Returning to Exercise (and Training) After Heart Surgery

broken-heart-01-2400px

I’ve had a bunch of requests for a blog post on getting back to exercise or training after heart surgery. These requests usually come from:  1) athletes who are contemplating an upcoming operation and are already worried about if/when/whether they’ll be able to get back to exercise afterwards or 2) athletes who’ve recently had successful operations and are looking to become active once again, but are looking for reassurance that it’s safe to do so.  I marvel every time I see an athlete patient get back to exercise after heart surgery, so I’m always encouraged by these inquiries.

For today’s discussion, let’s confine ourselves to what I call “conventional” heart surgery—the whole collection of heart operations that use a chest incision, with splitting of the breast bone (sternum), and make use of the heart-lung machine for cardiopulmonary bypass during the procedure. We’ll save for another day those procedures that are “less invasive” in some way, use some other incision or approach, and those that don’t make use of the heart-lung machine.  As examples, I’m talking about common operations like coronary artery bypass grafting (CABG) or heart valve repair or replacement.

At the outset, we need to have a big disclaimer.  Athlete patients are all different.  Their operations are different, too—even when we’re talking about just the commonly performed operations.  And because athletes and operations are all different, I can only generalize here.

If you’re an athlete patient, please use this post to become educated about some of the issues and help gather your thoughts for conversations with your own doctor(s). This is the only way to settle on plans that are right for you.

Athletes in this situation should remember that there are very real issues with the safety of exercise.  My best advice is to take things slowly and consult with your doctor(s) frequently.

 

Athletes and Operations are Unique

Athletes who need heart operations can be different in many ways.  Some need operation for congenital, or inherited, conditions they’ve had since birth (eg, atrial septal defect [ASD]).  Others need operation for acquired conditions that take many years to develop (eg, coronary artery disease, aortic aneurysm).  In still others, an emergency operation may be needed for some sort of acute problem (eg, aortic dissection).

In many cases, athletes will have conditions where the heart function is preserved, but some will have conditions where the heart has suffered some sort of damage, and become weakened, over time. Some athletes will be healthy except for their heart condition and others will have other medical conditions that affect not only the operation, but also the recovery.

Finally, athletes will come with all sorts of sports backgrounds and all sorts of future goals. Some will be young and others will be old.  Some will be recreational athletes, some will be exercisers, and some will be competitive athletes.  Some will have had high fitness levels before operation, and others will not.  The demands of the various sports are different, too.  Some have highly “dynamic” nature (eg, running).  Others have a high “static” nature (eg, weightlifting).

Heart operations are different, too.  In some cases, operations can be curative.  In others, the operation might better be thought of as “mending a broken heart.”    Moreover, in some cases the underlying heart condition can take a long time to improve, even if operation is successful.

For all of these reasons, there can be no “one-size-fits-all” prescription for return to activity, exercise, and training.  Instead, the prescription must be individualized.

 

Healing Up

Things need to get healed up after operation.  This should be obvious.

The surgical wounds need to heal after surgery. The skin incision ordinarily heals very quickly.  With either skin staples or absorbable sutures beneath the skin, the surgical wound usually seals in the first few days.  It’s worth paying attention to instructions for showering, bathing, and swimming.  Any infection of the surgical wound can be a major setback to healing.  Pay attention to instructions to watch for swelling, redness, or drainage that might be signs of infection.

Deeper, the breast bone (sternum) is like any other broken bone. We wire the sternum back together and in most cases, the bone knits back together just like any other broken bone.  This is a process that takes many weeks, but we often say that the bone regains about 75% of its strength in the first month, so long as healing proceeds correctly.  During the first month, we generally restrict activities that place stress on the sternum as it heals.  We ask patients to avoid pushing, pulling, reaching, or even just carrying heavy objects (more than 10 pounds).  Many surgeons also restrict driving for the first month.  All of these activity restrictions are important because exercise early after operation must usually involve the lower body, rather than the upper body.

Deeper still, the heart itself must heal up. Regardless of the exact operation, the handiwork here usually involves needle and thread.  The tissues are sewn together or new materials (eg, heart valves) are sewn into the heart.  Although the tissues or devices are fixed securely in place, it takes many weeks or even months for the affected tissues to heal completely.  Your surgeon will be in the best position to comment on the expected period of time that will be needed for healing and to offer advice about any longer term risks to the affected tissues, devices, or prosthetics used that might come with various forms of exercise.

