Timing for Mitral Valve Surgery

[Deesef]

I’m a 50-year-old male, 6’1”,  220 lbs.Had an echo about 1.5 years ago and was advised I need surgery.I was playing basketball and working out 2 or 3 times a week and felt fine. The surgeon, Dr. Dennis Pupello, agreed, but knowing I was very nervous said I could wait until my LA was 5.0cm.  Since then I've had several echoes. Last November my cardiologist was rather insistent that I have surgery.  He told me that people with my condition had a 5% chance yearly of sudden death.  This has me even more concerned.  The following is some results of the three last echoes,
10/25/00 4/18/01 11/02/01
LV dia.   6.6cm 6.5cm 6.78cm
LV sys   4.3cm 4.7cm 4.07cm
LVEF 64% 58% 69%
IVSd 11mm 11
LA              4.7cm           4.7cm           4.75cm
Regurgitation:  Moderately +3-4            Severe
                Severe

10/25/00, Conclusions: MVP.  Severe mitral regurg
4/18/01, Conclusions: Severe mitral regurgitation with MVP of both leaflets.
11/02/01, Conclusions: Dialated left ventricle with normal ejection fraction.  Severe MVP with  severe mitral regurgitation.

A year and a half ago I quit basketball and my workouts.  Now I go on walks of about 1.6 miles once or twice a week. The main thing I notice is my forceful heartbeat and that I look forward to sitting.  Does the above info. indicate surgery?  Is the possibility of sudden death a realistic concern? I know you cannot give a diagnosis but would appreciate what is indicated according to standards.
Thanks, Frank

[CCF-M.D.-CRC]

Dear Frank,
The timing of mitral valve surgery is more of an art than a science and there is not complete agreement amongst doctors (as seen in your case).  We tend to believe that earlier is better than later for mitral valve regurgitation and have a low threshold for recommending surgery.  The data for sudden death comes from the Mayo clinic and is specifically related to flail mitral leaflets.  If you have this condition then this would be another reason to proceed to surgery.  If there is dilation of the ventricle or any decrease in ventricular function we usually send people to surgery.  Finally, if I were to trust one doctor's opinion over another it would be the cardiologist who deals with the long-term care of patients with mitral regurgitation and not the surgeon who usually only sees patients just before and just after their surgery.

[debra21784]

Frank ,
It has always been my understanding that valve surgery should be done while it is "elective rather than "emergent.My valve surgery was done when I developed severe regurgitation.The whole premis of the surgery is not to cause added stress to the heart resulting in hypertrophy.If the cardiac surgeon is saying now,I would certainly go with that opinion,you have had two specialists tell you the same thing.That sounds pretty conclusive to me.I am sure they would not be recommending if it was not necessary.If the issue is fear, there are now centers that do minimally invasive cardiac valve repairs and you are home in about 5 days .Also, you want a surgeon who will make every attempt to repair the valve as a option.Research the cardiac surgeons,go to a large teaching facility for a second opinion if you want but act on the recommendations given to you.These doc's who do cardiac surgery don't make the recommendations lightly.Good luck

[pz]

Frank, With all the posted information above, how can you not go for the operation now? Sudden death as a 5% risk per year doesn't sound too great to me.
When my aortic valve was confirmed as needing replacement, I went in as soon as the surgeon could schedule the procedure. Open heart, out of the hospital in 4 days at 51 years old, back to work as a full time avalanche technician at Alyeska Resort in Alaska after 2 months. In the summer I am a construction laborer for a road building company in Anchorage.
I really had to get surgery to keep working the jobs I do. The whole process scared the hell out of me but I decided I had to take an active course as soon as possible. My operation was done in Anchorage Alaska by local surgeons. Due to the fact it was early in the process of the heart muscle changing shape and funtion, no damage was done that a good (artificial) valve wouldn't take care of by going back to regular rythyms.
There is alot of good advice above. I hope you are able to move on soon and get rid of that nagging worry of whether the doctors are right. As someone above said, they don't make these diagnosisese lightly. Good luck. I also have extensive experience now with Coumadin and self testing INR's for a couple of years if that could help anyone. Opinions are free. Do what you want with them, peter zug

[TL]

I was in your situation about two years ago. I had no symptoms, but had severe mitral regurgitation.  I was also very nervous about open heart surgery.  I did a lot of research and concluded that as nervous as I was about the surgery, I was much more nervous about the possibility of heart failure or a heart transplant.  If you wait until you experience symtoms, many times permanent damage is done to the heart.  If enough damage is done, heart failure is the result.  If I were you, I would focus on finding a surgeon that has a lot of experience with repairs to give you the best chance of a good outcome.  I had my surgery two years ago and have not had any complications.

