DEAR MAYO CLINIC: My father is having issues with his aortic valve. He is 53 years old and was told he needs to have a valve replacement. I was reading that there are different types of valves. Can you explain the differences and what option may be best?

ANSWER: There are four major valves in the heart, two on the left side of the heart (aortic and mitral) and two on the right side of the heart (pulmonary and tricuspid). Heart valves serve as “one-way doors” allowing blood flow through the heart. Valves can fail because they have difficulties opening (stenosis), leaking (regurgitation) or both. These conditions may lead to heart valve surgery. Sometimes, when the mitral or tricuspid valves fail because of regurgitation, they can be repaired. And if a valve is repairable, that is preferred to replacement.

However, many times, valves require replacement when they fail. There are two major types of prostheses used for valve replacements: mechanical valves and tissue valves. One type of prosthesis may be a better option for your father, so which valve is right requires some thought.

Mechanical valves are most commonly used when replacing the aortic and mitral valves. Types of mechanical prostheses have evolved over time, but most modern ones are made of pyrolytic carbon and have two tilting discs that allow blood to flow one way through them.

Mechanical valves require a cardiac surgeon to remove the existing valve — most commonly via a sternotomy (midline incision through the breastbone) — and requires stopping the heart (cardiopulmonary bypass). The greatest benefit of a mechanical valve is durability. Some of my patients are doing well with mechanical valves implanted in the 1970s. I generally think of mechanical valves as lasting forever. However, mechanical valves require the blood thinner warfarin to keep them from clotting and aspirin. Although there are new anticoagulant medications being used for other indications, the only blood thinner that is appropriate for mechanical valves is warfarin. Warfarin increases a patient’s risk of bleeding and is not suggested for use during pregnancy.

Tissue valves are made from porcine (pig) or bovine (cow) tissue, and can be used to replace any cardiac valve. Tissue valves can be implanted surgically, just like mechanical valves, where the old valve is removed and the new prosthesis is sewn in its place.

In the last 15 years, transcatheter valve replacement has emerged as a different way to implant tissue valves, used almost exclusively for aortic valve stenosis. This procedure, called transcatheter aortic valve replacement or TAVR, avoids the need for a sternotomy and often has a much shorter hospital stay. I always think of TAVR as a “valve on a stick” because a tissue prosthesis is crimped onto a balloon catheter, which is then placed in an artery (often the femoral artery in the groin) and snaked up to the heart. The TAVR prosthesis is then ballooned open inside the old valve, smooshing it out of the way. TAVR requires patients to have adequate blood vessels and a large enough native aortic valve to accommodate the new prosthesis inside of it.

There are two main benefits to a tissue valve. First, the potential option for transcatheter delivery (particularly in aortic stenosis); and second, the fact that after the initial implantation time period, they do not require warfarin, only aspirin. The biggest drawback of tissue valves is their durability. An average tissue prosthesis lifespan is about 10 years, however, in younger patients or those on dialysis, they can deteriorate much faster. When tissue prostheses fail, they become stenotic or regurgitant, just like native valves, and then require repeat replacement.

So, which valve is right for your father? The risk of valve infection does not differ between tissue and mechanical prostheses, and neither require immunosuppressive medications. If valve replacement is needed on a right-sided valve in a patient older than 70 or in patients with contraindications to warfarin, a tissue valve is likely the right choice. In patients younger than 50 or patients already on anticoagulation for other reasons, such as atrial fibrillation, a mechanical valve is often the right choice.

Although this doesn't apply to your father, I do recommend that young patients who want to become pregnant or who are participating in very physical sports with a high bleeding risk consider a tissue valve to avoid warfarin in the short term, with the knowledge that it is a temporary treatment expected to require repeat replacement. As your father is still relatively young, it is important that he talks with his cardiologist about the pros and cons of his personal situation so he can make an informed decision. ― Dr. Jeffrey Geske, Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota

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Related Articles 

• Mayo Clinic Minute: Robotic mitral valve surgery published 2/3/20
• Expert Alert: Robotic repair offers benefits for many patients with leaky mitral valve published 1/16/20
• Mayo Clinic Q and A: Mitral valve repair with minimally invasive heart surgery published 11/29/19
• Mitral valve repair and mitral valve replacement published 2/28/19
• Aortic calcification: An early sign of heart valve problems? published 2/27/19
• Sharing Mayo Clinic: Heart care gives Pat new rhythm published 2/24/19

The post Mayo Clinic Q and A: Mechanical or tissue heart valve replacements appeared first on Mayo Clinic News Network.