One final point is that healing may be impaired in some patients.  Conditions such as diabetes, a suppressed immune system (eg, from illness or medications such as steroids), or even just poor nutrition before operation can delay healing substantially.

 

Is the heart mended? Or good as new?  Does the disease continue even after the operation?

Thinking ahead to physical activity after operation, one very important consideration is: how healthy is the heart now?  Have we cured the problem?  Or have we mended the problem?  Or, perhaps, have we introduced some new problem?

The important question to consider is:  Does my current heart situation place me at increased risk for a future problem?  And, if so, how big is that risk?

As one example, sometimes an athlete will need operation to correct an atrial septal defect (ASD), an inherited condition.  If this condition is found before any damage has occurred to the heart or lungs, operation is curative and athletes can generally return to any form of sports activities after they’ve healed up.

As another example, sometimes an athlete will need coronary artery bypass surgery after a heart attack, or acute myocardial infarction (MI), in medical terms.  The “plumbing” can be fixed with operation so that blood flow is restored past all (or most) of the blockages in the coronary arteries.  It turns out, though, that it can take up to 2 years for the ruptured plaque that caused the MI to become stabilized.  During that time, the best advice might be to limit strenuous exercise because of the increased risk of repeat MI.

In yet another example, sometimes an athlete will need operation for repair of an aortic aneurysm.  Most often, a portion of the enlarged aorta is “repaired” by replacing the blood vessel with a synthetic, fabric substitute.  After successful operation, though, there may still be mild enlargement of the remaining aorta that deserves surveillance over time for possible enlargement.  Sports activities with a high “static” component (eg, weightlifting), where there can be large increases in the blood pressure, may not be advisable, for fear of accelerating aortic enlargement over time.

These are just 3 examples.  The scenarios are virtually endless.

 

New Medications

For some athletes, things can be so “normal” after heart surgery that no new medications are needed. Sometimes, medications that were required before the operation are no longer needed.  These athletes are fortunate.

For other athletes, though, new medications can be needed either because of the underlying heart condition or because of new hardware that’s been added. As an example, aspirin, beta blockers, and statins are often recommended for athletes who’ve had operation for coronary artery disease.  Each of these medications will have implications for the athlete.  As another example, blood thinners like warfarin (Coumadin) might be prescribed for an athlete with a mechanical heart valve. The anticoagulants also bring a potential risk of unwanted, serious bleeding in the event of bodily injury.  This is a factor which must be weighed when settling on what types of physical activity are safe.

 

Cardiac Rehabilitation

Cardiac rehabilitation, or “rehab” for short, is a supervised program that includes medical evaluation, development of a physical activity program specific for the patient, educational services, and individual and group exercise where the vital signs and EKG can be monitored. The structure of these programs may vary by location, but will usually involve both an inpatient phase and an outpatient phase.

At many heart surgery programs, the inpatient phase of cardiac rehab begins within the first couple days after operation, with both educational and exercise components. There are usually educational offerings about nutrition, medications, lifestyle modifications, and community resources.  There is also an exercise component that is tailored to the patient, usually involving walking at first, where there is close monitoring of the vital signs, the heart rhythm, and the oxygen level in the blood stream.  It’s important early after operation, together with the patient and family, to establish expectations and goals about physical activity.

Cardiac rehab continues with an outpatient phase, where patients can enroll in a monitored exercise program, often in a group setting, with several sessions per week. Athletes may sometimes fail to see the value in such a program, but these programs can actually provide some much needed structure to the early return to exercise.  Most importantly, these programs can provide confidence for the athlete that once they leave a structured setting, things will still be okay with their heart and safety during exercise.  I’d recommend a full cardiac rehab program for all athletes who are looking to return to exercise after operation.

For most patients, walking is the most appropriate exercise early after operation, with an emphasis on moderate exertion and increasing duration.

 

Support

Having a good support system is important for any patient after heart surgery. It’s particularly true for the athlete who is returning to a formal exercise or training program after heart surgery.  You can envision this support system as having a set of layers.

Closest to home, athletes will benefit from a family that helps to encourage a return to physical activity and works to make this possible. Family is usually the best support for ensuring continued good nutrition, ensuring restful sleep (including naps), and seeing to other various needs after the patient returns home from the hospital.

