Ask the Heart Doctor | Minimally Invasive Valve Surgery

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Dr. Lars Svensson:

Hello. Welcome to this chat we're going to have about valve disease and various approaches to doing valve surgery and the options that are available. I'm going to start off by asking my two colleagues here, Marc Gillinov, chief of the Department of Cardiothoracic Surgery, and Per Wierup, who's a master also at the robot and myectomy and very special procedures. What is minimal invasive heart surgery?

Dr. Marc Gillinov:

These days, minimally invasive heart surgery tends to mean anything that is not a standard full sternotomy, a full incision down the middle, which is the most common procedure, the most common approach to the heart. But we have partial sternotomies. In fact, Dr. Svensson pioneered what's called the J incision, which is a partial sternotomy that is less invasive. Then we have a variety of approaches that go through the chest wall on either side through small incisions. The most common in our practice of those is robotic or robotically-assisted surgery in which we can make very small incisions and now treat the mitral valve, the aortic valve, bypass surgery, take out certain cardiac tumors, close holes in the heart. But these days, incisions are getting smaller and smaller.

Dr. Lars Svensson:

Per, what's the benefit of minimal invasive surgery?

Dr. Per Wierup:

There are several benefits for the patient. I mean, first of all, we can do the surgery as good and as accurate as if we do it in the open way. But the patient has much smaller incisions, less bleeding, less pain, less trauma to the body, and less inflammatory response. That translates into the patient typically staying two, three, or four days after surgery, where they would normally stay a week or more. They also have a faster overall recovery and return to work.

Dr. Lars Svensson:

So add a couple of things just from a medical point of view. There's obviously the cosmetic benefit, especially with robotic surgery. The incisions are hidden, particularly as far as cuts on the center of the breastbone. Healing is quicker. We tell patients they can start driving two, three weeks after the minimal invasive J incision. What are you telling patients after robot surgery nowadays?

Dr. Marc Gillinov:

After robotic surgery, we tell them you can drive two or three days after discharge.

Dr. Lars Svensson:

Yeah. A lot depends how patients feel, but you don't have that restriction of waiting six weeks. There are breathing benefits, so people recover better from that. There's less bleeding and less pain. We have done a number of studies now on the benefits of minimal invasive J incision and robotic surgery, and as Per mentioned, the length of stay is shorter and recovery and getting back to work is also quicker.

Marc, which valves can you do with the robot?

Dr. Marc Gillinov:

The robot is very versatile. The most common valve that we either repair or replace with the robot is the mitral valve and mitral valve repair, particularly for prolapse. Mitral valve repair is the most common operation to do with the robot. We can now also replace the aortic valve and we can repair the tricuspid valve, meaning of the heart's four valves, we can manage three of them very well with the robot.

Dr. Lars Svensson:

Per, what about the tricuspid valve? You do quite a lot of congenital heart surgery, atrial septal defects and some of the other uncommon things.

Dr. Per Wierup:

It's very perfect to use the robots, are the minimal invasive approaches for them. Many of these patients, or most of these patients, are very young females, and they really demand a nice cosmetic result without any compromises of the safety and efficacy.

Dr. Lars Svensson:

Per, just carrying on, how do you actually set up the robot for robotic surgery?

Dr. Per Wierup:

First, we make really sure that the patient is suitable, that we're not taking any risks. Safety is the most important thing. Then we set up, so we establish the heart lung machine using a very small incision in the right growing crease. It's so small and so nice when we ask the patient afterward how they're doing, "Do I have an incision?" And then, once that is established, we make a small incision, and in females, typically in the fold under the right breast. Then we also puncture in a couple of small working ports that are typically a third of an inch. Then, with the 3D camera, we get the perfect visualization of the heart and the pathology. It feels like you're walking around inside the heart.

Dr. Lars Svensson:

Marc, J incision, how do you do the J incisions?

