Live Web Chat Transcript:
Latest Innovations in Mitral Valve Surgery - April 25, 2007

A. Marc Gillinov, M.D.
Cleveland Clinic Heart and Vascular Institute
Cardiothoracic Surgeon &
Surgical Director, Center for Atrial Fibrillation

Cleveland_Clinic_Host: Thank you for joining us! Today's chat with Dr. Gillinov will begin shortly. Please submit your questions by typing them below and then clicking 'Ask'. We'll get to as many questions as we can.

Cleveland_Clinic_Host: Welcome Dr. Gillinov and thank you for being with us today. Let's begin!

Speaker_-_Dr__Gillinov: I am very happy to be here. There are many great questions. I will try to get to as many as I can within this hour.

Before mitral valve surgery - Symptoms and types of mitral valve disease

golden: SHOULD YOU BE CONCERNED IF YOU HAVE A SOFT MITRAL VALVE MURMUR?

Speaker_-_Dr__Gillinov: If there is a murmur, this usually means abnormal flow through a heart valve. An echocardiogram should be used to identify the problem and to determine if surgery is indicated.

scarlet123_2: What does a small leaky valve mean?

Speaker_-_Dr__Gillinov: How much a valve leaks is graded by echocardiogram. A small leak, which may also be referred to as a grade 1 leak, is of no clinical consequence and we recommend periodic follow-up by echocardiogram. Operation is undertaken for leaks of grade 3 or 4.

Cleveland_Clinic_Host: Dr. Gillinov, there are a lot of questions about mitral valve prolapse. Can you discuss this condition?

Speaker_-_Dr__Gillinov: MVP affects 2 - 3% of the population. People with MVP have a slightly floppy mitral valve. About 3% of people with MVP develop a leak in the valve. This may require surgery. Most people with MVP have a benign condition and should undergo periodic echocardiogram, a non-invasive test to assess the valve.

Speaker_-_Dr__Gillinov: We have a Mitral Valve Prolapse Clinic at the Cleveland Clinic composed of specialists that address these issues in detail.

tranja: What is the difference between mitral valve disease and MVP?

Speaker_-_Dr__Gillinov: Mitral valve prolapse (MVP) is a form of mitral valve disease. MVP is very common and most people with MVP do not require surgical treatment. Surgery is recommended only if the MVP is associated with a severe leak.

cherylann: Is getting dizzy at any time in the day or night a problem related to MVP? With moderate to severe leakage in the mitral valve and tricuspid valve and an enlarged heart 4.5

Speaker_-_Dr__Gillinov: MVP (mitral valve prolapse) can cause a variety of symptoms, including dizziness, palpitations, and chest pain. If the mitral valve leak is severe, surgery is indicated, particularly if there are changes in the heart size like enlargement.

Lena: Getting MVP repaired is better than having a replacement. When should the surgery be performed in order to have a better success rate?

Speaker_-_Dr__Gillinov: Surgery should be performed when the leak is severe. Delaying surgery when a patient has symptoms or has decreased heart function increases operative risk.

Lena: I have been graded at a 2 on the scale for valve leaks. I have palpitations and suffer from fatigue. Is palpitations common for mitral valve leaks?

Speaker_-_Dr__Gillinov: Palpitations are common in people with heart valve dysfunction. If the leaks are only graded as a 2, surgery is probably not indicated. However, if there is some question concerning the severity of the leaks, a transesophageal echo is indicated.

homecarern: Is having a leaking mitral valve the same as having regurg,?My echo showed 3 + regurg,but cath and tee showed only a "leak"

Speaker_-_Dr__Gillinov: Regurgitation is another word for leak or a leaky valve. The echocardiogram is the best way to assess valve function rather than a catheterization. TEE (transesophageal echo) provides a particularly good view of the mitral valve and is employed when there is a question concerning the severity of regurgitation.

homecarern: Is it advisable to have a mvp with a leak but no regurg . repaired?I have no sob or cp . I am 68 yrs and doc says "better to do it now "than when i am older.

Speaker_-_Dr__Gillinov: Leak and regurgitation are the same thing. If there is a severe leak, we recommend early surgery, particularly if there are any symptoms or a change in heart size or function.

Lena: My second question is: If this problem was hereditary, wouldn't it have been diagnosed many years earlier?

Speaker_-_Dr__Gillinov: Mitral valve prolapse may have a very weak genetic component, but it usually does not run in families. It most commonly appears in patients in their late fifties--it was not present before.

richrose: What does EJECTION FRACTION mean - Eg 37 percent.

