46 Patient Questions Answered by Dr. Doug Johnston!
Written By: Adam Pick, Patient Advocate, Author & Website Founder
Medical Expert: Doug Johnston, MD, Chief of Cardiac Surgery, Northwestern Medicine
Published: July 31, 2023
Amazing!
During our recent webinar, “The Lifetime Management of Heart Valve Disease”, I received 46 patient questions that we did not have time to answer during the live event. Imagine my surprise when Dr. Doug Johnston, Chief of Cardiac Surgery at Northwestern Medicine and the featured speaker of the webinar, typed up answers to each patient question and asked me to post them to help educate our patient community. Downright wonderful!
Question 1: Lisa asks, “My son has congenital aortic valve stenosis and had a bovine replacement 5 years ago at 28 years old. Will he be able to have valve in valve or easier surgery?”
In cases like this, we would usually look at the echocardiogram, CT, and the operative report to determine. 1 What size and type of valve is in place, and 2. what the size and shape of the root is. In many cases valve in valve will be an option. Redo surgery sometimes is a better option in younger patients depending on whether we are able to implant a bigger or newer generation valve. — Dr. Doug Johnston
Question 2 – James asks, “Is there a less invasive “repair” procedure available for those with bicuspid aortic valve stenosis and descending root aneurysm — as opposed to traditional Open Heart Surgery with valve & root replacement?”
If I understand the question right, the answer is yes. We perform a large number of less invasive operations for patients with ascending aortic aneurysms and aortic stenosis. Part of the answer depends on whether the root of the aorta needs to be replaced, or just the ascending aorta. A CT scan will usually answer that question. — Dr. Doug Johnston
Question 3: Agi asks, “I had a bicuspid valve replaced and dilation repaired in 2020 . I have a new dilation of 3.3cm. Any advice?”
While 3.3 cm is slightly larger than a normal aorta in most people, this is a very mild enlargement, and is very typical when part of the aorta is replaced. Our usual protocol is to follow any patient with an aortic repair with periodic imaging with CT or MRI, usually at 1, 2, and then every 5 years if there are no changes. — Dr. Doug Jonston
Question 4: Allen asks, “Does replacing the mitral valve with a prosthetic valve reduce the number of possible ablation sites in correcting post surgery atrial fibrillation?”
That is an interesting question. The devices available for catheter ablation of atrial fibrillation are constantly evolving. I am not aware that any of these would be affected by the presence of a prosthetic mitral valve, but I will run this question by our EP colleagues and get back to you. — Dr. Doug Johnston
Question 5: Rosanne asks, “I am an 69 year old and had AVR 9 years ago for radiation induced aortic stenosis (Hodgkins disease), now need MVR. Is there a risk associated with radiation induced stenosis?”
This is a great question and the answer is something not widely understood. Radiation valve disease behaves differently, in every way, than valve disease not associated with radiation. Both aortic and mitral valve disease progress differently in patients who have had chest radiation. Radiation tends to produce more calcification which can make a reoperation more challenging, and in addition, radiation affects the heart muscle, aorta, and pericardium to different extents in different patients, making these operations more challenging, and riskier, than the average redo. This has led to radiation heart disease increasingly become a specialized area for surgeons and cardiologists. You may be interested in reading the consensus document I wrote with several colleagues which provides some more in depth information. — Dr Doug Johnston
Question 6: Kerry asks, “Had angioplasty for one small artery after infarction in 1985. In 2007, had bypass surgery with 6 bypasses. Just now got results from current echo test saying I have severe aortic stenosis. Current cardiologist wants to have valve replaced. Getting 2nd opinion August 3 with different surgeon in different hospital.”
There are a number of options to be considered for treatment of aortic stenosis in a patient with prior bypass surgery, including TAVR and redo surgery with SAVR. I would always recommend patients obtain more than one opinion. — Dr. Doug Johnston
Question 7: Duncan asks, “What are the latest developments in anti-calcification properties of bio-prosthetic heart valve tissue?”
There is a lot of research ongoing in this area. Several companies have introduced new anti-calcification treatments in the last few years. While animal studies can give us some idea of how effective these are, it will take many years to understand whether they are better in humans than the current generation of valves which are already very good. — Dr. Doug Johnston
Question 8: Julaine asks, “I now have mild aortic stenosis after having a prosthetic aortic valve replacement done 9 years ago. How is that possible?”