Dr. Marc Gillinov:

The J incision is a minimally invasive approach that is called a partial sternotomy as well. It is in the middle, but it starts well below where your neck meets your chest. You feel that notch here in the neck. We start below that so that you can wear an open collar shirt and then make a small skin incision and go through part of the bone. Through that, you can see the aortic valve, the mitral valve, the aorta, the largest artery in the body. You can work on the tricuspid valve. It's very, very versatile, and people recover very nicely from it.

Dr. Lars Svensson:

Yeah. Just to add and stress what Marc was saying, if patients need the ascending aorta done, then that's an approach that we can use for aortic surgery, whereas that's really not something we do on a regular basis with a robot. For example, I did an 84-year-old patient this morning, and that's the way we did it.

All right. What testing do you like to do on patients before minimal invasive surgery, and what makes a patient a candidate versus not a candidate for a robotic or a minimal invasive J incision?

Dr. Marc Gillinov:

Patient safety. We want to make sure we can always do exactly the same operation, fix your valve and make sure that your risk is extraordinarily low. How do we determine that? If it's a valve issue, you'll always have an echocardiogram or ultrasound of the heart to look at the valve of interest in all your other valves, make sure your heart function is good. You'll have a cardiac catheterization to look at the arteries of the heart. This is to ensure you don't have any blockages that require bypass surgery. Then, for the robotic approach, we also get a CT or a CAT scan to ensure that we can hook up the heart-lung machine to an artery and vein that are appropriate and safe. The three things we need in everyone are an echocardiogram, cardiac catheterization, and a CAT scan or CT scan.

Dr. Lars Svensson:

The patient has a cardiac catheterization, say has some coronary artery disease or has atrial fibrillation, what do you do for those patients?

Dr. Per Wierup:

I would say we address all the patient's problems. If we start with atrial fibrillation, and as I said, our most common minimally invasive procedure is robotic mitral. Many of these patients have a history of atrial fibrillation, and we treat that at the same time. We get perfect visualization, and we do the same ablation as if we would have done it openly. In the cases where the patient also has coronary artery disease, I think we are the only program who can offer a combination of both doing the mitral valve repair robotically and at the same time doing robotic coronary bypass surgery.

Dr. Lars Svensson:

So just to pick up on what Per was saying there, we do also robotic coronary artery bypass surgery. That's not something that is done around the country, but that is also an option. Sometimes that means two surgeons work on a patient with different expertise for different parts.

Marc, what about elderly patients, patients who've got pacemakers or have had previous heart surgery? What are your thoughts about minimal invasive and robotic surgery?

Dr. Marc Gillinov:

We can still do less invasive robotic surgery and minimally invasive surgery in people who are elderly regardless of age, as long as we have done our preoperative testing and we're sure we can do the operation and maintain safety. We've done robotic surgery and minimally invasive J incisions in people well into their 80s with no problem and in fact quicker recovery, shorter hospital stay. There's a particular benefit then for people as they get older. Pacemakers are not a problem, not a contraindication whatsoever.

Dr. Lars Svensson:

There is an individual selection approach. As Marc mentioned, if on CAT scan there's evidence of a lot of atheroma on a CAT scan in what we call a descending aorta or abdominal aorta, then we generally will avoid perfusion through the femoral artery for robotic surgery because that increases the risk of stroke. It doesn't necessarily rule out robotic surgery, but that is a factor. Sometimes for some of the coronary artery bypass surgery, it will require full sternotomy to do a full revascularization. In those cases, we may not always be able to do it robotically or, for that matter, with an invasive J incision.

Let's talk a bit about repair versus replacement with the two major approaches we use. Marc, do you want to start with that?

Dr. Marc Gillinov:

For the mitral valve, which is the valve that we repair probably most commonly, mitral valve repair is better than mitral valve replacement, particularly in people who have mitral valve prolapse, which means the valve is floppy. If you have mitral valve prolapse and the valve leaks, a valve repair will make you live longer than a valve replacement. With our expertise here in the largest mitral valve repair program in the world, we repair about 98 to 99% of people who have mitral valve prolapse, meaning they go home with their own valve that is simply fixed up or tuned up, and most of those repairs last a lifetime. A valve repair returns you to a normal life.