When it comes to returning to structured, independent exercise, I believe that a group setting is often best. We all know that it’s more motivating when we have friends to meet for the morning run or ride.  In the case of athletes with recent heart surgery, it’s also reassuring for the athlete to know that company is nearby if some sort of medical problem crops up during an exercise session.  Even if this possibility is unlikely, a group of fellow exercisers can provide some needed confidence.

Being able to share experiences with other athletes who’ve had similar surgery can often be helpful, even if those athletes aren’t close to home. There are a variety of support groups with an online presence, but two of my favorites are the Ironheart Foundation and Cardiac Athletes.  Both offer an opportunity to network with similar athletes, learn from their experiences, and also have a forum to “give back.”  You’re not alone.  Many other athlete patients are dealing with the same or very similar situations.

Lastly, for athletes who are looking for some good reading material, one good resource is a book entitled “Heart to Start,” by cardiologist James Beckerman, MD. I’ve written a review about this book previously here at the blog.  The book describes a gradual, structured path to resuming aerobic exercise and conditioning once cardiac rehab is completed.

 

Follow-up

It’s wise for athlete patients to put together a robust framework of medical support as they return to physical activity after heart surgery. Your “team” should include at least your heart surgeon, your cardiologist, and your primary care provider.  At the beginning, there might also be a nutritionist, your cardiac rehab specialist, or physical therapist, as well.  Perhaps you can think of other important team members as well.

Continuous dialog with your team is essential. Only you will be able to describe your goals and ambitions and ask for feedback about the advisability and safety issues.  Don’t assume that your doctor(s) will understand what it means to train for the masters national swimming championship or a marathon or a 70.3 triathlon.  If you envision several hours of aerobic exercise as well as strength training each weak, be prepared to describe this in detail, with expected exertion levels or heart rates, so that your doctor(s) can know exactly what you have in mind.  Don’t hold back.

Athletes should arrange for periodic visits with their doctor(s) so that they can discuss their plans for physical activity, share their experiences, both good and bad, develop plans, agree on any restrictions, and monitor progress. This is good advice for any athlete, but particularly good advice for athletes who have had heart surgery.

In thinking about what sorts of exercise or training is safe for their athlete patients, doctors don’t always have a bunch of accumulated scientific evidence to rely upon.  I’ve written previously here at the blog about consensus recommendations about the safety of sports for young, competitive athletes with various cardiac conditions.  These recommendations weren’t developed specifically for adult, recreational athletes after heart surgery, but they may provide a starting point for discussion.  Often, though, doctors must rely upon judgment and personal experience with similar patients.

 

Warning signs of a problem

I’ve talked previously about 5 important warning signs of potential heart problems: chest pain/discomfort, unusual shortness of breath, palpitations, blacking out (or nearly so), and unusual fatigue.  Athletes should be vigilant about these general warning signs and report them to their doctor(s).

There may also be additional warning signs to watch for, that are very specific to the type of surgery an athlete has had. Some examples would include:

  • For those with a mechanical heart valve, stroke symptoms (temporary or permanent loss of sensation or muscle weakness) would be important
  • For those with coronary artery disease, return of angina symptoms (chest pain/discomfort) would be important
  • For those with aortic aneurysms, return of chest, back, or abdominal pain would be important
  • For those with arrhythmias, return of an irregular heartbeat or palpitations would be important.

Sometime in the first few weeks after operation, you should have a discussion with your doctor(s) about any specific warning signs that are most important for you.  And then you should be vigilant.

 

Summary

Let me summarize the important points:

  • Each athlete’s situation will be different
  • Whatever the approach to returning to activity, pay attention to getting healed up, as a first priority
  • Participate in a cardiac rehab program
  • Consider your “new,” current heart situation as you make plans about the safety of exercise
  • Rely on your support network as you return to physical activity
  • Assemble a medical “team” to help as you return to physical activity
  • Make a list and be vigilant about warning signs that are specific to your circumstance

 

Related Posts:

  1. A Conversation with Cyclist and Heart Transplant Recipient, Paul Langlois
  2. Coach John Fox and Aortic Valve Replacement

Shaun White, Snowboarder, 1986 –

»¬°å¸ßÊÖShaun White

 

 

 

 

 

Shaun White is a 27 year old native of California who’s become equal parts snowboarder and pop celebrity.  In addition to enjoying great success in the X Games, White is also the 2-time defending Olympic champion in the halfpipe event.

