Heart Murmur Clinics Avoid Sudden Deaths

Medical Editor

The ‘murmur clinics,’ an innovative concept of medical attention for the heart, as well as the technology that allows implanting artificial valves without having to open the chest, enable resolving the problems that can produce sudden deaths.

 “It’s simply a matter of detecting early on a very silent and lethal condition: the narrowing of the valve that connects the aorta artery with the heart,” says Dr. Vitaly Piluiko, cardiothoracic surgeon affiliated with the Mercy, Aventura and Kendall Regional Hospitals, in Miami, Florida. 

The specialist explains that only one third of the people who suffer from this condition discover it and receive medical attention.  The majority of people die suddenly without suspecting it.  When the problem is detected early, it can be resolved by implanting an artificial valve. “We can do that now by minimally invasive means, without having to open the chest.  The advantages to the minimally invasive strategy include less trauma, less pain, less bleeding, less risk of infection, less hospitalization time and speedier recovery in two or three weeks instead of two or three months that it took to recover from totally open surgery.”

Normally, the aortic valve itself opens to allow the flow of the oxygenated blood that goes from the left ventricle to the aorta, which is the main artery of the body.  From the aorta, the blood passes to other arteries to supplying oxygen and nutrients to all the organs and tissues.  Two problems can present themselves in the aortic valve: narrowing or stenosis, and insufficiency or regurgitation.  In the first case, the valve does not open completely; in the second case, the valve allows blood from the artery to return to the ventricle.  The narrowing is the most common.  Narrowing due to plaque build-up can be so severe that the heart can not work productively.  This is when the person dies suddenly.

All the patients with aortic valve problems present a heart murmur.  With the establishment of the ‘murmur clinics,’ the idea is to identify those patients who have this heart murmur and determine if they have damage to the valve and are in danger.  Heart murmurs in children younger than two years of age can be benign.  Murmurs in older persons tend to be dangerous.

An artificial valve implant, whether mechanical or biological, reestablishes the blood-flow in the right direction.

The minimally invasive procedures have greatly facilitated the heart valve implants. Thanks to the development of medical science, it is possible to introduce remotely cannulas to the heart from the groin, in other words, through guides and catheters. Opening of the patient chest with wide incisions is avoided.  Visualization is achieved by means of ultrasound; the surgeon observes how the instruments advance until they reach the heart.  Then, in order to introduce and actually implant the valve, a three-inch incision is sufficient. When an aortic valve is implanted, an incision is made in the chest, close to the sternum; when the mitral valve is replaced, the incision is made on the side. 

SYMPTOMS AND TREATMENTS

According to the American Heart Association (AHA), when the valve opening narrows to about one-fourth its original size, symptoms are common. The most common symptom of an obstructed or leaky aortic valve is shortness of breath with exertion. This usually develops gradually over time, and some patients will just feel “out of shape.” Chest pain, lightheadedness or fainting may also occur. Recurrent fevers may indicate the valve is infected.

Replacing the valve requires open-heart surgery. In most adults, when the aortic valve is no longer working properly, it’s best to replace the valve, adds the AHA. Deciding when to perform aortic valve surgery and the type of valve to insert are complicated decisions for your doctor. Your aortic valve can be surgically replaced with any of these: a mechanical valve made of metal, which requires you to take blood thinners but is very durable; a valve made from biological tissue, which requires no blood thinners but may not last as long and may need to be replaced later; a homograft or valve from a donated human heart and preserved in special solutions may be use. For older people and people with significant disabilities, there is a choice of percutaneous valve. This approach is least invasive and requires no bypass machine; it is, however, associated with higher risk of stroke than minimally invasive surgery and, therefore, should be utilized in people who are very ill.

Each option has advantages and disadvantages. You should discuss them at length with your cardiologist and cardiac surgeon to find the best option for your situation.

For further information, write to INTL@hcahealthcare.com; call 305-480-6601 or 877-542-2362; or visit hcainternationalhealth.com By Alfredo Arango

Defective Heart Valves

It is much better to detect heart valve disease before the patient presents symptoms, according to the new guidelines of the American Heart Association (AHA), based on scientific evidence.  In many cases, timely detection of vascular abnormalities allows repairing the valves with minimally invasive robotic procedures and reverse the damage, process known as ‘reverse remodeling’. 

