Valve disease presentation by Dr. Kevin Hodges

[Chuck C]

Dr. Hodges is a surgeon at Northwestern Medicine. I found his presentation very well put together- excellent use of data and references and well communicated.

In my view, the entire hour long presentation is well worth the watch, but here is a timeline for some of his points:

3:00 - Start of Dr. Hodges presentation
8:00- Discussion of symptoms of heart valve disease
8:47- Presentation of the Eugene Braunwald graph, showing the cliff of survival if one does not get surgery once symptoms present. I have often posted this graph on the forum.
10:42- Data presented showing the stratification of long term outcomes, depending on severity of symptoms. This data makes a compelling case to getting surgery early vs late and not waiting until symptoms worsen. Later in the presentation, he actually makes the case for getting surgery before symptoms, once a patient becomes severe, particularly for low risk patients. There is growing evidence for this, which he presents well.
21:25- Discusses the issue of patients who are not sure if they have symptoms, slowing down and stress test echos- aka treadmill echos.
27:45 - Blood test for serum BNP levels. A blood test which is a marker for stress in the Left Ventricle.
29:20 - Atrial fibrillation. Discussion of how valve disease can cause afib. Also, the case for treating afib with Maze Procedure during OHS for surgical valve replacement, with data presented showing significant better outcomes when this is done.
40:20- More data supporting getting valve surgery done early, for those who are severe, especially those who are low risk surgical candidates. The numbers are striking when comparing outcomes for early surgery vs conservative care, which is sometimes called "watch and wait".
46:14- discussion for the new change to the American Heart Association guidelines supporting early intervention for mitral valve repair.
48:00- Presentation of data supporting the importance of getting mitral valve surgery done at an experienced high volume center.

My biggest take away is the urgency of not delaying surgery once a patient becomes severe with symptoms, which would apply to both aortic stenosis and regurgitation. Also, the emerging evidence that early intervention leads to much better long term outcomes. To be clear, early intervention does not mean operating when a patient is in the mild or moderate level. It would generally mean the patient is severe, but not waiting for symptoms, or getting surgery soon after symptoms present.

 

[Survived03]

Thanks Chuck. I was “symptom free” but demonstrated the classic BP drop during stress echo due to severe aortic stenosis. No heart wall damage thankfully but my cardiologist shined the light on the level of risk.

 

[Beach77]

Thanks Chuck! I'm going to go back and look at my results of the echo stress test. It might explain a few comments from my 2 doctors at the time.

 

[ottagal]

Thanks Chuck. Saw this presentation too! You did a great synopsis of highlights and salient points. I currently have severe aortic stenosis (bioprosthetic and almost 15 years with it) and now severe pulmonary stenosis. These results are based on the pressure gradient readings from the last echo. My situation is challenging as I "aced" both the both the stress echocardiogram test (bike) and the CardioPulmonary function test (treadmill). Seeing this will be my second surgery and will ALSO involve another heart valve, everyone wants to be certain about timing which is challenging. I am requesting further testing to ensure that the echos are consistent and accurate with the current diagnosis. I also read a rebuttal to the early intervention recommendation (in one of the cardiovascular journals). I'm not sure if I will be able to find it again as I didn't bookmark it. In "my" case, they have had a grand rounds with a number of specialists and they are divided on when to do an "intervention". Some are recommending it now and others are saying to "wait". Makes it hard to know what to do.

 

[Chuck C]

I was “symptom free” but demonstrated the classic BP drop during stress echo due to severe aortic stenosis. No heart wall damage thankfully but my cardiologist shined the light on the level of risk.

Very glad that your cardiologist had you get the stress test and that it helped to identify that it was time. And very glad that you were able to get your surgery before any damage occured. That is so very important.

 

[Chuck C]

I currently have severe aortic stenosis (bioprosthetic and almost 15 years with it)

Glad that you got 15 years. That's a good run.