Interestingly, White was born with a congenital heart condition known as Tetralogy of Fallot (TOF).  With this condition, there are 2 primary defects–a hole (septal defect) between the ventricles (the pumping chambers) and narrowing, or stenosis, of the pulmonary valve and trunk.  The remaining features include hypertrophy, or thickening, of the right ventricle which must do extra work to pump blood through the narrowed pulmonary valve, and an “overriding” aorta that is shifted in location above the septal defect.  This condition occurs in approximately 1 per 2,000 infants.

By report, White underwent 2 operations to repair this condition while he was an infant.  Today, most children have a complete repair in a single operation that involves closing the septal defect and enlarging the opening at the pulmonary valve or replacing the valve altogether.  Most patients do quite well after operation to repair TOF.  Over the long term, these patients may develop problems, even years later, like arrhythmias or leakage of the pulmonary valve.  For that reason, these patients need periodic monitoring indefinitely.

White is an example of the growing population of adult athletes who have some form of (often corrected) congenital heart disease.  It’s really not surprising that there are elite athletes in this situation.  In the specific case of corrected TOF with a good outcome, the most recent guidelines from the 36th Bethesda Conference suggest that athletes can participate fully in their sports.  There will be specific guidelines regarding the safety of sports for each of the many different congenital heart conditions.

There is increasing awareness in the medical community of the importance of exercise for teenagers and adults who have congenital heart disease.  Recent guidelines will help athletes and their doctors make thoughtful decisions about exercising safely.

 

Photo by http://www.flickr.com/photos/bfishadow/ User:bfishadow.

Coach John Fox and Aortic Valve Replacement

 

NFL Broncos head coach, John Fox, will reportedly undergo aortic valve replacement (AVR) this week.  I’ve gotten some inquiries over the weekend about his situation and I thought I’d take a few minutes to write about aortic valve problems and aortic valve replacement.

This story is reminiscent of Atlanta Falcons coach, Dan Reeves, who had urgent coronary artery bypass surgery in 1998, late in his team’s 14-2 season.  For reference, Reeves made an excellent recovery, rejoined the team just 3 weeks after surgery, and went on to coach for another 5 seasons.

Aortic Valve Disease

The aortic valve is the valve that lets blood out of the heart.  The left ventricle of the heart pumps blood out through this valve into the aorta with each heart beat.  At rest, this might amount to about 5 liters per minute.  The valve ordinarily has 3 tissue thin leaflets, but some individuals are born with just 2, a condition known as bicuspid aortic valve (BAV).

There are 2 different problems with the aortic valve.  The valve can become narrowed or it can leak.  Either situation produces trouble for the heart, which then must do extra work.  When the valve is narrowed, we call the condition aortic stenosis.  When the valve leaks, we call the condition aortic regurgitation.  When there is severe aortic stenosis or regurgitation, aortic valve replacement is often the only available curative treatment.

In this country the most common cause of aortic stenosis in adult patients, by far, is build-up of calcium in the valve leaflets over many years’ time.  This progressive calcification causes the valve leaflets to become thickened.  As a result, they don’t open or close easily and eventually they become immobile.  Severe aortic stenosis most often manifests in patients 60+ years old.  In individuals with BAV, this process occurs much earlier in life, and the condition often manifests in patients in their 40’s and 50’s.  Rheumatic fever is probably the next most common cause.  The normal aortic valve opening is about the size of a half dollar.  But with severe aortic stenosis, the opening can be reduced to the size of a drinking straw.

Aortic regurgitation may occur for a variety of reasons such as:  infection (that we call endocarditis) that destroys the valve leaflets; enlargement of the aorta that stretches the leaflets apart; rheumatic fever; or trauma.

Patients with severe aortic stenosis have symptoms of shortness of breath with exertion, chest pain/discomfort, or light-headedness or blacking out (that we call syncope).  Patients with aortic regurgitation most often have symptoms of shortness of breath with exertion.  Either condition can be revealed by listening to the heart with a stethoscope because either condition produces turbulent blood flow that can be heard as a heart murmur.  The diagnosis is confirmed using ultrasound, in a test known as an echocardiogram.

Once there are symptoms, patients with severe aortic stenosis need operation.  Once the heart function suffers because of aortic regurgitation, operation is needed.  In either case, we usually plan for operation at the earliest, convenient opportunity.  Emergency operations for aortic valve problems are unusual.