This is a very good question. All bio-prosthetic valves have a tendency to calcify over time. How fast this happens is very different from patient to patient and depends on age, kidney function, calcium levels, and other factors. When we talk about durability of tissue valves, we look at what the probability is that a valve will wear out in a certain timeframe to the extent it needs to be replaced. Typically what happens early in the process is the valve gradients will increase and the valve will progress from mild, moderate and eventually severe stenosis. — Dr. Doug Johnston
Question 9: Faith asks, “Please talk about steps a person can take to extend the life of a new biological valve. Drs often say, “there is nothing that can be done to make the valves last longer” but surely this can’t be true. We know some behaviors are bad- like smoking. Please share what kind of diet is helpful to help the valve not calcify as quickly- ie: plant based? Keto? Also- does the valve wear out based on how many times it beats- ie: we should exercise less? Does blood type affect valve life?”
While it is not strictly true that nothing can be done to extend the life of the valve, the only behavior that is known to shorten the durability is taking high doses of calcium. It has not been shown that any type of diet extends valve durability. Fortunately, there is no evidence that more heartbeats, i.e. exercise, is bad for valve durability. Thus what we tell patients is “enjoy your life, have the valve looked at with an echo once a year, and don’t worry about making any lifestyle changes for the sake of the valve.” — Dr. Doug Johnston
Question 10: Anonymous asks, “I had a laparoscopic aortic valve replacement in 2012. The bovine valve is now wearing out. Am I a TAVR candidate? 72 years old in otherwise very good health.”
Whether a patient is a candidate for TAVR valve in valve depends on the size and type of valve implanted, and the size and shape of the aortic root around the valve. The heart team typically will obtain a specialized CT scan to evaluate whether this is possible. — Dr. Doug Johnston
Question 11: Des asks, “I had an aortic valve, aortic stenosis and an aneurysm replaced/repaired in 2013. It was successful. In 2017 I contracted bacteriuma endocarditis. The valve was damaged. It has been 10 years and my valve seems to be okay but will have to be replaced. Would you do a full open heart surgery or would you do a minimal invasive heart valve replacement.”
In most cases a reoperation on a patient who has had ascending aneurysm surgery is done through a full sternotomy in order to get to the valve safely. In some situations valve in valve TAVR may be an option depending on the size of the valve that was implanted. — Dr. Doug Johnston
Question 12: Faith asks, “Are there any special things that apply for people who have valve disease due to radiation from cancer treatment or any long term considerations for radiated people to be aware of.”
Radiation to the chest, especially for Hodgkins disease, affects the heart valves, heart muscle, pericardium, coronary arteries, and aorta. Surgeons and cardiologists need to consider all of these affects to determine timing and which interventions to perform. Because valve disease progresses at different rates, it is important to think about the other valves and need for future intervention before replacing a single valve. — Dr. Doug Johnston
Question 13: Christine asks, I had MV repair June 2023 via Sternotomy and immediate started with occular migraines, is this common?”
I am not aware of any study connecting migraine and mitral valve surgery. — Dr. Doug Johnston
Question 14: Christine asks, “I had a hemi commando procedure almost two years ago. Is this because there was a build up of calcium in my Aorta?”
I can’t comment on why a particular operation was done. That’s a good question for your surgeon, or alternatively would be happy fopr our team to review your imaging and records if there is a question about what might need to be done in the future. — Dr. Doug Johnston
Question 15: Danny asks, “I have two mechanical valves; aortic and mitral via OHS in 2016 at the age of 46. I have radiation induced heart disease secondary to Hodgkins treatment in 1991. I also have cardiomyopathy with two heart walls affected. Is there any surgical intervention for someone like me?”
Mechanical valves can be a good option for young patients with radiation heart disease, because reoperations are more complex and risky in the setting of radiation. Radiation can also affect the heart muscle in different ways for different patients. Often this progresses slowly and patients may do very well clinically even if the heart muscle isn’t totally normal. In extreme cases if the heart muscle continues to worsen, patients may be considered for advanced heart failure therapies like ventricular assist devices or transplantation. — Dr. Doug Johnston
Question 16: Tina asks, “Appreciate Dr. Johnson’s comment about “finding the right team and the right center”, which resonates with me. What criteria would you suggest in considering to determine this? Thank you!”
Many centers highlight their volumes and outcomes for valve surgery online or in publications. In general centers which perform more complex cases, participate in clinical trials, and perform research in valve disease are ones to consider. One question to ask your physicians is “where would you send a challenging valve case?” — Dr. Doug Johnston
Question 17: Supreet asks, “I underwent 21mm Medtronic Mechanical AVR in 2006 in India. Based on my latest ECHO, the mean AV gradient is 39 mmHg because the mechanical valve used for my age back then is small right now. Additionally I also have proximal ascending aorta of 4.5cm. (Question#1) In my next surgery what will be the deciding factory? is it gradient or Ascending Aorta or both? (Question#2) Will the root need to be necessarily replaced as well?such as Bentall procedure including root, valve and ascending aorta all 3?”
