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FirstHealth of the Carolinas
Two steps forward and one step back By Dick Broom

“Two steps forward and one step back” isn’t an efficient way for blood to move through the heart. But that pretty well describes what happens when either of the two valves in the heart fails to close completely after blood goes through.

The valves are designed to keep blood flowing steadily in the same direction. If they don’t close properly, some of the blood can reverse course and cause stagnation.

That can happen with both the mitral valve, which regulates blood flow from the lungs to the heart, and the aortic valve, through which blood flows from the heart to the aorta. The aorta is the large artery that feeds all the others in the body.

The aortic valve can have trouble opening as well as closing. If it becomes stiff, it can stick, like a door you have to pull hard to open.

“Working that hard causes the heart, like any muscle, to become bigger and thicker, which makes it more prone to failure,” says John Streitman, M.D., of Pinehurst Surgical and a cardiac surgeon at FirstHealth Moore Regional Hospital.

When the sticky valve problem becomes serious enough, the valve can be replaced with one made of metal and plastic or one made of pig or cow tissue. The mechanical valves last indefinitely, but patients have to take bloodthinning medication for the rest of their lives because of the risk of clotting.

Clotting isn’t a problem with the cow and pig valves, but they last only 15 to 20 years.

“Aortic regurgitation”
While some people have aortic valves that don’t open smoothly, others have valves that fail to close properly.

“The heart squeezes and then relaxes, and if the valve doesn’t close completely when the heart relaxes, some of the blood backwashes into the ventricle,” Dr. Streitman says. “That is very inefficient and, over time, can lead to heart failure symptoms.”

The cause of the backwash, which Dr. Streitman calls “aortic regurgitation,” is a weakening and distension of the rim of the valve. When that happens, the leaflets of the valve, which are the parts that open and close, no longer meet in the middle.

“There are repair techniques we can use to shrink the rim back down to a normal size so that the leaflets are touching again and the value closes all the way,” Dr. Streitman says.

Sometimes, the aortic valve is so stiff with calcium deposits that it can’t be repaired. In those cases, the valve has to be replaced.

Aortic valve disease is more common than mitral valve disease, but heart surgeons at Moore Regional routinely treat problems with both types of valves.

If the mitral valve becomes enlarged or if a cord that supports one of the leaflets gets torn so that it doesn’t close tightly, blood can flow in the wrong direction. The most common symptom is shortness of breath during exertion, which is caused by blood backing up into the lungs.

Atrial fibrillation
A faulty mitral valve also can cause atrial fibrillation, an electrical disturbance that causes the heart to beat erratically. (See the story on atrial fibrillation on page 28.)

“If blood is going in the wrong direction, it increases the volume of blood in the left atrium, so the left atrium gets bigger, and that interferes with electrical conduction,” says Andy Kiser, M.D., who is also a Pinehurst Surgical and Moore Regional cardiac surgeon.

Depending on the exact nature of the mitral valve problem, there are different surgical procedures for correcting it, but most of the procedures are similar, Dr. Kiser says.

“We can open the heart and take out part of the valve and repair it with sutures,” he says. “Then we can put a ring around the valve to tighten the circumference so that the leaflets are meeting and the valve is closing completely.”

Until recently, mitral valve surgery always involved dividing the breastbone and opening the chest. Now Dr. Kiser performs many of these operations through a relatively small incision between the ribs on the right side of the chest. The heart still has to be stopped, however, and the patient is on a heart-lung machine until the surgery is finished.

The main advantage of the less-invasive procedure is a shorter recovery period.

“Patients are often back at work in three weeks, and one of my patients was playing softball four weeks after surgery,” Dr. Kiser says.

As with aortic valves, some mitral valves are in such bad condition that they can’t be repaired. Instead, they have to be replaced with either a mechanical or pig valve.

It isn’t always known what causes heart valve problems. Some are due to congenital abnormalities while others may be caused by infections. According to Dr. Kiser, a heart attack can also damage tissue in the area of the mitral valve and cause the valve to malfunction.

When Steve Baxter had a routine physical exam in May 2006, his doctor detected a heart murmur. An electrocardiogram (EKG) indicated he might have a mitral valve problem.

Another EKG three months later showed there had been no change, so there seemed to be little cause for worry. But three months after that, an EKG showed severe mitral valve regurgitation.

The valve wasn’t closing properly, and blood was backing up in his heart. Baxter’s cardiologist, Joseph Hakas, M.D., of Pinehurst Cardiology, said he needed surgery. “I couldn’t believe it,” says Baxter, who was only 48. “I felt fine. I was energetic. I walked, ran, fished, played golf—all the things I like to do. I would get a little tired at work in the afternoon, but I figured that was normal.”

One of the leaflets in Baxter’s mitral valve had somehow gotten torn and wasn’t opening and closing properly. With each beat of his heart, the valve allowed blood to back up into the left atrium. That was causing his heart to enlarge and forcing it to work harder than it was meant to.

On March 21 of this year, Andy Kiser, M.D., a cardiac surgeon at FirstHealth Moore Regional Hospital, repaired Baxter’s faulty heart valve using a relatively new procedure that doesn’t involve cracking open the chest. Instead, he operated through a 5-inch incision between the ribs.

It was still major surgery, however, and Baxter was in the hospital for six days. Barely a week after going home, he was walking four miles a day. Five weeks after the surgery, he was back on the golf course.

“I thought I felt good before the surgery, but I feel so much better now,” he says. “I guess I had sort of accepted a deterioration of my mental and physical energy, because it was so gradual. Now I feel 20 years younger. My mental energy is that much better. And that makes sense, because I’m getting all the blood to my head and the rest of my body that I wasn’t getting before. I hate to use the phrase ‘new lease on life,’ but I feel like that’s what I’ve got.”