[MJK]

Frank -
I was 44 years old last February when I started feeling exhausted and had breathing problems just walking up a flight of stairs. Although I had a heart murmur since I was two, I never suspected a heart problem or displayed any sympthoms. I thought
I was developing allergies or asthma.  After the lungs checked out, doctors started evaluating my heart.  

Imagine my complete surprise when the technician doing my echocardiogram called in a cardiologist, who very bluntly identified I required a mitral valve replacement within the next 3-6 months or else I would be in congestive heart failure. I was stage 4+ with severe mitral valve regurgitation. I quickly scheduled a second opinion, and an angiogram which revealed replacement was required not repair.  I was terrified.  

Long story short - I had valve replacement surgery with a St. Jude valve on May 1, 2001.  All I can say, is it's the best thing I ever did. Within five days of the surgery I was climbing stairs faster and better than I had in the months prior to the
surgery. After cardiac rehab, I feel stronger and better than I have since my 20's.  It's amazing what a difference oxygen makes. I am on coumadin, but doing great.

Use your time now to understand your insurance coverage, find a hospital and surgeon that has a proven track record, arrange the time off from work, and coordinate support after surgery.  But get going.  Don't wait until you can't walk a city block without getting dizzy. The better you feel going in, the stronger you'll be coming out.  I just never realized until after the surgery how bad I really was - because it was a slow disintegration.  Recovering from the surgery was not as painful as I imagined, and weekly I felt better and stronger.  

I was back at work within 7 weeks of the operation, celebrated my 45th birthday and now have the energy to do anything I want.  Don't let fear stop you, because the engineering and cardiac care is so solid for this kind of problem.  My cardiologist said that neither changes to my diet or levels of exercise would repair the regurgitation - only surgey can. My advice is DO IT and enjoy the gift of time and good health you'll be granted afterwards.  

Oh and one more thing - set up an email distribution list to blast status messages out to friends and family.  It took a lot of pressure off the family members at the hospital when one phone call to a friend sent a message that notified work, family and friends quickly of my status.  Good luck and good health!

[EDH]

Twenty-one years ago I was told that I have a mitral valve prolapse with severe regurgitation.  My doctors and I have monitored the problem annually ever since.  In years past my heart always seemed to adequately compensate for the problem and I have never experienced any obvious symtoms.

Although my mitral valve has been literally flapping in the breeze all this time, I was previously told that because I was without symtoms, to hold out for as long as possible in order to give medical science time to improve.

Now at age 54, apparently the trend, medical opinion and medical science has changed.  Thus, due to a slight enlargement of the left ventrical coupled with an increasing sensation of feeling tired more than usual, I am told that its better to operate sooner rather than later and that its time to seriously consider mitral valve repair.

In all honestly feelings of high anxiety abound but finding this site with your questions, commentary and the responses from the other participants is truly comforting, thank you.

I've schedule my operation for July 23, 2002 and will keep the readership informed.

[EDH]

Twenty-one years ago I was told that I have a mitral valve prolapse with severe regurgitation.  My doctors and I have monitored the problem annually ever since.  In years past my heart always seemed to adequately compensate for the problem and I have never experienced any obvious symtoms.

Although my mitral valve has been literally flapping in the breeze all this time, I was previously told that because I was without symtoms, to hold out for as long as possible in order to give medical science time to improve.

Now at age 54, apparently the trend, medical opinion and medical science has changed.  Thus, due to a slight enlargement of the left ventrical coupled with an increasing sensation of feeling tired more than usual, I am told that its better to operate sooner rather than later and that its time to seriously consider mitral valve repair.

In all honestly feelings of high anxiety abound but finding this site with your questions, commentary and the responses from the other participants is truly comforting, thank you.

I've schedule my operation for July 23, 2002 and will keep the readership informed.

[EDH]

Twenty-one years ago I was told that I have a mitral valve prolapse with severe regurgitation.  My doctors and I have monitored the problem annually ever since.  In years past my heart always seemed to adequately compensate for the problem and I have never experienced any obvious symtoms.

Although my mitral valve has been literally flapping in the breeze all this time, I was previously told that because I was without symtoms, to hold out for as long as possible in order to give medical science time to improve.

Now at age 54, apparently the trend, medical opinion and medical science has changed.  Thus, due to a slight enlargement of the left ventrical coupled with an increasing sensation of feeling tired more than usual, I am told that its better to operate sooner rather than later and that its time to seriously consider mitral valve repair.

In all honestly feelings of high anxiety abound but finding this site with your questions, commentary and the responses from the other participants is truly comforting, thank you.

I've schedule my operation for July 23, 2002 and will keep the readership informed.