Ask The Heart Doctor: Women's Heart Health-Part 2 - Valve Disease

Learn what you’ve always wanted to know about women’s heart care, from risk prevention to unique symptoms to specialized treatment options. In part two of this panel discussion, our heart doctors answer:
Minimally-invasive procedures vs. open surgery in women, what is factored in? Does age impact decision-making?

Meet our panelists:

Leslie Cho, MD, Cardiologist, Director, Cleveland Clinic’s Women’s Cardiovascular Center
https://my.clevelandclinic.org/staff/6638-leslie-cho

Christine Jellis, MD, PhD, Cardiologist, Vice Chair, Heart Vascular & Thoracic Institute – Patient Experience & Physician Engagement
https://my.clevelandclinic.org/staff/19994-christine-jellis

Donna Kimmaliardjuk, MD, FRCSC, Cardiac Surgeon
https://my.clevelandclinic.org/staff/30663-donna-kimmaliardjuk

Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Leslie Cho, MD:

Welcome everyone to a session on Ask Your Heart Doctor. Today our focus is on women and heart disease and joined by our surgeon as well as our cardiologist colleagues, and we're going to go around and introduce ourselves first. My name is Leslie Cho. I'm the Director of Women's Cardiovascular Center at the Cleveland Clinic.

Donna Kimmaliardjuk, MD:

I'm Dr. Donna Kimmaliardjuk, and I'm a cardiac surgeon with a special interest and focus on coronary artery disease and bypass grafting.

Christine Jellis, MD:

I'm Christine Jellis. I'm an imaging cardiologist with a special interest in advanced imaging. I'm one of the detectives and we use this imaging to figure out how bad heart disease is.

Leslie Cho, MD:

Perfect. So, we're going to start with some basic questions, and I know you have been so generous and asked us tons of questions. We're going to get through some of the common ones. 

Christine, there's a lot of questions about valves. So, there are many, many questions centered around aortic valve. And so when should a patient consider aortic valve surgery? And there's a lot of questions about in women, is the percutaneous option better or the surgical option better? So how do you think about that?

Christine Jellis, MD:

There's a lot there, isn't there Leslie, that we can cover. I think what I do when I'm talking to my patients about valves and valve surgery is I want to think about what's the right choice now versus what is going to be the right thing for them in 10 years or 20 years or 30 years from now. So we have to plan both in the short term and the long term. What we want to do is use all the diagnostic tools we have at our disposal to firstly, accurately diagnose the type of valve dysfunction. So, typically with aortic valves it would be leakiness, which we term regurgitation, or narrowing, which we term stenosis. We then have sophisticated algorithms and measurements we make with echo that can grade the severity of the valve problem into mild, moderate, and severe. Typically, if it's mild or moderate, we continue to watch those patients under surveillance with ongoing imaging and consultations.

We don't want to act too early. It's all about timing because our choices on what we do to the valves are not always a choice that's going to last someone for the rest of their life, and so we have to make sure that we in some cases can kick the can down the road in a safe way and not act prematurely. We have different types of interventions we can do on valves including repair, but often replacement. And as I'm sure many of you know, there are different types of valve replacements. One being mechanical, one being a tissue valve, and we have other specific types of valve replacements that are done in other indications. So, if we're going with a mechanical valve, there are considerations around blood thinners. So we have to look at the patient and there are other medical problems to determine if that's going to be safe as well as the age of the patient.

If the patient is older, they're more likely to be going to receive a tissue valve, and those valves typically have a lifespan of about 10 to 15 years. We've all seen shorter, we've all seen longer. So, we give that as an average. Because of that as you can imagine, if we put that valve in too soon, the patient may need a second valve within 10 to 15 years, and for a younger patient that obviously has implications on their longer-term care. So there's a lot that goes into that, and I think with the advent of transcatheter aortic valves, which are the minimally invasive valves that can be done through typically the femoral artery in the leg, that's given patients even more choices, especially for our older patients who may have been too sick to undergo surgical aortic valve replacement. So, a lot there, Leslie, and I'm sure there's other things we can discuss about that.