“Many people who have heart valve disease don’t have any symptoms until they’re middle-aged or older,” indicated the National Heart, Lung and Blood Institute (NHLBI), of the National Health Institutes of the United States.  The AHA recommends not waiting to reach an elderly age and begin suffering the results of a defective valve to then do something about it. The earlier the intervention to solve the problem, the greater the benefits during recovery. 

“Patients who are referred early, even before they have symptoms, do much better with valve surgery if they have moderate-severe or severe valve disease, because the heart muscle has not started to weaken at all”, explains Dr. Lynn Seto, cardiothoracic robotic surgeon affiliated with the Aventura Hospital and Medical Center, in Miami-Dade, Florida. “In fact, not only being referred before they have symptoms, but the earlier in that window between when they are diagnosed to when they have symptoms, the better they do with valve surgery. That is now the recommendation.”

Very early detection together with robotic surgery enables improving and speeding up the recovery processes, helping the patients return to their normal activities in less time and with fewer complications. Dr. Seto, who has performed more than 500 robotic surgeries to repair heart valves, tells of having had a patient, a mountain climber who, the second week after surgery to repair the valve was able to inform her that he had just finished running five miles.  

“Cardiovascular disease causes a lack of oxygen that makes the patient feel exhausted all the time.  The repair of the valves, more so with the less invasive, robotic procedures that exist today, makes the patient feel as if they’ve been given a new body”, assures Peter Carnegie, an expert in the robotic surgery procedures, who assists the surgeons in the operating room during these complex operations.

The difficulty is that, when there are as yet no symptoms, the person may think there is no reason to suspect he/she may be suffering from a cardiovascular condition.  However, there is a sign that might help.

“The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope,” expresses NHLBI.

This means that persons whose heart murmurs have been detected should be examined with some regularity to ensure there is nothing wrong with the heart valves.  Usually, heart valve disease is detected and diagnosed by means of an echocardiogram.

If a person begins to present symptoms of a vascular problem, it is with greater reason that action should be taken as soon as possible. These symptoms, as described by the NHLBI, are: “unusual fatigue (tiredness); shortness of breath, especially when you exert yourself or when you’re lying down; swelling in your ankles, feet, legs, abdomen, and veins in the neck.”

The NHLBI adds that “heart valve disease is a disease in which one or more of your heart valves don’t work properly. The heart has four valves: the tricuspid, pulmonary, mitral, and aortic valves. These valves have tissue flaps that open and close with each heartbeat. The flaps make sure blood flows in the right direction through your heart’s four chambers and to the rest of your body.

The AHA explains that “heart valve problems make the heart work too hard and can lead to heart failure. In some cases, valves don’t open enough (stenosis); don’t let enough blood flow through (stenosis); don’t close properly and let blood leak where it shouldn’t (incompetence, insufficiency or regurgitation); mitral valve flaps don’t close properly (prolapsed, more common in women), as pressure builds inside the left ventricle, it pushes the mitral valve flap back into the left atrium, which may cause a small leak.”

 “Heart valves can be repaired by separating fused valve flaps; removing or reshaping tissue so the valve can close tighter; or adding tissue to patch holes or tears or to increase the support at the base of the valve,” explains the NHLBI.

Today, the operation to repair heart valves does not necessarily have to involve opening the chest, as there are laparoscopic and, in the most advanced hospitals, robotic techniques, as well.   By means of small incisions, very fine instruments can be introduced into the heart to make the cuts and sutures necessary for vascular repair.

In the case of robotic surgery, which is the most advanced technology today for less invasive operations, the visualization available to the surgeon in the operating area is much better, as it is magnified and tridimensional; furthermore, the surgeon manages the robotic arms from a console.  This allows fine, more precise movements, without the trembling that the surgeon’s hands transmit when directly managing the instruments during the simply laparoscopic or open surgery. 