Speaker_-_Dr__Gillinov: Ejection fraction is a measure of the function of the left ventricle, the primary pumping chamber in the heart A normal value is approximately 65%. An ejection fraction of 37% represents a moderate reduction in heart function. Mitral valve surgery is recommended before the ejection fraction declines.

Eustis: I had endocarditis caused by streptococcus mitis which attacked a leaf of my mitral valve leaving something visible on the leaf. The doctors have described it differently, maybe a scar etc. What do you think about this?

Speaker_-_Dr__Gillinov: You probably have a vegetation on the valve. This is frequently a pea-sized mass of calcium, bacteria, and old blood clot. As long as the valve functions normally, this may not require specific treatment or surgery.

When is mitral valve surgery recommended?

AmyL: What factors determine when surgery is recommended?

Speaker_-_Dr__Gillinov: Mitral valve surgery is recommended when the leak or stenosis is severe.

Speaker_-_Dr__Gillinov: Today, we recommend early surgery even in patients without symptoms.

Cleveland_Clinic_Host: Dr. Gillinov, how do you determine what is best for you (as a patient)?

Speaker_-_Dr__Gillinov: The best approach is determined for each patient. This choice depends on patient preference, characteristics of the valve, and body type.

Types of mitral valve surgery

djm1950: I had an ASD repaired when I was eight years old, in 1959. I was recently told that I also have a cleft mitral valve and a small ventricular septal defect. About three months ago, I began to have shortness of breath and severe fatigue. My local doctor believes this is because of moderate regurgitation back through the mitral valve. How often can a cleft mitral valve be repaired, as opposed to requiring replacement? Can such a repair be by the "minimally invasive" technique? if so, how does that technique differ from other surgical techniques? Thanks very much.

Speaker_-_Dr__Gillinov: A cleft mitral valve is common with a particular type of ASD. Usually, such a valve is simple to repair. You may be a candidate for a minimally invasive technique depending upon your chest X-ray and body characteristics.

kathyrife: My daughter has a severe leak of her AV valve and we are being told that fixing it is really risky. Just wanted to know about this a bit more..what does fixing it involve? I know that you don't know her circumstances but if you could just give me some general info. Thanks

Speaker_-_Dr__Gillinov: Congenitally abnormal valves can usually be repaired with surgical techniques. We would be happy to review her records and help.

Traditional mitral valve surgery and minimally invasive mitral valve surgery

Eustis: You state in your information that mitral valve surgery is done both the traditional way and the less invasive way. Obviously, the patients condition and the valve's condition have a lot in deciding what procedure to use. May the patient request the less invasive way if they qualify? Do all surgeons perform these less invasive surgeries or only a few who are qualified? What if you have already been assigned a surgeon who doesn't do the less invasive surgeries, can you request one who does? Thank you, NP

Speaker_-_Dr__Gillinov: Almost all isolated valve surgery can be done minimally invasively, and patients should certainly explore this option as it is safe and effective and speeds recovery.

Eustis: Would you please describe "minimally invasive mitral valve surgery."

Speaker_-_Dr__Gillinov: There are a variety of techniques for minimally invasive mitral valve surgery. We offer all of them, which include 1) a right chest approach with a 2 - 3 inch incision;

Speaker_-_Dr__Gillinov: 2) a right chest approach with robotically assisted surgery

Speaker_-_Dr__Gillinov: 3) a partial upper sternotomy through a three inch incision; and 4) a catheter based approach that is currently experimental and available in a clinical trial.

cherylbuck: do you use the robot?

Speaker_-_Dr__Gillinov: We do use robotically assisted approaches for suitable patients. The surgical robot affords the surgeon unparalleled exposure of the mitral valve and is very useful for mitral valve repair.

Speaker_-_Dr__Gillinov: There is a section on our website if you want to learn more about this approach - http://www.clevelandclinic.org/heartcenter/pub/guide/surgery/roboticallyassisted.htm

pelican: How much more invasive is replacement vs repair

Speaker_-_Dr__Gillinov: Both replacement and repair can be performed minimally invasively. In general, long term outcomes are superior with repair. Therefore, we favor mitral valve repair, which is possible in almost all cases.

Mitral valve repair and mitral valve replacement

cherylann: What do you feel would be the reason to replace the valve as opposed to repairing the valve? Would high blood pressure (not stable) be factor?

Speaker_-_Dr__Gillinov: In almost all cases of mitral regurgitation (a leaking valve), we can repair the valve, which is generally preferable to replacement. In certain instances, like rheumatic heart disease, the valve is so severely damaged that replacement is performed.

