Surgeon Roundtable: Complex and High-Risk Heart Valve Surgery
Written By: Allison DeMajistre, BSN, RN, CCRN
Medical Experts: Edward Soltesz, MD, and Anthony Zaki, MD, Cleveland Clinic
Reviewed By: Adam Pick, Patient Advocate, Author & Website Founder
Published: September 11, 2024
Patients, their families and medical teams can all agree that there are inherent risks when undergoing any type of heart valve surgery. That said, treatment options and approaches may change when a patient is considered “high-risk” due to complex cardiac conditions, health problems, advanced age and/or heart valve reoperations.
To learn more about the therapeutic options and medical advances designed for patients considered “high-risk”, we sat down with two expert heart surgeons from the Cleveland Clinic. Dr. Edward Soltesz is the Lewis Endowed Chair of Cardiothoracic Surgery and the Surgical Director at the Kauffman Center for Heart Failure and Recovery. Dr. Anthony Zaki is a highly experienced cardiac surgeon who has guided many high-risk patients through critical decision-making processes with successful outcomes.
Key Insights For High-Risk Heart Valve Surgery Patients
Here are the important questions and answers addressed by Dr. Soltesz and Dr. Zaki:
Question: Why would a patient be told they’re at high risk for valve surgery?
Dr. Zaki said they often encounter patients who come to the Cleveland Clinic for evaluation after being told they are “high-risk” and believes this could be for several reasons. He said, “In general, we categorize risk into two categories, whether it’s for medical reasons or comorbidities or other medical issues, or surgical risk, whether they’ve had multiple surgeries in the past or if they have some other technical factor that makes the surgery high risk.”
Dr. Zaki added that a third category of high-risk patients may need an isolated valve or bypass or a combination of procedures at one time. He said, “A lot of patients come to us with that labeling of high-risk, and I’d like to say that often it is a subjective labeling and varies center to center and surgeon to surgeon.”
Question: What are the strategies to overcome the issues facing these high-risk patients?
Dr. Soltesz said many patients are told they’re high-risk at one particular center or program while not necessarily considered high-risk at another program. “I think one of the things we have seen here at the Cleveland Clinic are a lot of patients are declined surgery because they are considered too high risk,” he said. “They’re declined either because they have too many valves that need repair or replacement, they have low ejection fraction, and there’s a concern that they will not tolerate surgery.”
Dr. Zaki said that to overcome these issues, the Cleveland Clinic has access to several tools, resources, and tricks to successfully get these types of high-risk patients through an operation. “So, for example, if someone has been declined surgery at another center because their heart function is low, we have ways that we can support the heart during the operation, whether it’s with a temporary heart pump or some other technique to get the heart through that vulnerable operation period and on to recovery,” said Dr. Zaki.
Although that’s just one example, Dr. Zaki said that people are declined for other risks as well, including needing multiple valves repaired at once, having valve infections, or even having transcatheter valves that have been placed in the past that need to be removed or revised.
Dr. Soltesz commented, “Dr. Zaki brings up a very good point about patients who’ve had TAVRs in the past. TAVRs allow minimally invasive valve replacement, but many times, those TAVR valves need to be removed. Either they’re failing, become infected, or not in the correct position.” Dr. Soltesz then asked Dr. Zaki to explain about TAVR replacement.
Question: If a patient has been told they were at high risk for heart surgery in the past and had a TAVR, can they have a TAVR explant?
Dr. Zaki explained this is another situation they encounter quite often. “I just recently had a patient who said, ‘Well, if I had a TAVR a few years ago because surgery was too high risk, now that I need to have something done now, how has my surgical risk changed?’ And I would say that the comfort level with TAVR removal, especially at a large center like the Cleveland Clinic, has increased as the number of TAVR implants has increased. So if you go to a center comfortable removing, revising, and repositioning TAVR valves, that risk is mitigated compared to the risk you may have had up front.”
Dr. Zaki also added, “So, TAVR is a wonderful technology and is indicated for many patients, but just because you’ve had a TAVR in the past doesn’t mean that it can’t be removed if it needs to be, and there is a surgical option available to you.”
Question: What about getting a second opinion?
