A Not So Open & Shut Case
Many people never consider the importance of healthy heart valves. But what happens when a heart valve is not working properly?
Robert Epps, heart valve replacement survivor & CEO of the National Organization for Aortic Awareness
Robert Epps joined the Coast Guard right out of high school in Jersey City, New Jersey. During his boot camp physical, he was told he had a "benign" heart murmur. He was 18, and since he passed the physical, the news of a benign anything did not concern him, and he embarked on a successful Coast Guard career. His daily regimen included plenty of physical activity, and his heart never caused a problem, although in his 30s he was beginning to notice some fatigue. He never gave the heart murmur another thought, until 17 years later, when he was getting a checkup, and the doctor said, "Did you know you have a heart murmur?"
"Yes, but they told me it was benign," Epps said.
"Well, it isn’t benign anymore," the doctor said.
Your heart valves control blood flow into the heart, from one chamber to another and from the heart out to the lungs. Each valve has two important functions: To open correctly so that blood can empty from the chamber; and to close properly so that blood cannot flow backwards. A heart murmur signals a problem. We talked about valve disease with Robert Bonow, professor of cardiology and director of the Center for Cardiovascular Innovation at Northwestern University Feinberg School of Medicine in Chicago, Illinois, and a past president of the American Heart Association.
TWO BASIC PROBLEMS
Just as there are two primary valve functions, there are two primary valve problems — stenosis and regurgitation. "Stenosis just means tightness," Bonow said. "A stenotic valve can behave like a rusty gate that is tight and doesn’t want to open. Or it may be stuck open, in which case you can get blood leaking backward.
"Regurgitation occurs when the valve is not closing normally and leaking." The valves open when there is enough pressure in the chamber and close when the pressure changes on the other side, like the locks on a canal.
The two most common valve problems are aortic stenosis where the aortic valve is tight and mitral valve regurgitation where the mitral valve is leaking. One reason they are common is that both conditions are related to congenital abnormalities. (Find more on risk factors at Heart.org) "More importantly, with an aging population," Bonow added, "you get this wear-and-tear effect where the valves begin to thicken, and the aortic valve becomes tighter and calcified and doesn’t want to open. On the mitral side, the same wear and tear can make the valve leak."
HEED THE SIGNS
Robert Epps participating in an aortic symposium
In the majority of cases the doctor’s response will be to keep an eye on things. "Usually we tell our patients:Shortness of breath, fatigue, lightheadedness and chest pain may be signs of worsening heart valve disease. But valve problems can be severe with no symptoms. It is important to see your doctor. (Find more on recognizing symptoms at Heart.org)
‘You’re doing fine. We’ll see you next time. But between now and then, if any of these symptoms gets worse, make sure you call me,’" Bonow said.
Other patients are like Robert Epps, they come in for a checkup, and the
response is not ‘See you next time,’ it’s ‘See you in surgery.’ The public health officer that examined Epps wanted him to go directly to a medical center for immediate testing, but Epps, by now a chief in the Coast Guard, had a two-week inspection tour scheduled, and that was a higher priority for him. "The truth is I didn’t know what was happening," Epps said. "I did not know the severity of what was going on."
Epps attends the 2015 Mid-Atlantic Conference on Vascular Therapies
He went on his inspection tour, where he ran wind sprints on the beach trying to get his endurance back: "I was always feeling tired." In May 1996, he had an echocardiogram. The next day, they called him back for more tests, saying "Don’t lift anything over ten pounds." Tests showed he had an aortic aneurysm, a dissected aorta, aortic regurgitation, and a dilated left ventricle. As a result, Epps’ heart had become enlarged. "At times, it felt like a balloon was expanding through my ribs," he said.
While interviewing Epps before surgery, the doctor said, "You’re a chosen man because with all you have going on, you should not be here." Through the weekend, Epps wrestled with the ‘why me’ question: "I was in such good shape. I didn’t eat red meat. I didn’t drink. I didn’t smoke," Epps remembered. "As I sat in the hospital I really got a bad attitude about the whole thing. Then early on the morning of the surgery, God’s peace just came over me and I accepted what was happening."
