April 27, 2017 – 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 Deborah Kwon MD and surgeon Douglas Johnston MD answers questions about treatment options for valve disease.
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Mitral Valve Disease
bw: Hi. I am 65, and 3 1/2 years ago I had mitral valve repair for a badly prolapsing anterior flap at Cleveland. An annular ring was installed. At my last check up in my home area I was told that my posterior flap was mostly inoperative, which I assume is restricted by the ring. I also assume there now is back pressure in my heart, contrary to my original problem of stage 4 prolapse. MY heart, I was told at Cleveland, is already enlarged. My question is: Should I not be concerned at this time while I am still active and feel okay, or plan for some type surgery to alleviate this condition while healthy enough. I am not convinced that my medical care here in Arkansas has the means to new methods that you have a Cleveland. Any direction would be helpful.
Deborah Kwon, MD: It depends on how much mitral regurgitation there is. We would be happy to evaluate you here.
nene619: My doctor has told me I have a slight heart valve leakage. Can anything be done now to repair this?
Deborah Kwon, MD: For mild regurgitation we just recommend conservative management with heart healthy lifestyle - but nothing can be done to prevent further leakage - Control of BP is important. It also depends on the underlying cause of the leakage.
hvhelp: Sirs: I had a bio mitral valve replacement four years ago. I had an echo last week and it shows mild to moderate regurgitation (which started six months ago with my last echo), and also now peak mitral gradient 13 mm Hg, and mean transmitral valve gradient 6 mm Hg which says this is elevated even with the replacement. With both circumstances, how concerned should I be and does it appear re-replacement is in the cards, and on what time frame would you expect. Thank you.
Deborah Kwon, MD: At this time, conservative management and follow up echo would be required at this time.
liesel: I am a 78-year-old female with five stents in LAD. I have moderate mitral valve prolapse. Echo said Hypertrophied LV with mild LV dysfunction. Pulmonary hypertension, mild. I exercise five days a week and eat a heart healthy diet. Question: Is there anything else I could be doing to keep the mitral valve prolapse under control, like medication? Is there any evidence that Magnesium supplements are helpful??
Deborah Kwon, MD: Maintain healthy lifestyle, make sure blood pressure is well controlled. Outside of this there is no supplements that will help mitral regurgitation or prolapse.
Mitral Valve Surgery
queeniev: When is surgically repair or replacement for a mitral valve no longer possible? What is the criteria for surgery? Can a prolapsed mitral valve lead to a heart attack or other problems?
Deborah Kwon, MD: The prolapsed valve should not lead to heart attack but if you have CAD underlying and mitral valve disease, that could lead to a heart attack due to increased stress on the heart.
Criteria for surgery for MV Regurgitation - is when there is severe MR with presence of symptoms. If they have mitral valve prolapse without symptoms, if there is a drop in ejection fraction, or if ventricle becomes significantly dilated, or if there is more than 90% likelihood that the valve can be repaired - the patient may be referred to a valve center for repair - even before symptoms occur or there is remodeling of the ventricle. Also if they have atrial fibrillation, or pulmonary hypertension.
Douglas Johnston, MD: This would only occur if a patient is so sick other than the heart - it is rare that a surgery would be not possible due to the heart. We want to operate, however, when the patient is not really sick - because that is when they have the best outcome.
needfixed0317: I am a 68-year-old male. Had porcine mitral valve replacement and pacemaker installation January 2010. Replacement mitral valve began leaking shortly after installation. March 2017 diagnosed with calcification of that mitral valve and immediate valve replacement surgery advised. I am also in stage 3 kidney disease and have acquired cirrhosis of the liver. Had emergency inguinal hernia radical surgery February 2017. Large hematoma developed five days after surgery; still reducing. What would be the expected percentage for a successful outcome if I have the surgery?
