{"id":4849,"date":"2024-09-10T23:41:10","date_gmt":"2024-09-10T23:41:10","guid":{"rendered":"https:\/\/www.heart-valve-surgery.com\/learning\/?page_id=4849"},"modified":"2024-09-12T18:07:32","modified_gmt":"2024-09-12T18:07:32","slug":"complex-high-risk","status":"publish","type":"page","link":"https:\/\/www.heart-valve-surgery.com\/learning\/complex-high-risk\/","title":{"rendered":"Surgeon Roundtable: Complex and High-Risk Heart Valve Surgery"},"content":{"rendered":"<p>Patients, their families and medical teams can all agree that there are inherent risks when undergoing any type of heart valve surgery. That said, treatment options and approaches may change when a patient is considered \u201chigh-risk\u201d due to complex cardiac conditions, health problems, advanced age and\/or heart valve reoperations.<\/p>\n<p>To learn more about the therapeutic options and medical advances designed for patients considered &#8220;high-risk&#8221;, we sat down with two expert heart surgeons from the Cleveland Clinic. <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Edward-Soltesz-Cleveland-Ohio.php\">Dr. Edward Soltesz<\/a> is the Lewis Endowed Chair of Cardiothoracic Surgery and the Surgical Director at the Kauffman Center for Heart Failure and Recovery. <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Anthony-Zaki-Cleveland-Ohio.php\">Dr. Anthony Zaki<\/a> is a highly experienced cardiac surgeon who has guided many high-risk patients through critical decision-making processes with successful outcomes.<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><iframe loading=\"lazy\" title=\"YouTube video player\" src=\"https:\/\/www.youtube.com\/embed\/cavGzJNsO9s?rel=0?si=LRItLekvooUnw9s1\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>&nbsp;<\/p>\n<h2>Key Insights For High-Risk Heart Valve Surgery Patients<\/h2>\n<p>Here are the important questions and answers addressed by Dr. Soltesz and Dr. Zaki:<\/p>\n<p><strong>Question: Why would a patient be told they\u2019re at high risk for valve surgery?<\/strong><\/p>\n<p>Dr. Zaki said they often encounter patients who come to the Cleveland Clinic for evaluation after being told they are \u201chigh-risk\u201d and believes this could be for several reasons. He said, \u201cIn general, we categorize risk into two categories, whether it\u2019s for medical reasons or comorbidities or other medical issues, or surgical risk, whether they\u2019ve had multiple surgeries in the past or if they have some other technical factor that makes the surgery high risk.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-4851 aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/risk-categories.jpg\" alt=\"Heart Surgery Risk Categories\" width=\"650\" height=\"364\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>Dr. Zaki added that a third category of high-risk patients may need an isolated valve or bypass or a combination of procedures at one time. He said, \u201cA lot of patients come to us with that labeling of high-risk, and I\u2019d like to say that often it is a subjective labeling and varies center to center and surgeon to surgeon.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: What are the strategies to overcome the issues facing these high-risk patients?<\/strong><\/p>\n<p>Dr. Soltesz said many patients are told they\u2019re high-risk at one particular center or program while not necessarily considered high-risk at another program. \u201cI think one of the things we have seen here at the Cleveland Clinic are a lot of patients are declined surgery because they are considered too high risk,\u201d he said. \u201cThey\u2019re declined either because they have too many valves that need repair or replacement, they have low ejection fraction, and there\u2019s a concern that they will not tolerate surgery.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-4852 aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/declined-surgery-risks.jpg\" alt=\"Declined Heart Surgery Reasons\" width=\"650\" height=\"362\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>Dr. Zaki said that to overcome these issues, the Cleveland Clinic has access to several tools, resources, and tricks to successfully get these types of high-risk patients through an operation. \u201cSo, for example, if someone has been declined surgery at another center because their heart function is low, we have ways that we can support the heart during the operation, whether it\u2019s with a temporary heart pump or some other technique to get the heart through that vulnerable operation period and on to recovery,\u201d said Dr. Zaki.<\/p>\n<p>Although that\u2019s just one example, Dr. Zaki said that people are declined for other risks as well, including needing multiple valves repaired at once, having valve infections, or even having transcatheter valves that have been placed in the past that need to be removed or revised.<\/p>\n<p>Dr. Soltesz commented, \u201cDr. Zaki brings up a very good point about patients who\u2019ve had TAVRs in the past. TAVRs allow minimally invasive valve replacement, but many times, those TAVR valves need to be removed. Either they\u2019re failing, become infected, or not in the correct position.\u201d Dr. Soltesz then asked Dr. Zaki to explain about TAVR replacement.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: If a patient has been told they were at high risk for heart surgery in the past and had a TAVR, can they have a TAVR explant?