Before his surgery, Epps conferred with the surgeon about what kind of replacement valve they would use to in place of his damaged aortic valve.
There are two types of replacement valves — mechanical and biological. Each has pluses and minuses. Mechanical valves are made of strong durable materials and are the most long-lasting type of replacement valve. Mechanical valves will typically last throughout the remainder of the patients’ lifetime.
The downside to a mechanical valve is that it is a foreign object in the bloodstream and blood will clot around it. Those clots may prop it open or hold it shut. Because of this, mechanical valves require anti-coagulation therapy, usually warfarin. Warfarin requires monitoring and dietary changes. "The risk of the mechanical valve is that the patient could be over anti-coagulated and bleed or under anti-coagulated where the valve can then develop clots and put the patient at risk of strokes," Bonow said. "It also means that you’ve got to watch your lifestyle; it’s not going to be mountain climbing or ski racing if you’re on blood thinners. And you have to be really careful about vitamin K in your diet, which is in many things that we encourage people to eat – green, leafy vegetables."
Biological valves are created from animal valves or other animal tissue that’s strong and flexible. Tissue valves can last 10-20 years, and usually don’t require the long-term use of medication. Their downside is durability. For a young person with a tissue valve replacement, the need for additional surgery or another valve replacement later in life is highly likely. "The durability of a biological valve depends on how old you are when the valve is put in because of different metabolism," Bonow said. "A biological valve in a 65-year-old will last more than 20 years roughly 90 percent of the time, whereas a biological valve in a 20-year-old will not last more than 10 years in the majority of people. We tend to determine which valve to put in depending on how old someone is: over the age of 65 we strongly recommend biological valves. At younger ages, we recommend mechanical valves, but there is this uncertain age group between 40 and 65 as to what the right valve should be."
TWO TYPES OF REPLACEMENT VALVES
Mechanical replacement valves (left) are made of strong, durable materials that usually last for the patient’s lifetime.
Tissue replacement valves (right) are made from animal valves or other strong, flexible animal tissue.
Epps chose a mechanical valve; his primary consideration was durability. Because of his relative youth, a biological valve wouldn’t last forever: "At age 35, I figured that’s a lot of open-heart surgeries to come, so I passed on that option." He has incorporated the dietary changes into his life, and as for accidents, "I am more observant and cautious. I pay attention to my surroundings," Epps said.
"What I tell my patients is you’re taking one dark cloud away and replacing it with a new dark cloud," Bonow said. "You can’t guarantee that a new valve is going to last forever, whether it’s mechanical or biological. Sometimes people need a second operation, sometimes even a third one over the course of a lifetime. So you want to make sure that you’ve timed that first operation just right so that the risks and benefits of doing the surgery outweigh the risks of not doing it." The good news is that valve replacement surgery has a high rate of long-term success.
Recovering from surgery generally takes four to eight weeks. Immediately after surgery, while in the hospital, people are usually practicing very basic self-care but are soon encouraged to get up, breathe deeply and resume eating, drinking and walking. During the days and weeks following discharge from the hospital, patients gradually regain energy and return to their normal activity level.
In Epps’ case, he could not pick anything up because it would place stress on the breastbone that might cause movement while it was healing. "I had to be very careful. I couldn’t drive, for instance, because I might move the breastbone," Epps said. "Even getting in and out of bed was difficult because that takes your stomach muscles. At first I was in a recliner because the recliner kept me upright. I was home for six weeks, and out of those six weeks, probably three or four of them I limited my activities until that breastbone healed. My parents and my sister came down to help my wife, Miriam. We had only been married a few years and it scared her to see me so weak. It was a lot on her." (Read "No More ER" on heartinsight.org for Miriam’s perspective.)
