“Should Asymptomatic Patients With Moderate-to-Severe Mitral Regurgitation Have Surgery?” With Dr. David Adams

Recently, I received a great question from John Myers about asymptomatic patients with mitral regurgitation. John wrote to me, “Hi Adam, I’m 76 and in good shape. In 1999, I was  diagnosed with moderate-to-severe regurgitation even though I have NO physical symptoms. I’ve read that some surgeons believe having mitral valve repair sooner than later is preferable. Should I be worried? Should I get a second opinion? Thanks, John”

Luckily, during the 47th annual Society of Thoracic Surgeons meeting, I had the chance to ask John’s question directly to Dr. David H. Adams, chairman of cardiothoracic surgery at The Mount Sinai Medical Center in New York. Considering Dr. Adams’ clinical focus on mitral valve treatment, I thought you might like to see his response.

So you know, Dr. Adams has performed successful surgery on many patients in our community including Cindy Tarver, Mark Linnus and Monique Battaglia. To see Dr. Adams’ surgeon profile at HeartValveSurgeons.com, please click here.

For those patients and caregivers in our community that are hearing impaired, I have provided a video transcript of the interview with Dr. Adams below.

Adam: Hey, everybody. It’s Adam and I’m here at the STS convention in San Diego. We’re wrapping up day number two and we’re very happy to have Dr. David Adams from Mount Sinai Medical Center with us and as we’ve been answering questions all day, we’re going to pose a question to Dr. Adams and hear his response.

Dr. Adams: Great.

Adam: And so this is coming from John Meyers and John says, “I’m 76 and have been diagnosed with mitral valve prolapse since 1999. I’m in good physical shape and have no physical symptoms. However, my last echo was rated as moderate to severe. I have read that some surgeons have commented that having a repair sooner than later is preferable. In view of my age, should I be worried and should I definitely get a second opinion?”

Dr. Adams: That’s a big question. It’s actually got a simple answer. Adam, thank you very much for inviting me to participate. Congratulations on all of your work on behalf of patient education.

Adam: Thank you so much.

Doctor Adams: We’re all indebted to that. This specific man asks a very interesting question. He’s 76. He says he has moderate to severe mitral regurgitation. Feels great. Now let’s summarize by saying the first thing we want to know whenever we talk about intervening on a asymptomatic patient is the severity of regurgitation. He said moderate to severe. The guidelines are for severe regurgitation so that the first thing we always clarify regardless of the age is the degree of regurgitation so in a patient that has moderate to severe regurgitation, we would definitely recommend clinical follow-up. Now if the patient were symptomatic, let’s say, or beginning to have some leaking heart valve symptoms and we weren’t sure, we’d exercise because we have a patient run on a treadmill or exercise and then we perform the echo. We may bring out mitral regurgitation or the degree of severity of regurgitation in a more accurate way. So, if there was ever a question, we would always exercise the patient. The other thing that we have to recognize is this impact of age. I always say never have any age discrimination in mitral valve regurgitation. We try to repair every valve regardless of age in patients that we operate on. But, we are a little more selective in patients depending on their age. There’s a lot of data now, three papers out of four that have asked the question of “Should we operate on a completely asymptomatic patient with normal ventricular function that have severe mitral valve regurgitation?” The answer in three of the four papers has been “Yes, we should.” If you look at the long-term, survival is improved by early surgery so that’s — The mean age in these studies is anywhere between 55 and 64. They weren’t studying the 76-year old patients, so let’s agree that younger patients I think there is a survival benefit provided they have very safe surgery and provided they get a mitral valve repair. In this patient, a 76-year old patient, I first want to clarify his degree of regurgitation and, secondly, I always make best decisions talking to them. 76 is just a number. Some patients that are in excellent condition and that really look like they — Remember his life expectancy is 89, so a really healthy patient with severe mitral valve regurgitation that’s going to get a valve repair, I think the same arguments apply. Most patients like that, when they see the data, elect to have surgery in a fashion where they pick as opposed to having a complication. Let’s say he’s frail, the same patient, a more frail patient. Then, of course, we would want to wait for more — for a class 1 indication for surgery. Remember, asymptomatic surgery is a class 2A indication. What that means for a patient is that the majority of doctors –There are a lot of doctors that think there’s probably a benefit. A class 1 indication means all the doctors agree there’s likely a benefit so, again, a class 2 indication is good enough, I think, for young patients that have very long life expectancies and particularly considering those studies in asymptomatic patients. In a patient like this, we want to document the severity of regurgitation and we probably also perform a heart (cardiac) catheterization or at least try to characterize the peripherals sort of things like pulmonary artery pressure. I think he probably doesn’t need a second opinion. I think the next time he’s scheduled for an echocardiogram, I would recommend probably a stress echocardiogram.