Donna Kimmaliardjuk, MD:

Well, if I can just add to that, I completely agree. The other thing that comes into decision around timing is every surgery, every procedure we do comes with risk. So, yes, we do surgery here extremely well. We have incredible outcomes. However, it's always that risk:benefit ratio. So, even though we can offer surgery very, very safely, that 1% chance or 2% chance of a certain complication can and does still happen, and so that's why we wait until the risk of doing nothing is higher than the risk of doing surgery. Because I do meet patients and they worry, "Did we wait too long or why didn't they do surgery sooner?" And so absolutely comes into play with the valve type, but also the risk around doing surgery itself.

Christine Jellis, MD:

I'll just add to that, I think there's other considerations specifically for women. So sometimes we'll have smaller anatomy. Sometimes women go undiagnosed for longer for a variety of factors, and so sometimes we see women presenting with actually more severe disease or the guidelines that we sometimes use for classification of that mild, moderate, severe are often based on size. And so they may not be as applicable to women as to men. And so we've done a lot of work here at the clinic around specific types of valve disease, aortic, mitral valve, where we've been able to show that women perhaps need different cutoffs for determination if they should go ahead with surgery. That's an evolving area, but certainly something that we are very interested in because we want to make sure we're not missing the women who truly need intervention. There is nothing worse than when we see someone who has gone beyond the point at which they should have had surgery, and sometimes that can lead to worse outcomes. So, as I said, it's all about finding that sweet spot with the timing.

Leslie Cho, MD:

Absolutely. There's a lot of questions actually about that, whether women's sizes are different, from our audience here, from our patients, about how can we figure out for women those different sizes. And I think coming to center like this, coming to a place where we do 5,000 open heart surgeries, I think that's very important. There's another question and the question has to do with age. Is there an age cutoff? How do you think about age and surgery or age and a procedure? We'll start with Christine and then we'll go to Donna.

Christine Jellis, MD:

Sure. So, as the saying goes, age is but a number. I think obviously we have to take a common sense approach and for our patients who are young, we need to think about decades of life ahead of them and what are the best choices going to be. For our very elderly patients or those who perhaps have a lot of significant medical problems like severe emphysema, kidney dysfunction, liver dysfunction, it may be clear that they're not going to be a good surgical candidate because of high risk created by their other problems and so they may be more likely to benefit from a transcatheter valve.

Where it's a bit controversial is in between. In, for example, the healthy 65 or 70-year-old who ideally doesn't want to go through an open heart procedure, but our job as imaging cardiologists is to present all the data, pull in Donna and her team around the surgical piece. And as has been said, it's a patient-centered discussion around what is the best option now, but again, it's that investment in the long term. Are we better off doing surgery now while the person is younger, albeit a good 70-year-old, so that when they're 95 they're in the best situation?

Leslie Cho, MD:

Absolutely. What do you think?

Donna Kimmaliardjuk, MD:

No, I completely agree. The beautiful thing about here is we have other approaches than just our standard sternotomy approach. Let's be honest, most people don't want this cut. That's what they're most anxious about in the recovery. So, here we have surgeons that have expertise in all areas of heart surgery where we can potentially offer cuts between the ribs on the side on the right side for mitral valve or up on the right front of the chest for aortic valve or on the left chest for bypass surgery or small incisions. So there's ways to kind of mitigate surgery to make it easier for recovery, to make it easier in planning for future potential surgery that the patient might need in 15, 20, 30 years. And so there are options, and that's the beauty about coming here, is to be able to navigate those options with different surgeons and cardiologists.

Christine Jellis, MD:

I was just going to add one thing Donna and her team do really well is that they stratify patients so that then they're always going to ensure the best outcome. And so they will offer minimally invasive options to patients as long as they can give them the same phenomenal outcome as they would through an open incision. I have to say, you guys navigate that really well, and I think everyone can be guided by your expertise in that realm because we really want to make sure whatever choice we advise patients on and discuss with them, that they're going to get the best short-term and long-term outcomes.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at Heart at ccf.org. Like what you heard, subscribe wherever you get your podcasts or listen at clevelandclinic.org/loveyourheartpodcast.