Mitral Regurgitation Tool

Is surgery recommended for your Mitral Valve Regurgitation? This interactive tool, based on the American College of Cardiology and American Heart Association Guidelines for management of mitral valve disease will help determine if it is. The tool asks you several simple questions, considers your answers, and tells you whether you may be a candidate for surgery. Get answers today

Cleveland Clinic cardiologists were among the first clinicians in the country to use the device in an innovative procedure called transcatheter aortic valve replacement (TAVR)—a minimally invasive technique for replacing a diseased aortic heart valve.

New hope for patients

TAVR is indicated for patients, especially older patients, who are too high risk to undergo traditional open-heart surgery. The average age of patients undergoing TAVR is 84 years, and 20 percent are 90 years or older. The procedure requires only a small incision, and patients do not need to be on a heart-lung machine.

“One of the beauties of these transcatheter procedures is that we now have a new option for patients,” says Lars Svensson, MD, PhD, director of the Aorta Center at Cleveland Clinic. Dr. Svensson helped develop the new transapical technique beginning in 2004, and he was co-principal investigator of the clinical trial that tested the efficacy of TAVR.

Watch TAVR in action

TAVR received FDA approval in 2011 and then wider approval in 2012. Learn more in this video:

Dr. Svensson adds: “There are times when we have a family in front of us with high expectations, and this is the last hope for helping them. We go through all of the tests—and when we are able to say, ‘Yes, you are a candidate for TAVR,’ it’s wonderful.”

How it works

A) Balloon catheter in the diseased valve; B) Balloon with valve in place; C) Balloon inflation to secure the valve

TAVR delivers the collapsible artificial valve into the heart using a catheter. One approach involves a small incision in the groin to gain access to an artery. Other approaches are performed between the ribs (trans-apical) or in the top of the breastbone (trans-aortic). The artificial valve, made of porous wire mesh netting, is expanded inside the native heart valve by inflating a balloon—and almost immediately starts working.

The recovery time is relatively short, with many patients getting back to their normal lives within a couple of weeks. Cardiac rehabilitation is recommended.

It’s no wonder that Popular Science has selected the Edwards SAPIEN Transcatheter Heart Valve as the Grand Award Winner in the health category in the publication’s annual “Best of What’s New Awards.”

Cleveland Clinic’s TAVR experience

Cleveland Clinic was one of three early pioneering centers in the United States and one of more than 20 centers involved in TAVR clinical trials. In trials, patients who received the valve were 40 percent more likely to be alive a year later.

FAQs about percutaneous transcatheter aortic valve replacement can be found in previous web chat transcripts.

The link between Lp(a) and aortic stenosis

Patients are typically not screened for Lp(a) levels, but those with a common genetic variant for Lp(a) have a 60 percent greater risk of developing aortic calcifications than others, according to a new study in published in the New England Journal of Medicine.

Study results support
the need to intensify
lipid management in
patients with elevated
Lp(a) levels.

“It is interesting that Lp(a), a lipoprotein known to be associated with increased risk for premature cardiac risks like heart attacks, is now linked to an increased risk for development of aortic valve stenosis,” says Stanley Hazen, MD, PhD, Section Head of Preventive Cardiology and Rehabilitation at Cleveland Clinic.

Aortic stenosis is when the main valve regulating blood flow between the heart and the rest of the body is critically narrowed. Symptoms include fainting, heart attack or early death. Surgery can correct the disease.

Additional research on Lp(a)

An increase in cardiac risk in patients with high Lp(a) levels also was observed in a study published in 2010, where Dr. Hazen and other Cleveland Clinic investigators reported on the results of more than 2,700 patients followed over time. When the LDL (“bad”) cholesterol level was treated aggressively, an increase in cardiovascular risk associated with elevated Lp(a) levels was not observed.

The results “support the need to intensify lipid management in patients with elevated Lp(a) levels,” Dr. Hazen says.

What does it all mean?

The jury’s still out on who should be tested for Lp(a) cholesterol, and how it should be managed. The discovery doesn’t support widespread screening for Lp(a), but it raises a critical red flag.

According to a study published in the Journal of the American College of Cardiology, learning which patients have extremely high Lp(a) can help predict risk for heart attack in some individuals. European guidelines suggest treating patients with Lp(a) levels in the top 20 percent with niacin, though Cleveland Clinic’s Steven Nissen, MD, Chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, says there is no outcome data suggesting that niacin will work to lower cardiac risks associated with Lp(a).