In John Fox’s case, we know from reporting that he was in Charlotte, North Carolina to visit his doctor(s) about a known aortic valve problem–one that was being monitored and for which aortic valve replacement was being planned once this year’s football season was complete.  The initial news reports spoke about the possibility of a heart attack, but he apparently became light-headed while playing golf.  It’s not clear if he passed out completely.  He was taken to the hospital where additional testing was completed.  The Broncos then made the announcement that Fox would undergo surgery this coming week.

Aortic Valve Surgery

Aortic valve replacement is a very common heart operation today.  And while there are new technologies that allow for valve replacement in high-risk patients without conventional operation, the vast majority of patients undergo typical open heart surgery to replace the valve.

The patient has general anesthesia with use of a breathing tube to provide ventilation while asleep.  Access to the heart is gained by dividing all or part of the sternum and using a retractor to spread the rib cage open.  The first main part of the operation involves connecting the patient to a heart-lung bypass machine that sits at the side of the operating table and takes over the job of the patient’s own heart and lungs for a period of time.  This allows the patient’s heart to be still and empty of blood.

The next main part involves replacing the valve.  An opening is made in the aorta, the large blood vessel that carries blood away from the heart.  This allows the surgeon to look in and see the diseased valve.  In the most straightforward operation, the patient’s aortic valve is removed using scissors and any calcium-related debris is also removed.  A measuring tool is used to determine the correct size for a substitute valve which is then taken from the shelf.  Sutures are used to sew the substitute valve into the opening left behind where the patient’s valve was removed.  The opening in the aorta is then closed with sutures.

The last major part of the operation involves letting the patient’s own heart and lungs take back over again, and gradually reducing the amount of help that the heart-lung machine provides.  Once the patient’s heart is beating again, the sternum is re-approximated with wires and the overlying tissues and skin are re-approximated using sutures.  The entire operation usually takes about 3 hours.

There are several options for substitute valves.  Mechanical valves are made out of space-age materials and are designed to last forever, but patients must take blood thinning medications to prevent blood clots from forming on the prosthetic valve.  Tissue valves (eg, aortic valve “borrowed” from a pig) don’t require anticoagulants, but the valves don’t last forever.  The modern tissue valves can be expected to last 10-15 years in adult patients and then some will deteriorate; re-replacement of the valve may sometimes be needed.  In special circumstances, other more exotic options may be appropriate, but we won’t consider those options today.

Recovery from Operation

The typical patient wakes up soon after the operation.  The breathing tube and ventilator are withdrawn once the patient is wide awake and breathing on his/her own.  Most patients will spend a night in the intensive care unit and then several more days recovering in a regular hospital room.  A typical stay would be about 5-7 days.  We work hard to have patients up and walking on the first day after operation and most are walking laps around our hospital ward by the time they go home.

Many patients with AVR notice even in just the first couple days after operation that they no longer have the symptoms that led to discovery of their problem.  Particularly for aortic stenosis, the calcification of the valve happens so gradually that patient’s aren’t always aware of how much of a decrement there’s been in their exercise tolerance.

As the sternum heals, we ask that patients avoid physical activities that place stress on the sternum and shoulders (eg, pushing, pulling, reaching, etc.) for 1 month after the operation.  The sternum regains about 75% of its strength in about 1 month.  In my practice we also restrict driving for that same month.  Most any other activity is allowed and we encourage lots of walking as the preferred type of exercise.

Each patient’s situation with return-to-work is different, not only because each patient’s recovery is different but also because each patient’s job situation is different.  In Fox’s case, if all goes well, I wouldn’t be surprised to see him back at work, at least in some capacity, very quickly.

Best wishes to John Fox!

More on Athletes and Bicuspid Aortic Valve (BAV)

 

I probably get more inquiries from athletes with bicuspid aortic valve (BAV) than any other single heart problem.  Maybe that’s not surprising, given that I’m a heart surgeon and that many individuals with BAV need operation at some point.  Nonetheless, I think there’s considerable confusion about this condition, in terms of diagnosis, implications for the athlete, and its treatment.

I first wrote about BAV in a short post here at the blog back in 2009.  That post is a starting point for today’s discussion.

To quickly review, individuals with BAV have an aortic valve with 2 unequal–instead of the usual 3 equal sized–leaflets.  As a consequence, these individuals develop earlier calcification of the valve leaflets, leading to narrowing, or stenosis.  They are also predisposed to enlargement of the ascending aorta, the large blood vessel that carries blood flow away from the heart.  This can lead to stretching apart of the valve leaflets and leakage at the valve, known as regurgitation.