<\/strong><\/p>\n<p>Dr. Zaki explained this is another situation they encounter quite often. \u201cI just recently had a patient who said, \u2018Well, if I had a TAVR a few years ago because surgery was too high risk, now that I need to have something done now, how has my surgical risk changed?\u2019 And I would say that the comfort level with TAVR removal, especially at a large center like the Cleveland Clinic, has increased as the number of TAVR implants has increased. So if you go to a center comfortable removing, revising, and repositioning TAVR valves, that risk is mitigated compared to the risk you may have had up front.\u201d<\/p>\n<p>Dr. Zaki also added, \u201cSo, TAVR is a wonderful technology and is indicated for many patients, but just because you\u2019ve had a TAVR in the past doesn\u2019t mean that it can\u2019t be removed if it needs to be, and there is a surgical option available to you.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: What about getting a second opinion?<\/strong><\/p>\n<p>Dr. Soltesz said getting a second opinion is a theme they often talk about. \u201cI think second opinions are absolutely critical, not only for patients with heart disease but for all medical problems. I think it\u2019s essential for patients to make their own decisions as to what they want to do.\u201d<\/p>\n<p>Dr. Soltesz asked Dr. Zaki how he talks to patients coming in for a second opinion and how he relates some of the information about how what they do at the Cleveland Clinic can affect their recovery after surgery.<\/p>\n<p>Dr. Zaki replied, \u201cPeople are turned down for surgery for several different reasons by different providers. So the first thing I like to do when I meet someone who\u2019s been turned down at another center or by another surgeon is to try to understand why.\u201d<\/p>\n<p>Dr. Zaki continued, \u201cSo that involves taking a deep dive into the medical surgical history and talking to the patient and seeing what\u2019s going on and what conversations they\u2019ve had in the past, and that serves as the starting point. From there, I do my own assessment, my own evaluation, and I try to get an understanding of whether those risks are truly prohibitive or if we can mitigate or somehow circumvent them using the strategies and resources we have available here.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: When multiple valves need to be repaired or replaced, can they all be done at the same time?<\/strong><\/p>\n<p>According to Dr. Soltesz, addressing multiple valves using transcatheter technology is often not possible, so the valves must be dealt with surgically.<\/p>\n<p>Dr. Zaki added, \u201cThis has recently become more of a topic, with TAVR and transcatheter valves becoming more common. The thought out there, which I don\u2019t necessarily agree with, is transcatheter approaches may address one valve while just monitoring the other valves. What we see is that this may not correct all of the symptoms or problems for patients, and then they\u2019re referred to us because they had one valve fixed with a transcatheter approach but still have other valves that are still leaking or not functioning well, and they are still having symptoms.\u201d<\/p>\n<p>\u201cSo what we can do surgically at the same time and in a single operation is address all valves at once,\u201d explained Dr. Zaki.\u201dWhether a TAVR valve has been placed in the past or a Mitral Clip or any other transcatheter therapy was used, we can not only address that main valve or the one that\u2019s already been addressed, but we can fix the other valves in the heart.\u201d<\/p>\n<p>\u201cAt the same time, we can do bypass surgery for coronary artery disease. A lot of these patients with multivalve disease have atrial fibrillation. So we can do surgical ablations to get people back into normal sinus rhythm at the same time. While transcatheter technology is appropriate for many patients, people with multivalve disease, atrial fibrillation, coronary artery disease, open heart surgery can address all of these concerns in a single shot.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-4855 aligncenter\" src=\"https:\/\/www.heart-valve-surgery.com\/learning\/..\/Images\/atrial-fibrillation-rhythms-normal-2.jpg\" alt=\"Atrial Fibrillation\" width=\"650\" height=\"362\" \/><\/p>\n<p>&nbsp;<\/p>\n<p>Dr. Soltesz agreed, \u201cI think that\u2019s a good point, especially with atrial fibrillation. Atrial fibrillation is a growing problem in the US and worldwide, and we know it\u2019s been associated with a lot of comorbidity. We are able, at the same time of a surgical operation, whether it\u2019s the primary or a re-operation, to perform an extremely durable ablation that has tremendously high success rates of getting patients out of atrial fibrillation and into sinus rhythm, which reduces not only their risk of stroke long term, but reduces their risk of long term heart failure, dementia, and many other comorbidities that we have seen associated with atrial fibrillation.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: How can having previous heart surgeries affect the ability to perform an additional operation?<\/strong><\/p>\n<p>Dr. Soltesz pointed out that Dr. Zaki had recently done a fourth re-operation on someone with three previous heart surgeries. \u201cI think there are many patients out there who are erroneously told that they\u2019ve had too many heart surgeries. Can you tell us a bit about that, Dr. Zaki?