Dr. Soltesz said getting a second opinion is a theme they often talk about. “I think second opinions are absolutely critical, not only for patients with heart disease but for all medical problems. I think it’s essential for patients to make their own decisions as to what they want to do.”
Dr. Soltesz asked Dr. Zaki how he talks to patients coming in for a second opinion and how he relates some of the information about how what they do at the Cleveland Clinic can affect their recovery after surgery.
Dr. Zaki replied, “People are turned down for surgery for several different reasons by different providers. So the first thing I like to do when I meet someone who’s been turned down at another center or by another surgeon is to try to understand why.”
Dr. Zaki continued, “So that involves taking a deep dive into the medical surgical history and talking to the patient and seeing what’s going on and what conversations they’ve had in the past, and that serves as the starting point. From there, I do my own assessment, my own evaluation, and I try to get an understanding of whether those risks are truly prohibitive or if we can mitigate or somehow circumvent them using the strategies and resources we have available here.”
Question: When multiple valves need to be repaired or replaced, can they all be done at the same time?
According to Dr. Soltesz, addressing multiple valves using transcatheter technology is often not possible, so the valves must be dealt with surgically.
Dr. Zaki added, “This has recently become more of a topic, with TAVR and transcatheter valves becoming more common. The thought out there, which I don’t necessarily agree with, is transcatheter approaches may address one valve while just monitoring the other valves. What we see is that this may not correct all of the symptoms or problems for patients, and then they’re referred to us because they had one valve fixed with a transcatheter approach but still have other valves that are still leaking or not functioning well, and they are still having symptoms.”
“So what we can do surgically at the same time and in a single operation is address all valves at once,” explained Dr. Zaki.”Whether a TAVR valve has been placed in the past or a Mitral Clip or any other transcatheter therapy was used, we can not only address that main valve or the one that’s already been addressed, but we can fix the other valves in the heart.”
“At the same time, we can do bypass surgery for coronary artery disease. A lot of these patients with multivalve disease have atrial fibrillation. So we can do surgical ablations to get people back into normal sinus rhythm at the same time. While transcatheter technology is appropriate for many patients, people with multivalve disease, atrial fibrillation, coronary artery disease, open heart surgery can address all of these concerns in a single shot.”
Dr. Soltesz agreed, “I think that’s a good point, especially with atrial fibrillation. Atrial fibrillation is a growing problem in the US and worldwide, and we know it’s been associated with a lot of comorbidity. We are able, at the same time of a surgical operation, whether it’s the primary or a re-operation, to perform an extremely durable ablation that has tremendously high success rates of getting patients out of atrial fibrillation and into sinus rhythm, which reduces not only their risk of stroke long term, but reduces their risk of long term heart failure, dementia, and many other comorbidities that we have seen associated with atrial fibrillation.”
Question: How can having previous heart surgeries affect the ability to perform an additional operation?
Dr. Soltesz pointed out that Dr. Zaki had recently done a fourth re-operation on someone with three previous heart surgeries. “I think there are many patients out there who are erroneously told that they’ve had too many heart surgeries. Can you tell us a bit about that, Dr. Zaki?”
Dr. Zaki replied, “Patients who have had valve disease or heart disease throughout their lifetime may have experienced multiple open heart surgeries, and it is true that with the second and third operations, there is scar tissue. What we’ve learned from our experience here is that often, reoperation is just as safe as the first operation, whether it’s the second, third, or fourth time. And that’s only true at centers that have that experience. So we’re grateful and happy to be here at the Cleveland Clinic, where we have that experience, skill, and knowledge passed down from mentors like Dr. Soltez, who has passed on this understanding of how to deal with these re-operations. I think the adage, we’ve been in there too many times and can’t go back, should be tested or checked with a second opinion and may or may not be absolutely true.”
Question: How important is the idea of team-based care?
“We all work together,” said Dr. Soltez. “We learn from one another. We have a very close connection with our cardiology colleagues. We have conferences together where we review high-risk patients. We have conferences within our surgical staff where we review complex operations. So, I think one of the advantages of the Cleveland Clinic is that it is a true team-of-teams approach to treating patients.”
“But I also think on an individual level for a patient; it’s important for us to be able to engage in shared decision-making with our patients so that they understand what we can offer and we understand what they want as their quality of life, their survival, and their risk tolerance.”