Patient-prosthesis mismatch is a situation in which the implanted valve works correctly, but is small compared with the size of the patient, and this results in a valve gradient that is high. Often, patients with bicuspid valve disease may have issues with both valve and aorta, and this requires a careful review of the CT scan with the surgeon to determine 1. What are the considerations for implanting a larger valve. In some cases a root enlargement procedure may be the recommended. 2. Where an aneurysm is in the aorta and how extensive it is will determine the type of aortic operation performed. — Dr. Doug Johnston
Question 18: Rosanne asks, “Can you explain severe sub-annular calcification of a 9 year AVR?”
Calcification can develop before or after a valve implant. For reasons not well understood, some patients develop calcium only on the valve leaflets, some in part of the anulus, and some extensively on the anulus. — Dr. Doug Johnston
Question 19: Deena asks, “Could you discuss any long term risks with calcified mitral valve post a repair? In other words, what is the probability and/or factors that would cause the repaired mitral valve to continue to calcify and require more surgery eventually?”
Unfortunately calcification is common and not well understood. Risk factors for calcification include a history of radiation to the chest, kidney disease, and age. — Dr. Doug Johnston
Question 20: Anonymous asks, “Would you not consider the ACHA accreditation have value for choosing a center?”
Unfortunately, there is not a single form of accreditation which applies to valve centers nationally. Patients may find the information supplied by ACHA, or Adult Congenital Heart Association, the Bicuspid Aortic Foundation, the American Heart Association Mitral Valve Reference Center program, Marfan Foundation, among other sites to be valuable sources of information. — Dr. Doug Johnston
Question 21: Larry asks, “What is the percentage of having a stroke during open heart surgery?”
The risk of stroke varies widely according to the type of surgery, and most of all the patient’s own anatomy and risk factors. For healthy patients this is generally less than 1%. — Dr. Doug Johnston
Question 22: Michael asks, “What advice to you offer a patient who wants a particular surgeon but that surgeon is busy possibly because of their other responsibilities such as chief of surgery, department head, etc.”
Choosing a surgeon is a difficult and important decision. In some cases surgeons’ clinical focus and volume may change with administrative or academic responsibilities or over the course of their career. It is usually best to speak with team members at a particular center to see which surgeons focus on the procedure in which you are interested. — Dr. Doug Johnston
Question 23: Kim asks, “Are TAVR’s being done regularly on BAV replacement?”
TAVR is increasingly being done in bicuspid valves however there are a number of reasons why a valve may not be amenable to TAVR including asymmetric calcium, coronary artery heights, and the size of the aorta or annulus. Many centers consider TAVR in bicuspid valves only in older patients, because the date on long term durability is not as clear. — Dr. Doug Johnston
Question 24: Anonymous asks, “What kind of factors would make a BAV patient with regurgitation a poor candidate for valve repair?”
For a valve to be repairable, the leaflets of the valve need to be strong enough to support the repair, but thin enough not to become narrow after repair. Thickening and calcification are the most common reasons for a bicuspid valve not to be repairable. — Dr. Doug Johnston
Question 25: Fray asks, “I am having a valve-sparing aortic root replacement surgery at the end of August. How long dose the aortic graft last? What is life spam of aortic root sparing surgery?”
Aortic grafts can last the lifetime of a patient. Valve sparing root surgery is generally a durable operation, but overall durability depends on the condition of the valve leaflets and patient anatomy. — Dr. Doug Johnston
Question 26: Mark asks, “I’m 9 months out from SAVR (bicuspid valve). Is there a unique diet I should be following, other than a usual “heart-healthy” diet?”
There is no unique diet necessary for a valve replacement. — Dr. Doug Johnston
Question 27: Bob asks, “Just celebrated my 2 year anniversary of Dr Johnston doing on my AVR on 7/22/21 at Cleve. Clinic. Everything is great. Thank you Dr. Johnston. Everything With you and your team was truly a shared decision making process.”
Thank you and very glad to hear you are doing great! Shared decision making is a key part of the interaction between the patient and surgeron. This is something we are very passionate about.
Question 28: Fozia asks, “I am a 41 year old female, have had my re-do mitral valve replacement by a mechanical valve since 2016. Currently on warfarin. I want to go for a pregnancy. Is it possible?”
This is something that should be discussed in detail with your cardiologist. — Dr. Doug Johnston
Question 29: Anonymous asks, “I have been told “at a center for excellence” that I need open heart surgery due to a bicuspid aortic valve and an ascending aortic aneurysm at 5.1 cm. I have two questions: (1) Do I really need to have a SAVR vs. a TAVR? and (2) Will there be metal used to join the parts of my sternum and will I be able to have MRI’s in the future after heart surgery?”