Speaker_-_Dr__Gillinov: High blood pressure is not a factor. We can repair valves with high blood pressure.

pelican: can you tell if a valve needs repair or replacement ahead of time?

Speaker_-_Dr__Gillinov: Based upon the echocardiogram, we can estimate the probability of repair. For mitral regurgitation, or mitral valve prolapse, the probability of repair is approximately 95%.

glmusser: How long does mitral valve repair take?

Speaker_-_Dr__Gillinov: The operation usually takes 3 - 5 hours.

crusher: Would other heart anomalies preclude someone from having MV repair/replacement? ie. bypass, pacemaker, decreased function

Speaker_-_Dr__Gillinov: Other anomalies or cardiac conditions do not preclude mitral valve surgery. In fact, it is common to treat more than one condition during surgery. For example, some patients require bypass surgery or aortic valve surgery at the time of mitral valve repair.

spettersen: How long are biologic replacement mitral valves good for?

Speaker_-_Dr__Gillinov: Most biologic valves will last at least 10 years The older the patient, the longer they last. Among patients 65 years of age or older receiving a biological valve replacement, only a small percentage will eventually require a reoperation for a degenerated valve.

Mitral valve repair and age

boston: I want to know if newer procedures for repair or replacement can be successfully performed on an individual of advanced years? What if the patient already had a valve replacement in the past?

Speaker_-_Dr__Gillinov: There is no age limit for valve surgery, and techniques consistently improve. Previous cardiac surgery does not prohibit subsequent surgery.

Cleveland_Clinic_Host: Dr. Gillinov, there have been a lot of questions about advanced age and mitral valve surgery. Can older individuals still be considered as candidates for minimally invasive surgery?

Speaker_-_Dr__Gillinov: Yes. There is no age limit that precludes valve surgery or a minimally invasive approach. Older patients are excellent candidates for minimally invasive mitral valve repair.

After mitral valve surgery - diet and exercise

spettersen: Following a mitral valve repair procedure, what foods or vitamins should be decreased/avoided or increased/started to help assure that the valve remains healthy?

Speaker_-_Dr__Gillinov: Diet has no impact on valve function. A standard, heart-healthy diet is recommended, along with exercise, but these do not relate to the valve.

spettersen: Following a mitral valve repair procedure what limits should be placed on exercises to prevent valve strain or deterioration? Similarly, what exercise programs should be implemented to help maintain a healthy valve? How often should these exercises be done?

Speaker_-_Dr__Gillinov: Generally speaking, aerobic exercise is recommended. It is possible that very strenuous weight lifting could damage a valve, but this is exceedingly rare.

spettersen: Some Cardiologists recommend that iron or alcohol be avoided/minimized following mitral valve surgery as it could negatively impact the repaired valve, is this information correct?

Speaker_-_Dr__Gillinov: No, it is not correct.

Mitral valve re-operation

markt: If a mitral valve is repaired, what are the chances that it will need to be repaired again years later and generally what causes the need for a re-repair?

Speaker_-_Dr__Gillinov: Mitral valve repair is an extremely durable procedure. 10 years after mitral valve repair at the Cleveland Clinic, 95% of patients have maintained valve function and are free of reoperation.

Speaker_-_Dr__Gillinov: The most common reasons for repeat surgery after mitral valve repair are progressive changes in the valve with time and infection. Together, these are uncommon.

crusher: Can a previous replacement with a porcine valve be repaired and/or replaced either with invasive or min. invasive surgery?

Speaker_-_Dr__Gillinov: Occasionally porcine valves wear out. When this happens, reoperation is necessary. Occasionally, such reoperations can be performed minimally invasively. However, at reoperation, expert surgeons are required, and the focus is on patient safety and excellent outcomes.

General questions about mitral valve surgery

Horstmann_2: Is a person put on drug therapy after having valve surgery?

Speaker_-_Dr__Gillinov: Drug therapy is generally not necessary after mitral valve repair. In contrast, after valve replacement with a mechanical valve, lifelong blood thinner (such as coumadin) is necessary. Of course, patients may require medicines for other conditions that they may have.

Cleveland_Clinic_Host: We are receiving many great questions so far! Please remember that this chat is for general mitral valve surgery questions. Specific questions regarding your care require an evaluation by a physician.

jjohns465: How does calcification influence mitral valve surgery?