Stanley Hazen, MD, PhD

Dr. Hazen’s advice

The best prevention always includes the old-fashioned approaches: There’s no substitute for a healthy diet and exercise. But with this new information, patients with a strong family history of premature cardiac disease who show elevated Lp(a) could be candidates for aggressive LDL therapy, Dr. Hazen says.

“We don’t chase after lowering Lp(a) itself since, frankly, we have virtually no tools in our belt to do so,” Dr. Hazen says. “Rather, when Lp(a) is elevated, we become more aggressive at LDL lowering, with intensification of statin therapy.”

Learn more

High Blood Cholesterol: What You Need to Know

What You Need to Know About Heart Valve Disease

Cleveland Clinic’s website was our go-to site when my wife, Karen, and I were trying to get answers. Was there any way to avoid surgery? Was mitral valve repair a possibility for me?

Our research built our trust in Cleveland Clinic after looking at outcomes statistics for valve surgery and the likelihood of valve repair vs. replacement. We also learned that A. Marc Gillinov, MD, cardiac surgeon in Cleveland Clinic’s Heart & Vascular Institute, was the expert in mitral valve repair who had helped actor Robin Williams in 2009. So, we sent my medical records to Cleveland Clinic for evaluation. 

We trusted Cleveland Clinic after looking at outcomes statistics for valve surgery.

A lasting first impression

When we made the appointment, we were counseled by phone by Cathy Kielar, practice nurse manager for Cardiothoracic Surgery, who really eased our  anxieties. We drove our RV from Indiana to Cleveland Clinic, which provided us all of the comforts of home during our two-week stay.

When we met with Dr. Gillinov, he confirmed that the mitral valve might not be the cause of my rapid heartbeat, and that the repair surgery was the first step to see if the symptoms resolved. He then said something that got our attention. My mitral regurgitation had progressed to the point where, within 6 months, it would start damaging my heart. It was time to have the surgery.

My minimally invasive mitral valve repair

The surgery experience, while frightening, went very well. I was hospitalized for just four days for the minimally invasive mitral valve repair. Dr. Gillinov assured us that the surgery was straight-forward, and the valve was in good condition. And, even better news, the valve had never been infected as previously suspected.

But there was also some not-so-good news. After surgery, I had a rapid heartbeat. I was told this was normal after heart surgery, but my tachycardia symptoms seemed to get worse over time. After six months passed, Dr. Gillinov suggested that I consider an ablation and referred me to Walid Saliba, MD, Director of the Electrophysiology Lab at Cleveland Clinic. 

Life has changed dramatically since
the ablation.

Relief after ablation

Four weeks of being on a heart monitor device showed a rapid heart rate of 180 beats per minute. Ablation surgery was scheduled for the spring.

We thought the valve repair was the answer, but it was just the beginning. After Dr. Saliba reviewed the case, he was confident he could help.

During an electrophysiology (EP) test, the tachycardia started up and doctors were able to isolate it and eliminate it in short order. Dr. Saliba told me he “got it” during the ablation, and that “it will not be back.”

My return to the cockpit

Life has changed dramatically since the ablation. I no longer have to take days off work because of extreme fatigue or heart palpitations. And I don’t need to take any medications. In every way, this was a miracle cure.

Scot Blesch

I was itching to get back in the air. After the required recovery period, I went to my cardiologist for a complete workup. I sent 2¼ pounds of medical records to the Airplane Owners & Pilots Association and Federal Aviation Administration (FAA) for medical review. I also passed a flight physical before being approved to fly again. This was 1 year, 1 month and 1 day after the valve repair.

The very next day, I took my wife for a long flight to celebrate.

Today, I take daily walks and my energy level is great. I’m also working on my commercial pilot’s license, which I did not previously pursue because of my condition. After 40 years, I’m no longer facing tachycardia.

My advice to pilots and patients

My message to pilots and anyone facing a heart condition: You can fly again and likely won’t even be grounded as long as I was. Don’t put off taking care of your health. And seek out the best resources like Cleveland Clinic. They gave me the best heart care possible—and they gave me back my wings.

