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SAINT THOMAS HEALTH'S MEDICAL MONDAYS: Innovations In Cardiology -- February 18, 2013 -- Dr. Chandrashekhar Ramaiah and Dr. Evelio Rodriguez

SAINT THOMAS HEALTH'S MEDICAL MONDAYS | News Notes
Monday, February 18, 2013
Innovations in Cardiology
Chandrashekhar Ramaiah, MD | CT Surgeon
Evelio Rodriguez, MD | CT Surgeon

SAINT THOMAS HEART       

News notes via www.webMD.com

Minimally invasive surgery has revolutionized the surgical field over the last two de­cades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replace­ment at certain specialized centers worldwide because of excellent results. We have de­veloped a robotic mitral valve surgery program which utilizes the da Vinci® telemanipu­lation system allowing the surgeon to perform complex mitral valve repairs through 5mm port sites rather than a traditional median sternotomy. In this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and take a look at the other cardiac surgical procedures for which da Vinci® is currently being used. 

Saint Thomas Heart | GIVING HEART PATIENTS MORE TREATMENT OPTIONS

Through the combined efforts of Saint Thomas Heart cardiothoracic surgeons and cardiologists, previously inoperable patients with severe valvular heart issues are benefitting from the latest advancements in valve technology.

THE SAINT THOMAS HEART VALVE CENTER APPROACH

The Saint Thomas Heart Valve Center includes cardiologists and cardiac surgeons who are versed in the most current techniques and practices in the management of valvular heart disease. A variety of treatment therapies are discussed, including transthoracic, transesphogeal, stress and 3D echocardiography, as well as cardiac MRI.

The Valve Center's multi-disciplinary team meets bi-weekly to evaluate patients who are referred to the Center. The consultations are performed in an open, collaborative format. By combining these specialties in a unified approach, Saint Thomas Heart is able to provide a more complete diagnostic picture for patients with severe valvular heart disease.

Additional testing needed to complete the evaluations will be arranged at clinic visits, with a full report provided to the referring physician at the conclusion of the consultation. Our goal is to then return patients to their primary care physician or cardiologist for subsequent management. When appropriate, recommendations regarding surgery, including suitable timing and techniques, will be part of the consultation process.

PATIENT BENEFITS AND LIFE-SAVING TREATMENT OPTIONS

During the winter of 2011, 87-year-old Herschel Bouldin noticed a significant decrease in his once seemingly endless reservoir of energy. After numerous doctor visits proved to make little difference in improving his health, Mr. Bouldin was referred to the Saint Thomas Heart Valve Center for further, more specialized testing and evaluation. The Valve Center physicians concluded that Mr. Bouldin suffered from severe aortic stenosis and would require immediate surgery. Due to several existing health factors, it was determined, however, that Mr. Bouldin would not survive conventional open-heart surgery. So, Saint Thomas Heart cardiac surgeons and cardiologists proposed a new, state-of-the-art procedure called Transcatheter Aortic Valve Replacement – or TAVR.

TAVR is a minimally invasive procedure that is performed in a unique, hybrid operating room that utilizes the most advanced imaging equipment available today. The surgery is performed on a beating heart and with a catheter that is inserted through the groin. The procedure does not require cardio-pulmonary bypass and patients experience significantly shorter recovery times. These significant factors, which lower risks and increase the ease of recovery, can make TAVR a life-saving procedure for inoperable heart patients. Such was the case for Mr. Bouldin.

On April 13, 2012, The Saint Thomas Heart Valve Center team performed the TAVR procedure on Mr. Bouldin. Within 4 short days after his surgery, Mr. Bouldin was back in the home he has shared with his wife Freda for nearly five decades.

Heart Valve Disease Treatment

Diseased heart valves can be treated both surgically (traditional heart valve surgery) and non-surgically (balloon valvuloplasty).

What Happens During Traditional Heart Valve Surgery?

During traditional heart valve surgery, a surgeon will make an incision down the center of your sternum (breastbone) to get direct access to your heart. The surgeon then repairs or replaces your abnormal heart valve or valves.

What Happens During Minimally Invasive Heart Valve Surgery?

Minimally invasive heart valve surgery is a type of surgery performed through smaller incisions. This type of surgery reduces blood loss, trauma, and length of hospital stay.

Your surgeon will review your diagnostic tests prior to your surgery to determine if you are a candidate for minimally invasive valve surgery.

Often, the surgeon and cardiologist (heart doctor) will use transesophogeal echo (an ultrasound transducer probe that is passed down the throat) to help determine the functioning of the valve before and after surgery.

