By now, you have probably heard the news that actor and former California governor Arnold Schwarzenegger underwent heart surgery last week. Per reports, the scheduled surgery was performed at Los Angeles-based Cedars-Sinai to replace a pulmonary valve, or pulmonic valve, which is positioned between the heart and the lungs, allowing for blood to travel to the lungs from the right ventricle of the heart.
Early reports claimed that the 70-year-old had emergency open heart surgery. Now that the dust has settled and Schwarzenegger is on the mend, even tweeting – “It’s true: I’m back! I went to sleep expecting to wake up with a small incision and woke up with a big one – but guess what? I woke up, and that’s something to be thankful for” – let’s take a look at what led up to the surgery.
We tapped Karen Gersch, MD, a cardiothoracic surgeon at Grand Strand Medical Center in Myrtle Beach, S.C., to learn more.
It was reported that Schwarzenegger had this same valve, the pulmonic valve, replaced in 1997. Why did he get it replaced 20 years ago?
He was born with a heart defect called aortic stenosis, which causes the heart to pump harder than usual to get blood through the aortic valve. The method the doctors used to fix his aortic valve in the 90s was called a Ross procedure, where you take the person’s native pulmonic valve, move it to the aortic position and then replace the missing pulmonic valve with a cadaver (deceased person’s) valve.
Why did he have to get the pulmonic valve replaced again this time?
In the late ‘90s when his doctors removed his congenitally bicuspid aortic valve – he had two leaflets instead of the normal three – and replaced it with his pulmonic valve, this procedure left him without a pulmonic valve. At the same time, they replaced his God-given pulmonic valve with a cadaver valve. These donor valves last approximately 20 years, at best, and then fail, which is what happened to Mr. Schwarzenegger.
So, people typically do not get their pulmonary valves replaced like he did?
Correct. Usually, pulmonary artery or pulmonic valve problems are issues we see in children. His was an iatrogenic pulmonary valve problem, meaning we (physicians) created it.
Naturally, the next question is why?
By “us” (physicians) taking his pulmonary valve to use in the aortic position, we created that pulmonary valve problem. At the time, it made the most sense. However, no valve replacement is permanent. It’s always associated with failure of some type. But what his doctors wanted to do was to ensure the longest survival on earth before he had a valve failure. So, in 1997 his options were:
- a Ross procedure, which would give him maybe up to 20 years before he experienced a valve failure;
- a mechanical valve replacement in the aortic position that would have meant he would have to have been on a blood thinner for the rest of his life , or
- a bio prosthetic valve, which is a valve that is made of cow or pig parts, and those only last, in young people, maybe 10 years. Then he would’ve had to have a reoperation.
So, in ’97, he was presented with the information and given the option: “hey, Arnold, you’re in your 50s. What do you want?” He chose the Ross procedure because it would give him the longest, disease-free course of action.
On Twitter, Schwarzenegger said that “he went to sleep expecting to wake up with a small incision and woke up with a big one.” What type of procedure do you suspect the physicians at Cedars-Sinai were expecting to perform in order to fix his failing pulmonic valve?
I know the surgeons at (Cedars) Sinai. I know them all very well. I’m sure they had a plan. They likely said we can do one of two things. 1) We can take you back, open you up and replace your pulmonic valve or 2) we can attempt to replace your pulmonic valve through a minimally invasive catheter-based intervention, which is “experimental” in the pulmonic position. The latter failed. Obviously, it wasn’t going as smooth as they wanted and they didn’t want to subject him to any potential injury so they converted over to an open heart surgery in a very controlled, very thought out manner. He is alive so they did a good job.
Why is a catheter-based valve replacement considered experimental?
It is not experimental in the aortic position or in pediatric populations in the pulmonic position, but in adults, there’s not much literature or data to show that doing a trans-catheter pulmonic valve replacement, in a person who has had a previous surgery, would work. So they said let’s try it, if it doesn’t work, worst case scenario, we’ll open you up and do the old-fashioned surgery. And that’s what we do. When we do these trans-catheter valve procedures, patients know there’s always a possibility that it may not work and we have to convert over to an open heart surgery. It happens fairly infrequently in the aortic valve position, but he was a little different since they were working on the pulmonic artery.
Was Schwarzenegger’s recent pulmonic valve replacement from a cadaver?
We don’t know what they used on this pulmonic valve replacement. It honestly depends on how hostile the pulmonic valve looked on that reoperation.
What kind of symptoms would he have been experiencing with this deteriorating pulmonic valve? More than likely, he was being followed rather diligently because, again, the expectation was that his pulmonic valve was going to fail. So, I’m sure his cardiologist had a pretty diligent follow up on him and they more than likely intervened before he was terribly symptomatic.
When we do surgeries on the valve, we follow people forever with the anticipation that these valve surgeries are not meant to last forever. They have their own life expectancy. So, even though he probably didn’t have any symptoms, his cardiologists probably told him that it was time to get it fixed before he started having heart problems related to his dysfunctional valve. But the symptoms of a deteriorating pulmonic valve are usually shortness of breath and fatigue – those are the biggest complaints.
How long do open heart surgeries typically last?
Well, it was a reoperation so it takes a long time. Since he had a previous surgery, they had to go through scar tissue and that probably took 8-9 hours of surgery, easily. First time surgeries take about 4-6 hours.
What is the expectation for his recovery?
We’re talking about a broad range of people. People who have reoperations oftentimes are older and will have problems as older people. Each person is individualized. Some folks are more highly functioning before they go into surgery and they recover in just a few months. Others are clearly older and if they’re having a reoperation, they’re going to have a little longer recovery. It might be 3-6 months. Mr. Schwarzenegger might have a three-month recovery, but for sure, reoperations take months to recover from.
Dr. Karen Gersch is a cardiothoracic surgeon at Grand Strand Medical Center, an affiliate of HCA Healthcare and member of HCA’s South Atlantic Division.
Schwarzenegger Photo Credit: Joe Seer/Shutterstock