Lifelong Management of Heart Valve Patients

If you're living with a leaky mitral valve, valve repair can restore your heart health and your lifestyle. Cleveland Clinic cardiac surgeons Marc Gillinov, MD, and Tarek Malas, MD, explain why valve repair is often better than replacement, how robotic surgery can speed up recovery and what patients can expect after surgery.
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Lifelong Management of Heart Valve Patients
Podcast Transcript
Announcer:
Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.
Marc Gillinov, MD:
I'm Dr. Marc Gillinov, Chair of the Department of Cardiac Surgery at the Cleveland Clinic.
Tarek Malas, MD:
I'm Tarek Malas. I'm a cardiac surgeon here at the Cleveland Clinic main campus.
Marc Gillinov, MD:
We want to talk with you about mitral valve surgery, specifically mitral valve surgery for people who have mitral valve prolapse. Mitral valve prolapse is also called degenerative mitral valve disease, or a floppy mitral valve. Those all mean the same thing. Some people who get mitral valve prolapse also develop a leak to the valve. A leak has another name as well, it's called regurgitation.
When the leak or regurgitation of the mitral valve is large, the person needs heart surgery. The person needs that valve fixed in order to ensure a normal life. What we're going to talk about here is mostly how we repair these valves. In general, the approach used to be “your valve is broken, get a new one.” It turns out that when you've got expert surgeons, you can actually get your valve repaired. If we repair your floppy or prolapsing valve, you are much better off.
Dr. Malas, you can tell us. What's good about repair? Why do we do this every day?
Tarek Malas, MD:
Absolutely, these are all fantastic points to bring up. A valve repair is better than a valve replacement in general because of the durability of the valve, as well as preserving your actual native tissue leaflets of the valve. When we repair a valve, we actually reuse your own tissue and reconstruct it so that your valve is functioning as if it's a normal valve. If we're able to repair your valve, we can actually put you back on your normal life expectancy.
On the other hand, if we replace a valve, that involves replacing it with a prosthesis, whether that's a mechanical valve or a tissue valve, and those are types of valves that we can use in place, that's still an excellent option for surgery. However, that does come with some important nuances. For example, if you're replacing your valve, some patients may require being on lifelong anticoagulation, or in the case of a tissue valve, this is a valve that deteriorates over time and may require redo replacements over time.
Marc Gillinov, MD:
Most of our valve repairs, most mitral valve repairs, last a lifetime. You can do anything you want after a valve repair. There are no limitations. You can do whatever you want after a mitral valve repair. You are back to completely normal life. You don't have any medicines you're saddled with.
You just keep on doing what you're doing. If you like to run marathons, go scuba diving, sit behind a desk all day, it doesn't matter. Your valve doesn't care if you have broccoli or occasionally you have some french fries. So, you can get a valve repair and just move on to your completely normal life.
One of the coolest things about this is that Dr. Malas and I can usually do a mitral valve repair robotically. Tell everyone, why do patients like that so much?
Tarek Malas, MD:
There are so many advantages to having robotic surgery, Marc. First of all, the incisions are way smaller than having standard open-heart surgery. That translates to a faster recovery, going back to your normal life much faster, and also less pain and a faster recovery overall. That means that within a few weeks, patients are back to their jobs, they're back to running, they're back to doing whatever they want.
The beauty of that is we don't have any bone cutting in robotic surgery. We actually use three slender robotic arms that go into the chest. That allows us to do the same operation with the same durability and the same power of that operation, just in a much faster recovery. That's a fantastic option for surgeons.
Marc Gillinov, MD:
I think the advice for patients and also for doctors, cardiologists and all of us is if you've got a patient who's got a severe leak to the valve, the mitral valve has a severe leak, severe regurgitation, get it fixed. The valve is broken, it's not going to fix itself. If you leave it alone, it's going to shorten the person's life. So, get it fixed.
Then, when you think about getting it fixed, choose a team that can offer you a very high likelihood of a valve repair, 99% in our hands, and explore the idea of a robotic, less invasive approach, so that you not only get back to normal life, but you get back to normal life as quickly as possible.
Tarek Malas, MD:
When you choose a center like the Cleveland Clinic, you want to make sure you choose a center that has volume, that has experience – and that shows in our outcomes. We have some of the best outcomes in the country. When you come here to the Cleveland Clinic, you're not just getting a surgery, you're getting a lifelong team that takes care of your heart health. That's what Marc and I can offer you here.
Marc Gillinov, MD:
It's comprehensive, it's complete and it's successful.
Tarek Malas, MD:
So, Marc, I have a question that some patients have been asking. What can patients expect after the first few weeks after surgery? What role does cardiac rehab have in their recovery?
