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Re: Mitral Valve Regurgitation and Surgery
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Re: Mitral Valve Regurgitation and Surgery

Posted By Ashwin Gada on February 02, 1999 at 18:47:18:

In Reply to: Re: Mitral Valve Regurgitation and Surgery posted by CCF CARDIO MD - CRC on February 01, 1999 at 10:56:51:






I am a 45 year old male from India.  I was told I have Hart murmur about 17 years ago and probably from birth.  My father passed away at the age of 83 and mother is 77. My mother has MVP for years.  Recently I moved from Cleveland to India and back to US and accepted a job offer in Dayton area.  Recent (1/4/99) visit to a family doctor (new) made my doctor nerves of my heart murmur and EKG results, followed by ECHO and visit to a cardiologist.  Young cardiologist has put me on LISINOPRIL (ZESTRIL 5mg) and METOPROLOL (TOPROL XL 50MG) and a follow up visit in about a month.  He wants me to have a MVR within a year or as soon as my family returns from India.  Mean while he wants ECHO done every three months.  TEE was performed to rule out vegetation in MV. Stress test was fine.  Following stress test he asked 30 minutes walk every day. I am 5 6 and 125 lb. My BP is normal @ 120/75 and HDL/LDL is 34/169. I have some breathlessness since childhood.  For last 10 years or so I have problem sleeping. After the medication I am not able to sleep every other or third night. Following are the history and results of my recent EKGs.
9/26/95:  LVIDd 54, LVIDs 34, LVPWt 11, IVSt 11, Ladiam 36, Aerotic Root diam 32.    Left Ventricular Wall, Motion, Size, ejection fraction Normal. There was no segmental wall motion abnormalities seen. There is no paricardial effusion. The mitral valve leaflets were somewhat myxomatous appearing, particularly, the anterior leaflet of the mitral valve. Diastolic motion was normal, but there was striking prolapse.  Color flow Doppler, shows sever mitral insufficiency. Minimal tricuspid insufficiency. In comparison with the previous study done in 11/90, there has been no appreciable change in left ventricular systolic function. No evidence of pulmonary HTN. There does not appear to be any significant hemodynamic change from the previous study.
1/4/99:  RVd 20, LVd(diastole) 52, LVd(systole) 29, IVSd/IVSs 8, LVPWd/LVPWs 8, Left Atrial 48 mildly dilated. ARoot 32, AV 24. Mitral valve is moderately thickened. Particularly anterior medial leaflet and demonstrates a mild to moderate amount of mitral valve prolapse. Due to the thickness of the valve vegetation can not be rule out (It was ruled out by TEE). Mild thickening of the left intraventicular septum just below the aortic valve. Left ventricular systolic function is normal. Ejection fraction is estimated at 55-60%.  The aortic valve is thin and is tri-leaflet with normal cusp separation.
Sever mitral insufficiency with excentric regurgitant jet approaching 5 meters per second in velocity Trivial to mild aortic insufficiency. Mild tricuspid insufficiency.
With the above situation please explain including qualitative gains:
1) Doctors in Dayton have not seen my ECHO history, Is it important that he compares the results with my 1995 and 1990 Echo? 2) Do I Need surgery? 3) Replacement v/s Repair of MV? 4) Is there any other medical diagnosis need to be ruled out other then the heart condition to relieve the symptoms of insomnia.  5) If surgery is helpful but not required, then how close/frequent follow up is required?  
Since I do not see much difference in my cardiac history, or any major changes in the symptoms, this whole thing is driving me crazy. Thank you for taking time to answer my question.
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Dear AG,
With the above situation please explain including qualitative gains:
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 Re
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.
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Dear Doc:
Thank you for your response.  Q to follow up
1) What is the difference between sever mitral insufficiency and Mitral regurgitation?  Or what does insufficiency in my ECHO report mean?
2) What, dilated Left Atrial effect the Mitral Valve funcion or vice versa?
Thank you.
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