Dr. Lars Svensson:

So Per, patients who've had, let's say a previous aortic valve replacement or mitral valve replacement, what's the role for the minimal invasive incisions in those patients and what are your thoughts?

Dr. Per Wierup:

Yeah, especially if they've had a previous aortic valve replacement, that valve is sitting a little bit covering partially the mitral valve when you're coming from a sternotomy. We find the minimally invasive approach very helpful there. You can come from the side, and when we use the robot, we can angulate the camera so that we simply see around the corner and then we can do it there.

Dr. Lars Svensson:

One of the provisors, though, is how the previous surgery was done, and the question is if the lung on the right side is stuck down, because that may affect whether one's able to get safely to do the mitral valve and get an approach that is appropriate for a safe repair.

All right, let's talk about patients, the selection of the mechanical versus biological valves, and the way you think about that nowadays, Marc.

Dr. Marc Gillinov:

There are two broad options: a mechanical valve or a biological valve. The mechanical valves are made primarily of carbon. They more often than not last a lifetime, meaning people who get a mechanical valve are usually thinking, "I won't meet a heart surgeon again." But they have to take a blood thinner and that blood thinner has to be Coumadin, which means that they need repeated blood tests every month to make sure that their blood is appropriately thinned and they're at some risk for bleeding. But with a mechanical valve, you might be done for a lifetime, may last your whole life.

The biological valves, which are pig or cow valves, don't require any blood thinners, but they can wear out. Most of the time, they'll last about 10 years, and the older you are, the longer they last. If somebody is in his or her 70s, they would for sure choose a biological valve. If somebody is 25 years old, he or she might choose a mechanical valve, but it's really up to the patient.

Dr. Lars Svensson:

Okay, good. Yeah. Let me just touch on one thing that we didn't touch on the aortic valve. As you've heard, for the mitral valve, we have a very high success rate of doing mitral valve repairs with a robot and patients who have leaking mitral valves, something that exceeds 95%. The durability long-term is just as good as a full sternotomy and obviously quicker recovery, less complications. We've done about 2,700 robotic mitral valve repairs now with superb results, but we can also do aortic valve repairs. The last couple of days, I've done three of them, and it depends on what kind of valve it is. If it's a bicuspid valve, that's usually a straightforward operation and that can be done with a mini invasive J incision. If it's a more extensive procedure and potentially needs coronary artery bypass surgery, better myocardial protection, then I usually have to use a full sternotomy for that and do what we call a re-implantation operation. We preserve the valve, replace the aortic root, hook up the coronary arteries, and attach those to the side of the new plastic Dacron tube. We do a lot of repairs here at the Cleveland Clinic for the aortic valve, which is not typically done anywhere else around the country. We have a very big series of those patients.

Let me just make one comment about biological valves. We just finished a study looking at patients who had a new biological valve done with what we call RESILIA tissue, and that was on an older stent. With a 10-year follow-up, the durability was the same from the age of 50 to 85 years of age. Less than 2% failed within 10 years, which is an improvement on the older valve that we used to use, and we've shown that.

Now, the valve that is marketed now by Edwards is slightly different from the one we used in the research study, but it has that RESILIA treatment. It's called the INSPIRIS valve, and that is a valve we'll often use for replacement of the aortic valve.

Dr. Per Wierup:

We either use the pig valves or the cow valves, and there are studies speaking in favor of one and others speaking in favor of the others. I would more look in... In a place like Cleveland Clinic, we repair 99, 99.6% of our mitral. The remaining that really needs a mitral replacement, their pathology are so advanced, either if it's because extensive destruction from infection, endocarditis, or if they have very extensive calcification that we have to work on. In both those instances, which are typically the only cases where I replace the valve, you have a challenge in getting the valve seated nicely in the heart. For me, it's very important to have a good sewing cuff so that we can really seal it off so that the valve doesn't leak around it.

