How Your Heart Surgeon Picks the Best Valve For You

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.

Xiaoying Lou, MD:

Hi, everyone, I'm Xiaoying Lou, and I'm an adult cardiac surgeon here at the Cleveland Clinic main campus. I specialize in valve surgeries, and have special interests in aortic surgery in particular, but do the whole breadth of adult cardiac surgery. And to my left here is Dr. Malas.

Tarek Malas, MD:

My name is Tarek Malas. I'm a cardiac surgeon here, also at main campus of the Cleveland Clinic. My surgical specialties involve valvular surgery, minimally invasive robotic surgery as well. And I also do a lot of the breadth of cardiac surgery as well.

Xiaoying Lou, MD:

Cool. And today we're going to be talking about just common questions, and clarifying different questions that patients have about valve surgery, and the types of valves, and the longevity of those valves. We look at the patient, and the patient's age, and all these other factors that go into consideration of the valve, and our choices and preferences for whether we would prefer a tissue valve or mechanical valve for that particular patient.

Ultimately, it is a patient preference and a shared decision making process that goes into the type of valve. In particular for a tissue valve, if we go down that route, and we have a variety of tissue valves. I generally prefer a cow valve in the aortic position and a pig valve in the mitral position. Is that true for you too?

Tarek Malas, MD:

I actually follow that same principle, and there's many different ways to do this, and some institutions may recommend different things, but that's generally our approach here at the Cleveland Clinic.

Xiaoying Lou, MD:

And I think it does offer better hemodynamic profile, but ultimately it depends, in particular the patient's anatomy and everything. And we always tailor our approach to the patient and their anatomy.

There is always some concern that when we put in a tissue valve, we say that if we take out your old leaflets and put this tissue valve in, that there is an expected life expectancy of that particular tissue valve, and there's a durability component to it. And I think there are newer generation tissue valves now, and we always try to use good valves that have really good durability profiles. And there's newer valves that have come out with anti-calcification technology that we incorporate into our valve choices as well here.

But generally, I think you can get about 15, even 20 years off of some of these tissue valves at this point. And so much of the data, and especially a big bulk of the data that has been collected here at the Cleveland Clinic, has demonstrated that, particularly in younger patients who are getting tissue valves and are worried about durability, the biggest risk factor that concerns durability is the pressure gradient across the tissue valve that we put in.

So we assess these gradients across the valve, the pressure increase across that valve that we put in, in the operating room. And if we can get that gradient as low as possible, usually that's a really good prognostic factor for that valve lasting a long time.

And the ways to do that are to really put in the biggest size tissue valve that your particular anatomy can accommodate. And there are ways that we as surgeons can help with that, to help accommodate a bigger size valve. And things that we do here include an annular enlargement procedure, which I explain to patients is: you have a circle that the valve goes in, and we can cut across that circle and sew a patch to that circle, and basically enlarge the dimensions of the valve that we can put in for you.

And in addition, we offer, particularly for the aortic valve position, aortic root replacements, which allow us to get a bigger size tissue valve in, if that's the case as well. And I think those combinations of adjunctive procedures allow for a great result for that tissue valve. The biggest size tissue valve that we can get in, and accommodate additional valves in there, if you are a TAVR candidate, for instance in the future.

Tarek Malas, MD:

So Dr. Lou's made some excellent points. And one important point that I tell my patients is, it's important to go to a center or to a surgeon that has a lot of experience in replacing and repairing valves. That can really help alter your course, and try to improve, alter the course of the disease, and try to improve your life expectancy.

And like Dr. Lou had said, sometimes we can repair valves. And if that's an option, we can see that patients, even in the mitral/aortic realms, we can see that patients have a survival curve that almost matches the general population.

Now, you can either repair or replace a valve. And a replacement is also an excellent option, and it does give you a good life expectancy in general. It really depends also on the type of valve. So when you go see your surgeon, it's important to have that discussion, because that discussion relies heavily on your values and what you want as well.

Like Dr. Lou had mentioned, if we look at the comparison between a valve replacement of a tissue valve versus a mechanical valve, there are some important differences that you should think about. Generally, for a mechanical valve, that's the valve that's made by industry, that's a valve that can last for a long time. But you do need to be on blood thinners for that type of valve, and that can have some important implications on your quality of life.

Some patients prefer not to be on blood thinners, given the inherent risk of being on a blood thinner. And that may not be necessarily the best option. The benefit of a mechanical valve is it lasts for a long time. And some of our younger patients prefer that type of valve. On the other hand, a tissue valve is a stented valve that has treated animal tissue. And one of the questions that my patients ask me all the time is, is this a pig or a cow transplant? Will I reject that valve?

The answer to this question is, not really. This is a valve that uses animal tissue. And that animal tissue is treated so that you don't reject it. The main reason your replacement valves degenerate over time is just because of wear and tear, and not because your body rejects it.

Some people go through their valves faster than others, and that may be related to age or certain other types of factors. But in general, the tissue valves could last anywhere from 10 to 20 years, and that depends on your age.

The benefit of a tissue valve is, you may not necessarily need to be on blood thinners, just baby aspirin. Some surgeons may put you on blood thinners for the first three months after a mitral valve replacement, but in most cases, you just need baby aspirin for life. And that will improve your quality of life from a bleeding point of view, where you don't need to be on blood thinners. But that does bring forward, down the line, a re-replacement once that valve deteriorates.

Xiaoying Lou, MD:

The current guidelines really are different for the type of valve, whether the aortic valve or the mitral valve, but the aortic valve being the most common valve that we deal with in the cardiac surgery community.

If you're over the age of 65, generally we are recommending moving forward with a tissue valve. Under the age of 50, a mechanical valve or a Ross procedure. And in between, it's really a shared decision making process through all of this. And in particular with the aortic valve, it's definitely a heart team approach that we have here, which is based on, our cardiologists are involved, and our surgeons, we are involved. And then we offer these recommendations, and then we look at patient's lifestyle, and preferences and all of those things.

And then I think that's a big factor. I think someone who's very active, and potentially is at more risk of cuts and bruises, because of the line of work, or activities that they enjoy doing, tissue valves may be a very good option.

And as we were saying earlier, as long as we put in the biggest tissue valve that we can for that space, and try to optimize that as much as possible on our end, we get really good longevity out of that tissue valve. And then if they were to need another valve, there are additional options of a TAVR [transcatheter aortic valve replacement] procedure down the road, or another re-operation, which we do all the time here.

Tarek Malas, MD:

And I'd like to echo those comments as well. It's important to meet both your cardiologist and your surgeon to have that discussion, to discuss what you want, what your values are, and what you're to expect out of your surgery.

One other very important approach is, we can also sometimes do this in a minimally invasive way. That can be done through either what Dr. Lou had mentioned, what we call a TAVR valve, which is a valve that's passed through the catheters. And rather than having an open heart surgery, we can sometimes do that that way. Or sometimes that can be done robotically or through a smaller incision. And those are all important discussions to have with your surgeon to see if you are a candidate.

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