Question: What does the conversation sound like when a patient comes to the Cleveland Clinic?
“The first thing I understand when meeting with a patient is that they’ve been through a long process before they’ve gotten to me,” said Dr. Zaki. “They’ve been through either a primary care doctor or cardiologist and perhaps have been through several different centers before coming to me.”
“I feel like the most important step is to hear from them about what they’ve been through and their expectations. That serves as a good starting point for me. From there, I will do my own evaluation and assessment using our team approach, as Dr. Soltesz described. Then we make a plan, and as Dr. Soltesz mentioned, not every patient is the same, and not every valve disease is the same.
Dr. Zaki explained that he asks the patient, “What are you looking for? What are your goals? What are your values? What are you expecting from your treatment plan?”
Asking these questions helps guide the discussion to develop the best solution together.
Question: A final recommendation from Dr. Zaki’s experience as a heart surgeon at the Cleveland Clinic
“This is something I tell family and friends who have medical issues: Ask questions, get a second opinion, and move forward when you’re comfortable,” said Dr. Zaki.
Dr. Soltesz added, “And it’s important to recognize that as a patient, you have control of your health, and it is in your best interest to ask questions about what you just heard, get a second opinion, and then make an informed decision with your family and with your practitioners about how to proceed.”
Thanks Dr. Soltesz, Dr. Zaki and the Cleveland Clinic!
On behalf of the HeartValveSurgery.com patient community, thank you, Dr. Soltesz and Dr. Zaki, for sharing your skilled and knowledgeable insight into this vital topic to help inform our high-risk surgical patients. We would also like to thank the Cleveland Clinic for continuing to care for heart valve patients and keep them informed!
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Keep on tickin!
Adam
P.S. For the deaf and hard of hearing members of our community, we have provided a written transcript of the video below.
Written by Adam Pick
- Patient & Website Founder
Video Transcript:
Dr. Edward Soltesz: Hi, I’m Dr. Ed Soltesz. I’m a heart surgeon here at the Cleveland Clinic and I’m the Lewis Endowed Chair in Cardiothoracic Surgery and also the Surgical Director of the Kauffman Center for Heart Failure and Recovery. Today I’m here with my colleague, Dr. Anthony Zaki.
Dr. Anthony Zaki: Hi, good to meet you all. My name is Anthony Zaki, one of the staff cardiac surgeons here at the Cleveland Clinic as well.
We’re happy to join you today to answer some of your questions, um, and provide you with this information.
Dr. Edward Soltesz: We wanted to focus today on complex high risk valve surgery and particularly focused on some areas such as multi valve surgery and reoperations. So I’d like to just begin, and Anthony, why might a patient be told they’re high risk for valve surgery?
Dr. Anthony Zaki: Yes, this is something that we encounter quite a bit at the Cleveland Clinic. Patients come to us for an evaluation being told that they are quote unquote high risk, and that could be for several reasons. In general, we categorize risk into two categories, whether that’s a, for medical reasons or comorbidities or other medical issues that a patient may have, or surgical risk, whether they’ve had multiple surgeries in the past or whether they have some other technical factor that makes the surgery high risk.
And the third category, which is part of their surgical risk, is how many procedures do they need done at once, whether it’s an isolated valve or bypass or if it’s a combination of multiple things. Um, so a lot of patients come to us with that labeling of high risk, and I’d like to say that that often time is a subjective labeling, and that varies center to center and surgeon to surgeon.
We like to meet a patient for the first time, go through their medical complaints, go through their history, and kind of understand for ourselves what it truly is, their risk level.
Dr. Edward Soltesz: We realize is that for many patients, when they’re told they’re high risk in one particular center or program may not necessarily be high risk at another program.
Or it may be risk mitigation strategies, uh, that may be available, uh, at one program or another. And I think, well, you know, one of the things we have seen here at the Cleveland Clinic are a lot of patients are declined surgery because they are considered too high risk. They’re declined either because they have too many valves that need repair or replacement, that they have low ejection fraction, and there’s a concern that they will not tolerate surgery.
So, Anthony, what are strategies we particularly use, uh, to overcome some of these issues?