On the next Mayo Clinic Radio program, Dr. Charanjit Rihal, a cardiologist at Mayo Clinic, will discuss aortic valve repair and replacement. Also on the program, Dr. Alice Gallo De Moraes, a critical care specialist at Mayo Clinic, will explain how Rapid Response Teams help hospitalized patients get critical care when they need it. And Dr. Susan Moeschler, an anesthesiologist and researcher at Mayo Clinic, will share her research on the challenges women face as medical professionals.

Here's your Mayo Clinic Radio podcast.

The post Transcatheter aortic valve replacement / Rapid Response Teams / women in medicine: Mayo Clinic Radio appeared first on Mayo Clinic News Network.

On the next Mayo Clinic Radio program, Dr. Charanjit Rihal, a cardiologist at Mayo Clinic, will discuss aortic valve repair and replacement. Also on the program, Dr. Alice Gallo De Moraes, a critical care specialist at Mayo Clinic, will explain how Rapid Response Teams help hospitalized patients get critical care when they need it. And Dr. Susan Moeschler, an anesthesiologist and researcher at Mayo Clinic, will share her research on the challenges women face as medical professionals.

To hear the program, find an affiliate in your area.

Use the hashtag #MayoClinicRadio, and tweet your questions.

Mayo Clinic Radio is on iHeartRadio.

Access archived shows or subscribe to the podcast.

Mayo Clinic Radio produces a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

The post Mayo Clinic Radio: Transcatheter aortic valve replacement appeared first on Mayo Clinic News Network.

On the next Mayo Clinic Radio program, Dr. Charanjit Rihal, a cardiologist at Mayo Clinic, will discuss aortic valve repair and replacement. Also on the program, Dr. Alice Gallo De Moraes, a critical care specialist at Mayo Clinic, will explain how Rapid Response Teams help hospitalized patients get critical care when they need it. And Dr. Susan Moeschler, an anesthesiologist and researcher at Mayo Clinic, will share her research on the challenges women face as medical professionals.

To hear the program, find an affiliate in your area.

Miss the show?  Here's your Mayo Clinic Radio podcast.

Use the hashtag #MayoClinicRadio, and tweet your questions.

Mayo Clinic Radio is on iHeartRadio.

Access archived shows or subscribe to the podcast.

Mayo Clinic Radio produces a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

The post Mayo Clinic Radio: Transcatheter aortic valve replacement / Rapid Response Teams / women in medicine appeared first on Mayo Clinic News Network.

Surgery to replace a failing heart valve restored Dorothy Ganong's quality of life and gave her back the ability to engage in an active lifestyle.

Dorothy Ganong of Eau Claire, Wisconsin, struggled with labored breathing for more than two years. She would run out of breath halfway up a flight of stairs and practically have to crawl to the top. During an average day, Dorothy would often sit in her recliner to catch her breath, but she was a busy woman who wanted to get things done. She says it was frustrating to think her life was slowing down so much.

"I could tell my breathing was really bad," she says. That's when Dorothy decided it was time to make a change.

An assessment at the Cardiac Center's Valve Evaluation Clinic at Mayo Clinic Health System in Eau Claire revealed that Dorothy had severe narrowing of her heart's aortic valve — a condition known as aortic valve stenosis. This severely impeded the flow of blood out of her heart and was causing her symptoms.

After Dorothy’s diagnosis, her care team recommended heart surgery to replace the valve in hopes of allowing her to resume the active life she enjoys.

"Combining all of the skills and expertise of our multidisciplinary team, and working with the patient to align with their needs and lifestyle allows us to select the procedure and leverage the best skills of each participant, resulting in a better quality of life for our patients," says Fearghas O'Cochlain, M.D., an interventional cardiologist, who was part of the team that provided Dorothy's care.

Capitalizing on expertise

In July 2016, Dorothy was seeing an allergist. When medications and breathing treatments didn't ease her symptoms, she was referred to a pulmonologist to determine if she had chronic obstructive pulmonary disease. Fortunately, that physician listened to her concerns and symptoms, and felt it might actually be her heart that needed extra care and attention.