Looking through the reader comments here at the blog and reflecting on the athlete inquiries I’ve received, I thought I’d cover some of the major issues.

First, you’re not alone!

BAV is one of the most common congenital heart conditions, occurring in about 2% of individuals.  In large-scale pre-participation cardiac screening programs for young, competitive athletes, BAV is one of the most commonly identified abnormalities.

Historically, a heart murmur was the most common reason affected individuals were identified.  Today, echocardiography (ultrasound) for screening or diagnostic purposes for some other heart problem is the most common way that BAV is detected.

Finally, athletes are not spared.  Several contemporary elite triathletes have BAV and I’ve written about their stories in:

Examples from other sports would include Arnold Schwarzenegger, among others.

And of course the problem occurs in everyday, recreational athletes, too.  Check out Anthony DiLemme’s blog, Anthony’s Heart Valve Replacement Saga.  He’s a 30-year-old 8th grade science teacher, a cyclist and outdoorsman, who is chronicling his story with BAV–from diagnosis, to evaluation, to preparations for upcoming valve replacement surgery.  His story is typical.

On the bright side, there is ample evidence that, in the modern era, life-expectancy is not shortened for individuals with BAV compared to the general population.  That’s important to keep in mind.

Before operation is needed

It’s worth knowing if you have BAV.

Aside from the problems with aortic valve stenosis or regurgitation or with enlargement of the aorta, individuals with BAV can also suddenly develop the problem of aortic dissection.  With aortic dissection, the aorta can develop a tear on its inside wall, leading to unraveling of its layers, and even rupture.  This is thought to occur at a rate of about 0.1% per year in adults.  This can be a life-threatening problem and is more apt to occur with progressive enlargement of the aorta and with uncontrolled high blood pressure.

The American College of Cardiology (ACC) in conjunction with the  American Heart Association (AHA) has issued guidelines for the evaluation, monitoring, and treatment of individuals with BAV:

  • Patients with known BAV should undergo:
    • An echocardiogram to evaluate the aortic valve for stenosis or regurgitation and to assess for any other structural heart problems
    • A chest CT scan to make measurements of the diameter of the aorta at various points along its length.
  • Cardiac CT scan or magnetic resonance imaging (MRI) are alternatives if echocardiography is not available or possible for some reason
  • If there is enlargement of the beginning portion of the aorta to greater than 4.0 cm, the individual should have a yearly assessment of the diameter of the aorta
  • Medical therapy may be useful to slow or halt the progression of aortic valve disease and aortic enlargement by reducing the blood pressure and the blood pressure across the aortic valve.  Beta-blockers (eg, metoprolol) are recommended for this purpose.
  • Because BAV may be an inherited condition, first-degree relatives of individuals with BAV should undergo evaluation.

In my opinion, these are useful guidelines for athletes and non-athletes, alike.  The guidelines do not address the frequency of surveillance for individuals with BAV and no enlargement of the aorta.  For these individuals, provided there is no other relevant heart disease, it may be appropriate to have follow-up echocardiogram and/or CT scanning every 2 years.

The data regarding the progression of disease in athlete patients with BAV are limited.  Guidelines specifically for athletes come from the Proceedings of the 36th Bethesda Conference in 2005.  Parenthetically, it may be time for an update.  The guidelines were developed by an expert panel based on the scientific information available at that time:

  • Athletes with BAV, no significant valve stenosis or regurgitation, and an aortic diameter less than 4.0 cm can participate fully in their sport(s)
  • Athletes with BAV and enlargement of the aorta to between 4.0 and 4.5 cm can participate safely in only low and moderate intensity sports (this would exclude the typical endurance sports of swimming, cycling, running, triathlon, etc.)
  • Athletes with BAV and enlargement of the aorta to greater than 4.5 cm can participate safely only in low intensity sports (eg, golf, bowling, billiards).

The issue has not been studied very well, but one recent study suggests that continued participation in sports for periods of up to 5 years does not change the natural history and progression of BAV.  Instead, even with continued sports participation, the progression of both valvular and aortic disease is no different from that in the general population.

Who needs operation?