Adam: Well, as always, thanks for your support. Thanks for your ongoing education through your own website, mitralvalverepair.org. I want to thank you again for just taking the time to share your insight and all your clinical work and research in our community. We really appreciate it.

Doctor David H. Adams: Well, thank you. And I’ll say again, I think it’s just amazing leadership for you to come to this Society for Thoracic Surgeons and I’m sure you’ve had no problem attracting a lot of very important valve surgeons to come and talk to you because we’re all honestly really impressed by the work that you’re doing on behalf of all our patients.

Adam: And on behalf of all the patients and the caregivers out there, thank you for all you’re doing. We really appreciate it.

Dr. Adams: Thanks, Adam.

Keep on tickin!

Adam Pick
Written by Adam Pick

Adam Pick is a patient, author of The Patient's Guide To Heart Valve Surgery and the founder of HeartValveSurgery.com.

To learn how Adam has helped millions of people with heart valve disease, watch Adam's video, subscribe to his free newsletter, or visit his Facebook, or Twitter pages.

  • Gene Parrish

    This is a great question and interesting answer from Dr. Adams. I wonder if his response would apply to patients with aortic regurgitation.

  • Jack Child

    Thanks for the very useful discussion on whether or not to have valve surgery (and when).
    I am 73 years old, with some other problems (high blood pressure, high cholesterol) which are pretty much under control. I exercise regularly and have no symptoms. Over the last few months I have had a number of tests and four medical opinions. Two say I should do valve replacement now, and the other two say “listen to your symptoms”, and don’t do surgery until you get severely out of breath when exercising or climbing stairs. Any advice?
    I would be having the surgery done at the Walter Reed Army Hospital here in Washington, DC. Does anyone have any news or opinion on Walter Reed valve replacement surgery?

  • Theresa Callanan

    I had my mitral repair surgery performed by Dr. Adams on 3/2/10, and just celebrated my one year anniversary. I was 54 years old when I had my surgery, and was very tired and had incidents of breathlessness when exerting myself. I had no doubts that I needed surgery, which made the decision easier. In fact, after meeting with Dr. Adams for my initial consultation, I knew he was the one I wanted for this surgery. He is a truly gifted surgeon, and because of his skill I am now enjoying a beautiful life. Mt. Sinai Hospital was a positive experience from beginning to end. Everyone was so kind, and their kindness reflected what Dr. Adams passion as a surgeon reflected…that the needs of the patient be met at every level of treatment. Thank You Dr. Adams from the bottom of my heart!

  • John Myers

    Dear Adam,

    This is John Myers. Thanks so much for passing on my question, “Should asymptomatic Patients with moderate-to severe mitral Regurgitation have surgery? I just had my latest ECHO on Feb 26. 2011, so although I worry a bit, I’ll probably wait until my next ECHO, as suggested by Dr Adams, in early 2012 to talk with my cardiologist abut having a stress ECHO, unless I experience some symptoms before them. I main reason for my good health is that I exercise six days a week, 15 weight machines plus 30 minutes on a exercycle, 3 days a week, plus 60 minutes of walking or exercyle, three days a week. I d;id have a stress ECHO, several years ago and passed w;ith flying colors. Thanks again. By the way, I plan to live past 89 years. I just hope my mind continues to work well.
    John

  • PAT HARRIS

    I was asymptomatic too until one day, I had severe pains up both sides of my jaws. I’m the original take a couple of Ibuprofen & call it good. However, my husband called 911 & I spent 3 days in hospital find out, only then, that I had atrial fibrillation. When I was released, having been given coumadin & other drugs, was only home about 1-1/2 hrs & had a stroke (11-11-09). Came very close to ‘checking out’, spent 10 days in hospital (5 in CCU & 5 in rehab) & found out I had mitral valve problem. NEVER KNEW I HAD A-FIB OR MITRAL VALVE STENOSIS but would caution you that, if you have accompanying A-Fib or develop it, you’re 5X as likely to have a stroke. I got lucky and have only minor residuals from the stroke but 2.5 cm clot lodged in my cerebellum. Had mitral replacement on 4/12/10 and feel great since. Also survived knee replacement surgery on 11/1/10. I HAVE TO TELL YOU ALSO, IF YOU’RE NOT ALREADY AWARE, IF YOU DEVELOP A-FIB YOUR 5X AS LIKELY TO HAVE A STROKE AND, TRUST ME, IF YOU SURVIVE IT, IT WILL CHANGE YOUR LIFE FOREVER!!!
    Pat Harris