For further information, write to INTL@hcahealthcare.com; call 305-480-6601 or 877-542-2362; or visit hcainternationalhealth.com.

By Alfredo Arango
Medical Editor

Three New Year’s Resolutions….

Three New Year’s Resolutions…. It’s that time of year when I like to look back on the year and spend a few moments thinking about and planning for the year ahead. If you’re contemplating your 2012 resolutions, might I recommend one? Learn CPR. The AARP has made it easier than ever to learn something about CPR. They don’t earn you a certification, but there’s a library of videos they provide to introduce you to CPR basics and they urge you to use what you know even if you aren’t certified. They say that the guidelines for administering cardiopulmonary resuscitation have changed greatly over the past few years, making CPR both easier to provide and more effective, regardless of whether you’ve had formal training. Permanent brain damage or death can happen in just a few minutes without oxygen, but the AARP reports that even CPR performed by someone who hasn’t been formally trained can sustain a person in need until skilled medical technicians arrive. These are the videos the American Heart Association provides to introduce three approaches to CPR. Each video is only about 60 seconds! Hands Only CPR Mouth to Mouth CPR AED Assisted CPR Of course your resolutions are completely your business, but this is a great one I hope you’ll at least think about. Hoping your holidays are fantastic and your resolutions are, too! Dr. Downing

Being a Prepared Patient

Being a Prepared Patient – it’s not as difficult as you might think! At Florida Heart and Vascular, the physicians and office staff are dedicated to providing you the best care and service. To tell us more about how you can prepare for your next visit and help us take care of you, our Practice Manager, Sue Clausi appears on the blog today to help you know how to get the most out of your next visit. First, please understand that we are happy to help you know the details you have provided us about your insurance or about the medications that have been prescribed to you by our office. When you turn to us for care, you get the whole package – great care from our physicians and great service from our office staff. But there are ways you can prepare yourself to get the most out of each visit and keep track of important details you need to know about your care plan anyway. Please review these tips and contact me by calling your favorite Florida Heart and Vascular Care location if you have any questions. Bring your insurance card. It helps us process your claim with your insurance provider so much more quickly if we have all the details on your card. We’ll make our own copy and then each time you visit us, we’ll ask you for the card again so we can always be sure we have your latest, greatest provider details on file. Record your medications. Knowing you take a blue pill every morning is not enough. Make a list of each medication you’re taking that includes the following information about each medication: • Name of the medication • Dose you were prescribed • Prescriber of the medication (prescribing doctor’s name) • Your questions about the medication Most of the above information can be found on the prescription bottle itself. You can bring the bottles if that’s easier for you, but for some a list is preferable. Just be sure you have all of the information correct and be sure to include any medications you take – not just those prescribed by Florida Heart and Vascular Care physicians. Include over the counter medications you take regularly as well as any supplements. Consider sharing this document with anyone else you tell the details of your care. Perhaps a spouse or a friend or adult child of yours assists you with your care planning. There could be instances when it’s a good idea for them to know these details about you, too. Don’t wait for an appointment. If you have questions about how often to take a medication or how much to take or if you have a new symptom that worries you, please call us. We never want you to wait until your next scheduled appointment if you have pressing or worrisome questions on your mind. Know specifics about your recent tests. For instance, know when you had your last EKG and where the test was administered. At the time of the test, request that the results be sent to Florida Heart and Vascular Care. Some patients even take a self addressed stamped envelope so the administrators of their tests can’t forget to send the results to us! If you forget to make that request, knowing where you had the EKG and when will help us tremendously when we start trying to find those results for you so your doctor can have all the information they need related to your care. Write down your questions for the doctor. If you’re like me, you’re a bit nervous when you go to the doctor and nervousness can lead to forgetfulness! In the days before your appointment, as you think of things to ask, jot them down and bring that list of questions with you. Those are the tips I have for today. Please remember – It’s about you, it’s about me, it’s about all of us at Florida Heart and Vascular Care working together to take care of you, so I thank you for your attention today. Please ask to see me at your next appointment. If I’m at the location you’re visiting that day, I would love to meet you personally! Sue Clausi Practice Manager at FHVC Northwest

Dr. Masroor on Valve Surgery

The Heart and Vascular Center offers all surgical options for valve repair and replacement. Procedures on the mitral, aortic and tricuspid valves can be done using either traditional (open) surgery or a minimally invasive approach. The less invasive approach requires only two small incisions – a 2 to 3 inch incision on the right side of the chest and a 1.5-2 inch incision in the groin (for the heart-lung machine).

