Ask the Doctors May 2012 Issue

Ask The Doctors: May 2012

I’m 81 and had a bovine aortic heart valve put in 12 years ago, along with bypass surgery. I’m in generally good health, but the valve is starting to leak. The hospital where I have gotten my care doesn’t seem anxious to operate on an 81-year-old. What are my options regarding my aortic valve?

Whether or not you should get surgery for your leaking bioprosthetic aortic valve depends on more factors than just your age.  The fact that this would be your second open heart surgery would make the procedure more risky, mainly due to the presence of postsurgical scar tissue known as “adhesions” which tend to form in the chest. My recommendation would be for you to get a second opinion from a large academic medical center, such as Cleveland Clinic. The possibility of a second heart surgery should still be considered, because it is the tried-and-true method for fixing the problem. However, if the risks are felt to outweigh the benefits by the doctors evaluating you, another option could be transcatheter aortic valve insertion (TAVI), a minimally-invasive procedure in which cardiologists implant a new valve inside of the old one.

Be advised, however, that at the present time TAVI is only FDA-approved for use in severe narrowing of the native aortic valve. Only a few patients, mainly in Europe, have received TAVI for your problem, and as such this treatment for a leaking bioprosthetic valve would still have to be considered “experimental.”

I recently read that blood pressure (BP) can differ from one arm to the other and that if you have much of a difference in pressure readings between the two arms, it could signal heart trouble. Is there anything to this? Should I be alternating arms when I check my blood pressure at home?

If you have been sitting quietly for at least five minutes, then the pressures in your two arms should be very similar—usually within 10 to 15 millimeters of mercury (mmHg) of each other. Traditionally, an interarm difference greater than this has been associated with “subclavian stenosis,” a condition in which there is a significant narrowing in the blood vessel connecting the aorta to the arm, usually caused by plaque formation due to atherosclerosis. However, patients with subclavian stenosis generally have exertional symptoms such as pain or fatigue from the affected arm. In the absence of symptoms, it is unclear how to interpret the significance of different arm pressures. 

Investigators recently published an article in the journal Lancet which analyzed multiple other studies that reported blood pressures checked in both arms of patients with established vascular disease. They found that an interarm difference of greater than 15 mmHg in systolic BP was associated with a two-and-a-half-fold greater risk for atherosclerosis of the blood vessels supplying the limbs, known as peripheral vascular disease (PVD). Persons with this degree of interarm variation also appeared to be at increased risk for atherosclerosis of the blood vessels supplying the brain (cerebrovascular disease or CVD), and for death due to cardiovascular or other causes, compared to those who did not. 

Another smaller study was published this past month in the British Medical Journal which found a 3-fold increased risk of death over 10 years in patients with a BP difference >10 mmHg between arms. This finding, although striking, requires validation in larger trials. The next time you are at your doctor, it is reasonable to ask what the pressures are in each arm, and whether or not you will need further testing. When checking your BP at home, it’s generally appropriate to stick with one arm (usually the left) for all measurements. To obtain more guidance regarding appropriate home BP monitoring, please have a look at the article entitled “Checking Your Blood Pressure at Home,” located on our patient-oriented - Website: my.clevelandclinic.org.