Dorothy then met with Dr. O'Cochlain, who ordered heart-related tests at the Valve Evaluation Clinic. The clinic provides complete evaluation and diagnostic testing for complex valvular heart disease. To assess her condition, Dorothy had a CT angiography. This exam combines a CT scan with an injection of a contrast media to produce pictures of blood vessels and tissues, and to evaluate blood flow through vessels going to the heart.

"Working with patients that have an identified heart valve problem, such as Dorothy, is a team effort." — Fearghas O'Cochlain, M.D.

She also had an X-ray, electrocardiogram, pulmonary function test, frailty assessment, cardiac catheterization and a carotid ultrasound to determine specific and appropriate intervention, which are integral components of the Valve Evaluation Clinic.

For most procedures, the various testing and consults are coordinated among the interventional cardiologists, radiologists, echo cardiographers and cardiovascular surgeons. "Working with patients that have an identified heart valve problem, such as Dorothy, is a team effort," says Dr. O'Cochlain. That collaboration makes the Cardiac Center team “unique in the area," says Ann Rufledt, a physician assistant and coordinator for the Valve Evaluation Clinic.

Returning to good health

After the evaluation was complete, Dorothy sat down with her son and daughter to share the test results and her care team's recommendation that she undergo heart surgery called transcatheter aortic valve replacement. She says she didn't have the surgery to live longer. Rather, she wanted to continue to live an active life without the worry of pain or inability to breathe easily.

Dorothy was especially interested in this procedure because it only requires a small incision instead of a sternotomy, which would involve cutting through the chest bone to access the heart. On the day of the procedure, an incision was made in Dorothy's groin. A catheter was inserted through the incision and guided up an artery to her heart where the new valve was inserted to replace the underperforming valve.

"I am thankful for the whole team that cared for me at Mayo Clinic Health System and for all the other patients that have had this before me and shared their success stories, which gave me the encouragement to have it done, too." — Dorothy Ganong

Dorothy spent four days in the hospital after surgery. The cardiac rehabilitation team kept her motivated through exercises and helped her gain confidence to get her back to her daily routine. She continued rehabilitation appointments after going home. A couple months later, she began to notice significant changes. She could breathe easier, go on longer outings, and sleep better at night.

"It just really changed my life," says Dorothy. "I am thankful for the whole team that cared for me at Mayo Clinic Health System and for all the other patients that have had this before me and shared their success stories, which gave me the encouragement to have it done, too."

If anyone is thinking about having this surgery, Dorothy advises, "Just go do it."

To hear more about Dorothy's story, you can view a video of Dorothy speaking at the 2017 Her Story, Her Heart event in Eau Claire.

HELPFUL LINKS

• Learn more about transcatheter aortic valve replacement.
• Read about the Valve Evaluation Clinic.
• Connect with others talking about heart health on Mayo Clinic Connect.
• Explore Mayo Clinic Health System.
• Request an appointment.

The post Breathing Easier After Minimally Invasive Heart Surgery appeared first on Mayo Clinic News Network.

ANSWER: Whether you need surgery to replace your aortic valve due to aortic stenosis depends on the severity of your condition. Mild to moderate aortic stenosis typically does not require surgery. But, surgery is necessary for severe cases of aortic stenosis. If left untreated, severe aortic stenosis can result in heart failure.

The aortic valve is located between the bottom left chamber of your heart, the left ventricle, and the main artery that leads away from your heart, the aorta. The valve is made of three flaps of tissue, called leaflets, that swing open when blood pushes against them. After blood has gone through the valve, the leaflets swing closed to keep the blood from flowing back into the heart.

Aortic stenosis happens when the opening in the aortic valve is narrowed. Valves affected by stenosis limit blood flow. Your heart has to work harder to squeeze blood through the narrow valve than it does when the valve opening is normal. Aortic stenosis can be caused when a person is born with an aortic valve that has only two leaflets, rather than three. More commonly, though, the condition develops as a result of aging.

Aortic stenosis tends to get worse over time. When it first develops, mild aortic stenosis typically doesn’t have any symptoms. But, as the condition progresses, the extra work required of the heart to pump blood through the narrow valve may cause symptoms, such as fatigue, shortness of breath, chest pain, lightheadedness or fainting. In some cases, though, these symptoms can be subtle, and they may go unnoticed.