\u201d<\/p>\n<p>Dr. Zaki replied, \u201cPatients who have had valve disease or heart disease throughout their lifetime may have experienced multiple open heart surgeries, and it is true that with the second and third operations, there is scar tissue. What we\u2019ve learned from our experience here is that often, reoperation is just as safe as the first operation, whether it\u2019s the second, third, or fourth time. And that\u2019s only true at centers that have that experience. So we\u2019re grateful and happy to be here at the Cleveland Clinic, where we have that experience, skill, and knowledge passed down from mentors like Dr. Soltez, who has passed on this understanding of how to deal with these re-operations. I think the adage, we\u2019ve been in there too many times and can\u2019t go back, should be tested or checked with a second opinion and may or may not be absolutely true.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: How important is the idea of team-based care?<\/strong><\/p>\n<p>\u201cWe all work together,\u201d said Dr. Soltez. \u201cWe learn from one another. We have a very close connection with our cardiology colleagues. We have conferences together where we review high-risk patients. We have conferences within our surgical staff where we review complex operations. So, I think one of the advantages of the Cleveland Clinic is that it is a true team-of-teams approach to treating patients.\u201d<\/p>\n<p>\u201cBut I also think on an individual level for a patient; it\u2019s important for us to be able to engage in shared decision-making with our patients so that they understand what we can offer and we understand what they want as their quality of life, their survival, and their risk tolerance.\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: What does the conversation sound like when a patient comes to the Cleveland Clinic?<\/strong><\/p>\n<p>\u201cThe first thing I understand when meeting with a patient is that they\u2019ve been through a long process before they\u2019ve gotten to me,\u201d said Dr. Zaki. \u201cThey\u2019ve been through either a primary care doctor or cardiologist and perhaps have been through several different centers before coming to me.\u201d<\/p>\n<p>\u201cI feel like the most important step is to hear from them about what they\u2019ve been through and their expectations. That serves as a good starting point for me. From there, I will do my own evaluation and assessment using our team approach, as Dr. Soltesz described. Then we make a plan, and as Dr. Soltesz mentioned, not every patient is the same, and not every valve disease is the same.<\/p>\n<p>Dr. Zaki explained that he asks the patient, \u201cWhat are you looking for? What are your goals? What are your values? What are you expecting from your treatment plan?\u201d<\/p>\n<p>Asking these questions helps guide the discussion to develop the best solution together.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Question: A final recommendation from Dr. Zaki\u2019s experience as a heart surgeon at the Cleveland Clinic<\/strong><\/p>\n<p>\u201cThis is something I tell family and friends who have medical issues: Ask questions, get a second opinion, and move forward when you\u2019re comfortable,\u201d said Dr. Zaki.<\/p>\n<p>Dr. Soltesz added, \u201cAnd it\u2019s important to recognize that as a patient, you have control of your health, and it is in your best interest to ask questions about what you just heard, get a second opinion, and then make an informed decision with your family and with your practitioners about how to proceed.\u201d<\/p>\n<p>&nbsp;<\/p>\n<h1>Thanks Dr. Soltesz, Dr. Zaki and the Cleveland Clinic!<\/h1>\n<p>On behalf of the HeartValveSurgery.com patient community, thank you, <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Edward-Soltesz-Cleveland-Ohio.php\">Dr. Soltesz<\/a> and <a href=\"https:\/\/www.heart-valve-surgery.com\/surgeons\/dr-Anthony-Zaki-Cleveland-Ohio.php\">Dr. Zaki<\/a>, for sharing your skilled and knowledgeable insight into this vital topic to help inform our high-risk surgical patients. \u00a0We would also like to thank the Cleveland Clinic for continuing to care for heart valve patients and keep them informed!<\/p>\n<p>Related Link:<\/p>\n<ul>\n<li><a href=\"https:\/\/consultqd.clevelandclinic.org\/rethinking-risk-in-reoperative-cardiac-surgery-large-series-suggests-a-new-frontier-in-safety\">Rethinking Risk in Reoperative Cardiac Surgery: Large Series Suggests a New Frontier in Safety<\/a><\/li>\n<\/ul>\n<p>Keep on tickin!<br \/>\nAdam<\/p>\n<p>P.S. For the deaf and hard of hearing members of our community, we have provided a written transcript of the video below.<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"cms.php","meta":{"_acf_changed":false,"footnotes":""},"categories":[8],"class_list":["post-4849","page","type-page","status-publish","hentry","category-before-surgery"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4849","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/comments?post=4849"}],"version-history":[{"count":21,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4849\/revisions"}],"predecessor-version":[{"id":4878,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/pages\/4849\/revisions\/4878"}],"wp:attachment":[{"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/media?parent=4849"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.heart-valve-surgery.com\/learning\/wp-json\/wp\/v2\/categories?post=4849"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}