Dr. Lars Svensson:

Yeah. That's a good point. Yesterday, I had a patient who had to have a re-operation, a failed mitral valve repair done through the right chest incision, so not robotic, but also needed the aortic root replaced in the ascending aorta and aortic valve. In that patient, I have to use a full sternotomy. As far as the mitral valve, it was a metal ring, and so that took quite a bit of time to clean that out. In that case, I used the Epic valve, but it's a pig valve because we've got some evidence maybe the pig valves hold up a bit better in the mitral valve position than the pericardial valves, the cow valves, whereas in the aortic position, except for unusual situations like patients with left ventricular assist devices, we prefer using the cow valve in that situation.

All right. Marc, when should patients have interventions for their valves? Let's start with the mitral valve.

Dr. Marc Gillinov:

You should have an intervention on your mitral valve when it's broken, when it leaks a lot. The most common problem with the mitral valve today in the United States is a leaking mitral valve. When that leak is caused by prolapse or excessively floppy tissue, and when that leak is severe, it's time to start thinking about getting it fixed. Many people think, "I feel great. Why should I get it fixed?" The answer is because if you don't get it fixed, you will develop symptoms, like shortness of breath, fatigue, and when you develop symptoms, you may have heart damage. Therefore, with the mitral valve, when it leaks a lot, the valve is broken, it's not going to fix itself, and you should get it fixed. It's not an emergency, but within a few months.

Dr. Lars Svensson:

Yeah, good point Marc was making there. We now know what happens with the mitral valve when it's leaking: it decompresses into the left filling chamber, so the left atrium. That's an easier way to pump blood than pumping it out of the aortic valve, because then you're pumping against the blood pressure of the aorta. If mitral valve repair surgery is delayed, then the left ventricle has to pump much harder, and it may appear to be weaker after surgery. That's something that we see.

We occasionally see that also with aortic valve with longstanding aortic valve regurgitation, but particularly for the mitral valve, the mitral valve repair, even though successful, may not entirely return the left ventricle to normal if it's a longstanding problem. That's why we've gone to earlier intervention for mitral valve regurgitation.

Dr. Per Wierup:

Yeah. Again, for the same reason, for regurgitation, you really don't want to wait until the patient has symptoms because then it can be almost too late. It's important to have serial echo, close follow-up. When you have a severe leakage, there are clear criteria from the cardiologist when they should send us. The fact of waiting for symptoms belongs to the past.

Dr. Lars Svensson:

I'll just add for aortic valve stenosis, the symptoms, and in one sense, fortunately they show up earlier, they are tiredness, not able to keep up with exertion at the same level, sometimes dizziness, that's usually pretty late, and chest pain may also occur also, can be late. Sometimes problems with the legs, feeling weak, but that's also tends to be late. But with the aortic valve and a narrowed aortic valve, the symptoms tend to occur a bit earlier. Unfortunately, for the mitral valve and a leaking aortic valve, that's fairly late. Again, with leaking of the aortic valve, as with the mitral valve, you tend to start getting damage to the left ventricle, particularly scarring, and then maybe not an entire recovery from that over time.

So, can two valves be done at the same time with the robotic or the minimal invasive J incision, Marc?

Dr. Marc Gillinov:

With robotic, we can do two valves, the mitral valve and the tricuspid valve at the same time. I suspect, in the near future, we'll be able to add the aortic valve to the list of things we can do robotically at the same time. With the J incision, the minimally invasive incision in front, we can do three valves at the same time, mitral, aortic and tricuspid. People need not think it's more serious to need the tricuspid valve or to have two valves. We can do those at Cleveland Clinic, one valve, two valves or three valves. We can do it at Cleveland Clinic with remarkable success.

Dr. Lars Svensson:

Per, in patients who've had previous biological valves that fail or patients who've had, say, a previous mitral valve repair and come back because it's failed, what are you thinking about how to handle that, and at what stage do you start considering transcatheter cardiology type procedures, in other words, mitral valve clips or TAVR?

Dr. Per Wierup:

If we start with the failed mitral repair, we've learned, and we have a growing experience since the last 10 years of doing re-repair that have shown if you can do a nice re-repair, these patients do way better in terms of long-term survival. We are getting, I would say, very good at repairing those valves, and we are getting patients from all over the US to do that. Our go-to is to do re-repair, and we have really many tricks up our sleeves.