Now I can fly again. I got my wings back. I’m back in the air after mitral valve repair and ablation surgery—and after 2¼ pounds of medical records were reviewed and approved by the Federal Aviation Association (FAA). As a pilot of 25 years, who was “grounded” for a period of time because of my heart condition, there is no sweeter recovery than returning to the cockpit.

My journey with heart medical issues began at age 14, when I was diagnosed with a heart murmur that was eventually determined to be mitral valve regurgitation. That’s when the mitral valve does not close tightly, allowing the blood to flow back into the heart, which can cause shortness of breath and fatigue. Some days, I felt so weak and tired that I would stay home from work. But most days, I carried on with business as usual. I knew my limits, and when I felt my symptoms flare up, I’d take a time-out. Sometimes, my symptoms of rapid heartbeat would last minutes. Other times, they would last a whole day, and I’d be so tired that I would need to lie down. Most of the time, though, I felt pretty good.

“As a pilot, there is no sweeter recovery than returning to the cockpit.”

Eventually, in 1988 when I was in my early 30s, I earned my pilot’s license after passing the medical exam. I was given additional tests—an electrocardiogram (EKG) and echocardiogram—and I continued getting echocardiograms every few years. At that time, my heart condition was not progressing, so I continued to fly and manage my symptoms with diet and exercise. In 1993, I became an instrument rated pilot and flying became even more of a passion.

Fighting Infection

Fifteen years later, my mitral regurgitation progressed to moderate, but my symptoms were not much different. I noticed the rapid heartbeat slightly more often. I was given a heart monitor to wear, which recorded my heart rhythm and sent data to my doctors for evaluation. The device revealed that I had a type of tachycardia, which is a faster than normal heart rate. I began seeing a cardiologist annually, but still there was no real change in my condition.

Then, my health took a turn for the worse in 2011 when I contracted a severe flu, which escalated into pneumonia. Though I recovered fully, several months later I had a nagging low-grade fever. My doctor, an internist and flying buddy, ordered blood cultures because he was vigilant about my heart condition. Everything looked normal, so I was given an antibiotic. But weeks later, the fever was back, and a second set of blood cultures revealed a staph infection. I was hospitalized the same day, but I felt fine.

Scot Blesch

Doctors were “just sure” that my mitral valve was infected, but an esophageal echocardiogram did not show any “vegetation” on the valve. So, I was sent home with a portable IV of medication to treat an infection called staph capitis.

At that time, doctors suggested that I’d need a mitral valve replacement soon. And, after visiting my cardiologist that summer, he was convinced that surgery was the next step. Even though the echocardiogram looked no different than the prior year, he said it was possible that the mitral regurgitation had progressed to “severe” status. And who knows if the valve would get infected again. That is when my wife began researching Cleveland Clinic.

Tune in later today at 2:30 p.m. (ET) to learn how Scot got his wings back.

Do you have a question about heart valve disease and conditions? Edward Savage, MD, Chairman of the Robert and Suzanne Tomsich Department of Cardiac Surgery, Cleveland Clinic Florida and Bruce Lytle, MD, Chairman of the Sydell and Arnold Miller Family Heart & Vascular Institute, answer your questions about this topic during a live webchat Tuesday, Feb. 5, 2013, at noon (ET).

Get answers to your health questions and concerns. It’s easy to be part of our live chat events, led by Cleveland Clinic doctors and health professionals.

About heart valve disease and conditions

Heart valve disease occurs when one or more of the four valves in your heart don’t work to allow blood flow from one chamber to another, or close to prevent blood from leaking back out.

If left untreated, a faulty heart valve can reduce quality of life and even become life-threatening resulting in stroke or cardiac arrest. Heart valve disease can be treated with lifestyle changes and medication therapy but may eventually require surgery to repair or replace the damaged valve.

Possible questions for this webchat

• What symptoms would I experience if I have a heart valve problem?
• How are faulty heart valves treated or replaced?
• Are there any new advancements in heart valve disease treatment?

Dr. Savage is a cardiothoracic surgeon who specializes in reoperative and complex cardiac surgery, valvular diseases, mitral valve repair, surgical approaches to heart failure and minimally invasive heart surgery.

Dr. Lytle is a cardiac surgeon with a special interest in coronary artery disease, arterial bypass grafting, valvular heart diseases, valve surgery, re-operations and diseases of the thoracic aorta.