Marc Gillinov, MD:
Those are good questions because the surgery happens in a very discrete block, three, four hours and that's that. We say, your echo looks good, but you do have some recovery. You'll be in the ICU usually for a day for monitoring, then go to a private room, walking around, and get out of the hospital in four or five days. When people go home, they're tired. I mean, you're tired, you're walking around, you can do things. If you had robotic surgery, you can pretty much drive yourself home, although we don't recommend it, you want to have someone with you.
You'll be tired initially, just as if you had any surgery, a gallbladder, an appendix or a heart surgery. You'll be a little bit tired, but you'll be active doing things. Walking is the key activity. You're not going to be in bed. You'll be walking and you'll be doing things, and at about four or five weeks, your cardiologist will see you and say, "You look good for cardiac rehab," which is worth doing.
Cardiac rehab is like an exercise class with a personal trainer where you go three times a week. They look specifically at you, personally train you. You are 60 years old and you're 5’9” and you weigh this much and your heart rate is whatever it is – they give you a specific exercise program, and it speeds up the recovery. Mostly people enjoy it as well. So, while the surgery and the hospital experience is going to end in three, four, five days, the recovery's going to go on for a little bit, but it's not a hard recovery. It's an active recovery.
Tarek Malas, MD:
That's the beauty of doing a comprehensive follow-up here at the Cleveland Clinic where you have cardiac rehab. We help build your stamina and your endurance after a big surgery like open-heart surgery. In addition to that, we also help build your confidence so you're back to getting to your normal life.
Marc Gillinov, MD:
Yeah, I tell people who had mitral valve repair for mitral valve prolapse, you don't really have heart disease. We are not sure what causes mitral valve prolapse, what makes these valves leak. What we do know is that once the valve's repaired you have a normal life expectancy, and that's pretty special.
Therefore, I tell people, if someone asks you, "Did you have heart disease after your mitral valve repair?" You could say, "Not really. I had a plumbing problem. I went to some world-class heart plumbers here at the Cleveland Clinic, got my valve fixed up through some little incisions, and I'm good to go scuba diving, skydiving” – well, maybe not skydiving – "I'm good to go scuba diving, run a marathon, do whatever it is I was going to do otherwise."
Tarek Malas, MD:
So, the question comes up about at what age patients should have their valves repaired or replaced. Generally speaking, when you're younger, we prefer to repair your valve. We almost always try to repair your valve. In expert centers, repairs are generally better than replacements.
So, when you're younger, we always try to repair your valve if we can. In some cases, we can't repair your valve, we just replace your valve. For example, in the setting of rheumatic heart disease or the valve is just too calcified or in settings of infections. In the majority of patients, we can repair your valves.
Patients who are older and who have valves that are not repairable, we generally lean more towards replacement. Replacements are great options. Generally, we lean towards a bioprosthetic valve replacement in older patients, in the majority of cases just because that's a valve that provides excellent safety, excellent durability and fits very well in that context.
Marc Gillinov, MD:
The average age at which people have surgery for mitral valve prolapse, the most common leaking valve, mitral valve prolapse, is 59 years old. We don't really think of you as being in an older age group till your mid-70s and beyond. So, if you come in with mitral valve prolapse and you're 59, 69, 75, we're still going to be thinking mitral valve repair is at the top of the list.
Now, if you're 80, we'll be looking carefully at your valve. The key there is to have a quick and safe operation. Oftentimes, a repair is the quickest, safest thing to do in an 80-year-old. If you're 80, 85, and you wind up with a pig valve, you're still going to be much better off than you were with the native valve, the broken valve you brought to us.
The key message when you're thinking about surgery for a leaking mitral valve, particularly mitral valve prolapse, is that you want to think about three things. First, low-risk operation. You want to go to a center that does this a lot, where the risk of surgery is one in a thousand or less, like it is here.
The second thing you want is a very high likelihood of repair of the prolapsing valve, 98, 99% chance of repair. Then the third thing is you want options. You want, particularly, the option of a less invasive or robotic approach if it's appropriate. So you want low-risk, high repair rate, lots of options for a less invasive approach.
Tarek Malas, MD:
One key message I have for patients is to choose a center and surgeons that will take care of you and not just do the surgery. They will take care of you in the long term, and you have a dedicated team of multiple disciplines that will spend time and help you make it through this journey of recovery. It's a journey. It's not a race. So, you want to have a center that will do a good follow-up for you. This is something that we can offer very well here at the Cleveland Clinic.
Announcer:
Thank you for listening to Love Your Heart. We hope you enjoyed the podcast. For more information or to schedule an appointment at Cleveland Clinic, please call 844.868.4339. That's 844.868.4339. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.

Love Your Heart
A Cleveland Clinic podcast to help you learn more about heart and vascular disease and conditions affecting your chest. We explore prevention, diagnostic tests, medical and surgical treatments, new innovations and more.