MVR timing

[Cindy__0__0]

Posted by Cindy on April 23, 1999 at 20:57:36
I have enquired before but have a few more questions.
My husband is 41 and in good health. He has MVP w/regurgitation, and thickened leaflets, diagnosed in 91. In 97 contracted BE, TEE showed vegitation on the leaflets and ruptured chordea, and what the DR called moderately to severely enlarged LA, which was 51mm, partial flail leaflet. One year later reg. Echo showed  3-4+ regurgitation, LA 46mm. Currently we are waiting on copies of our records to send to Dr. Cosgrove.
I have several questions.
1. Why would his LA be smaller now?
2. The size of his LA when he was first diagnosed in 91 was 38mm, do they take this into consideration in determining if it is called moderately, or severely enlarged?
3.His BSA is 1.95m2,what would be the normal size LA for him?
We were told that the reason for waiting is they don't know whether the valve is repairable or not, a) since we "don't know" is it best to wait?
b)why is it better to wait even if he does need to have a replace?
4. In his records since the BE it is saying that his MVP and regurgitation are "secondary" to BE. When looking at this, would a Dr giving a second opinion tend to have a different approach to treatment ie: thinking it has not been an ongoing process, and that his LA and LV size would be close to his normal etc.
Thank you for any information you can give with these questions.
Regards,
Cindy
Posted by CCF CARDIO MD - CRC on April 26, 1999 at 14:15:34
Dear AG,
I have answered your questions below and included some from other patients.
Q:  Why would his LA be smaller now?
A: It depends on where they measured the atrium.  Most likely this measurement was in a slightly different location.  The atrium does not generally decrease in size.

Q:  The size of his LA when he was first diagnosed in 91 was 38mm, do they take this into consideration in determining if it is called moderately, or severely enlarged?
A: Sure, you have to look at the whole picture.
Q: His BSA is 1.95m2,what would be the normal size LA for him?
A: 3-4 cm.

Q: We were told that the reason for waiting is they don't know whether the valve is repairable or not,
a) since we "don't know" is it best to wait?
b) why is it better to wait even if he does need to have a replace?
A: The timing of valve surgery is more of an art than a science.  It's always better to wait if possible but not too long or the heart may be damaged.  The bottom line is that he will need valve surgery sooner or later.

Q:  In his records since the BE it is saying that his MVP and regurgitation are "secondary" to BE. When looking at this, would a Dr giving a second opinion tend to have a different approach to treatment ie: thinking it has not been an ongoing process, and that his LA and LV size would be close to his normal etc.
A:  I'm not sure of the point of your question.  He had to have an irregular valve (although perhaps not as severe) before he got the BE or he would not have had the infection there.  If he has a flail leaflet now he has to have surgery - repair if possible and replacement if not.
Hope this answers your questions.  Feel free to write back with additional questions.
Here are some questions from other patients.  Not all will apply to you.
*******************************
Q: Doctors in Dayton have not seen my ECHO history, Is it important that he compares the results with my 1995 and 1990 Echo?
A: Not necessarily.  The important results are the current tests although it is helpful to review the progression of the disease.
Q: Do I Need surgery?
A: Only your doctors can answer this question.
Q:  Replacement v/s Repair of MV?
A: In general it is better to repair the valve if possible.  If not possible replacement is the next best option.
Q: Is there any other medical diagnosis need to be ruled out other then the heart condition to relieve the symptoms of insomnia.
A: Generally valvular abnormalities do not cause insomnia.  However, worry about the situation may.
Q:  If surgery is helpful but not required, then how close/frequent follow up is required?
A: This would depend upon the particular case and varies from monthly to yearly.
I have enclosed other questions from patients below.  They may not all apply to you. Hope this helps.
Q: What symptoms can I expect in the next few years?
A: Hopefully you will have an operation before you develop symptoms.  Once symptoms develop damage has been done to the heart that can not be reversed.
Q: How does the doctor decide when is the best time for an operation?
A: Usually serial echocardiograms are performed and the ventricular function and valve function are watched very closely.  Once there is any sign of worsening surgery is recommended.
Q: Also, I have read about minimally invasive surgery. Is such surgery possible for mitral valve repairs? Are the results for minimally invasive surgery different from regular open-heart surgery?
A: Minimally invasive mitral valve repair has been pioneered at the Cleveland Clinic and is highly successful in properly selected patients.  If you are considering coming to Cleveland I would recommend Dr. Cosgrove to perform your surgery.  

