity, etc. With more regurgitation, you can develop the symptoms you describe and that would signal a need for treatment with either cardiac surgery or catheter-based MitraClip based on your situation.

Schmidty266: Hello, I have mitral valve prolapse and mitral valve insufficiency.  I'm wondering if I'm really going to have to have surgery.  I'm being told it gets worse as you get older, it's mild to moderate now. I'm being watched on meds for symptoms, but they don't seem to help. I have low BP.

Amar Krishnaswamy, MD: It sometimes gets worse and sometimes does not. You should be followed clinically on a regular basis with an echocardiogram every few years to keep an eye on the regurgitation.

Aortic Valve Disease

lookingforinfo: 15-year-old diagnosed with trivial Aortic Regurgitation. Heart and value structure normal. No murmur/syndrome/disease. No restrictions and follow up in two years. Can patient outgrow this? Is this normal/pathological/physiological. Can anything further develop? Can be seen in four views on echo. No family history of heart disease. Heart structure normal, no bicuspid valve. Patient's cardio thinks this can resolve spontaneously? Is that possible? An athlete, high level competition, works out with weights. Has no restrictions. Doctor says no disease is present and doesn't classify this as a disease. What is the possibility of this progressing from trivial to worse if the heart structure is normal? Thoughts on spontaneous resolution. Thank you.

Robert Cubeddu, MD: Trivial regurgitation is often seen and it is not considered abnormal. The fact that the aortic valve is not bicuspid is reassuring. In the absence of any other findings you should not be limited by any activities, and you may live a normal healthy lifestyle. Surveillance echo in two years may be advisable if remaining concern persists.


Aortic Aneurysm

bill7001: Hello: Age 83 and in good health...I have (over two years) had a stable aortic aneurism 4.7, also stenosis of the aorta and surrounding arteries. No angina at this time. HR/BP/Cholesterol levels all excellent. Dr. has me on a wait and see status. I'm taking Aspirin, Folic Acid, Doxazosin/Cardura and Atorvastatin 10mg.  Is this what I should be doing? Do you have any suggestions to improve or keep things stable?? Foods...drinks; Meds?? Thank you.

Robert Cubeddu, MD: It seems that your aortic aneurysm is stable and not progressing. Most important is to maintain you blood pressure well controlled. Keeping low on salt intake and avoiding excess caffeine is therefore advisable. Everything else you are doing seems to be fine.

Robert: I have a thoracic aneurism 4.9 cm.   I do not want open heart procedure. Chances for catheter through groin?

Robert Cubeddu, MD: Different to abdominal aneurysm, thoracic aneurysms are most commonly managed with open heart surgery. The option for catheter based approach will depend on the anatomy, the specific location of the aneurysm, its size and the relationship with adjacent vessels.


Fibroelastoma

Summerland: I have been incidentally diagnosed with two pedunculated masses: dx fibroelastoma. Upper edge of the left atrial appendage and aortic valve (right coronary cusp) both 1mm in size. I have been put on aspirin 81mg. Am concerned about embolisms. I am yet to have an embolism. I get a TTE every six months to check for growth. Am I just waiting to have a stroke or are my fibroelastoma so small that they just should not be thought about? I have read that individuals who have had a stroke will have the fibroelastoma removed. Is there a certain size that a surgeon would remove the fibroelastoma?

Amar Krishnaswamy, MD: It is difficult to comment specifically on your fibroelastoma(s) or their size without reviewing the echocardiograms directly. Routine follow-up echoes are not often indicated, especially since proper evaluation usually requires an invasive transesophageal echocardiogram. Without a history of embolism and a fibroelastoma that is truly only 1mm in size, aspirin therapy is considered adequate and the overall risk of embolism in this setting is quite low.

Reviewed: 02/17

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