In most cases where there is need for valve surgery as well as aneurysm repair, TAVR will not be recommended because TAVR does not address the aneurysm, and in rare cases the aneurysm may rupture when a TAVR is expanded. Many cases of ascending aortic repair and valve replacement can be performed with a small incision approach. This is our practice at Northwestern. There are a variety of methods which can be used to close the sternum including stainless steel wire, titanium plates, and polymer closure, all of which are compatible with MRI. — Dr. Doug Johnston
Question 30: Mary Jo asks, “Can you discuss how aortic valve replacement sizing is important to future intervention?”
If valve in valve TAVR is going to be considered when a bioprosthetic valve fails, the original valve needs to be large enough to accommodate a new valve inside it. In general at least a 23 mm valve is necessary, although larger valves are recommended in larger patients. — Dr. Doug Johnston
Question 31: Joni asks “Can aortic valve repair be done with minimally invasive techniques?”
Absolutely! We utilize both upper hemi-sternotomy J incision and mini thoracotomy approaches in bicuspid valve repairs. — Dr. Doug Johnston
Question 32: Anonymous asks, “What are your thoughts on antibiotics for dental work post-valve repair surgery?”
Unfortunately the guidelines for antibiotics with dental work have changed over the last few years and many patients and physicians are confused. We continue to recommend antibiotics for dental procedures in patients with valve repairs or replacements. — Dr. Doug Johnston
Question 33: Bob asks, “I’m not sure how to word this, but in the event a patient’s insurance and financial resources prevents them from seeking surgery at a “center of excellence”, how do we vet the centers that are in our network and more or less have to utilize.”
In many situations, a case can be made to the insurance company that a different procedure will be performed at the out of network institution, for example a minimally invasive procedure, or a repair vs replacement. We see these situations frequently, and I’m sorry for the frustration it causes. — Dr. Doug Johnston
Question 34: Joni asks, “I have been having palpitations, sip on Fireball Whiskey, and it calms the “girls down!” Last echo, my Cardiologist said your regurgitation “got better” and he never heard of that.
Sometime regurgitation can appear better from one echo to another based on how much fluid is in the body or how full the heart is. — Dr. Doug Johnston
Question 35: Delise asks, “Is it important to know what caused a patient’s valve disease in order to know how best to fix it? Ischemic, degenerative, rheumatic, etc.”
It is important to understand the valve pathology – are the leaflets thickened? Calcified? Are they floppy? Are they tethered? This helps us to determine whether repair is an option and how to get a successful repair. — Dr. Doug Johnston
Question 36: Pat asks, “What two valves would you recommend if you’re mid-30s, you’ve outlived your Ross, and you’re due for your 3rd sternotomy to replace your neo-aortic and pulmonic valves (due to severe aortic regurgitation)? Mechanical Aortic and new donor or double tissue?”
That is a great question. The thought process around valve choice is different in a patient who has had multiple prior sternotomies vs a first operation. In general we tend to think more about mechanical valves when a patient is having their 3rd or 4th operation, especially in the 30’s and 40’s, however lifestyle and patient preference is still an important part of the decision making. — Dr. Doug Johnston
Question 37: Barry asks, “I had TAVR a few months ago all went well but first nite crud broke off and had a 6 “minor” strokes recovered but still on thinners. First Eliquis for and now Plavix and off the Eliquis and the baby aspirin. Risk or repeat stroke risk? I have Edwards Bovine device Aortic size 23 mm.”
Stroke after SAVR or TAVR is a tough problem to sort out, because at least half of these occur not during, but early after the procedure. These can come from the native valve, the new valve, the ascending aorta and arch, the carotid arteries, and sometimes from the atria from early atrial fibrillation. Choice of anticoagulation is usually a joint discussion with the cardiac and neurology teams. The good news is that having a stroke early after the procedure does not necessarily mean that your stroke risk is increased in the longer term. — Dr. Doug Johnston
Question 38: DV asks, “What is considered a large valve replacement? Mine was 23mm.”
That is a great question. Large is a relative term. What matters is that the valve has an adequate area for blood flow compared to a patient’s body size. 23 mm is the “middle” sized valve and is adequate for most patients, however might be small for a very large patient. — Dr. Doug Johnston
Question 39: Melissa asks, “Is it better to do something with mitral valve prolapse and regurgitation when it’s moderate or severe?”
