Timing of Repair

[dave]

I've was diagnosed with MVP about 3 years ago.  I had an Echo done at that time, again 6 months after that, again another 6 months later, and then annually since that time.  Through that time period, my valve leakage has increase from "moderate" to "moderate to severe" (my cardiologists terminology).   During the same time frame, my heart size measurements (chamber size) has remained fairly stable.  I am 39 years old.  My cardiologist said I am definitley a canidate for repair when the time comes.

I live a fairly normal life style for an office worker/manager but find myself fatigued and tired more than I would like (I believe this affects my overall work performance).  Two flights of stairs will leave me moderately winded for a few minutes.  Holding a conversation during a brisk walk will require some periodic "deep breaths" to keep pace.  Also, I don't recover very quickly from heavier work (lifting) as I used to - and shoveling snow for 10 minutes exhausts me.  Overall, a person could live with these annoying symptoms.

QUESTION #1
My cardiologist has advised that it is better to wait for surgery until my heart starts to enlarge - especially if I can put up with the symptoms.  Do you agree?  If so, how much enlargement indicates that it is time for surgery?

QUESTIONS #2  
I know that there are too may variables to promise anything, but what is your best guess regarding how long a valve repair will last (a ball park time frame to give perspective is better than being kept completely in the dark)?

QUESTION #3
Since I'm only 39, would it be better to wait on a repair to delay the risk or timing of re-repair or replacement?



THANK YOU FOR THIS EXCELLENT FORUM.  IT IS A GOD-SEND.  IT HELPS EDUCATE, ENABLEING US TO ASK MORE SPECIFIC QUESTIONS OF OUR PERSONAL PHYSICIANS !

[CCF CARDIO MD - DLB]

1. The answer to this question has changed in the past couple of years. With significant leakage and some symptoms that may be related to the valve, I would favor repair now.

2. The hope is that, assuming you are a candidate for repair in the first place, it would last permanently.
    
3. I think that there is no good reason to wait. Assuming the repair is successful, you most likely would not need repeat surgery. We do a lot of mitral valve repair, and no longer see any benefit in waiting until the heart starts to visibly decompensate.

[Stan H.]

I found out I had MVP with moderate to severe regurgitation 3 years ago.  Although I probably had MVP for over 15 years, I never had any symptoms that I was aware of.  My ejection fraction was 75% and heart chambers only mildly dilated, so the recommendation of the surgeons was to wait.  My cardiologist, however, urged me to have the surgery early to avoid any complications that might develop.  I waited.  Within a year, I developed PVCs...not a major issue, but something I didn't have before.  I was getting an echo every 6 months and was put on Cozaar and Toprol.  By 12/98 my PVCs had gotten much more frequent and the echo had shown a very slight increase in my lv and la size.  To be cautious, my cardiologist scheduled a follow up echo for 3/99.  The 3/99 echo showed severe enlargement of the la, moderate enlargement of the lv, an increase in regurg to severe, and a drop in my ejection fraction to the high 60s.  I went in for a repair on 5/17/99.  The dilated left atrium apparently pre-disposed me to a-fib, and I had a pretty rocky 3 1/2 weeks battling the transient a-fib...a frightening post op complication that required some very nasty medication.  I'm fine now...trivial regurg is all that remains, a-fib is history, my ejection fraction is back to 75%, and my heart chambers are back to normal dimensions.  I still have some PVCs in the form of extra beats, but they are very mild and should dissipate with time.  In retrospect, I should have taken the advice of my cardiologist.  I got away lucky...no heart damage and a successful repair.  I did learn that the valve can worsen very quickly and with no warning.  I also think the extra years of worrying about the possibilty of surgery were an un-needed source of stress.  I believe I could have avoided the post op complications and the PVCs had I had the surgery earlier.  As terrifying as the thought of surgery is, early surgical intervention seems to be a very prudent course of action.  Moderate to severe regurg will progress although the time frame is unpredictable.  Ultimately, the decision is yours to make.  Good luck.
(I can be e-mailed at ***@****)

[CCF CARDIO MD - DLB]

One strong reason to operate early is to try to avoid the onset of atrial fibrillation.

[kd]

I have been confused for some time by the wait/don't wait attitude toward mitral valve repair/replacement.  You said there has been a change in the last couple of years.  Can you tell us what caused the change?
I have a regurgitation which went from mild in 1997 to a 3+/4 in 1998 and is holding steady.  The cardiologist who was called in for a second opinion who says there is not atrial growth but surgery should probably happen in the next year.  The local cardiologist agrees with the dx but says that the need for surgery may not happen for 5 or more years.  Is it just CCF and some of the major teaching hospitals that go for the earlier surgery?  Is it experimental?
My local dr says that my EKG is suprisingly normal.  Why would it be suprising?  (I think it's because of all the BP meds I'm on.)

Thanks again SO much for educating us.
kd

[CCF CARDIO MD - DLB]

The reason for the change is that mitral valve repair (as opposed to replacement) is less risky surgery. Thus, it is appropriate to use it on patients who are minimally symptomatic. I would not call this approach experimental, but it is the approach taken by most leading medical centers.

[kd - repair vs replacement timing]

So, what I am understanding you to say is that if a mitral valve repair was going to be made, the cardiologist may opt to do it before the heart muscle was enlarged.  If a replacement was to be done, he/she might wait until their was more damage because of risk factors.
That helps.
Both cardiologists just said surgery on my mitral valve.  It's possible one was thinking repair and the other, replacement.  I guess I will have to ask more questions the next time I see them.

Thanks,
kd

[CCF CARDIO MD - DLB]

Not every valve can be repaired. Only if there is a reasonable likelihood of successful repair would I recommend early surgery.