 

When less invasive valve surgery is possible, patients generally experience less pain, fewer complications, shorter hospital stays and reduced recovery times compared to traditional valve surgery. Each case is evaluated to ensure the best possible outcome for the patient.

 

• Traditional valve surgery – involves making an incision through the sternum to reach the valves in the heart. Depending on the problem, a heart valve may be repaired or replaced.
• Minimally invasive aortic valve surgery – the Heart and Vascular Center excels in performing minimally invasive surgery to repair and replace the aortic valve. Most people with isolated aortic valve problems are able to have the less invasive approach.
• Minimally invasive/robotic mitral valve repair/replacement – the mitral valve in the heart can often be repaired or replaced in a minimally invasive procedure, through a small incision in the chest.

 

Learn more about Dr. Masroor on the Our Physicians area of our website.

Dr. Dorman on New Guidelines for managing Patients with Heart Valve Disease

Valvular heart disease is one of several cardiac disorders that affect a large number of people who require diagnostic procedures, surgical intervention and long-term management. When the American College of Cardiology (ACC) and the American heart Association (AHA) announced updated guidelines for management of patients with valvular heart disease, they released information giving more emphasis on patient preference for treatment of some disorders and they suggested more aggressive treatment in certain instances. Here’s a quick review of the new guidelines, but you can read my full article here.

Tissue Valves Versus Mechanical Valves. Fundamentally, the new guidelines open up the use of tissue valves to patients of all ages and even to those in renal failure, assuming careful discussion of benefits with their doctors.

Aortic Stenosis. Of the more than 300,000 people worldwide who undergo open heart surgery to treat malfunctioning or diseased heart valves each year, most are patients who exhibit clear symptoms of valve disease. However, the new guidelines suggest more aggressive treatment of certain patients with asymptomatic aortic stenosis (AS) stating that aortic valve replacement is reasonable for some patients with moderate aortic stenosis whereas before AVR was only indicated for  symptomatic patients with severe AS.

Early intervention for mitral valve regurgitation. For mitral valve regurgitation (MR), mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic MR. The guidelines recommend that patients should be referred to surgical centers experienced in MV repair. They go as far as saying that early intervention for mitral valve regurgitation should only be performed at centers with a high likelihood of successful MV repair because of demonstrated expertise in this area. Luckily for my patients, I have successfully repaired a high percentage of mitral valves by utilizing an etiology-based repair strategy (that is, a strategy that’s based on the origin of the disease. Read my blog on the strategy for more information.) At JFK, our experience in valvular heart disease sets us apart from other community programs that focus primarily on coronary disease.

-Dr. Dorman

Diabetes and Heart Health

November is American Diabetes Month and according to the American Diabetes Association, people with diabetes have a higher-than-average risk of having a heart attack or stroke. They go on to say that heart attacks and strokes strike diabetics more than twice as often as people who do not suffer from the disease. With that in mind, I’d like to review some of the basics of diabetes. If any of the symptoms sound familiar to you, then please contact our office right away. 

Diabetes mellitus (MEL-ih-tus), or simply, diabetes, is a group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin. 

All people with type 1 diabetes and many with type 2 must take insulin every day and regularly monitor blood glucose levels to make sure they don’t go too high or too low. Even with meticulous attention, diabetes still can cause complications like heart disease, vision problems, nerve damage, and kidney ailments, shortening lives.
Understanding Diabetes
The two main kinds of diabetes—type 1 and type 2—are quite different in origin, although people with both diseases face the same challenge: keeping blood glucose in a healthy range. Type 1 is an autoimmune disease, in which the body attacks its own cells, destroying the cells in the pancreas that make insulin. In type 2, the pancreas makes at least some insulin, but the body is unable to use it properly. Both diseases have significant genetic origins in addition to environmental influences. 

