Mitral Valve Disease

karenj: If I have mitral valve leak - is it safe to get pregnant?

Speaker_-_Dr__Stewart: Mitral regurgitation that is not severe does not increase the risk of pregnancy substantially. In patients with severe mitral regurgitation, we sometimes let women carry the pregnancy - however it probably increases risk slightly. Symptomatic mitral regurgitation with heart failure should be treated prior to attempting pregnancy

Aortic Valve Surgery

gunsong: Do you repair-replace aortic valve when there is mild increase in Left ventricle before more damage is done or do you follow pt with echos and monitor progression of enlargement in left ventricle before intervening surgically? When is the right time to repair-replace aortic valve? What determines whether you spare, repair or replace an aortic valve? Thank-you

Speaker_-_Dr__Stewart: Without having specifics of your situation, it is hard to answer this question without vague generalities. Our most significant concern for left ventricular status is decrease in systolic function (reduced LV ejection fraction) or increase in end systolic LV size (size of the main pumping chamber during its squeezing phase).

gunsong: What criteria do you use to decide if a pt with isolated aortic valve insufficiency-regurgitation with aortic prolapse and some rheumatic involvement without any significant stenosis would have sparing, repairing or replacement of the aortic valve? What criteria do you use to determine if a pt. can have the minimally invasive valve repair or replacement vs dissecting the sternum?

Speaker_-_Dr__Stewart: Repair is most successful in patients who have pure aortic regurgitation, without leaflet calcification. This is most common in young patients with aortic prolapse, such as bicuspid aortic valve.

Speaker_-_Dr__Stewart: The question of some "rheumatic involvement" may mean that aortic repair is less feasible and desirable. So, the situation needs to be individualized.

Speaker_-_Dr__Stewart: Most single valve first time surgeries can be done using minimally invasive techniques. With a few exceptions. This includes valve repair or replacement of the mitral, aortic or tricuspid valves. When we add coronary bypass, a second valve, or other surgical plans, the feasibility of minimally invasive surgery is less.

gunsong: What is the life of an aortic valve sparing"David procedure" vs repair vs a replacement?

Speaker_-_Dr__Stewart: The David procedure involves repair of a native aortic valve during ascending aortic replacement with a conduit. It is quite durable. With an 88 to 99 percent freedom from reoperation at 10 years from operation. However, outcome is worse in patients proportional to the underlying aortic problem with aneurysm and dissection patients having less optimum long term results.

berkwiev: My husband has Cad and aortic stenosis. He had Cabg in 1993 an several stents thereafter. What his best options to replace the aortic valve

Speaker_-_Dr__Stewart: A 73 year old with severe aortic stenosis can easily have aortic valve replacement after previous CABG and stents, if the aortic stenosis is severe enough to warrant this. We would be happy to review your husband's medical records or see your husband to determine the best course of treatment.

gunsong: What type-brand of tissue valve do you use and how long do they last? How long does a repair of aortic valve last?

Speaker_-_Dr__Stewart: A variety of tissue valves all provide excellent long term durability. Mainly we use bovine pericardial valves of the stented type. We expect to last 15 to 25 years.

gunsong: If a pt has an EF of 50%per echo and 60% per TEE and mild left ventricle enlargement would you repair-replace the aortic valve?

Speaker_-_Dr__Stewart: We don't have enough information to provide an opinion

angela: are there other ways of repairing/replacing aortic valve other then a small incision of the sternum something that might be less invasive?

Speaker_-_Dr__Stewart: Yes - rather than the full thoracotomy - most single valve operations at CCF are done using a minimally invasive 3 to 4 inch midline vertical incision.

Speaker_-_Dr__Stewart: Additionally, transcatheter techniques without surgery are in research and development - with some early successes in humans.

Aortic Valve Disease

ron: Can you exercise if you have a bicuspid aortic valve?

Speaker_-_Dr__Stewart: Yes - you can exercise.

angela: from angela; is there a blood pressure med. that will slow down my aortic valve from getting worse? I am presently on 30mg of procardia at this point I have a mod. to severe regurgitation

Speaker_-_Dr__Stewart: Blood pressure control is a good idea. Higher pressure in the aorta makes the aortic valve leak more. Any blood pressure medications would be fine to do this. Seek a blood pressure below 130/80.

4boys: My son has a bicuspid aortic valve? Can he play competitive basketball? Sometimes he takes energy drink before a game. Is that ok for his valve? how serious is that?

Speaker_-_Dr__Stewart: Presuming he does not have symptoms, or weakness of the heart muscle, exercise may be very reasonable.

Speaker_-_Dr__Stewart: In patients with aortic regurgitation (AR) that is not severe, competitive athletics seems very reasonable.

Speaker_-_Dr__Stewart: In severe AR, in an asymptomatic patient, decisions about athletic competition should be individualized by the doctor.

Speaker_-_Dr__Stewart: Energy drinks are ok though they often contain caffeine.

Valve Surgery – General

gunsong: Do you recommend a record review before we schedule an appointment? Can appointments be made with you if you decide surg is necessary after you review the records?

Speaker_-_Dr__Stewart: We do have a method for record review at the Cleveland Clinic prior to a surgical appointment. Call the resource nurses at 866-289-6911 or chat online with a nurse from the website http://www.clevelandlclinic.org/heart and they can help you.

Valve Disease

karenj: What type of symptoms do you have if your valve is leaking?

Speaker_-_Dr__Stewart: Some people have shortness of breath or other symptoms when the valve leakage has become severe. Others have no symptoms despite advanced valvular disease.

jean1226: If you have aortic valve calcification, is it ok to take a calcium supplement? Are there medications you can take to decrease the calcium and avoid surgery?