For a structural valve deterioration of a mitral prosthesis, that is considered to be a high-risk surgery here in the US, with a mortality rate of around 15%. We have looked up about 500 of our patients like that, and our risk here is less than 1% if we go in and replace and give them a new prosthesis. That is our standard approach for that. It's only if the patient's overall comorbidity, if the patient is simply too sick, then we recommend a valve-in-valve.

Dr. Lars Svensson:

Let me just touch also on aortic valves. In our hands, the first re-operation after aortic valve replacement that's been done previously, the risk since 2010 has been the same as the first operation. That does not carry an increased risk for us. It's really only re-operations after the age of 85 that we have a higher risk of re-operations. There's obviously the big debate about TAVRs versus open AVRs, and we do most of our isolated aortic valves as minimal invasive operations, and we think that's the best place to start, particularly as patients potentially are looking at multiple procedures over time. We think it's important to maybe have one, if not two, biological valves as an option, and then after TAVR, when patients are much older, at least based on our experience, enhance.

Now, there will be new American College of Cardiology and American Heart Association, and I represent the American Association for Thoracic Surgery on the rewriting of the valve guidelines. There'll be an update coming out towards the end of this year, early next year, on guidelines on valve treatment. Usually, there's a simplified document too, and we'll certainly be reviewing that and discussing that.

After valve surgery, what should life be like, Marc?

Dr. Marc Gillinov:

Life should be good after valve surgery. If it's a valve repair, your life is not only good, it's normal. You have your own tissue. You get an echo once a year, and otherwise, there's little to no maintenance after a valve repair. After a valve replacement, you can be as active as you wish. A bioprosthetic replacement, a tissue valve doesn't require any blood thinners, meaning you can ski, you can swim, you can bike, you can do whatever you want.

If you've had a mechanical valve and you're on blood thinners, you need to be a little bit cautious about high-impact or high-risk activities. But people who've had valve repair and valve replacement are running the Boston Marathon, they're playing tennis. They're living life and doing everything they want to do.

Dr. Per Wierup:

We recommend them to get back to being active, practically as quick as possible. We, though, want the breastbone to heal, and if it's very strenuous exercises, we recommend that they wait about three months for that. Normally, it's healed after two months. But otherwise, in general, it's safe to get moving and really exercise. I would refrain from taking maybe hot saunas and then jump into ice cold water because you get a very high blood pressure with that. That's normally not so good.

Dr. Lars Svensson:

Yeah, that's an interesting point you make. A patient I operated on today, he's a super fit guy. He basically trains like a professional sportsman and he came in and showed me some videos of some of my NBA players that I've operated on and them returning to playing basketball in the NBA. In fact, Jeff Green got his ring and the championships a couple of years ago, 11 years after having his aortic valve and root replaced. We all have had a lot of professional sportsmen that have gone back to playing professional sport, and that's what we hope happens. Usually, I recommend people to wait about eight weeks before they get back into loosening up and training. Jeff Green took a year before he signed a contract again for the NBA. This is obviously well known and something that I'm not disclosing that we haven't already talked about and we've done interviews together.

So initially, your body is going to tell you if you're overdoing it. As Per said, I don't recommend people do a lot of squats and push the limits on bench pressing when they've had repairs. We don't have any evidence that it may break down repairs, but we don't encourage that. One of the residents reviewed a series of mine of the aortic root re-implantations and the freedom from re-operation at 15 years is 95%. In other words, 5% failure in the first 15 years after surgery, and that's probably going to continue at 20 years, maybe 93% or something like that. Mitral valve repairs, similar, excellent results.

Once you've had a successful aortic valve re-implantation or mitral valve repair, that should be good for life and you should be back to completely normal if you have the surgery done in time and you should recover fully.

One of the questions was what about shortness of breath? That can certainly happen after surgery if somebody has residual heart failure and the left ventricle doesn't fully recover, or there's some other breathing problems after surgery, or that were present before surgery. That's always a possibility.

What about medications long term for patients with mitral valve surgery, including atrial fibrillation and anything else, Marc?