If you or someone you care about will be experiencing heart valve surgery, there are a number of things to consider and prepare for beforehand. Here is a helpful, downloadable checklist for pre-planning for surgery and recovery.
Dr. Robert Bonow
The prognosis is good for patients who undergo valve replacement surgery, and most people return to a normal lifestyle. "Replacing a valve doesn’t mean you make an 85-year-old a 45-year-old, but you can make that person a healthy 85-year-old," Bonow said. "They can return to the age-adjusted longevity and lifestyle."
To a large degree, a patient’s future is determined by the timing of the operation. Sometimes people wait too long before going in for a checkup. "If the timing has not been right, the person may be left with a weak heart, atrial fibrillation or elevated blood pressure in the lungs," Bonow said. "In some cases, the surgery successfully removes the primary problem but you’re left with complications related to the longstanding effects of the valve problem before the surgery was performed.
"This is why it’s important to be followed by a physician who’s experienced with treating valve conditions if you’ve got a heart murmur or a valve problem, so that you can have those discussions about when the best time for the surgery would be so you don’t get to the point where you may have waited too long."
Epps made a full recovery, but that does not mean there haven’t been lifestyle changes. He has cut back on physical activity – he used to run three miles a day. His surgeon advised him not to strain, so he does not work out with heavy weights or do activity that requires him to hold his breath for extended periods of time because of its effect on blood pressure. "I walk more now and enjoy riding the bike because you work the heart and strengthen the knees and legs at the same time," he said. "But that’s about it, nothing too strenuous."
As founder and CEO of the National Organization for Aortic Awareness, Epps shares his story, which includes two other open-heart surgeries for aortic dissection. He has written a book, The Human Aorta: Your Super Highway of Life.
He often hears from people that they prefer not to know what’s going on, a thoroughly human response. "I understand that," Epps said. "I tried to find all kinds of ways to get out of it. But just because you don’t know what’s going on doesn’t mean you can’t be a victim of the outcome. I tell them, ‘You need to get this checked out; if you don’t want to do it for yourself, do it for the people who are depending on you.’"
The American Heart Association has a wealth of information about heart valve disease.
TAVR replacement valve
Previously replacement surgeries required a full sternotomy (cutting open the chest), but now there are less invasive surgeries that allow access to the heart through smaller openings in the chest. Some mitral valve repair can be accomplished coming in from the side. These are all still considered open-heart surgery: patients have to be fully anesthetized, and the heart can’t be functioning during the operation. "You’ve got to connect the patient to a heart-lung machine to oxygenate the blood and keep it pumping to the brain and other organs while the heart is being operated upon," Bonow said. "Having circulation taken over by this pump is a risk. That’s why you want to have surgery done in places that have a lot of experience with this operation so they can minimize the amount of time on the heart-lung machine."
In addition to these surgical advances, there is now a catheter-based replacement option for the aortic valve – transcatheter aortic valve replacement (TAVR). This is the same catheter technology that’s used to open coronary arteries with stents. In TAVR, a stent is inserted across the tight aortic valve. Inside the stent is a biological valve that remains in place once the stent is opened. In TAVR, you’re not taking out the old valve and replacing it with a new one, you’re putting a new valve inside the old valve and pushing it aside. There are two types of catheter-based valves that are now available and approved by the FDA. "TAVR has really opened up a whole new vista for patients who require aortic valve surgery," Bonow said.
The mitral valve is more complicated. The catheter techniques to either repair or replace it are not as well developed as that for the aortic valve. "This is an area of lots of research and lots of exciting opportunities in the future," Bonow said.
At this time, TAVR is recommended only for those in whom the risks of surgery are high. "Right now, we still recommend open-heart surgery for people considered at low risk for surgery," Bonow said. "We have a long track record with these valves. And we don’t know about the durability of transcatheter valves. Thus far they appear to be lasting quite well. And there’s always the risk of strokes when you start putting things across the blood vessels and expanding things inside the valve."