Aortic Valve Surgery and Congenital Heart Disease, Bicuspid Aortic Valve

ken4: My son needs an aortic valve replacement he is 20 years old. I am thinking about a homograft. What is better the ross procedure or a homograft valve alone? What are the chances he will need the valve replaced in the future?

Speaker_-_Dr__Pettersson: The reason to choose a tissue valve alternative is to avoid having to take Coumadin - a blood thinner - for the rest of his life. Any tissue valve alternative is associated with an increased probability for need for future operation.

Speaker_-_Dr__Pettersson: The ross operation means taking the patients own valve in the pulmonary artery and implanting that as an aortic valve. And replacing the pulmonary valve with a homograft. The patient's pulmonary valve comes from a low pressure system and even if the valve in most of the cases can withstand systemic pressures this is not always the case and there is some risk that the pulmonary artery dilates and the valve becomes leaky. The homograft in the pulmonary position will degenerate over time and this may or may not be consequential.

Speaker_-_Dr__Pettersson: If a patient has a homograft or a regular tissue prosthesis to replace the aortic valve, this valve will degenerate and the patient will get an average durability of such a valve of about 10 or 15 years - a homograft not being different from any other tissue valve prosthesis. In summary, this means that the durability of a Ross procedure can be lifelong. But, at the same time, you take a chance of getting in trouble with both valves. The chance of requiring another operation is about 25% at 10 years, fairly evenly distributed between the two valves.

Speaker_-_Dr__Pettersson: A homograft replacement of a valve really has no advantage over replacement with a tissue prosthesis but would provide a more difficult next operation. You should seek a surgeon with vast experience with either of these procedures.

Cleveland_Clinic_Host: Is there a higher risk for surgery later in life if surgery was done when young for congenital heart disease?

Speaker_-_Dr__Pettersson: People who have had surgery for congenital heart disease in the past should definitely have follow up with a cardiologist who has had some experience with congenital heart disease. The issues in this patient population are very diverse.

Speaker_-_Dr__Pettersson: The same thing is true in choosing a surgeon. They should choose a surgeon who has experience with congenital heart disease.

Cleveland_Clinic_Host: Is there an age cut off for seeing a pediatric surgeon?

Speaker_-_Dr__Pettersson: The issues are different in patients who are adults or those who are children. The surgeon who is going to deal with these patients need to have a good congenital heart surgery experience.

bill: I have a bicuspid aortic valve – can this be repaired or do I need a replacement?

Speaker_-_Dr__Pettersson: Repair or not depends on whether the valve is leaky or stenotic. Leaky bicuspid valve are repaired in up to 70% while it is unlikely that a stenotic valve can be repaired.

Speaker_-_Dr__Pettersson: Bicuspid valve is often associated with an enlargement of the ascending aorta, Which may or may not need to be addressed at the same

greg07: I have a 13 year old with a bicuspid aortic valve and aortic leak. When do you know he is ready for surgery? Can he play sports? They said they need to watch him for now.

Speaker_-_Dr__Pettersson: A leaky aortic valve even severely leaky is not always associated with any impairment of physical performance. You may even be a top athlete with this condition.

Speaker_-_Dr__Pettersson: This patient needs to be followed by a cardiologist with repeated echos every year or second year. Surgery is advisable if a patient becomes symptomatic or if the size of the heart ventricle progressively increase, or contraction decreases.

Tricuspid Valve Surgery

d-777: Do you know anything about tricuspid valve repair? I have a leaky tricuspid valve and I am looking for an experienced surgeon.

Speaker_-_Dr__Pettersson: I have a lot of experience with this. The evaluation of patients with tricuspid valve disease is much more complicated than many other heart problems. Tricuspid valve leak is often a consequence of other heart problems. It may be left sided heart disease, it may be pulmonary hypertension, it may be a right ventricular problem. Understanding of all these issues is important to determine whether the patient will benefit from valve repair or replacement or not.

Speaker_-_Dr__Pettersson: The surgery itself is not technically particularly demanding compared to other cardiac procedures. Postoperative management may be more difficult. We will be happy to help you out.

Septal Defects: Atrial Septal Defect (ASD) and Ventricular Septal Defect (VSD)

crusher: Two years ago at age 48 I had a procedure to close a PFO. They used a catheter procedure to deliver an amplatzer septal occluder. It was discovered via MRI prior to the procedure that I had actually had many very very small strokes as a result of having this opening in the heart. One year after the procedure I had another MRI to determine if there were any new signs of stroke. Thankfully, there were none. My question is...do I need to keep having periodic MRIs to look for strokes 2, 3 or more years after the procedure or can I assume after the first year the problem has been corrected?

Speaker_-_Dr__Pettersson: If you don't have any new symptoms, I don't think you need to repeat MRI every year. I would advise you to stay in contact with both your neurologist and cardiologist to check your condition once a year.

bob45: I have an enlarged heart. I was diagnosed with a VSD. Are there any nonsurgical treatments for this – or do I need surgery? Will the surgery correct my heart size.