Douglas Johnston, MD: We would need to know the other things such as CT scan of chest which shows the condition of the valve, heart and other structures of the chest. We would be happy to evaluate you here and have a method to send in records. Please contact us at www.clevelandclinic.org/heartnurse.
dricke: Are there any new indicators that are used to determine the repair or replacement of mitral valves? I'm concerned that waiting is detrimental to the heart long term. I do not have much of the usual symptoms of swelling in legs, breathing difficulties or erratic afib. But I tend to me a preventive maintenance type of person and fix things before they break down further. I asked this because I am picking up that Cleveland Clinic has adjusted their thinking toward earlier intervention then had been done in the past. I am a 68-year-old male who had rheumatic fever as a child. It burned the mitral. As a result I have permanent afib, leaking valve, but no outward symptoms. Blood pressure is fine, I used warfarin with excellent results since 2006, and low dosage lovastatin. I walk four miles a day. I'm only symptomatic when I go uphill or climb a number of steps. Thank you. Dennis
Douglas Johnston, MD: The decision would depend on change in heart function, how bad the valve function is and how bad you feel when walking hills or steps. We do believe that early surgery is important but we look at all the numbers to make that decision - we use a team approach with the surgeon and cardiologist to determine the decision about timing. We are happy to evaluate you here.
hcmpatient: I am an HCM patient and had myectomy surgery at Cleveland Clinic in 2005. At the same time, a repair was accomplished for my prolapsed mitral valve, using a procedure I think called an Alfin stitch. Now I exhibit mitral insufficiency with a 55% resting ejection fraction (70-75% at stress). My atrium is enlarged (5.1 cm), possibly from the regurgitation due to the leaky valve (2.0/4.0 at rest, 3.5/4.0 at stress). I do not have a history of poor rhythm or Afib, but have had at least one episode with silent PACs. My stamina is reduced from earlier times, but I do not exhibit shortness of breath. My cardiologist tells me that my enlarged atrium makes me a candidate for Afib, and possibly stroke. He has suggested I consider a procedure called a mitral clip. My understanding is that this procedure is relatively new and experimental. Please tell me whether you think a mitral clip is appropriate for me and how risky this procedure would be. Thank you.
Douglas Johnston, MD: If your first procedure was an Alfieri stitch and because you had a myectomy, the mitral regurgitation is probably from a more complex reason - the question is really how bad the regurgitation is and if a procedure is actually necessary. The Mitral clip is probably not the best procedure for you but we would need to evaluate you further to see if a procedure is necessary and what procedure would be required. You can contact your surgeon's office or we can set you up with a cardiology evaluation.
ksuvet: Dr. Johnson performed a complete pericardiectomy approximately four years ago. Will this complicate heart valve surgery if it is deemed necessary in the future? I have gotten along well after surgery but do have some mitral valve insufficiencies.
Douglas Johnston, MD: It makes it a little more difficult to get to the heart for reoperation, but we do an lot of reoperations on patients who have had pericardiectomy - it will not increase the mortality - however it makes the surgery a little more complicated - we have a lot of experience with this.
Sharmonica: I am a 71-year-old female what was diagnosed with mitral valve regurgitation about nine years ago. It has remained moderate to severe with no symptoms. What are qualifications for the less invasive repair or replacement of the valve?
Douglas Johnston, MD: See prior question for indications. Minimally invasive qualifications would require catheterization to see if you have coronary artery disease or indications for other heart surgery and CT scan to determine if you have plaque in the aorta or any other issue with anatomy of the heart that would make minimally invasive surgery more difficult.
Percutaneous Mitral Valve (MitraClip & Transcatheter Mitral Valve Replacement (TMVR))
hvhelp: Sirs: On October 1, 2012 my mitral valve was replaced with a 33-mm bovine pericardial Carpentier-Edwards bioprosthesis. The valve has developed moderate regurgitation and is being considered for being replaced again with any further deterioration. I've inquired locally about any possible trans-catheter possibility and been told that none are possible with that size replaced valve. Is that true even at Cleveland? I would travel there when the time comes if you were able to do it without open heart surgery. Thank you. James
Deborah Kwon, MD: Most mitral valves can be treated with percutaneous valves however we would need to look at CT scans and other testing to determine if you are a candidate - you would require a full work up to see if you were a candidate.
onrylee: Would the "Mitra Clip" procedure be most likely to be successful if the patient's leaky valve condition is considered to be: *mild to moderate *moderate *moderate to severe”, *severe”, or, does it matter? Thanks
Deborah Kwon, MD: Currently the eclip is only approved for severe mitral regurgitation due to degenerative mitral disease - it has to be severe to qualify and the anatomy has to be favorable to the mitral clip.
onrylee: I have read that Cleveland Clinic does one to two of the mitra clip procedures daily. Do you have stats that indicate percentages of success? And, if so, what are the parameters that define "success"?