[Nathan Jones]

This may be a circumstance where the patient's input may help the physician.  In my case, I concluded that (1) surgery was inevitable so I preferred to get it over with and (2) with an earlier surgery a repair of the valve was more likely, i.e. if a valve deteroriates significantly it may be that the surgeon may have to replace the valve.  

     Different people feel differently about the situation and there is not right answer just the best answer for you and your cardiologist/surgeon to decide.  You could always ask your cardiologist what they would do if it were their heart whether they would wait or get it fixed sooner.

     All in all I think my decisiion to have early surgery when my mitral valve was moderate to severe and sympton were just appearing was the right one.  Had I waited, I would probably have a mechanical valve.

[CCF CARDIO MD - DLB]

I agree. I think earlier surgery is better. It is difficult, though, to take someone who is feeling relatively well and recommend surgery and I never try to force a patient to have surgery in this situation.

[Mario]

DAVE YOUR QUESTION MAY HIT HOME FOR MANY VALVE PATIENTS. I MYSELF HAD A HOMOGRAFT PUT IN MAY 1999. MY AORTIC VALVE WAS DAMAGED DUE TO A CHILDHOOD BOUT OF RHUEMATIC FEVER. I KNEW EARLY ON SURGERY WOULD EVENTUALLY COME CALLING. THE MILLION DOLLAR QUESTION WAS "WHEN". MY CHILDHOOD HELD FEW RESTRICTIONS, ONLY HAVING TO BE CAREFUL TO KEEP ANY INFECTION AT ARMS LENGTH. I WAS MONITORED BY MY CARDIOLOGIST YEARLY MOSTLY TO COMPARE ECHOES TO SEE IF THERE WAS ANY SIGNIFICANT INCREASE IN HEARTS' SIZE.I WAS ABLE TO KEEP EVERYTHING STABLE TILL ABOUT MY MID 30'S. LOOKING BACK I COULD NOW NOTICE THAT I WAS DOING LESS AND LESS PHYSICAL ACTIVITY BECAUSE OF THE LEAK. ALSO THE RESTRICTION WAS NOT SO MUCH "DURING" BUT RATHER "AFTER". FOR EXAMPLE, IN MY ONE HOUR KARATE CLASS ALTHOUGH TOWARDS THE END I WAS STILL ABLE TO KEEP UP WITH THE REST OF THE CLASS I FOUND AT TIMES IT WOULD TAKE ME A WHOLE DAY OF REST TO GET RID OF THAT TIRED FEELING. SO I WOULD DO LESS AND EVENTAULLY DROP OUT OF KARATE CLASS BECAUSE THE RECOUPERATION TIME WOULD BE TOO LONG, IT WAS JUST NOT WORTH IT BECAUSE I WOULD BE TOO TIRED THE NEXT DAY AT WORK.THE FACT THAT MY HEART GREW TO 70 MM COUPLED WITH THE INCREASE IN SYMPTOMS WERE THE DECIDING FACTORS. THE SURGERY ITSELF WAS NOT HALF AS BAD AS I THOUGHT AND I DO NOT DREAD THE REPEAT SURGERY IN HOPEFULLY 15 YEARS. I FEEL THAT I AM NOW IN VERY GOOD SHAPE AND 4 MOTHS POST OP I RESUMED MY KARATE. THE BIGGEST DIFFERENCE NOW IS NOT SO MUCH THE "DURING"
BECAUSE ALTHOUGH I COULD OUTLAST ANYONE I STILL GET TIRED BUT THE "AFTER" MEANING THAT AFTER AN INTENSE 1 HOUR CLASS I AM BACK IN A REFRESHED STATE 30 MINUTES AFTER THE COARSE. IT FEELS SO GOOD TO BE ABLE TO RECOUP MYSELF SO QUICKLY.REMEMBER WHEN THE DETERIORATION HAPPENS OVER THE PERIOD OF SEVERAL YEARS IT MIGHT NOT BE SO APPARENT BUT AFTER YOU ARE FIXED YOU BEGIN TO SEE THE RESTRICTIONS THE LEAKY VALVE HAD PLACED ON YOU. IF I HAD TO DO IT ALL OVER AGAIN I WOULD OF HAD THE SURGERY SOONER, BUT HINDSIGHT IS 20/20 VISION. ALL THE BEST AND IT IS SO MUCH BETTER ON THE OTHER SIDE OF THE SURGERY.....MARIO

[SUSAN MERCK]

My husband John contracted endocardidis (ms) bacteria growing on his heart valves. Two valves were affected and we were told that he would have to under go valve replacment. The day has come that his cardiologist has recommended repair to the mitral valve. He is not have any major problems with tiredness and his heart is not enlarged but his EF is 60%. He believes that early surgery is the way to go instead of waiting until his heart is enlarged and is having syptoms (symptoms). We agree with him and we are in the process of finding a surgeon. My questions is-can they use keyholes to repair the valve? We do not want them to open his chest up if there is a choice. Maybe there is someone in Europe? Thank you for this service its wonderful.

[Patrice]

I AM GOING IN FOR MVP IN 4 WEEKS AND I AM CONCERNED ABOUT THE COMPLICATION OF A-FIB.  DOES THIS HAPPEN RIGHT AFTER SURGERY?  WHAT ARE THE CHANCES OF GETTING A COMPLICATION LIKE THIS?  WHAT DO THEY GIVE YOU FOR THIS?  IT WAS STATED THAT "SOME VERY NAST MEDICATIONS"  WHAT DO YOU MEAN?  ANY INFORMATION WOULD BE GREATLY APPRECIATED!!