Type 2 diabetes is far more common than type 1, affecting more than 90 percent of the nearly 26 million people with diabetes in the United States alone. Unlike type 1, type 2 can sometimes be prevented or at least delayed through healthy eating, exercise, and weight loss. Significant weight loss can put type 2 into remission but may not be a permanent solution. 

Statistics

• According to the 2011 National Diabetes Fact Sheet that was released Jan. 26, 2011, 25.8 million children and adults in the United States—8.3% of the population—have diabetes.
• Diagnosed: 18.8 million people
• Undiagnosed: 7.0 million people 

Complications

• Heart disease and stroke
• High blood pressure
• Blindness
• Kidney disease
• Nervous system disease (Neuropathy)
• Amputation
• More than 60% of nontraumatic lower-limb amputations occur in people with diabetes.
• In 2006, about 65,700 nontraumatic lower-limb amputations were performed in people with diabetes. 

You can prevent or delay the onset of type 2 diabetes through a healthy lifestyle. Change your diet, increase your level of physical activity, maintain a healthy weight…with these positive steps, you can stay healthier longer and reduce your risk of diabetes. 

Diabetes often goes undiagnosed because many of its symptoms seem so harmless. Recent studies indicate that the early detection of diabetes symptoms and treatment can decrease the chance of developing the complications of diabetes. 

Type 1 Diabetes

• Frequent urination
• Unusual thirst
• Extreme hunger
• Unusual weight loss
• Extreme fatigue and irritability 

Type 2 Diabetes*

• Any of the type 1 symptoms
• Frequent infections
• Blurred vision
• Cuts/bruises that are slow to heal
• Tingling/numbness in the hands/feet
• Recurring skin, gum, or bladder infections 

*Often people with type 2 diabetes have no symptoms 

Before people develop type 2 diabetes, they almost always have “prediabetes”—blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. There are 79 million people in the United States who have prediabetes. Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during prediabetes. 

How to Tell if You Have Prediabetes

While diabetes and prediabetes occur in people of all ages and races, some groups have a higher risk for developing the disease than others. Diabetes is more common in African Americans, Latinos, Native Americans, and Asian Americans/Pacific Islanders, as well as the aged population. This means they are also at increased risk for developing prediabetes. 

There are three different tests your doctor can use to determine whether you have prediabetes: 

• the A1C test
• the fasting plasma glucose test (FPG)
• the oral glucose tolerance test (OGTT) 

The blood glucose levels measured after these tests determine whether you have a normal metabolism, or whether you have prediabetes or diabetes. 

If your blood glucose level is abnormal following the FPG, you have impaired fasting glucose (IFG); if your blood glucose level is abnormal following the OGTT, you have impaired glucose tolerance (IGT). Both are also known as prediabetes. 

How to Prevent Prediabetes

Prediabetes is a serious medical condition that can be treated. The good news is that the recently completed Diabetes Prevention Program (DPP) study conclusively showed that people with prediabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity. They may even be able to return their blood glucose levels to the normal range. 

While the DPP also showed that some medications may delay the development of diabetes, diet and exercise worked better. Just 30 minutes a day of moderate physical activity, coupled with a 5-10% reduction in body weight, produced a 58% reduction in diabetes. 

Choose healthy foods, make healthy meals and be active 30 minutes a day.  These tips are the best way to prevent diabetes complications or type 2 diabetes. 

• One Step at a Time. It’s easier to make lifestyle changes over months and years. Think of each small step as one piece of your effort to change your habits.
• Bad habits? Accept that you have bad habits you need to change. If you believe you have a problem, you will probably succeed in making some changes.
• Ready, Willing and Able. To succeed at making lifestyle changes, the change must be important to you. For example, maybe you want to live long enough to see your grandchildren grow up. You must have more reasons to change than reasons not to change.
• Exercise. It’s part of a healthy lifestyle for everyone, and it’s especially important for people with diabetes. The goal is to get active and stay active by doing things you enjoy, from gardening to playing tennis to walking with friends.  