Deborah Kwon, MD: We do probably twice a week - contact the nurses in our resource center for outcomes. It is only approved for degenerative mitral valve disease so it is not used for all patients with mitral valve disease - the patient needs to be screened to determine if eclip is appropriate and also have to be deemed a non-surgical candidate as well.
golding101: I had mitral valve repair surgery in 2013. I now have mitral valve stenosis due to scar tissue that has developed or from the ring being too small. Do you think that there will ever be a procedure/surgery developed that could correct my stenosis without me having to have open heart surgery?
Douglas Johnston, MD: It is very unlikely that a transcatheter procedure could treat this, because the ring is rigid. Even with a balloon the stenosis can return. Repair or replacement in this scenario is complex - it involves removing the ring and starting from scratch to see what is involved to achieve a competent valve.
Aortic Valve Disease
larryw: Dr. has told me I have leaky aortic valve and stenosis, likely result of radiation therapy underwent in my twenties. Dr. said I don't need valve replacement yet. Is there anything I can do to forestall surgery?
Deborah Kwon, MD: You need close follow up - that is unpredictable how quickly the valves will progress. In the meantime remain active. There is nothing you will do that will affect the progress of the valve.
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.
Deborah Kwon, MD: That can just be physiologic - it is acceptable for valves to have trivial valve leakage and that to be acceptable. Especially without a bicuspid valve. We would not recommend follow up echo unless there is change in symptoms such as change in exercise tolerance. We have a cardio-athlete center here - Dr. Dermot Phelan is director if he wants further evaluation.
User123mm: I am a 37-year-old male with a bicuspid aortic valve and enlarged aorta. I am active, physically fit, with no symptoms. What are the indicators for when surgery should be performed?
Deborah Kwon, MD: It depends on how well your bicuspid valve is functioning and how enlarged your aorta is. For dilated aortas we use 5.0 cm as an indicator of when surgery may be necessary.
Darrell: Can I exercise if I have mild aortic stenosis.
Deborah Kwon, MD: Yes - we typically do not give restrictions until the valve is severe, assuming there is no aortic aneurysm.
Ca.wolf: I am a 47-year-old healthy active male with a family history of bicuspid aortic valve disease. My mother has had her bicuspid aortic valve replaced twice and my cousin has a bicuspid aortic valve. Should I be screened for a bicuspid valve by an echocardiogram even if no Regurgitation present? Should I be screened for aortic aneurysm?
Deborah Kwon, MD: I would say yes. The guidelines recommend all first degree relatives with bicuspid valve be screened with echo.
Nama4: I am a 72-year-old woman with a leaky aortic valve. My 83-year-old brother had his replaced three years ago. My cardiologist seemed unconcerned two years ago, the last time I was examined. Should I go every three to five years for a re-check or will I know when mine needs attention? I am healthy, take no meds, and feel great.
Deborah Kwon, MD: If the interval at which echo is done depends on how much leakage you have now. If it is mild, can do it every three to five years - if it is moderate then need it yearly.
Ca.wolf: Should a 46-year-old healthy asymptomatic male who has both a mother with bavd, surgically repaired, and a cousin with bavd be screened with an echocardiogram even if no regurgitation is heard under auscultation? What is the timeframe for the screening? What is the risk of aortic aneurysm for such a person?
Deborah Kwon, MD: 50% of patients with bicuspid aortic valve also have aortic valve dilation. All patients with bicuspid aortic valves should be screened for aortic aneurysm.
Aortic Valve Surgery
pharmerbrad: I am a 47-year-old male in good health (6'4", 195#) except for a very leaky bicuspid aortic valve, which will require surgical attention. There is no stenosis or calcification. I am being monitored with periodic echocardiograms with my cardiologist. Question #1: How durable are aortic valve repairs? Question #2: Do you use the On-X aortic valve at Cleveland Clinic, and if so, are your cardiologists comfortable with keeping those patients at INR 1.5-2.0, as they are approved for? This is appealing to me because I am very active (mountain biking, hunting, running, etc.) and find the lower risk of bleeding to be desirable. I am also not impressed by the limited lifespan of tissue valves (esp. in young active patients), and would not like the prospect of multiple heart surgeries down the road.
Douglas Johnston, MD: Yes we use Onx valves especially with patients who mechanical valves are appropriate.
Deborah Kwon, MD: For patients who do not have risk of bleeding - we still typically go by the threshold of two-three for INR because of more long term data.
Douglas Johnston, MD: IF you are fixated on mechanical valve - then I think the Onx would be good for you. However we have very good success and put in a lot of biologic valves in very young active patients - we give the patients all the data to help them decide. There is also the option of valve in valve TAVR down the road possibly so that is an option.
brirx: I am a 57-year-old active male having aortic valve replacement surgery, due to congenital subaortic stenosis and now severe aortic regurgitation. I had the valve repaired at age 14. My doctors and myself have decided on the On-X valve. What is your recommendation?