Operation is needed if there is severe aortic valve stenosis, severe valve regurgitation, or significant enlargement of the aorta.  Again, there are ACC/AHA guidelines for when operation is needed:

  • Aortic valve replacement is recommended for nearly all patients with severe valve stenosis (valve opening less than 1.0 cm2)
  • Aortic valve replacement is recommended for patients with severe valve regurgitation if there are symptoms due to the regurgitation (eg, shortness of breath with exertion) or evidence that the heart is suffering because of the regurgitation (enlargement of the left ventricle)
  • Repair or replacement of the beginning portion of the aorta is recommended if there is enlargement of the aorta to greater than 5.0 cm or if the rate of increase in the aortic diameter exceeds 0.5 cm per year

Sometimes more than one indication for operation may be present, so there is the additional guideline for patients who need operation for aortic stenosis or regurgitation:

  • In patients needing valve replacement because of stenosis or regurgitation, the aorta should be repaired or replaced if the aortic diameter exceeds 4.5 cm.

I know from discussion with athletes over the past few years that there are differences of opinion among cardiologists and heart surgeons about these guidelines.  These differences of opinion may be legitimate.  Consensus guidelines are developed to be broadly applicable, but the guidelines may not be applicable in a given athlete patient’s circumstance.  There are a multitude of patient-specific circumstances that must be considered when deciding if and when operation is needed.  Only your cardiologist and heart surgeon will be in a position to make those considerations.

In practice, the indications for aortic valve replacement for severe aortic stenosis or severe aortic regurgitation are straightforward and uncontroversial.  It’s also clear-cut that patients with significant enlargement of the aorta to greater than 5.0 cm need operation for replacement of the aorta.

One situation that seems particularly ripe for differences of opinion is that of the athlete with BAV, no significant stenosis or regurgitation, but with an aortic diameter of 4.5 to 5.0 cm.  This is an unfortunate situation for the athlete patient because the consensus guidelines do not yet recommend operation, yet advise against strenuous sports activities.  My personal approach to endurance athletes in this situation would be to offer operation if the patient wanted to continue to participate in endurance sports (after operation) and was willing to assume the risks of operation.  But I recognize that not all cardiologists or heart surgeons would agree.

Options for operation

Substitute valves.  There are 2 broad categories of heart valve substitutes that can be used to replace the human aortic valve:  mechanical valves or bioprosthetic (“tissue”) valves.

  • Mechanical valve.  These valves are constructed from high-tech materials that are designed to last essentially forever.  Unfortunately, these materials may cause tiny blood clots to form on their surface and, for that reason, patients must take blood-thinning medications (eg, warfarin) forever to prevent this complication.  The major brands include St. Jude Medical, Medtronic, Sorin-Carbomedics, and On-X.
  • Bioprosthetic valve.  This type of valve is made primarily from animal tissues.  One example is the aortic valve “borrowed” from a pig.  Another example is a valve that is made from “fabric” borrowed from the pericardium of the cow.  These valves have the advantage that blood clots are much less likely to form on their surface, so patients do not need to take blood-thinning medications (other than, perhaps, aspirin) in the long term.  They have the disadvantage that they do not last forever.  Young patients who receive these valves may need to have the valve re-replaced because it “wears out” at some point.  The major manufacturers include Medtronic, St. Jude Medical, and Edwards Lifesciences.

Aortic replacement.  When the aorta is enlarged in the setting of BAV, there are a couple possibilities:  the valve needs to be replaced–or it doesn’t:

  • With valve replacement.  When the aorta needs to be replaced along with the aortic valve, we call this procedure an aortic root replacement.  This is a complicated operation technically and must be tailored very carefully to the patient’s specific situation.  Options include:
    • Mechanical valve conduit.  Products are available that combine a mechanical valve attached to a Dacron fabric tube.  This is used, as a unit, to replace the patient’s aortic valve and beginning portion of the aorta.  The coronary arteries are re-implanted into the Dacron tube.  Of the options listed here for aortic root replacement, this is by far the most common.
    • Bioprosthetic valve conduit.  This is not commercially available, but can be assembled in the operating room.  The operation is like described above for the mechanical valve conduit.
    • Medtronic Freestyle valve.  This is a unique product that is a porcine aortic root that can be used to replace the human patient’s aortic root, like the other operations above.
    • Ross procedure.  This is the most technically complicated option.  The patient’s aortic valve and beginning portion of the aorta are removed.  The patient’s own pulmonary valve is removed and then used to replace the aortic valve and beginning portion of the aorta.  The coronary arteries are re-implanted into the pulmonary valve trunk.  A cryopreserved pulmonary allograft (the pulmonary valve and trunk from a human cadaver) is then used to replace the patient’s pulmonary artery.
  • Without valve replacement.  When only the aorta must be replaced, a Dacron fabric tube is used.

