Q & A with Dr. Bruce Lytle - Cleveland Clinic webchat

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ElectLive

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Getting an opportunity to "chat" with world class surgeons from the comfort of your own home is a pretty amazing thing, I think, and for those not aware, it's something that the Cleveland Clinic does every few months, in the form of online webchats. I saw a recent one posted, and just thought I'd pass along the link: http://my.clevelandclinic.org/heart/webchat/1300_ask-the-heart-surgeon.aspx

It's fairly broad-brush, for good and bad, not much depth on any particular issue, but it also covers a lot of ground. I'm not familiar at all with Dr. Lytle but I know some here are. Obviously, some of the information and guidance given represents just this one surgeon and his surgical center, although both of course are highly regarded. Anyway, the full text is quite large, so I'm pasting below a few excerpts that I thought touched upon some of the more common topics posted here the past few months:


Q: I am a 53 year old man with severe stenosis of my aortic valve. With the exception of this little problem I am quite healthy and fit. I have heard that the On-X mechanical valve has claims that they are safer and have reduced risk of blood related problems. Is this a suitable substitution for the more established and proven mechanical valve products on the market?

Dr__Lytle: The On-x valve is a reasonable choice as a valve substitute but the length of follow up is less than some other mechanical prostheses. At present, there are not data that clearly indicate that one mechanical valve is better than another over time.

Q: Do you recommend a tissue aortic valve for young healthy adults, favoring the risk of reoperation over the long term risk of Coumadin use.

Dr__Lytle: Most of the time.

Q: What is the risk of both temporary and permanent A-Fib after aortic valve replacement surgery? If a tissue valve is implanted, and a second or third operation performed later, does the risk of developing A-Fib increase with each surgery?

Dr_Lytle: The likelihood of temporary atrial fibrillation occurring after aortic valve replacement surgery is around 25 to 30%. The risk of atrial fibrillation in any situation increases with increasing age and with the length of time that someone has had valve surgery, so a second operation is more likely to have atrial fibrillation than a first operation, in part because they are older.

Q: Can biological valve ever be considered for an adolescent [ my grandson is 13/6 yr old 6' 4''] with AS and severe AI after balloon catheterization instead of mechanical valve if teenager does not want to take warfarin and wishes to lead a more active/normal life? what are statistics for how long biological valve can last before reoperation becomes necessary?

Dr_Lytle: The risk of aortic valve replacement for a patient in their mid 30s is extremely low. If someone is in good health at that age group, the risk is probably somewhere in the neighborhood of 1 in 400 operations in an experienced center. Second operations do not appear to carry with them much of an increased risk relative to first operations when the factors of age and co-morbidities are accounted for. Third operations are less common and there is less information associated with those situations but in our studies of our own patients, most of the risks are associated with co-morbidities rather than the number of operations.

Dr__Lytle: Valve replacement in a teenager is a difficult issue. In general, all types of biologic operations deteriorate faster in younger patients than in older patients. Because it is less likely that teenagers would need an aortic valve replacement, there are many fewer statistics associated with those outcomes in that age group. In general most people would feel that if a biologic valve implanted in a teenager would last for 10 years that would be pretty good at that point. There are other more complex operations available and their advisability really relates to the details of what is going on. We would be happy to review your grandson’s data should you wish.

Q: Please compare the advantages and disadvantages of the Edwards Magna and the Medtronic Mosaic aortic valves, specifically expected longevity, opening area and performance, and viability for future transcatheter procedures.

Dr_Lytle: The Edwards Magna and Medtronic Mosaic aortic valves are both valves that are used in America today in relatively large numbers. In adequate sizes we believe that both valves will be available for future transcatheter procedures. There has not been a clear separation in longevity between these 2 valves in part because neither has been followed for a dramatically long period of time.

Q: What is the down side of transcath placement of a new aortic valve vs open heart surgery replacement?

Dr_Lytle: There are a series of trials that are designed to provide the answers to those questions. The concerns about transcatheter valve replacement that are so far: risk of stroke; risk of periprosthetic leak; the risk of rhythm disturbances including heart block; and the unknown longevity of transcatheter valves.

Q: Hi, I have a bovine aortic valve and it will need to be replaced at some time in the future, is open heart surgery my only choice.

Dr_Lytle: At the present time it is the only choice available in America. We would anticipate that transcatheter valve re-replacement will be possible in the future. We don't yet know whether it will be better and for whom it will be better.

