Ask the Doctors July 2011 Issue

Ask The Doctors: July 2011

I’m 62 and have mitral valve prolapse that is considered severe. I have 40 percent regurgitation and it’s worsening, causing ever increasing shortness of breath. My doctor wants to replace the valve soon, but I don’t want open heart surgery. Is transcatheter mitral valve replacement approved in the U.S., as it is overseas? If not, should I consider going abroad for the surgery?

It is important to remember that you are not alone: your concerns about open-heart surgery are shared by many others with valvular heart disease. And the option of valve repair or replacement in the cardiac catheterization laboratory, as opposed to the operating room, can seem particularly attractive. However, transcatheter mitral valve surgery is relatively new, and is not currently approved for general usage in the United States. Should you travel to another country to get the work done? I would not make that choice lightly. Novel clinical techniques should be welcomed and explored, but I would also respect our country’s protocol of FDA approval, which helps to protect people from as-yet unproven procedures.

Please note that mitral valve prolapse with severe regurgitation is generally treated with repair, not replacement. Such surgeries can be done in a minimally-invasive manner, not requiring a median sternotomy (a vertical incision through the breastbone.) Rather, a modest incision between the ribs can be used, reducing the amount of trauma involved. Another, newer option is robotic surgery, in which the cardiothoracic surgeon controls robotic arms which repair the valve through the smallest possible "keyhole" incisions.

Mitral valve repair­—especially that done via minimally invasive approaches—carries with it a very low rate of nonsurvival or major complications. And the amount of postoperative pain, as well as the time required for recovery, are much less than that of traditional open-heart surgery. As such, I would strongly encourage you to consider one of the newer, less traumatic forms of heart surgery. A consultation at Cleveland Clinic with one of our cardiothoracic surgeons specializing in this type of procedure would help inform your judgement regarding how to proceed further.

I just read that the time of day or night you take certain blood pressure medications can have a lot to do with how effective they are. In particular, I noticed that ACE inhibitors, which I take, are much more effective if taken before bed. My doctor never told me that. Is this true and what difference does the time of day make?

The response to medication can vary tremendously between different individuals. ACE inhibitors are particularly potent at lowering blood pressure, so care must be taken in their use. If you are experiencing daytime hypotension (low blood pressure), then you may be better off taking the medication at bedtime, rather than in the morning. This is because the peak serum concentrations of the drug will occur several hours after you take it. If consumed at bedtime, these peak levels will occur while you are sleeping, and be less likely to cause uncomfortably low blood pressures. Another situation which suggests the usefulness of bedtime administration is the presence of hypertension (systolic BP>130 or diastolic BP>85) in the early morning hours.

On the other hand, if you take your medication in the morning, and your blood pressure is optimal all day long, then you are probably fine continuing to take it on the same schedule. Remember that, when you are taking a drug long-term, you build up levels in your system which never reach zero during a 24-hour period. So, during the entire day, there is always some degree of coverage.

I urge you to discuss these issues further with your doctor. If you bring records of your blood pressure, performed morning, noon, and night, he or she will be able to give you further recommendations regarding the optimal timing of your antihypertensive medication administration.