Dr. Anthony Zaki: Well, the great thing about the Cleveland Clinic is we have access to several tools, resources, tricks to get these type of patients successfully through an operation. So for example, if someone has been declined surgery at another center because their heart function is low, we have ways that we can support the heart through the operation, whether it’s through a temporary heart pump or some other technique to get the heart through that vulnerable operation period and onto recovery.
So that’s just one example. People are declined for other risks as well. needing multiple valves repaired at once, having valve infections, or even having transcatheter valves that have been placed in the past that need to be removed or revised or taken care of.
Dr. Edward Soltesz: Dr. Zaki brings up a very good point and one of those was, uh, patients who’ve had TAVRs in the past.
TAVRs obviously allow minimally invasive valve replacement, but of course, many times those TAVR valves need to be removed. Either they’re failing, they’ve become infected, or they are not in the correct position they need to be in. So, tell me a little bit about removing a TAVR valve.
If a patient’s been told that they were high risk for heart surgery in the past and they had a TAVR, can they have a TAVR explant surgically?
Dr. Anthony Zaki: This is something we encounter all the time. I just recently had a patient who said, well, if I had a TAVR a few years ago because surgery was too high risk.
Now that I need to have something done now, what has my surgical risk changed at all? And what I would say to that person is that the comfort level with TAVR removal, especially at a large center like Cleveland Clinic has increased as the number of TAVR implants has increased. So if you go to a center that’s comfortable removing and revising and repositioning TAVR valves, then that risk may is mitigated compared to the risk that you may have had upfront.
So TAVR is a wonderful technology and it is indicated for a lot of patients, but just because you’ve had a TAVR in the past doesn’t mean that it can’t be removed if it needs to be and a surgical option available to you.
Dr. Edward Soltesz: Yeah, that’s very true. And I also think that one thing, a theme you’ve heard us talk about is having another opinion.
And I think second opinions are absolutely critical, not only for patients with heart disease, but for all medical problems. I think receiving a special second opinion for a specialist is critical for everyone. And I advocated for my patients even who come to see me. But I think it’s essential for patients in their own decision making as to what they want to do.
Anthony, when you talk to patients many times they’ve been to other programs, they’ve seen other practitioners, they’ve come to see you for a second opinion. How do you relate with them how some of the things that we do here can affect their recovery after surgery?
Dr. Anthony Zaki: Yeah, this is something, and I couldn’t agree more with you, Dr. Soltesz, about getting a second opinion and the importance of that. People are turned down for surgery for several different reasons by different, different providers. So the first thing I like to do when I meet someone who’s been turned down at another center or by another surgeon is to try to understand why.
So that involves taking a deep dive into the medical surgical history and talking to the patient and seeing what’s going on and what are the conversations that they’ve had in the past. And that serves kind of as the starting point. And from there, I do my own assessment, my own evaluation, and I try to get an understanding if those risks are truly prohibitive or if those risks that we can mitigate or somehow circumvent using some of the strategies and the resources that we have available here.
Dr. Edward Soltesz: Now, one of the things that we’ve heard patients ask is, can all valves be addressed in a single operation. If you have multiple valves, uh, that need repair or replacement, can they all be done at the same time? And obviously when we talk about transcatheter valve technology, uh, that is oftentimes not the case.
But surgically, how, how do we deal with that surgically?
Dr. Anthony Zaki: Again, this is something that has become more of a topic recently with TAVR valves and transcatheter valves becoming more common. The thought out there, which I don’t necessarily agree with, is transcatheter approaches may address one valve and will just monitor the other valves.
And what we see is that patients that may not correct all of their symptoms or all of their problems, and then they’re referred to us or to the surgeons to say, well, I had one valve fixed with a transcatheter approach, but I have these other valves that are still leaking, are still not functioning well, and I still have symptoms.
I don’t feel 100%. So what we can do surgically at the same time and in a single operation is address all of the valves at once. Whether a TAVR valve has been placed in the past or whether a MitraClip or any other transcatheter therapy has been used in the past, we not only can address that main valve or the valve that’s already been addressed, but we can fix the other valves in the heart.