Douglas Johnston, MD: AT 57 you can go for a bioprosthetic valve or an Onx valve - either one would be good option - it depends on lifestyle and other factors.
mdonaldson: I had my aortic valve replaced at your hospital in 2012 with an Edwards Pericardial Tissue Heart Valve. I have read that the average duration of tissue valves is about 10-15 years? I assume that those statistics were determined based upon valves that were replaced 10-15 years ago. So my question is have there been changes to the newer generation of heart valves that would increase their longevity and what do you think I can expect based upon the year and type of replacement I got? Thank you.
Douglas Johnston, MD: The tissue treatment on the valves has changed over the year. The data is on valves put in the 90s and the early 2000s. Even with older valves we know that patients in their 60s have only a 5% chance of needing a reoperation at 10 years. 25% at 15 years and 45% at 20 years.
lee90048: Can you advise what are the criteria for various options for aortic valve replacement or repair? Does a severe aortic stenosis require an extensive open chest procedure?
Douglas Johnston, MD: Severe AS requires a replacement but does not involve an extensive open procedure unless the patient has other problems that require surgery - it can be done through a small incision through the chest that does not involve cutting the bone.
Transcatheter Aortic Valve Replacement (TAVR)
Thanksgiving: I had TAVR surgery 1/2010 (an Edwards Valve). It was successful, but has now calcified and I am going to need another surgery. Since the calcification process cannot be prevented, and this will repeat itself, I am wondering why hasn't someone come up with a way to pretreat the valve so that the calcification will not adhere. (This is a silly analogy, but somewhat like the Teflon coating, or Pam spray, that we use in cooking so things won't stick????).
Douglas Johnston, MD: The leaflets are all pretreated to prevent calcification but the technology is not perfected. As of now there are no valves that can completely prevent calcification.
Thanksgiving: I had successful TAVR surgery (Edwards Valve) in 1/2010. It has since calcified and I will need the surgery repeated. Because the calcification process will happen again, (probably because of all the radiation that was given to me when I was younger.), I have been trying to gather knowledge to help stop this. I have read that Vitamin K2 can help prevent calcification of arteries. Is this true? Is this something you would suggest? If so, what dosages? I am 71 and weigh 114. Thank you.
Deborah Kwon, MD: That has not been known to prevent calcification and we would not recommend this at this time.
Thanksgiving: I am a 71-year-old female who had Edwards TAVR surgery seven years ago. It was successful, but my leaflets have calcified again already and I now will need a repeat surgery. If this happens so soon again after this next 2nd surgery, will I be able to have a 3rd one, etc.?
Douglas Johnston, MD: Unlikely trend to have a TAVR with third one, depending on your case, it may be worthwhile to consider an open surgery either now or in the future if you need surgery again.
aa0660sober: Hello, I am a 56-year-old woman, 165lbs 5' 9", was diagnosed with aortic stenosis but current cardiologist tells me that replacing valve through the same way they did catheterization will not last. Question: is that true? The bed side manner of surgeon gave me a bad feeling therefore will not have open heart. I do not have the down time and recoup time.
Deborah Kwon, MD: You would be low risk for surgical AVR and while we have a trial for low risk TAVR, we can evaluate you.
Douglas Johnston, MD: Here most patients in this age risk have sternal sparing valve surgery - it is not through a catheter, however the incision is not through the sternum. The recovery is faster and patients are happy with this approach.
Deborah Kwon, MD: The European data is suggesting TAVR valves last about eight years at this time, which is less than a minimally invasive or traditional approach with a bioprosthetic valve.
Besenfeld: Which is the better way to replace the aortic valve, going through the groin with a catheter or open heart surgery? The patient is 81 years old and in general good health. Thank you.
Deborah Kwon, MD: For an 81-year-old it is reasonable to go through the groin for TAVR.
Douglas Johnston, MD: The overall recommendations for moderate risk group - either is acceptable and the patient would need to be evaluated. If you are low risk, which you still may be at 81, then it would be part of a research study for TAVR. If you are high risk, then TAVR would be appropriate.
Besenfeld: How long has the going through the groin been around for the aortic valve replacement, and would a surgeon not have more room to connect the replacement valve by open heart surgery?