What Is Heart Valve Repair Surgery?

The mitral valve is the most commonly repaired heart valve, but the aortic, pulmonic, and tricuspid valves may also undergo some of these repair techniques.

If your valve can be repaired, your surgeon will perform any of the following types of valve repair procedures.

• Commissurotomy. Fused valve leaflets, or flaps, are separated to widen the valve opening.
• Decalcification. Calcium deposits are removed to allow the leaflets to be more flexible and close properly.
• Reshape leaflets. If one of the leaflets is floppy, a segment may be cut out and the leaflet sewn back together, allowing the valve to close more tightly.
• Chordal transfer. If a leaflet of the mitral valve has prolapse (floppy; lacking support), the chordae are transferred from one leaflet to the other. Then, the leaflet where the chordae was removed is repaired (see above).
• Annulus support. If the valve annulus (the ring of tissue supporting the valve) is too wide, it may be reshaped or tightened by sewing a ring structure around the annulus. The ring may be made of tissue or synthetic material.
• Patched leaflets. The surgeon may use tissue patches to repair any leaflets with tears or holes.

The advantages of heart valve repair surgery include:

• Decreased need for life-long blood thinner (anticoagulant) medication
• Preserved heart muscle strength

What if my Heart Valves Cannot Be Repaired?

When you have aortic or pulmonic heart valve disease, valve replacement surgery is usually performed. In some cases, the aortic valve can be repaired.

During valve replacement surgery, the faulty valve is removed and a new valve is sewn to the annulus of your original valve. The new valve can be a:

• Mechanical valve. It is made totally of mechanical parts that are tolerated well by the body. The bi-leaflet valve is used most often. It consists of two carbon leaflets in a ring covered with polyester knit fabric.
• Biological valve. Tissue valves (also called biologic or bioprosthetic valves) are made of human or animal tissue. Animal tissue heart valves may come from pig tissue (porcine) or cow tissue (bovine). Tissue valves may have some artificial parts to help give the valve support and to aid placement.
• Homograft valve (also called allograft). It is an aortic or pulmonic human valve that has been removed from a donated human heart, preserved, and frozen under sterile conditions. A homograft may be used to replace a diseased aortic or pulmonic valve.

What Are the Pros and Cons of Each Type of Heart Valve?

• Mechanical heart valves. The advantage to mechanical heart valves is their sturdiness. They are designed to last for many years. There are also drawbacks. Due to the artificial material involved, people who receive these valves will need to take life-long blood-thinner medication (anticoagulants) to prevent clots from forming in the mechanical valve. These clots can increase the risk for a stroke. Also, some people report a valve ticking sound that is usually not bothersome. It is the sound of the valve leaflets opening and closing.
• Biological heart valves. The advantage of biological heart valves is that most people do not need to take life-long blood thinners, unless they have other conditions (such as atrial fibrillation) that warrant it. Biologic valves, traditionally, were not considered as durable as mechanical valves, especially in younger people. Previously available biologic valves usually needed to be replaced after about 10 years. However, some studies show that some biologic valves may last at least 17 years without decline in function. This represents a new milestone in the durability of biologic valves.
• Homograft heart valves. Homografts are ideal heart valves for aortic valve replacement, especially when the aortic root is diseased or there is infection. The heart's natural anatomy is preserved and patients do not need to take life-long blood thinners. However, the limited availability is a drawback in some settings.

Are There Non-Surgical Options for Heart Valve Disease?

Yes. Balloon valvotomy is used to increase the opening of a narrowed (stenotic) heart valve. It is used for select patients who have mitral valve stenosis (narrowing of the mitral valve) with symptoms, select older people who have aortic stenosis (narrowing of the aortic valve) but are not able to undergo surgery, and some patients with pulmonic stenosis (narrowing of the pulmonic valve).

What Happens During Balloon Valvotomy?

During a balloon valvotomy, a specially designed catheter is inserted into a blood vessel in the groin and guided to the heart. The tip is directed inside the narrowed heart valve. Once there, a tiny balloon is inflated and deflated several times to widen the valve opening. Once the cardiologist is satisfied the valve has been widened enough, the balloon is removed.

During the procedure, the cardiologist may perform an echocardiogram (ultrasound of the heart) to get a better picture of the valve.

New non-surgical procedures to treat valvular disease, such as transcatheter aortic valve replacement (TAVR), are being tested and may provide additional treatment options using a catheter for valve disease in the future (NOW at SAINT THOMAS HEART)