  • Guy Mattiaccio

    Small world, I too have no symptoms, am 56 excellent health, been a tri-Ahlete for 12 years 1980-1990s, and I have a Mod-severe condition. My Cardiologist seems to want me to have surgery sooner then later and its not MiMinally invasive. I don’t even want to think about craken the ribs when there are other options. It seems Halifax Hospital in Daytona does not offer minimally invasive?
    The cardiologist keeps on refering to the size of my heart as it may get too big to repair the valve then replacement would be the only fix? I say my heart is a little larger then reqular because of my athletic background, and not regurgitation, wich I know I have had all my life. I’ll keep on reading this site for more info. Thanks for the opportunity
    she has not mention a stress echo-I guess I need to. My next echo is in September

  • Patricia Shabel

    Thank you, Adam, for this interview and all of the work that you do regarding heart valve surgery. It really is amazing and makes such a difference! I learn so much more about this since my surgery in December 2009, and you also helped me be able to prepare for it before I had it. Thank you again for your amazing work!

  • Tony

    Hello. I am 53 yrs old, have Mitral Prolapse with severe regurgitation. I mountain bike, kayak, xc ski, lift weights, and occationaly race bikes/kayaks in a Biathlon. I have no symptoms of my problem, though sometimes a little a-fib. My cardiologist says definitely a repair. Six months ago it was ” 1-5 years ” to have surgery, now it is the sooner the better. The doc says lets not wait till something happens causing heart damage. So now I believe I will have surgery within the next two months.

  • MARYANN

    Hi doctor Adam I was wondering if you can answer a question for me? My mom is 85 years old and recently had a heart syonogram with the results we were told she has a leaky valve which is at a four plus count. being a diabetic and high blood and haveing had congestive heart failure in the past what do you suggest we do to fix this problem do you think open heart surgery would be the only way to go or is there any other solution that is not so invasive to be done. I would greatly appreciate your response. thank you.

  • Keemo Sabe

    Hi Doctor Adam,

    I am 70 years old and I was put on an echo-cardiogram test.

    My aortic valve leaks 10%.

    I feel no sympthoms and I am a physically active, 180 pounds man.

    I have been excersicing regularly over the last 20 years jogging 3 miles every day for 45 minutes without any symptom of exaustion,

    My cholesterol and glucouse is within the norm.

    All my blood levels are normal.

    On a scale of 1 to 10, how concerned should I be about a 10% leaking of my aorta valve now at age 70?

    Thank you!

  • lesley daley

    hello i went to see my doctor yesterday as i was diognosed with a heart murmur he then went on to tell me i have a leaky heart valve when me and my husband tried to ask more questions about this all we got in response was i will send for you in five years time??? can someone please explain this to me i am a 45 year old female and would love some answers thank you

  • Gene Parrish

    Lesley, that was a pretty weak answer you got, and I don’t blame you for wanting to know more. If you have a murmur, you probably do have some degree of valve leakage, but unless you have an echocardiogram, it’s impossible to know exactly the amount of leakage. Most likely, you have had the murmur for some years. I wouldn’t be too upset right now, in that some people live with leaky valves for many years, even decades. However, I would insist on an echo so that you can accurately track the progression in the years to come.

  • lesley daley

    thanxs for replying gene, i have had a echo sometime ago i also i tests done on my heart a few years ago and nothing showed up??? as i had a mini stroke about 4 yrs ago but was lucky no damage to my heart when i had the echo wouldnt it have shown up t

  • Gene Parrish

    Yes, that’s right. If you had any leakage at that time, it would have shown up. However, if the amount of leakage was minimal (what they call “trace” leakage) – the cardiologist will usually not even mention it, because at that level, it’s not significant enough to worry about. Actually, it’s not uncommon for people in their 50s and 60s to have trace leakage when no other evidence of valve disease is present.

  • lesley daley

    thank you for replying i went back to my doctors and complained about the way i got treated and i am know getting refered for a 2nd opion. as my doctor wasnt happy with the way i was treated. i get out of breath very easy i dont drink or smoke . i am only 45 years of age and dont understand any of this!!!!

  • Gene Parrish

    Good for you, Lesley. I hope your doctors can diagnose your case properly. There are a number of things that can cause a person to sense a shortness of breath – and not all of them serious. But you need to find out for sure. I hope you will post again when you get the answers.

  • lesley daley

    hi well i am back again sorry it has took so long but you all know what doctors are like. well we went for my 2nd opinion and was told the leak inmy heart in getting worse so i might have to get the valve replaced im pleased in a way for getting the 2nd opinon but also nervous so know waiting for yet another hospital appiontment to see what they are going to do :) p.s will keep the updates cumming when i have news thank you for all you help :)

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