Q:  I don't have any symptoms (shortness of breath, pain, etc.,), and wonder what would happen if I waited until symptoms started.
A: Once symptoms develop it is often too late to reverse the damage done.  Thus we operate before symptoms start.
Q:  If surgeons at the Cleveland Clinic can perform the procedure, how soon could I get in?
A:  The wait for a surgical time will depend somewhat on the surgeon with Dr. Cosgrove having the longest wait for elective procedures of about 3-5 months.
Q:  They say my cordae is torn, is that serious and is that possible to repair and is that possible via "keyhole"?
A:  Yes and yes however the particular surgical approach will depend upon the specifics of your case.
Q: I am 41 years old, very active phyiscally and have played basketball weekly since high school. Upon doctors orders I have stopped, will I be able to resume basketball?
A: Most people are able to resume their previous activities after surgery.
Q:  Do you have any suggestions on how to break this news to my you children (ages 5 & 9) that Daddy has to go to Cleveland for a heart operation?
A:  I would be straightforward and explain things in terms they can understand.  
Q: How do I know if I am a candidate for repair of the mitral valve vs. replacement?
A: Repair of the mitral valve vs. replacement with a bioprothesis or mechanical valve can only be determined in the operating room.  If the damage is not repairable then it is replaced.  The bioprothesis valve is from either a pig or cow and lasts about 10 years.  The advantage is that long-term anticoagulation is not required.  The disadvantage is that it will need replaced.  The mechanical valve (usually a St. Jude's) lasts for a lifetime but requires anticoagulation with coumadin.
Q: Does MVP get worse?
A: Yes,  MVP can worsen with time.  
Q: What will a heart cath show?
A: Cath is the "gold standard" to determine the degree of mitral regurgitation and also will determine if blockages in the coronary arteries exist that need bypass surgery at the same time.
Q:  Is surgery necessary if there is no other  leak besides the MVP?
A: It may be necessary depending upon the degree of regurgitation.
Q: Do you at the Clinic recommend valve repair surgery to everyone with MVP or is it only for those with certain problems?
A: It is better to repair the valve if technically feasible.  
Q:  For the surgery, do you have to crack open the rib cage to get to the damaged area? On
average, how long does the surgery take? -
A: Some surgeons are performing "mini" mitral valve repairs where a smaller incision is used and the breast bone is not cracked.  The use of this approach will depend upon the specific case.  Surgery usually takes from 2 to 4 hours.
Q: How long (approximately) is recovery time?
A: Usually 5 to 7 days in the hospital and 4 to 6 weeks at home.
Q:  Are there any dietary or other restrictions before/after the surgery we should know about? -
A: Limit salt intake to help cut down on fluid overload.  Otherwise no restrictions except what your doctor tells you.
Q: Statistically, how many patients diagnosed with mitral valve disorders are treated with repair versus replacement surgeries, and what are some of the advantages/disadvantages to both types of surgeries?
A:  About 85% of persons with Mitral Valve Prolapse will get repair.
Further information can be found at:
Dr. Cosgrove's Bio.
http://www.ccf.org/heartcenter/staff/cosgrove.htm
CCF Information about Mitral Valve Surgery
http://www.ccf.org/heartcenter/patinfo/patguide/heartva.html
Other sites:
http://www.hs.washington.edu/locke/vislab/proj/cardio.html
http://www.emedicine.com/EMERG/topic314.htm
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.