Q: I understand that the Edward Sapien transcatheter aortic valve was recently given FDA approval for otherwise inoperable patients. Please discuss your expectations for the evolution of catheter valve replacement, specifically the likelihood it will be approved for younger and lower risk patient groups. Also, are there any limitations in applying this technology to patients who already have a bioprosthetic aortic valve? Is there a minimum valve size that would be required to successfully implant a catheter valve and not negatively impact the opening area? Current first time aortic valve replacement patients must consider all of these things when evaluating the long term impact of valve choice, so thanks for any advice you can give on reasonable medical expectations for the future.

Dr_Lytle: We believe that transcatheter aortic valve procedures will have an important part in the treatment of aortic valve disease in the future. At the present time the valve has been approved for use in “inoperable” patients. Patients that are not “inoperable” still can receive the valve when involved in specific clinical trials.

Dr_Lytle: It will be the case that patients with bioprostheses will be able to have a second valve procedure carried out with the use of transcatheter valves. Whether that procedure will be safer than open reoperation, we don’t yet know, and that strategy is not yet approved in the United States. In general, the minimum valve size that appears to lend itself to implanting a transcatheter valve is 23 mm. or greater. I think it is highly likely that in the future valve and valve re-implantations will be possible. Whether they will be desirable as yet remains to be seen.

Q: Are the higher stroke events in transcatheter aortic valve replacements a fixable problem? Is it both a short term and long term risk? Is the use of an increased blood thinning regimen such as Warfarin being considered?

Dr_Lytle: The higher stroke events in transcatheter aortic valve replacement probably is a situation that there are least approaches to trying to diminish. The devices that are designed to lower the risk of stroke events are themselves investigational devices at this time. There is clear evidence that the transcatheter valve results in a slight increase of stroke events over the short term. The long-term risk is less clear because the long-term follow-up is less robust. We do not believe at the present time that warfarin is likely to be effective in preventing these events as at least some of them probably are on the basis either of calcific or atherosclerotic embolization at the time of the procedure.

Q: Hello I have been told by my cardiologist that I need mitral valve surgery before the end of January and I am researching a place to have surgery. Any information you can give me would be appreciated: What type/manufacturer of mitral heart valves do you prefer to use for someone age 65?I s there a big difference in manufacturers? What’s better mechanical or tissue? Do you prefer to repair or replace a mitral valve? Can you tell before surgery if repair is an option? How long does a repaired valve last? How long does a replaced valve last?

Dr_Lytle: In most circumstances we prefer to repair rather than replace mitral valves. That is possible about 90% of the time. And - in our experience when repair is possible, the valve functions for at least 10 years about 90% of the time. When the mitral valve must be replaced, we usually use a biologic valve for someone 65 years of age and older.

Q: I am a 59 year old female who had mitral valve repair in June. The valve had failed due to an underlying connective tissue defect. I was told there is a 95% chance that this is a lifetime repair. Is this a nationwide average or Cleveland's average? How does my connective tissue disorder affect the probability of reoperation in the future?

Dr_Lytle: The 95% success rate relates specifically to the Cleveland Clinic experience. If you have a connective tissue disorder, the likelihood of reoperation over your lifetime is greater than if you do not. Both for mitral valve problem and for other problems that may develop that do not involve the mitral valve.

Q: Are there tests to identify the type of tissue disorder? I was told the tissue was overly stretchy and fragile.

Dr_Lytle: There are clinical and genetic tests to examine connective tissue disorders. It matters what particular connective tissue disorder you have.

Q: Coming from out of town, what would be the plan for follow-up; and how long a stay after surgery?

Dr_Lytle: The stay is a week to 10 days. Follow up is in the Clinic, by phone in conjunction with your local physicians and every couple of years thereafter.

Q: Does the Cleveland Clinic perform stem cell surgery for cardiac repair?

Dr_Lytle: At the present time stem cell treatments are investigational procedures and the Cleveland Clinic has been involved in some trials of stem cells. However, we have no open trials at this particular time. In this country, however, stem cell treatments are the subject of trials at the present time. See www.clinicaltrials.gov to search on stem cell studies.
 

ottagal

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Thanks for posting. A few lingering questions that I have had were answered!
 

Lionheart

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EL
Thanks for posting. A few of those were questions that I had before my surgery. Very helpful and interesting.
There are times when I think each of us would like to have a knowledgeable cardiac surgeon at our disposal to answer all of our questions. We could probably keep one busy for a lifetime.
Thanks
John
 

ElectLive

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Joined
Jun 26, 2011
Messages
631
Location
Atlanta, GA
There are times when I think each of us would like to have a knowledgeable cardiac surgeon at our disposal to answer all of our questions. We could probably keep one busy for a lifetime.
Yes, very true. I thought I had a lot of questions before my surgery, but have had countless more ever since.

Well, for all those with an endless supply of questions, looks like the next scheduled CC webchat covering valve issues will be with Dr. Marc Gillinov - mark your calendars for February 10.
 
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