Speaker_-_Dr__Pettersson: VSD means leak of blood across the ventricular septum so that the right ventricle and lung circulation are exposed to higher flow and pressures. A consequence of this is that the patient can develop a pulmonary hypertension. These defects needs to be closed before that happens.

Speaker_-_Dr__Pettersson: You need to be examined by a cardiologist with understanding of congenital heart disease to decide if you need and if you can have an operation. The fact you have enlarged heart suggests that if this is all related to the VSD, that your VSD is fairly important. If you don't have pulmonary hypertension, but still have a large left to right shunt, which is surgically corrected, your heart size would be reduced after surgery.

Cleveland_Clinic_Host: If you would like more information regarding adult congenital heart surgery, please visit the Cleveland Clinic Heart and Vascular Institute web site at www.clevelandclinic.org/heart. For general health information you may also wish to visit www.clevelandclinic.org/health

Subaortic Stenosis

larry: What is subaortic stenosis? Do you need to have surgery to treat? If so – can you use minimally invasive surgery?

Speaker_-_Dr__Pettersson: Subaortic stenosis means there is a fibrous membrane or thickened muscle under the aortic valve causing obstruction.

Speaker_-_Dr__Pettersson: If it is a membrane, this may overlong term affect the aortic valve and cause the aortic valve itself to become leaky. Whether or not it is reasonable to operate depends on how severe the obstruction is and the severity of symptoms.

Speaker_-_Dr__Pettersson: Response to stress is a way to decide if a borderline stenosis is important or not. Surgery may be performed minimally invasive.

Coarctation of the Aorta

maryb: I had coarctation of the aorta surgery when I was younger-what is that?

Speaker_-_Dr__Pettersson: Coarctation of the aorta means a narrowing of the aorta. It usually occurs immediately after the take off of the aorta to the left arm. It results in increased blood pressure above the narrowing (in your upper body) corresponding with lower pressure in your lower body.

Speaker_-_Dr__Pettersson: Patients operated on for coarctation may have some residual narrowing and need to check their blood pressure. So that would be our recommendation.

Coronary Arteries and Congenital Heart Disease: anomalous coronary arteries, myocardial bridging

hcat: I have been diagnosed with anomalous coronary arteries, a congenital heart defect. How is that treated?

Speaker_-_Dr__Pettersson: We would decide if this is a risky variation of abnormality or an innocent one. The conclusion will decide if we will recommend an operation or not.

Speaker_-_Dr__Pettersson: The operation may be a reconnect the coronary artery in a better place on the aorta or a bypass procedure. In one variation, the course of the artery is in the wall of the aorta and opening the artery immediately opposite to its take-off will relieve the problem.

ric5: My coronary arteries – if I understand this right come from the right side of my heart and not the left – I was born with this. I am not sure my doctors know what to do with me. What should I watch for? Can I live with this or do I need surgery?

Speaker_-_Dr__Pettersson: Abnormalities related to the origin of the coronary arteries and their distribution may be totally innocent or associated with some risk of intermittent problems with the blood supply to the heart.

Speaker_-_Dr__Pettersson: The information you provide does not allow me to categorize your particular problem. If you are completely asymptomatic it is unlikely it is anything important. If you would like to know more about this you would need to make an appointment with a cardiologist who is particularly interested in these abnormalities and the Clinic has several of these.

sharon: I am a 45 year old female with symptoms of chest pain and irregular heart beats. A couple weeks ago my doctor diagnosed myocardial bridging – what is that – can you do bypass surgery to correct?

Speaker_-_Dr__Pettersson: A myocardial bridge means that an artery is surrounded by muscle. This results in squeezing of the coronary artery during contraction. If you have true bridging and proven impaired blood supply to the corresponding area of the heart muscle, surgery to correct that can be done. Surgery can be dividing the bridge or possibly bypass, depending on what it looks like.

stewie118: I 45 years old and had my last OHS 12 years ago for an asd closure. During the surgery a stitch was left inadvertently left in my right coronary artery (a vent site placement.) This caused me to have a seizure followed by and Mi the day after my surgery. It also induce ventricular tachycardia. It was determined that the right coronary artery was narrowed 60-80%. The stitch was found during an EP/angio 7 months later. There was much talk about what to do, but ultimately it was just left alone. I am wondering if this artery will become more narrowed with time and what should be done now. The only reason I found this information out was when I switched doctors and hospitals five years later and my arrhythmia doctor told me he read it in my records. Thank you for this wonderful chat.

Speaker_-_Dr__Pettersson: Most likely you have developed additional blood supply via collateral arteries so the consequences of your narrowing in the right coronary artery presently are none. Stress testing combined with echocardiography could determine whether you have any abnormalities which need to be addressed or not.

Speaker_-_Dr__Pettersson: The mechanism of the injury isn't obvious to me since the course of a right coronary artery has no relation to a normal asd.