A Surgeons Guide to Heart Valve Health

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Tarek Malas, MD:

My name is Dr. Tarek Malas, and I'm a cardiac surgeon here at the Cleveland Clinic on Main Campus. And my surgical specialty involves valvular surgery, robotic minimally invasive surgery, as well as the general breadth of cardiac surgery.

Xiaoying Lou, MD:

Hi, and I'm Dr. Lou, Xiaoying Lou, and I do adult cardiac surgery here at the Cleveland Clinic Main Campus as well. I also do the whole breadth of adult cardiac surgery and particularly have interest in valve surgery and aortic surgery.

Tarek Malas, MD:

Today, we're going to talk about the basics of valvular surgery. It's a complex topic, and many of you have questions about what are the important factors about valvular surgery. So I'm just going to start with a basic overview of what we do in valvular surgery. But prior to that, we're going to talk about some anatomy. So I'm going to give you a discussion about the heart and the types of valves involved. So the heart has four different valves, and the way the heart is, it's like a circuit. We have the right side and the left side, and like a circuit, the blood goes through the right side and then through the left side.

And I'll explain what that means. When we talk about the right side, we have blood returning from the whole body, and it comes back to the right side, and the right side receives that blood. And the important valves on the right side are the tricuspid and the pulmonic valves. And these valves are very important in preventing backflow of blood so that everything keeps moving forward. So the right side pumps blood to the lungs so that the blood can be oxygenated so that your body and your tissues have enough oxygen to survive.

Once the blood reaches the lungs and is oxygenated, then it comes back to the left side of the heart. And those two valves there are the mitral valve and the aortic valve. And on the left side of the heart, the blood goes through the mitral valve first and then is pumped through the ventricles and out your aorta. And the aorta is the main tube. It's the main artery that comes out of the heart that provides blood supply to the rest of your body. And once it goes through all your body and oxygenates your tissues, it goes back to the right side like a circuit.

Xiaoying Lou, MD:

Yeah, it's really a beautiful dynamic machine and process. And that was very eloquently done. It felt like it was a red blood cell going through with the entire circuit. And in conjunction with all those valves that we talked about, those four main valves that Dr. Malas had mentioned, various things can happen to those valves that cause problems. Obviously, every part of that valve needs to work in concert to be able to pump blood efficiently through your whole body and supply blood for everything that we do in our daily lives.

The main valves that we as surgeons see and have to kind of fix and deal with are on the left side of the body, which, based on Dr. Malas' description, that's a main kind of pumping chamber of the heart. And that's why those valves potentially can get wear and tear faster than valves on the right side of the heart and cause more problems and more symptoms for patients. So we see a lot of aortic valve disease. That's probably the most common kind of valve condition that we see here anywhere as cardiac surgeons and as cardiologists. And then, in addition, on the left side of the heart, that mitral valve.

And both of those valves can have stenosis, meaning obstruction, and usually from calcium and degeneration just over time. Or patients can be susceptible to it because they've had things like rheumatic disease or other disease processes that have accelerated the degeneration of those particular valves. In addition, those valves can be leaky as well. So the aortic valve can be leaky, the mitral valve can be leaky, and all of that can kind of leak blood backwards into the lungs and then backwards to the right side of the heart as well.

On the right side of the heart, you've got your tricuspid valve and your pulmonic valve that we talk about. And typically we don't see as much pulmonic valve disease. Those affect kind of congenital patients or patients were born with certain conditions that affect that pulmonic valve. But it can have problems as well and we can do pulmonic replacements and repairs as well. And then the tricuspid valve, the valve mainly on the right side of the heart that's in between the pumping chamber... sorry, the right atrium and the right ventricle and controls kind of the outflow on that right side of the heart, that valve can also, in rare instances, have stenosis or blockage.

Primarily, it's a kind of regurgitant valve that can cause problems, and that's a valve that can kind of leak backwards as well. And when that valve leaks backwards, the right side of the heart can fail and cause congestion backwards into your liver and swelling in your legs and all of those things. So those are the main ways that we see these valves manifest in terms of disease states.

Tarek Malas, MD:

Yeah. That's an excellent description, and what we actually do is we try to optimize those valves because those valves are so important for the heart function, and if those valves are obstructing the blood flow, that can be problematic. So we try to fix those problems either through repairing or replacing those valves.

And the same applies when you have a leaky valve. The problem with a leaky valve is when your heart's trying to push blood forward, a lot of that blood comes back to your heart, and we try to prevent that by either repairing or replacing the valve.

Xiaoying Lou, MD:

The typical symptoms that patients come in when they have a valvular issue is it could be a range of symptoms, and it really largely depends on where the valve is located. So Dr. Malas went into a really good discussion about the right-sided heart valves and the left-sided heart valves. And I'll just start with the left-sided heart valves. And when you have valves that are affected on the left side, whether they are stuck or calcified and not allowing blood to flow forward or leaking backwards, the process is kind of the same. Not of blood is pumping forward outside of the aortic valve and into the aorta into the rest of your body.

So you basically have what's called a low cardiac output state, and that can cause a range of symptoms. You can have some chest pain because there's not enough blood flow going into the coronary arteries and down supplying the heart muscle, and your muscle can kind of feel it because it's not getting enough blood flow into the coronary arteries. For the aortic valve in particular, because it's a kind of a low cardiac output state if you're not getting enough blood out of that particular valve, patients can present with dizziness and lightheadedness. They can pass out.

And if that valve becomes leaky backwards, every valve on the left side of heart, if it goes backwards, it goes into your lungs. And so your lungs can get flooded with fluid as well. So patients can be really short of breath over time. They can be dyspneic with exertion, and they can get really tired easily. Some patients who have aortic valve or mitral valve problems, they just say that they just can't do the same things that they were able to do beforehand. And it's a progressive process, so they just notice it over time.

They just can't climb up that hill as easily as before, not able to ride their bike as before, and just don't feel like they have the same energy and can't do the things that they want to do in their lives. And that's really a big thing that people come in with that I hear all the time, especially when we evaluate patients with valves on the left side of the heart and heart failure over time, I think, that's symptoms of heart failure and their heart just not able to kind of pump the same way that they used to.

Tarek Malas, MD:

Yeah. That's an excellent point. And a lot of these disease processes are dynamic, and they'll change with time, and they'll progress to become worse and worse. So, initially, symptoms may be mild, but then after that, with time, they do progress, and that's when most patients go see their doctors to say, "Hey, what's going on? And let me evaluate what's going on." The same thing on the right side as well. You do have patients who can present either with fatigue or sometimes that backflow of blood can actually pool in certain parts of the body, like the legs, and you can have some swelling in your legs.

And it can sometimes present as well with what we call arrhythmias. Arrhythmias are irregular heartbeats, and sometimes that can precipitate those irregular heartbeats because the heart is full of volume or full of blood that it can't push forward, and sometimes that can cause some palpitations or some chest tightness as well. So that's why it's important to discuss these... if you ever have any of these symptoms, to discuss this with your cardiologist or your cardiac surgeon. And it's important to see a team that has a lot of expertise, and this is something that we do very well here at the Cleveland Clinic.

Xiaoying Lou, MD:

Great. I was just going to say, a lot of patients come in, and they're like, "I didn't know that this was a symptom. I just thought I was getting older and wasn't able to do the same things that I was able to do before." And there could be some component of that.

But it's better to get checked out because I think it is your valve, we can get you feeling better and on your way and doing all the things that you enjoy in your life. And we're happy to take care of you here with our multidisciplinary team.

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