In "my" case, they have had a grand rounds with a number of specialists and they are divided on when to do an "intervention". Some are recommending it now and others are saying to "wait". Makes it hard to know what to do.

Your situation is complex, involving two valves. It is good that you are getting multiple opinions, although it's vexing that they're divided. It would make things a lot easier if they had a consensus, but at least you're getting a lot of good input as to the pros and cons of each option. I'm usually in the camp of getting things done sooner rather than later. I would always tell my consultants that I'd rather get surgery a few months too early than a few months too late.

Best of luck in the challenging decision before you and please keep us posted.

 

[Pmacky09]

Thanks for sharing this! My bicuspid aortic valve is severely stenotic (and I'm experiencing shortness of breath with even mild exertion now). I saw the surgeon last week after an angiogram and he advised that surgery would probably in July-August of this year (he rated me as NYHA 1-2). I'm in British Columbia where wait times for surgery are a real concern, and I'll be sharing this with him to try and push for an earlier date.

 

[ottagal]

Glad that you got 15 years. That's a good run.


Your situation is complex, involving two valves. It is good that you are getting multiple opinions, although it's vexing that they're divided. It would make things a lot easier if they had a consensus, but at least you're getting a lot of good input as to the pros and cons of each option. I'm usually in the camp of getting things done sooner rather than later. I would always tell my consultants that I'd rather get surgery a few months too early than a few months too late.

Best of luck in the challenging decision before you and please keep us posted.

Thanks Chuck. Appreciate the input and best wishes. Yes, I agree that it would be nice to have a consensus. One surgery being proposed is the Konno procedure (never heard of it) to increase the current aortic valve size (that has the bioprosethic valve) for future TAVI aortic valve. It comes with risks. Pulmonary valve does not require decision making on my part as they recommend a homograft (as too high stroke risk with mechanical valve). So I have lots to think about. Do I do two tissue valves, a mechanical aortic and tissue pulmonary? They figure pulmonary valve should get 10-15 year run and could do TAVI with that in future. No crystal ball here and hopefully with more consults, echos and time I will be able to make the best decision that resonates with me. I do agree that I got a good run of 15 years with the bioprosthetic aortic valve. Cardiologist thinks that I should even get a longer run second time around as I am 15 years older. Who knows?

 

[ottagal]

Glad that you got 15 years. That's a good run.


Your situation is complex, involving two valves. It is good that you are getting multiple opinions, although it's vexing that they're divided. It would make things a lot easier if they had a consensus, but at least you're getting a lot of good input as to the pros and cons of each option. I'm usually in the camp of getting things done sooner rather than later. I would always tell my consultants that I'd rather get surgery a few months too early than a few months too late.

Best of luck in the challenging decision before you and please keep us posted.

Oh and one more thing....Current surgeon who did consult with told me that he has a long wait list! 6-12 plus months! I said, well put me in the queue even if the decision isn't made.

 

[HokieHaden]

Thanks for sharing this - very informative. I was born BAV and was always asymptomatic, right up to last year’s decision to have AVR and aortic root repair (surgery was 6 months ago tomorrow, in fact). This video has confirmed I likely made the right decision to go ahead and have the replacement and repair done even before symptoms arriving.

 

[Chuck C]

Current surgeon who did consult with told me that he has a long wait list! 6-12 plus months! I said, well put me in the queue even if the decision isn't made.

I think that's wise to get in the queue now. I know that your team has not come to consensus yet as whether to do surgery or wait, but you can always opt out of the queue if ultimately the decision is made to wait.

 

[Amy]

I haven’t watched the presentation referenced here, but by chance I happened upon this study (which may be referenced in the presentation) -

https://openheart.bmj.com/content/4/1/e000588

This also may help you make up your mind, if you’re waiting to decide on AVR and are severe.

As far as the quoted (mere) 90% mortality rate in this paper for patients who HAD the surgery, that may be due to inclusion of a lot of much older, non-congenital patients, etc. At least I hope it is. : )