This health chat will open on Monday, Feb. 4, 2013 to allow you to submit questions. We will try to answer as many questions as possible during the chat. Please create an account to attend the chat and submit your questions.

New technique

Cleveland Clinic, however, didn’t find such an answer acceptable. Through extensive research and innovation, we pioneered a new minimally invasive procedure to replace diseased aortic valves in patients who are considered too old, frail or sick for conventional surgery. The technique is called transcatheter aortic valve replacement (TAVR), which was approved by the FDA this year. Already, we’re performing more than a dozen a week.

TAVR is a revolutionary procedure, one of the many innovations that is helping America cope with the diseases of aging. Yet as innovative as medicine already is, we could be doing far better.

Improving standard of care

Here’s a stunning fact: It takes 13 years to take a new healthcare innovation from the point where we’ve demonstrated its benefit to the point where it has been established as the standard of care.

We need to reform our medical institutions so that they energize innovation through clearly articulated goals and strategies, and so that their culture does not automatically discourage the new and untried. In our society, medical advances are brought to the patient bedside through the mechanism of the marketplace.

Investing in innovation

At Cleveland Clinic, we’ve created a technology transfer organization that takes innovations created by our 3,000 doctors, invests in them, determines if they are commercially viable and if they are, license, patent, and start companies around them.

We now have almost 300 patents issued in the last 10 years, with 1,700 in the queue. We have spun off 45 start-ups. We want those ideas out and in use.

Recently, Cleveland Clinic Innovations – our tech transfer arm – sponsored Cleveland Clinic’s 10 annual Medical Innovation Summit. More than 800 leaders in healthcare, business, law, finance, media and research came together in one place to share information, debate ideas and promote medical innovation for the good of patient care everywhere. Few issues can be more critical to the health of our nation.

A novel transcatheter mitral valve system could completely change the story for patients who are not currently eligible for surgery. The concept was developed by José Navia, MD, a surgeon in the Department of Cardiovascular and Thoracic Surgery, and colleagues at Lerner Research Institute (LRI) and Cleveland Clinic Innovations.

“The main purpose for everything we do is to help patients, and as patients with heart failure are getting older and sicker, we were looking for ways to give them options,” Dr. Navia says of the inspiration for his idea.

The Cleveland Clinic Innovations team helped to develop the idea and broaden the concept, which uncovered even greater opportunity than Dr. Navia had initially imagined. Dr. Navia worked with LRI engineers and researchers to design and test prototypes.

How the idea grew

The transcatheter mitral valve delivery started as a simple idea for a ring that would repair a leaky heart valve, eliminating the need for sutures. But the product idea evolved into a new way of performing mitral valve surgery percutaneously (through a catheter). Through the innovation process, it was expanded into a complete system for heart valve replacement.

“This innovation shows how a simple idea can evolve into a platform technology,” says Mary Kander, senior commercialization officer at Cleveland Clinic Innovations. “It takes a comprehensive team of surgeons, researchers and engineers working together to develop a full range of technology.”

Transcatheter Mitral Valve System

How the system works

Here’s how transcatheter mitral valve system works: The valve stent framework, tissue valve and delivery system safely and securely attach the valve to the valve annulus without using sutures. The new stent valve is implanted over the existing valve during a percutaneous procedure. “This is a further evolution of percutaneous valve surgery,” Kander explains.

The road ahead

Currently, mitral valve implantation procedures that can be performed percutaneously are not available to patients. Before procedures using the device developed by Dr. Navia and his team can be implemented, lots of studies and further scrutiny take place.

After testing, gaining patents (some still pending) and approaching medical companies to gather their insight and interest in the project, the transcatheter mitral valve system was licensed to NaviGate Cardiac Systems, Inc., and the Clinic continues to collaborate with the firm on further development and studies.

“Once animal studies proves the safety and effectiveness of this device, we can begin use in people. In a year, we’d like to be doing the first human procedure in Europe,” Dr. Navia says, noting that NaviGate is simultaneously seeking approval overseas and in the United States.

The transcatheter aortic valve system (TAVR) has provided treatment to many patients who are not candidates for aortic valve surgery. Patients with mitral valve disease are hoping that in the future this will be an option for them. Dr. Navia is working on answers for these patients.

More Information

Learn more about percutaneous interventions for valve disease

Learn more about heart failure

Learn more about mitral valve repair

More Information

Download a free guide on valve disease and treatment options