Heart failure can happen before symptoms develop or become obvious. For that reason, surgery to replace the aortic valve often is recommended when there is severe aortic stenosis, even if no symptoms are apparent. Your doctor can determine the severity of your condition using a test called an echocardiogram — an ultrasound of the heart.

Replacing the aortic valve is the only effective treatment for stenosis. It relieves obstruction to blood flow through the heart, improves symptoms, helps your heart work better and allows you to live longer. During the procedure, a surgeon removes the narrowed aortic valve and replaces it with a mechanical valve or a tissue valve.

Valve replacement generally is performed during open-heart surgery. But, a less invasive approach, called transcatheter aortic valve replacement, or TAVR, is another option. In TAVR, doctors insert a catheter into an artery in your leg or into a small incision in your chest. They guide the catheter to your heart and into your aortic valve. A balloon at the tip of the catheter, which has a folded valve around it, is then inflated. This pushes open the aortic valve, stretches the valve opening and expands the folded valve into the aortic valve. Doctors then deflate the balloon and remove the catheter. In some cases, a self-expanding valve may be inserted into the aortic valve, and a balloon isn’t used.

If you have severe aortic stenosis, but you don’t have any symptoms or any evidence of heart failure, it is possible that surgery to replace the valve could be delayed. But, in that situation, you would need close supervision and follow-up care with your doctor. Eventually, everyone with severe aortic stenosis does need valve replacement surgery at some point. — Dr. Vuyisile Nkomo, Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota

The post Mayo Clinic Q and A: Mild to Moderate Aortic Stenosis Typically Doesn’t Require Surgery appeared first on Mayo Clinic News Network.

“Transcatheter aortic valve replacement has become transformational for patients who need a new valve and are at high-risk for surgery or inoperable. But we have been lacking long-term data for this group of patients who are considering this procedure,” says study lead author David R. Holmes, Jr., M.D., a Mayo Clinic interventional cardiologist. “Before this study, we only had 30-day information. This is a milestone and will help us better guide patients and learn as physicians.”

For the study, researchers used the Transcatheter Valve Therapies Registry, developed by the Society of Thoracic Surgeons and the American College of Cardiology, combining 12,182 TAVR patient procedures performed from November 2011 through June 2013 and linking to Centers for Medicare and Medicaid Services administrative claims for one-year data using direct Medicare patient identifiers (name and social security numbers).

Other important results from the study are:

• Median age of patients was 84 years old, and 52 percent of patients were female.
• 8 percent of patients were discharged directly to home.
• Thirty-day mortality was 7 percent.
• 4 percent of survivors were re-hospitalized only once, and 12.5 percent twice.

TAVR received U.S. Food and Drug Administration approval in 2011. It is used with increasing frequency for the treatment of severe aortic stenosis in patients who are at high or prohibitive risk for surgical aortic valve replacement, Dr. Holmes says.

Aortic valve stenosis happens when the valve narrows. The narrowing prevents the valve from fully opening, restricting blood flow from the heart into the aorta and then to the rest of the body. In TAVR, a minimally invasive procedure, physicians access the heart through a blood vessel in the leg or, less often, through an incision in the chest. A catheter is inserted through the access point, and the physician guides the catheter to the heart. Once in place, the replacement valve is passed through the catheter and positioned into place, and catheters are removed.

Other study authors and members of the TVT Registry are J. Matthew Brennan, M.D., M.P.H., David Dai, Ph.D., Sean O’Brien, Ph.D., and Sreekanth Vemulapalli, M.D., all of Duke Clinical Research Institute; John Rumsfeld, M.D., Ph.D., Denver VA Medical Center; Fred Edwards, M.D., University of Florida; John Carroll, M.D., and Fred Grover, M.D., both of University of Colorado; David Shahian, M.D., Massachusetts General Hospital; E. Murat Tuzcu, M.D., Cleveland Clinic; Eric Peterson, M.D., M.P.H., Duke University Medical Center; Ralph Brindis, M.D., M.P.H., University of California; and Michael Mack, M.D., Baylor Scott & White Health.

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MEDIA CONTACT: Traci Klein, Mayo Clinic Public Affairs, 507-284-5005, email: newsbureau@mayo.edu

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