Douglas Johnston, MD: Almost 10 years we have been doing TAVR. When putting in the valve through the chest, the surgeon cuts out the old valve and sews a new valve in place. In TAVR, a new valve is placed in the old valve.
Pulmonic Valve Treatment
kaberasley: I am 59 years old, post Tetralogy repair in my teens with good result for many years. The right ventricle is enlarged to the point where pulmonary valve replacement is indicated (RVEDV=175) and I am scheduled for transcatheter implantation of a Melody valve at Cleveland next month. I suppose my exercise tolerance has been declining for a long time, but has been noticeable only in the last couple years and has felt significantly limiting for only a few months. My question is: what is a typical heart recovery like? Might I feel years younger all at once, or is there a long process of gradually improved function?
Douglas Johnston, MD: It is likely gradually improved function over the next few months after the procedure. The heart needs time to get used to the new valve and get stronger - just like going to the gym and getting in shape.
Tricuspid Valve Treatment
Nannybo: What about treatment(s) for a regurgitating tricuspid valve, assessed as "severe?" What is the status and outlook for percutaneous procedures to repair regurgitating tricuspid valves? Is Cleveland Clinic currently able to execute such a procedure? What are the other options, given the inherent difficulty of tricuspid valve surgery?
Douglas Johnston, MD: We are doing percutaneous tricuspid valve replacements as part of a research study. We also have a good number of patients with open surgery who require tricuspid valve surgery. Not everyone needs to be treated with percutaneous repair. We would be happy to evaluate you here.
Nerijuspap: Hello. Sorry for recording errors, I'm not Russian. Lithuanian. I would like your appraisal of my study. I want to hear more opinions exercise test. 1) The objective diagnostic 2.krūvio reason for termination of Sub-maximal SSD. ECG changes during exercise maximum horizontal ST depression V2-V4 der -0.5mm -0.6mm -0.6mm. Deepened negative T wave V2-V3. Rhythm abnormalities observed. The reaction in a pile of hypertensive type ... Functional cardiac output PWC 2.36 The average... Myocardial reserve ... satisfactory metabolic unit of 8.2. Functional class. Coronary deficiency, signs of potential. Coronary reserve is satisfactory. Left ventricular signs of deficiency, not revealed. Physical capacity of 150 W 2min 3600 kgm good job. ECG RETURN after three minutes of arterial blood pressure. Return after five minutes SSD negryzo. The sample of ischemic heart disease in respect questionable. Sorry for mistakes because translates from Lithuanian language. I am a man, 30 years old.
Douglas Johnston, MD: We would need to review your records here - we have methods to do that - please contact us for more information - www.clevelandclinic.org/heartnurse.
Minimally Invasive Valve Surgery
adourian: These questions are related to the use of a thoracotomy on a patient that has paroxysmal afib and the need for an isolated aortic valve replacement:
1. What are the pros and cons of using a thoracic incision in addition to its aesthetic value?
2. What % of time is a reversion to a sternotomy necessary and why?
3. Can an ablation be performed in addition to a valve replacement?
4. Can the atrial appendage be closed off as well?
5. What are the outcomes rates in comparison to a partial "J" sternotomy?
6. What are the complications rate vs. partial sternotomy?
7. Who does the ablation, the surgeon replacing the valve or an electrophysiologist
Douglas Johnston, MD: 1) The thoracotomy incision allows for less pain in post op period and somewhat faster recovery. It also makes reop down the road if necessary easier.
2) In our experience it has been less than 2 % of cases, usually due to scar tissue around aorta or heart that we did not see on preop testing - it is not common but can happen.
3) A surgical ablation cannot be performed in this incision - but it is possible to do catheter based ablation in some cases after surgery.
4) Not through this approach.
5) The risk of surgery is the same as compared to a J incision and the recovery in our experience has been a little faster.
6) The same.
7) We don't do concomitant ablation with this incision - but typically it would be the surgeon during the surgery at the same time.
Coronary Artery Disease
Sallyc: I have had in one year 2016 3×2 stents and a heart ablation three times cad rehab and was told I have small artery disease. Tried eccp treatment with no help. I still have PVC like crazy, chest pain and pressure all the time, and that’s at rest. Shortness of breath with any activities or any emotion, on all kinds of meds. I’m at my wit ends! My doctor is at a loss of what to do. What else can i do to get me back to my old life? I need help please!
Deborah Kwon, MD: We would need to evaluate you - we have options for in person appointments and online evaluations.
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