Valve Replacement Surgery Risks

[Miriam__0]

  I've written to the forum before regarding my 86-year-old father's condition and your replies have been very helpful.  My father, who has severe aortic valve stenosis, has finally met with the surgeon who would be doing his aortic valve replacement surgery.  He's been referred by the surgeon to an excellent cardiologist to schedule the heart catheterization.  This cardiologist also wants to evaluate the state of my father's carotid arteries,  since 15 years ago one of them was giving off clots (discovered by his ophthalmologist) and was cleaned out surgically.
  In our discussion with the surgeon, he mentioned that the catheterization would show whether or not my father needed bypass surgery as well as the aortic valve replacement.  He also wants to do a transesophageal echocardiogram to assess the state of the mitral valve, which has some regurgitation probably due to the aortic stenosis.  The surgeon did say that the more procedures that have to be done during the open heart surgery, the higher the risk to my father.  My question today is, since my father has not had any symptoms of blockage in his coronary arteries (angina, chest pain, etc.), is it absolutely necessary to do the bypass surgery even if the catheterization does show blockage?  In other words, can the surgeon take the "if it ain't broke don't fix it" route rather than doing everything just because he's "in there"?  I did ask him that and he indicated that's a possibility but it seems as if most people who need both procedures done do go ahead and have them both done.  I just want to make sure that at 86 years old, my father is exposed to the minimal risk necessary and wondered what others in this situation tend to do.
  I'm also curious as to what they will do if the doppler test they're doing on his carotids shows blockage there?  Would they want to clean them out prior to the operation or is it just to know that there is an issue with his carotid arteries so they can prepare for it?
  Any further information you can provide will be greatly appreciated.
  -Miriam

[CCF Cardio MD - MTR]

_
Dear Miriam, thank you for your question.  You ask a number of insightful questions
that are common questions we face daily as cardiologists.  I assume that your
father is rather symptomatic from his aortic stenosis to be referrred for
aortic valve replacement(AVR) so the issues now are whether or not to do a
cardiac catheterization first and how to investigate the carotid arteries.  It
is common practice to electively perform a cardiac catheterization in patients
over the age of 40 prior to valve replacement surgery to exclude coronary artery
disease.  With aortic stenosis (AS), coronary artery blockages can be concealed since
blockages cause symptoms similar to AS like shortness of breath and chest pain.
Since patients with AS are usually symptomatic from the AS, occult coronary disease can
be concealed.  However, we don't have good non-invasive tests that can be used
in place of catheterization to exclude coronary disease.  Whether coronary artery
bypass grafts are indicated in your father cannot be answered until a catheterization is
done.  If he has severe blockages, the surgeon would need to know beforehand to
plan the surgery.  Severe blockages can potentially cause a heart attack during
or after the surgery so they are usually bypassed to prevent this complication
from occuring.  The mitral valve often leaks in patients with AS since the blood
pressure within the left ventricle is so elevated that the mitral valve cannot
stayed closed when it should. The mitral valve would be best evaluated with a
transesophageal echocardiogram.  The carotidarteries should be evaluated with  
a doppler ultrasound test to look for new blockages and
a recurrent blockage at the site of the prior carotid surgery.  If a severe
carotid blockage is present, your father would be at risk of developing a stroke
during surgery when the heart is stopped and he is placed on a heart-lung
machine while the surgeon replaces the valve.  If a severe blockage is present,
a combined carotid/valve surgery can be done or the carotid artery blockage can
be fixed first.  As you can tell, these decisions are subjective and depend on
the experience of your cardiologist and cardiac surgeon.  There is no "right"
answer for your father, but certainly, he should not be placed at undue risk
for any of these procedures.  I suggest that you meet with his cardiologist
and have a frank discussion about how AVR will affect his quality of life and
how to adequately prepare for the surgery (with the aforementioned tests).  At
age 86, your father would be at higher-risk with any of these procedures, but
the risks should not be prohibitive.  I recognize that this is a difficult situation
so please write back with additional questions if you need to.  I hope you find
this information useful.
Information provided in the heart forum is for general purposes only.  Specific
diagnoses and therapies can only be provided by your physician.