The AHA / ACC guidelines for valve disease suggest intervening on a mitral valve when the regurgitation is SEVERE, because only in patients with severe regurgitation do we have good data suggesting that the risk of intervention is less than the risk of ongoing medical management or what is called “watchful waiting”. — Dr. Doug Johnston
Question 40: Carrie asks, “Can an aortic aneurysm be repaired with minimally invasive incision?”
Yes, depending on where the aneurysm is in the aorta. Ascending aortic aneurysms, and some aneurysms involving the arch of the aorta, can often be repaired with a minimally invasive approach. Descending aortic aneurysms may be repaired with a stent-graft, which is called a TEVAR. — Dr. Doug Johnston
Question 41: Lisa asks, “I am 58 year old with a calcified aortic valve, preparing for future surgery. Should I discontinue my calcium supplements?”
There is a lot of emerging evidence to suggest that certain regimens of calcium supplementation may accelerate calcification of both native aortic valves and bioprosthetic valves. Unfortunately we don’t know if there is a dose which is low enough to avoid affecting the valves but high enough to benefit bone health. Increasingly, surgeons and cardiologists are recommending stopping supplementation for patients with aortic stenosis, however we need more data to understand who will benefit most from stopping supplementation. — Dr. Doug Johnston
Question 42: Bill asks, “How often does exercise intolerance happen with mitral valve repair when the new mitral valve mean gradient is high such as 13 mmHg at HR 90 post exercise?”
It is not unusual to see an elevated mean mitral gradient with exercise after some mitral valve repairs. Depending on the type of disease in the leaflets and the size of the mitral anulus, in some cases repairing a valve results in a valve that does not leak but has mild stenosis at rest. With exercise those gradients can increase, however most patient with mild resting gradients have normal exercise tolerance. — Dr. Doug Johnston
Question 43: Deb asks, “I am 62 and just got my surgery date of 8/28 for bicuspid aortic valve with severe stenosis. Considering a sternotomy instead of mini-SAVR for setting up for the valve-in-valve for my replacement. Have CT Scan 8/8 to determine best option. Do you concur?”
Our practice is to obtain a CT scan on every patient in whom we are planning an aortic valve replacement. This helps us determine whether a minimally invasive approach can be done safely, and in addition, whether there is an aortic aneurysm that also needs to be repaired. Here at Northwestern, the majority of SAVR is performed minimally invasively, and we routinely are planning for future valve in valve. It is always worth asking why a decision would be made to perform a sternotomy rather than a mini approach. — Dr. Doug Johnston
Question 44: Assunta asks, “What deems someone to be “frail “to not have open heart surgery? Is weight an issue?”
Weight can certainly be an issue in terms of risk for surgery. On the one hand, patients with a high body mass index (BMI), who are very overweight, have an increased risk for pneumonia, infection, blood clots, and other complications after surgery. Patients with very low BMI, especially if they have blood tests consistent with malnutrition, may have difficulty healing with surgery. — Dr. Doug Johnston
Question 45: Anonymous asks, “My latest echo shows my Edwards valve 15 years old has moderate regurgitation. With elevated prosthetic gradient due to pathologic prosthetic regurgitation and/or pathologic prosthetic obstruction. peak velocity is 4.00 m/s. AV area by continuity equation is .09cm2. AV acceleration time is 111 ms. How long before you think I might need a new one and would you recommend TAVR? I am 63 and exercise daily.”
We think about the indications for intervention for prosthetic valves in the same way as for native valves. In general, a velocity of 4 m/s would be considered severe aortic stenosis and be an indication for reintervention. Reintervention with redo SAVR or valve in valve TAVR are options the heart team will consider based on the size of the prosthetic valve, the shape and size of the aortic root, and function of the other valves as well as the coronary arteries. — Dr. Doug Johnston
Question 46: Assunta asks, “Is a person who has severe aortic stenosis considered to be in “heart failure”?
Heart failure is a condition in which the heart can’t pump enough blood to support the body’s normal functions. It can present as not enough blood going forward to the organs, in which case patients have fatigue, may have kidney problems, low blood pressure, etc. It also may result in too much blood backing up through the heart, which causes shortness of breath, retaining fluid, ankle swelling, etc. Heart failure is a late event in aortic stenosis and is usually when the valve disease is very advanced. Many patients with severe AS may have fatigue as their only symptom, and are not yet in heart failure. — Dr. Doug Johnston
Many Thanks Dr. Doug Johnston!!!
I have to extend a mighty “THANK YOU” to Dr. Doug Johnston for taking the time to answer the patient questions submitted during our special webinar, “The Lifetime Management of Heart Valve Disease” webinar.
Keep on tickin!
Adam
Written by Adam Pick
- Patient & Website Founder
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