Sources: www.diabetes.org

www.fhvcare.com/your-health

News from Dr. Cubeddu: Heart Disease is Number One Killer of Women

A recent study noted that more than 40 percent of women do not realize that heart disease is the number one female killer. According to the American Heart Association, in 2007 one in 30 female deaths were due to breast cancer; whereas, about 1 in 3 was attributed to a heart disease.

 Heart disease is the number one killer in men too. In fact, it’s even more prevalent in men. In the past few years, the overall number of deaths attributed to cardiovascular disease has been dropping, but for women the improvement has been slower.

 It is estimated that over 40 million American women live with cardiovascular disease, but too many are unaware of the risk they face. By speaking to a physician, you can become more aware of the risk factors, signs and symptoms, and ways to protect the heart. So in case you haven’t heard this startling statistic, ladies, I wanted you to know, and I want you to make it a point to have your cardiovascular health assessed. Heart disease does not discriminate. Please learn more about your cardiovascular health soon.

Dr. Hoffberger on new possibilities for younger patients and interventional cardiology procedures

Dr. Hoffberger on new possibilities for younger patients and minimally invasive procedures

I’m with Dr. Florin. Did you see his recent blog post on the importance of making diet and exercise choices to yield a healthier you? Choose a healthy diet and stick to it. Introduce more physical activity into your day and keep it up.

Healthier diet

With all the information that’s out there about eating healthy, aren’t we really at a place where it’s more about having self control and sticking with a healthier diet than being educated about what a healthier diet is? Use what you know and just eat well. Eat fruits, eat vegetables, limit saturated fats, choose foods made with whole grains instead of white flour, drink skim or low fat milk. All of these things you have heard before and they’re summarized well in this article on about.com. 

Adding activity

Maybe you noticed a recent Florida Heart and Vascular blog entry about a large study out of Taiwan that found exercising fifteen minutes a day could add three years to your life. You have fifteen minutes you can use differently in your day. Look for it until you find it. It’s that important for your overall health.

The possibilities for you

The latest minimally invasive procedures in use today are the best the field of Cardiothoracic Surgery has ever seen. Compared to traditional and more invasive procedures, these new procedures can mean fewer days in the hospital, less pain during recuperation, and a faster return to normal life – in many cases, it means a return to life that’s even better than before. These procedures provide new options for younger patients. Before, the more invasive procedures were considered appropriate further into the progression of a patient’s heart disease and weren’t good options in earlier stages of disease.

The new possibilities are solid and trusted and better, but they work best in just the right circumstances – when a patient has taken good care of themselves via diet and exercise and following directions of the experts they involve in their care. The better shape you are in before a major operation, the better the outcome and quicker the recuperation.  

Dr. Hoffberger

Dr. Dorman on how disease origin impacts mitral valve reconstruction strategy

My hobby, my interest, my life’s work is repairing mitral valves. I’ve been doing it for quite some time now and I’ve learned a few things along the way in order to reach two of my greatest accomplishments at JFK Medical Center: maintaining under 1 percent mortality rate for coronary surgery and zero percent for straight aortic and mitral valve surgery, whether repair or replacement.

At the Valvular Heart Institute at JFK Medical Center, we have adopted and applied an etiology-based strategy to treat and correct MR by utilizing mitral valve repair techniques that address the underlying cause of the mitral valve dysfunction. Translated: At JFK, we consider the cause of the disease and plan our strategy of treatment based on knowing the disease’s origin. With this concept as my guide, I have personally been a part of demonstrating that a high percentage of mitral valves can be repaired with excellent long-term outcomes and with no additional surgical risk.

For instance, instead of replacing valves unnecessarily in cases of abnormal left ventrical function, we use asymmetric rings to correct just the diseased area of the valve instead of replacing the whole thing and we use other disease specific rings to treat conditions such as mitral regurgitation in congestive heart failure patients. These are strategies designed to prevent valve replacements when we can. And our techniques work. Experience shows us that the very origin of mitral valve disease requires different surgical approaches and the right approach for the right disease means stable, long-term valve repair for the good people who turn to us for care. Read more details in my etiology article.