And, at the same time, we can do bypass surgery for coronary artery disease. And a lot of these patients with multivalve disease have atrial fibrillation. So we can do surgical ablations to get people back into normal sinus rhythm at the same time as well. So whereas transcatheter technology is appropriate for many patients, people with multivalve disease, atrial fibrillation, coronary artery disease, open heart surgery can address all of these concerns in a single shot.
Dr. Edward Soltesz: Yeah, I think that’s a good point, and especially is the case with atrial fibrillation. Atrial fibrillation is a growing problem in the U. S. and worldwide, and we know it’s been associated with a lot of comorbidity. We are able at the time of a surgical operation, whether it be the primary operation or even a re operation, to perform an extremely durable ablation that has tremendously high success rates of getting patients out of atrial fibrillation and in sinus rhythm, which reduces not only their risk of stroke long term, but reduces their risk of long term heart failure, dementia, and many other comorbidities that we have seen associated with atrial fibrillation.
Anthony, I recently saw that you had done a fourth time re operation on someone, someone who had had three previous heart surgeries. So, can you tell me a little bit about how previous heart surgeries affect your ability to operate. I think there are many patients out there who are erroneously told that they’ve had too many heart surgeries that so in quote unquote, we can’t go back in a fourth or fifth time.
Can you, can you tell us a bit about that?
Dr. Anthony Zaki: And this is something that we encounter quite a bit. Patients who have had valve disease or heart disease throughout their lifetime may or have experienced multiple open heart surgeries. And whereas it is true that the second operation and the third operation, there is scar tissue.
What we’ve learned in our experience here is that oftentimes reoperation is just as safe as the first operation, whether that’s the second, third, or fourth time. And that’s only true at centers that have that experience. So we’re grateful and we’re happy to be here at the Cleveland Clinic where we have that experience and we have that skill and that knowledge that’s been passed down from mentors of mine like Dr. Soltesz who have kind of passed on this understanding of how to deal with these re operations. I think that adage of, we’ve been in there too many times, we can’t go back, It should be tested or it should be checked with a second opinion and may that may or may not be absolutely true
Dr. Edward Soltesz: Very true. And I think one of the things we’ve heard repeatedly is this idea of team based care.
We all work together. We learn from one another. We have a very close connection with our cardiology colleagues. We have conferences together where we review high risk patients. We have conferences within our surgical staff where we review complex, uh, operations. So I think one of the advantages of the Cleveland Clinic is just that it is a true team of teams approach to treating patients.
But I also think on an individual level for a patient, it’s important for us to be able to engage in a shared decision making with our patients so that they understand, uh, what we can offer and we understand what they want for as their quality of life, their survival, their risk tolerance. So, you know, the last question, uh, Anthony, is when you talk with patients, uh, in the clinic?
What does the conversation sound like?
Dr. Anthony Zaki: The first thing I understand when meeting with a patient is that they’ve been through a long process before they’ve gotten to me. They’ve been through either a primary care, a cardiologist, and perhaps have been through several different centers until coming to me.
And often I feel like the most important step is to hear from them what have they been through, what have they been told. And often, what are their expectations? And that, that serves as a good starting point for me. And from there, I do my own evaluation and my own assessment, uh, within our team approach that Dr. Soltesz described. And then from there, we make a plan. And like Dr. Soltesz mentioned, not every patient is the same, and not every valve disease is the same. And so, a discussion with the patient about what are you looking for, what are your goals, what are your values, what are you expecting from your treatment plan, it really helps guide the discussion and together we come up with the best solution possible.
Dr. Edward Soltesz: Well, we’re going to close now, but I just want to ask for one final comment, one recommendation for patients from your experience as a staff Cleveland Clinic heart surgeon.
Dr. Anthony Zaki: And this is something I tell family and friends who have medical issues. is ask questions, get a second opinion and move forward when you’re comfortable.
Dr. Edward Soltesz: Excellent. And it’s important to recognize that as a patient, you have control of your health and it is in your best interests to ask questions that you just heard, get a second opinion, and then make a informed decision with your family, with your practitioners, um, as to exactly how to proceed. Thank you very much for listening today. We’re excited to be able to share some of our practice here at the Cleveland Clinic.
Dr. Anthony Zaki: Thank you.