Valve repair.  There is recent interest and experience with aortic valve repair–instead of replacement–for patients with BAV.  These techniques are most applicable to situations in which there is regurgitation, rather than stenosis, of the valve and when there is also enlargement of the aorta.  To help correct the regurgitation, the cusps of the patient’s valve leaflets can be tailored, with the valve leaflets left in place.  Then, a Dacron fabric tube can be used to reconstruct the aorta, in a so-called valve-sparing aortic root replacement.  This procedure has the particular benefit that no artificial valve (with the disadvantages described above) needs to be used.  The potential downside relates to durability.  Questions currently remain about how long such repairs will last and whether patients might require re-operation at some point in the future.  This valve repair option is one that might best be pursued at a center that specializes in this problem.

After operation

The recovery from heart surgery can be hard to predict for any given patient, but we know that young otherwise healthy patients tend to do well.  Most patients spend about a week in the hospital after operation and then are able to go home.

Early after operation, and for perhaps the first month, we typically limit activities that place stress on the shoulders and sternum.  This gives a chance for the sternum, which was split during the operation, to heal completely.  So for that first month, we usually advise no driving, lifting, pulling, pushing, reaching, etc.  During that first month we recommend ample walking as the best form of exercise.  After the first month, patients are generally allowed to return gradually to all of their previous activities.

Patients who’ve had aortic valve replacement and/or replacement of the aorta will require life-long monitoring by their doctor, with periodic echocardiogram and/or chest CT scanning.  Over time, there will be some patients who develop problems with the prosthetic heart valve or enlargement of some portion of the aorta (that hasn’t already been replaced) that requires operation.

Athletes will ask when they can return to their sports.  Consensus guidelines from the Proceedings of the 36th Bethesda Conference recommend:

  • Athletes with mechanical or bioprosthetic heart valves may participate in low and moderate intensity sports
  • Athletes who are taking blood-thinning medications should avoid sports where bodily injury, with potentially life-threatening bleeding, might occur

The first recommendation does not include the endurance sports.  The truth is that there is not much scientific information about what happens to such athletes if they do return to endurance sports.  At issue are the potential long-term effects of repeated episodes of high heart rate and high blood pressure that accompany intense exercise.  Unanswered questions include:  Can a bioprosthetic valve wear out more quickly than expected?  Does the (unreplaced) aorta enlarge over time?  If so, how quickly?  Do medications like beta-blockers limit any potential harm?  We just don’t know.

Yet I’m personally aware of a good number of athletes who’ve returned to endurance sport after operations of various sorts for BAV, presumably after discussion with their doctors.  Athletes should have detailed discussion with their doctors about any prudent limitations to exercise after operation and settle on a mutually agreeable plan.

Related posts:
1.  Aortic stenosis and bicuspid aortic valve (BAV)
2.  Elite triathletes and heart problems
3.  Index to blog posts and online articles

Jeff Green, NBA Basketball Player, 1986-

 

Jeffrey Green is a forward for the NBA Boston Celtics basketball team.  After a college career at Georgetown he was one of the top draft picks in 2007, playing first for Seattle and later returning to the Celtics for the 2010-2011 season.

As part of a physical examination related to his contract for the 2011-2012 season, he was found to have an aortic root aneurysm.  He underwent a valve-sparing aortic root replacement operation with a Dacron graft on January 9, 2012.

We’ve talked previously here at the blog about aortic root aneurysm, or enlargement of the aorta just as it exits the heart.  There have been discrepancies in the media coverage of the details of Green’s situation, but aortic root aneurysm can develop in individuals with bicuspid aortic valve or Marfan’s syndrome.  A handful of other NBA players, including Green’s Celtics’ teammate, Chris Wilcox, have had similar operations.  I’ve also written about triathlete, Normann Stadler, who had a similar but urgent operation when a large aortic root aneurysm was discovered unexpectedly.

Green made a very quick recovery from operation, returning to dedicated rehab in March and returning to basketball by summer.  He signed a new 4-year contract with the Celtics in August and had an outstanding 2012-2013 season.