Tricuspid valve repair

[Vicki__0__0]

  : : My significant other, Rob, recently underwent cardiac catheterization.  We
  : : were then told he suffers from tricuspid valve regurgitation, and needs to
  : : have his tricuspid valve repaired.  We were told that the repair
  : : consists of placing a ring around the valve to reduce its insufficiency,
  : : and that the procedure is well-established and quite straight-forward as
  : : cardiac surgeries go.  The cardiologist went on to say that since Rob's
  : : condition is in the early stages (his symptoms are limited to mild shortness
  : : of breath and fatigue)and his health is otherwise very good, he doesn't need
  : : to rush into the surgery.  We are trying to process this information, and
  : : make the best decision regarding the surgery.  
  : : The Cleveland Clinic is one of three facilities the cardiologist recommended
  : : for the surgery.  
  : : What should we consider in choosing a facility and a surgeon, and how can
  : : we get information on those considerations for each facility and surgeon?
  : : How can we know what kind of annuloplasty should be done - for example, De
  : : Vega's semicircular annuloplasty vs. adjustable annuloplasty? Are there
  : : minimally invasive options available?  What can we do to evaluate the
  : : risks?  Rob is an avid horseman, sailor, skier, hiker, swimmer and cellist.
  : : The first time he was on roller blades (about 3 years ago), he skated 14
  : : miles - at age 75.  Are there special considerations we need to be aware of
  : : because of his age, even with his remarkable fitness?
  : : Thank you very much for being willing to spend your time answering
  : : questions in this forum.  It's a relief to have a venue such as this to
  : : turn to, and we greatly appreciate your efforts!
  : :    
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  : Dear Vicki,
  : Thank you for your question.  There are a few questions I have.  How old is Rob? (84?)   Are there any other reasons that he would need heart surgery? (i.e. - blocked arteries or a second leaky valve)  How severe are his symptoms?  Do they limit him significantly?  Did the doctor mention what the ejection fraction (the pumping capacity) of his heart was?
  : Generally if the only problem is tricuspid valve regurgitation surgery is not necessary.  If there is a reason that surgery will be done anyhow then the tricuspid valve is repaired at the same time.  The other indications to repair the valve would be severe heart failure and/or severe symptoms due to the regurgitation.  A third indication would be an infected valve.  The type of repair done and the approach used will be up to the surgeon.
  : In choosing your surgeon and hospital the factors to consider are what is their success rate with the operation in question, how many similar types of cases have they performed, what is the mortality rate, what is the nurse to patient ratio for post-operative care and how is the facility ranked by independent reviewers.  Dr. Cosgrove is one of the surgeons here that has done many, many valve repairs and I would highly recommend him should you need surgery.  The process would be to call [phone] and they will schedule you to see one of the cardiologists here who would order any necessary tests in the evaluation for the need for surgery.
  : In the meantime you should have regular follow-up with your cardiologist at home  and serial echocardiograms to follow the progress of the valve and pumping chamber function.
  : Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an appointment at Desk F15 with a cardiologist
  Rob is 78.  He has been under a cardiologist's care for several years due to a
  regularly irregular heartbeat and  tricuspid valve regurgitation.  A few
  years ago, the cardiologist tried to shock Rob's heart back into a regular
  rhythm, but the attempt was unsuccessful.  Rob has been taking Coumadin and some
  other heart-related drugs since that time - unfortunately, I don't remember
  their names, and haven't been able to get him on the phone.  I think one of the
  drugs helps regulate his heartbeat.
  Last December, he began to feel fatigued much of the time, and experienced mild
  shortness of breath on exertion.  This was a marked change for him.  He decided
  he'd been spending too much time as a couch potato since the cold weather set in
  and tried to increase his daily activity in order to regain his prior level of
  fitness.
  When his fatigue and shortness of breath didn't improve, Rob discussed the situation
  with his cardiologist, who ordered an ultrasound.  The ultrasound showed some
  fluid around Rob's heart, and the cardiologist prescribed furosemide.  A repeat
  ultrasound showed that the fluid was gone, but Rob's symptoms didn't improve.  
  About six weeks ago, he underwent cardiac catheterization.  I saw the order for
  the procedure - it said it was being done to rule out right bundle branch
  block.  When the cardiologist came to see us after the procedure, he said he'd
  gladly trade his vascular system for Rob's - that there was no evidence of any
  blockage.  He went on to say that Rob's tricuspid valve showed a greater degree
  of insufficiency than he had previously believed to be present and that the
  condition would probably deteriorate over time, but he couldn't predict how fast
  or severe the deterioration would be.  He said he thought the valve was only
  15% to 30% efficient.
  He then said that if Rob had edema in his feet and/or abdomen, and/or was showing
  signs of liver damage, he would strongly recommend surgery to repair the tricuspid
  valve - that under those circumstances, you either have the surgery or die from
  the lack of it.  However, because Rob's only symptoms to date are the fatigue
  and shortness of breath, the cardiologist said the decision to have the surgery
  is far more personal and a lot less clear cut.  He said we have to weigh the
  risks of a less-than-optimal outcome against Rob's current quality of life.  
  Rob wants to have the surgery - he wants to get back the fitness and energy
  he's had until a few months ago, and wants to ward off further degeneration of
  the valve.  He's in excellent health otherwise, and believes that the risk of
  the surgery is outweighed by the prospect of a longer, more active life. I think
  I'm more scared by the prospect of the surgery than he is - he's confident he'll
  survive the surgery itself, although he's concerned about the risk of infection
  afterward, since he believes that risk to be largely random.  
  Based on this information, does the surgery seem indicated?  I'll get Rob onto
  this web site and have him read/print your reply.  His next appointment with his
  cardiologist is in mid-July, and I want him to bring up your suggestion of the
  serial echos.  Should he see a second cardiologist for another opinion?  If he
  seeks a second opinion, should he expect to have to undergo catheterization
  again?  I'll write to the facilities being considered for the surgery and
  ask them the questions you specified so we can begin the evaluation process.
  Thank you very much for your initial reply, and for your time and effort in
  reading this follow-up.  The many people who love Rob want to do all we can to
  help him make the best decision, and you have been a big help to us.  Thanks again!

[Cleveland Clinic, MD]

_
Dear Viki,
As you discuss in your message the decision to proceed with surgery is not a straight forward one.  I can't really comment on whether surgery is indicated without having all of the data to review.  It is not entirely clear to me that having the surgery will take care of all of his symptoms but it may.  A second opinion would be OK if you wanted it and he should not have to undergo a second cardiac cath.  I do agree with his cardiologist that he should not rush into anything and if he decides to go ahead with the surgery to have it done at a major medical center.  Hope this helps.