Doc Talk: Options available for high-risk cardiac patients

12/10/2013 6:00 AM

08/08/2014 10:20 AM

In the United States, approximately 2.5 percent of the population has valvular heart disease (VHD), a problem with one of the heart’s four valves, which are located between the four chambers of the heart. Its crucial these valves open and close properly in one direction to allow blood to flow to the two atria and two ventricle chambers that pump and circulate blood on to the body. While surgery remains the best treatment for most patients, there is an alternative for those considered too high of a risk for surgery.

Types of valve disorders

VHD has multiple causes including congenital defects, infection on one or more heart valves, rheumatic fever, and aging. Age-related, or degenerative valve disease, has the highest prevalence and affects approximately one in eight people age 75 and older. The two valve conditions most commonly caused by age-related degeneration are aortic stenosis and mitral regurgitation.

Aortic Stenosis is usually caused by hardening of the valve leaflets due to calcium deposits forming on them. This makes the leaflets stiff and restricts the flow of blood from the left ventricle to the body. People who develop severe aortic stenosis often develop symptoms as a result of this limited blood flow. These symptoms include angina (heart-related chest pain), shortness of breath, dizziness or fainting, and fatigue.

Mitral regurgitation is a more complex problem involving leakage of the mitral valve and blood flowing backward from the left ventricle to the left atrium instead of forward from the left ventricle to the body. Symptoms can include shortness of air, fatigue, palpitation, swollen feet and ankles and heart failure.

How is VHD diagnosed? Normally a heart murmur is heard on physical exam. This can lead to further testing such as an echocardiogram and referral to a cardiologist. Based on these findings, additional testing can be recommended.

Treatment

Although medicines can help with the symptoms caused by VHD, the only definitive treatment has been open heart surgical valve repair or replacement. Because these conditions are commonly seen in elderly and frail people, there can be a higher risk of major complications or death associated with surgery in this patient population. Sometimes, heart valve surgery is not recommended because the risks of surgery may be greater than the benefits of having the valve repaired or replaced. In the past, people considered at too high a risk for surgery have had no good alternative options.

About three years ago, a new option – transcatheter aortic valve replacement or TAVR – became available in the United States. Rather than needing open heart surgery to replace the aortic valve, doctors can insert a new aortic valve inside the diseased one. There are several ways to gain access to the heart to do this that does not require open heart surgery. The new valve is mounted on a catheter which can be advanced through one of the arteries in the legs or by making a small incision in the chest. At this time, only people who are at too high of a risk for standard open heart surgery can qualify for TAVR.

Similarly, people with severe mitral regurgitation also have alternatives to open heart surgery to repair the mitral valve. A less invasive option for mitral valve repair that will soon be available at Via Christi Heart Valve Clinic. As with TAVR patients, only those who are considered high surgical risk will be candidates for this initially.

Heart valve clinic

Individuals who are undergoing evaluation for non-surgical valve replacement require an extensive workup. This is best done in a team format consisting of cardiologists, cardiothoracic surgeons, and the supporting staff members that work with them. This team approach allows for instant collaboration between physicians and helps guide the treatment options available to a patient. In addition to VHD, a heart valve clinic team can also provide evaluation for other structural heart problems.

Caring for patients with complex cardiac valve disease can be challenging, particularly when conditions such as advanced age and co-morbid illnesses are involved. Now, there is a specialized cardiac care resource that can be accessed for people with valvular heart disease. A heart valve clinic combines the expertise of a multidisciplinary team of physicians including cardiologists and cardiothoracic surgeons for evaluation and treatment of complex diseases of the cardiac valves and other structural heart issues. Referral to a heart valve clinic can provide a “one stop shop” to access the staff and resources necessary to provide detailed evaluation of these complex problems.

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