Speaker_-_Dr__Stewart: Oral calcium supplementation does not accelerate aortic valve calcification, and is ok if indicated for soft bones or osteoporosis.

Speaker_-_Dr__Stewart: Some people believe that cholesterol lowering medications, like statins, will decrease the process of progressive valvular scarring.

sabake: My husband has a mechanical valve and is on coumadin. He needs to have a procedure and stop his coumadin. Is that safe? How long is that safe for?

Speaker_-_Dr__Stewart: There are small risks associated with being off anticoagulation for a patient with a mechanical valve. This consideration should be part of the decision to do any procedure, and how to manage blood thinners. For a patient with low risk of blood clots, being off coumadin for a few days is not very high risk. But should be decided on an individual basis by the physician.

gmateam: What does an echo show? Why would someone need a TEE and what is the difference between the two?

Speaker_-_Dr__Stewart: A regular echo from outside the chest (transthoracic echo) makes ultrasound pictures of the heart by bouncing sound waves in between the ribs to see the heart.

Speaker_-_Dr__Stewart: A transesophageal echo (TEE) makes ultrasound pictures from an endoscope in the food tube (esophagus), so no ribs are in the way of accurate picture taking.

rgs1152: What is a valve gradient? Is 51 bad?

Speaker_-_Dr__Stewart: There are several different kinds of aortic valve gradients. The most interchangeable is a "mean aortic valve gradient." When that gets above 40 or 50, it often means severe aortic valve narrowing. However a peak instantaneous gradient of 51 is likely to correspond to a mean gradient of about 30 or 35.

Speaker_-_Dr__Stewart: More important than the gradient itself, is if the valve has caused the patient to have symptoms.

amyp05: I have a murmur and the doctor said I have mild leaky mitral valve. Is there a chance that it may stay like that - or does it always get worse? Will I need to have surgery?

Speaker_-_Dr__Stewart: There is a good chance it will stay that bad and no worse. A follow-up echo in a few years seems reasonable.

bluecat: My doctor is monitoring my valve function. I have a moderate leak but he said it is not time to operate yet. How often should you be checked?

Speaker_-_Dr__Stewart: That is a good question to ask your doctor - but probably every year or two.

tomg: I have two valves that are leaking - both my mitral and tricuspid valve? Why would that occur?

Speaker_-_Dr__Stewart: There are many reasons why that could occur. We would need to know more information - such as an echocardiogram. An in-person evaluation may be warranted.

kjf754: I have a leaky tricuspid valve and right sided heart failure. CAn that be caused by the leaky valve?

Speaker_-_Dr__Stewart: Yes. Tricuspid regurgitation and weakening of the right ventricle may co-exist and cause each other (like a chicken and egg phenomenon). A search for causes of this may be warranted.

Speaker_-_Dr__Stewart: A test for lung disease may also be worthwhile.

george: What is a heart MRI used for? I have an aortic valve leak - would that be helpful to have an MRI?

Speaker_-_Dr__Stewart: Magnetic resonance imaging (MRI) is a new and sometimes useful way to image the heart. It is often used after echo studies, and especially in certain problems such as thoracic aortic diseases and some other problems.

Dental Procedures and Medications

btennessee: What is Dr. William Stewart's opinion on stopping or continuing pre-medicating prior to dental work for someone with mitral valve prolapse. Also, how often should a person with mitral valve prolapse have an echocardiogram? What if any symptoms indicate the valve has increased leakage?

Speaker_-_Dr__Stewart: Most medications do not to be stopped for dental work however, if substantial bleeding is anticipated such as a tooth extraction, medications like coumadin, may be held for 3 to 5 days at the discretion of the physician.

Speaker_-_Dr__Stewart: Depending on how severe is the mitral regurgitation this interval might vary from yearly to 10 or more years. For example if no mitral regurgitation or other LV abnormalities are seen, another echo may be unnecessary. In contrast, a prolapse patient with significant regurgitation may require yearly echocardiograms.

Speaker_-_Dr__Stewart: Presence of symptoms or increase in the leakage warrant in-person evaluation.

firsttimer: Having MVP, should one take antibiotics before dental work?

Speaker_-_Dr__Stewart: The newest guidelines do not require any antibiotics for this type of person. Before 2007, prolapse patients with a murmur or valve leakage by ultrasound were formerly recommended to have antibiotics - a rule which is now changed.

firsttimer: What criteria was used to change the ruling re: taking antibiotics prior to dental work?

Speaker_-_Dr__Stewart: Go to http://www.clevelandclinic.org/heartcenter/pub/guide/disease/valve/sbe.htm and you will see links to the scientific statement by the American Heart Association - it has the references for the SBE guidelines.

Mechanical Heart Valves

wondering: I have two mechanical valves - aortic and mitral. The clicking noise bothers me and I don't like to take coumadin. Are there any other valves that would work for me that are long lasting? Could they remove my mechanical valves for a new not mechanical valve?

Speaker_-_Dr__Stewart: Reoperation does not seem justified just for the clicking noise if you are feeling well.

Speaker_-_Dr__Stewart: We have very very rarely removed a functioning valve for any purpose.

abee: I have aortic insufficiency. Do you know anything about the ross procedure?

Speaker_-_Dr__Stewart: The ross procedure involves replacing the patient's aortic valve with their own pulmonic valve, and then replacing their pulmonic valve with a human valve (homograft). It is much less popular now than it was 10 to 20 years ago, because it creates two postoperative valves with potential problems. In very specific and unusual circumstances, we still use it.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Stewart is over. Dr. Stewart, thank you again for taking the time to answer our questions today.

Speaker_-_Dr__Stewart: Thank you for having me.