Speaker_-_Dr__Gillinov: Calcification complicates mitral valve surgery. At Cleveland Clinic, we have extensive experience with management of calcified mitral valves. Relying upon this experience, we have developed the expertise to repair most calcified mitral valves.

crusher: What are "biologic" valves?

Speaker_-_Dr__Gillinov: These are valves that are made from the heart of pigs or cows. They do not require blood thinners.

AmyL: In most cases, does mitral valve surgery stop the leak or reduce the severity of the leak?

Speaker_-_Dr__Gillinov: All valves leak. Even normal valves if examined in detail by echocardiogram, have a small leak. The objective of mitral valve repair is to reduce the leak to a normal level, which is usually grade 1 or less.

Choosing a heart surgeon for mitral valve surgery

susan: What factors should patients consider when choosing a surgeon for mitral valve surgery?

Speaker_-_Dr__Gillinov: Mitral valve repair is superior to mitral valve replacement. So, the first factor to be considered is the surgeon's or team's repair rate. This relates directly to experience. A high volume center will tend to have better results.

Catheter based procedures for mitral valve disease

sos123: My Wife is a transplant patient . Regular surgery is unavailable. Can she be a candidate for a catheter procedure?

Speaker_-_Dr__Gillinov: Cleveland Clinic is involved in a variety of trials of catheter-based technology for heart valve disease. She may be a candidate for such an approach. We would be happy to review her information.

Atrial fibrillation and mitral valve disease

doswingle: Will you be discussing Atrial Fibrillation?

Speaker_-_Dr__Gillinov: Atrial fibrillation (afib) is common in people with mitral valve disease and is corrected at the time of valve surgery, usually with a minimally invasive approach.

Horstmann: Does persistent atrial fibrillation worsen a slightly leaky mitral valve? At what point should surgery be considered? Thank you, Doctor.

Speaker_-_Dr__Gillinov: Atrial fibrillation does not necessarily cause increased mitral valve dysfunction. Surgery should be considered when 1) the leak is severe or moderately severe or 2) the atrial fibrillation is very symptomatic and not controlled by medicine.

Cleveland_Clinic_Host: Dr. Gillinov, we've had a lot of questions about A-Fib. Can you discuss in more detail?

Speaker_-_Dr__Gillinov: Atrial fibrillation is an abnormal heart rhythm that is very common, affecting more than 3 million people in the U.S. It is particularly common in people with mitral valve disease. When a person has both mitral valve disease and atrial fibrillation, surgery can correct both problems at the same time.

Speaker_-_Dr__Gillinov: Some people with isolated atrial fibrillation are candidates for catheter or surgical based ablation. We will actually be having a chat event on this topic in June.

tstiven: Is SVT common when you have MVP?

Speaker_-_Dr__Gillinov: There have been several questions about arrhythmia, including atrial fibrillation and SVT with mitral valve disease. Such arrhythmias are common in patients with mitral valve disease and can be managed at the time of mitral valve surgery. If the mitral valve dysfunction is not severe, requiring surgery, then the arrhythmia can be managed medically or through catheter ablation.

Marathoner: I'm a long distance runner with a 3 year history of AFIB and a small mitral valve leak. Would continued running eventually cause additional mitral valve problems? Should I be running at all?

Speaker_-_Dr__Gillinov: Exercise, particularly aerobic exercise, will not damage your valve. If you develop symptoms, like decreased exercise tolerance, then you should have a repeat echocardiogram.

Aortic valve surgery

richrose: If time permits I would like Dr. Gillinov to review latest advances for Aortic Valve Replacement. I have surgery scheduled in 2 weeks by Dr. Gillinov so would VERY MUCH appreciate his thoughts in this specific area.

Speaker_-_Dr__Gillinov: In the last decade there have been substantial advancements in aortic valve surgery. These include development of minimally invasive approaches and application of valve prostheses with superior hemodynamics and durability. We offer a variety of approaches and valve substitutes in order to fit the procedure to the individual patient.

Mitral valve repair - device recall?

bjlyon: I had a mitral valve repair at Cleveland Clinic in November 2005. I understand that a variety of implantable cardiac devices manufactured by Shelhigh have been recalled by the FDA, including annuloplasty rings and mitral valve repair kits. Does CC use devices made by Shelhigh and how can I find out what type of device was implanted during my surgery?

Speaker_-_Dr__Gillinov: We do not use equipment from Shelhigh at Cleveland Clinic in cardiac surgery. If you contact us or call your surgeon's office, we can tell you what sort of material was used on your valve.

© Copyright 2007 The Cleveland Clinic Foundation. All rights reserved. rev. 6/07