Dr. Marc Gillinov:

If at all possible, we like to get people off blood thinners. The good thing, amongst many, about mitral valve repair is that if you get a mitral valve repair, you generally don't need an anticoagulant or a blood thinner. We do recommend a baby aspirin each day after a mitral valve repair.

If you come in and you have a mitral valve problem and you also have atrial fibrillation, we will add on to your mitral valve repair an operation called an ablation or also it's called a maze procedure, M-A-Z-E. This ablation or maze procedure for atrial fibrillation, more often than not, cures the atrial fibrillation. That's good because if your atrial fibrillation is cured and goes away, you don't need blood thinners. If somebody, on the other hand, develops atrial fibrillation years later, as many people do with aging, atrial fibrillation alone would cause the need for blood thinners. But at the time of your operation, we want to do everything we can to fix your own valve, make sure you have a good heart rhythm and just leave you with a baby aspirin a day.

Dr. Lars Svensson:

And what about patients who have a mitral valve replacement? Would you put them on Coumadin for three months after surgery or what's your current practice?

Dr. Marc Gillinov:

That's a good question. If somebody's had a mitral valve replacement with a pig or a cow valve, a bioprosthesis, we don't usually put them on Coumadin or blood thinners, but many surgeons do. We don't have data yet to tell us, should you put them on blood thinners or shouldn't you? So, at this point, we don't, unless they have another reason, although we may vary amongst ourselves.

Dr. Per Wierup:

I place many of mine on a period of Coumadin or DOAC, but practically, as I said before, the ones that I replaced the valves are the ones that are very, very sick. Many of them also have atrial fibrillation, which increases the risk for clots. On the other hand, if we have endocarditis patients, infection in the heart, some of them could have had a stroke before surgery, and then I'm very hesitant to give anticoagulation because it can cause late bleeding. We make very individualized judgments.

Dr. Lars Svensson:

As you've heard, as much as possible, we use minimal invasive incisions for robotic surgery for the valve surgeries, and that includes the tricuspid valve, mitral valve, and aortic valve. As much as possible, we repair the valves because the durability is very good and it's better than biological valves. But I'm going to put my colleagues on the spot here because this is a question many of you ask. If you were to have to have a replacement of your aortic or mitral valve, what valve would you choose, and what would you do long-term about that valve?

Dr. Marc Gillinov:

First, I would choose my surgeon, one of you two. I'm 64 years old. I expect and pray that I will live a good, long time. For either valve replacement, aortic or mitral, I would choose a tissue valve. I would actually choose a cow valve for an aortic valve. I'd choose a pig valve for my mitral valve. If those valves or that valve wears out in 10 years, now I'm 74. I would be between having surgery again or having a cardiologist put a valve in, going up an artery or vein in my leg. If I'm a healthy 74, I'd probably have surgery again.

Dr. Per Wierup:

I agree with Dr. Gillinov. Apart from that, I would definitely have a repeat open heart surgery when my biological valve would deteriorate, and I would pick my surgeon, one of you two. No, I think that is really what determines the risks and the outcome.

Dr. Lars Svensson:

Yeah. I think, as I was hinting, I would be prepared to, as was also stated now, have two in series biological valves. A biological valve, and I've been saying that since the age of 50 because I have a very active lifestyle and with some risk of bleeding and problems with dealing with mechanical valves and Coumadin.

First time, biological valve, repeat biological valve, and then, if I'm in my late 80s, I might consider a TAVR, but that's because I trust my colleagues. Or I can always go to Home Depot and buy a big mirror and do my own re-operation.

We have great people here. As I said, the results of re-operation for the aortic valve and as past stressed on the mitral valve here at the Cleveland Clinic are very low. As you've heard, we do a lot of the straightforward operations with the minimal invasive and robotic surgery. Then we do a lot of complex surgery, multiple re-operations, combined with coronary artery bypass surgery, or failed operations. People come from all over the country here, and some of our most common patients from outside our state of Ohio are other doctors, because they know where to come when you have a complex problem or a simple procedure that you want to recover quickly from. Welcome to the Cleveland Clinic.

Thank you, guys.

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