Oct 25, 2018
Chest pain, shortness of breath and swollen feet are just some of the symptoms of heart valve disease. Dr. Vinod Thourani discusses how we diagnose and treat malfunctioning heart valves.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thank you for joining us today. We’re talking with Dr. Vinod Thourani, Chairman of Cardiac Surgery at MedStar Heart and Vascular Institute and MedStar Washington Hospital Center. Welcome, Dr. Thourani.
Dr. Vinod Thourani: Thank you so much.
Host: Today, we’re talking about options to treat heart valve disease. The heart has four valves that control the flow of blood through the heart into the rest of the body. When a valve is damaged or diseased, the flow is disrupted, which can lead to serious health implications. Valve disease risk increases with age and it’s estimated that more than half of people ages 70 and older have some heart valve function issues. As more people in the U.S. live longer, a growing population of people will require heart valve treatment. Dr. Thourani, what symptoms might a patient experience that would indicate a valvular disease?
Dr. Thourani: It’s a little bit different for the different valves that we have. For instance, the aortic valve has three common symptoms. You can get chest pain, which is similar to coronary artery disease, but it’s really due to the valve. You can also have shortness of breath, where you get winded when you walk up the stairs. Maybe you used to be able to walk up the stairs without getting winded, now you start to get winded. Aortic stenosis can have that symptom, also. And the third is you actually have something called syncope, where you get lightheaded. All of us, when we get up in the mornings, sometimes when we get up quickly out of bed, we get a little lightheaded - that’s not really aortic stenosis. But you can, with aortic stenosis, if you stand up or do activities, you can actually pass out or get lightheaded. So, for the aortic valve, those are the three main symptoms--chest pain, shortness of breath, or syncope. The mitral valve, which is another commonly diseased valve, really shortness of breath is the main symptom that you have, and so you have to be cognizant that you’re not able to do the activities that you were before, six months or a year ago. It has the potential of being a mitral valve issue because now the blood is going back into the lungs, and so really your lungs get overloaded with fluid and you get short of breath.
Host: How long would those symptoms have to present before a patient would maybe worry that they had something wrong with the heart?
Dr. Thourani: So, unlike coronary artery disease, which is sometimes, all of us have heard of--you have a heart attack, or myocardial infarction, and that can occur acutely. Aortic stenosis, mitral regurgitation--it usually takes a much longer time period, so it’s over the years or months that this occurs, and so it’s not nearly as acute of symptomatology as you would with coronary artery disease. I do want to mention the tricuspid valve - sometimes in our societies we call it, it’s called the forgotten valve. And you can get what we call tricuspid regurgitation, or leakage, and the big symptom for that is pedal edema, so your feet swell more than before. There are a lot of reasons to have your feet swell, but of course the tricuspid valve is also one reason where you can have liver congestion or pedal edema.
Host: Why do they call it the forgotten valve?
Dr. Thourani: Because, since the aortic valve and the mitral valve are so prevalent as far as disease pathologies, and that’s really what we are looking for, sometimes the tricuspid valve is not what we are looking for. So, I think that it’s very important for your physician, and we have a lot of them at MedStar Washington Hospital Center and in the Heart Institute, that specialize in valve disease, so it’s really important for everybody to look at all four valves by the diagnostic modalities that we have here.
Host: Could you walk us through the diagnosis process for a patient if they’re concerned that they have a heart issue--how do they get to you and how do you progress that to develop a treatment plan?
Dr. Thourani: So, as a cardiac surgeon, there’ve been multiple people who have seen the patient before they come to me. The first place is an internist who usually sees the patient, and the easiest way to diagnose somebody is just examination. A stethoscope—you can actually hear the murmurs within the heart by listening to various parts of the chest. If the internist does have murmurs, then it’s commonly sent to a cardiologist. A cardiologist will also listen to the heart. They are specialized in heart disease and valve disease, but they’ll also most likely order a transthoracic echocardiogram, and that’s a sonogram just like you do if you’re looking at the baby in a pregnant woman. It goes over the heart and this TTE is what it is commonly called, transthoracic echocardiogram, it’s an ultrasound that specifically can look at the valves. If the transthoracic echocardiogram shows disease, then really you need to be seen by a valve specialist, and they will take you to the next step of more advanced imaging or options for the patient.
Host: How often do valve disease patients require surgery, or is it something that often can be handled medicinally?
Dr. Thourani: So, the way that all valvular disease is really graded is mild, moderate or severe. So, those patients who are clearly mild or moderate do not require any surgical therapies at the time. However, it’s very important for a cardiologist--specifically, here at the Heart Institute we have cardiologists who are specifically interested in valve disease, and it’s really important for them to manage the patient with proper medications. And that pharmacologic treatment is really what’s the best, and sometimes you can keep that mild to moderate valve problem for life, if you’re on the proper medications. However, if it does go to the severe aspect of any valvular disease problem, then really it should be seen by an interventional cardiologist and a cardiac surgeon. And here, we have a valve team that is dedicated who just concentrate on valvular disease, and so I really think you have to hone in on specialists. This is not something for just everybody to treat. I think it’s very important for the heart team to evaluate patients with valve disease, and the reason is is that over the last 10 years there’s been a dramatic change in the management and the treatment of these patients with severe valve problems. Before, it was just surgery. And now, we have a multitude of options, which a lot of them now are less invasive, or quite simply a needle stick instead of opening the chest up, so we have so many different options compared to 15 years ago. A dedicated valve team will be able to really look at the patient in totality. We have an entire team of almost 30 to 40 people who just deal with a valve patient. We’re able to look at them from a frailty point of view, and then we’re able to, as a team, huddle together with CT personnel, with echocardiographers, with surgeons, with interventional cardiologists, and we sit down and we decide what our recommendation is, looking at a lot of the different pathways that we have. So, the patient gets phenomenal equipoise because we now have a dedicated team that has spent a lot of time and energy finding the best treatment modality for them.
Host: So, this is an excellent center of care for heart and vascular diseases, for valve diseases. Is there any way that a patient can reduce their risk of having this happen to them in the first place?
Dr. Thourani: I think that’s a great question. So just like there have been a lot of changes and advancement for interventional procedures for valve disease, they’re also making strides in the management of these patients. The earlier that patients are evaluated and diagnosed with a valve problem, they can be treated with antihypertensives and sometimes anti-lipid medications, and a bevy of different medical therapies to try to keep them at that mild to moderate valve disease pathway. So, our goal eventually is really to see patients earlier in their course, and maybe we can prevent them from having a procedure. If they need a procedure, then we have a heart team dedicated to helping them, but wouldn’t it be nice to try to have them live longer without a procedure.
Host: Is that level of education something that the cardiologists are working with, the general cardiologists, before they even get to you?
Dr. Thourani: Yes, they are, and we again at the Heart Institute have this phenomenal bevy of noninvasive general cardiologists who can help manage that, and that’s what we are concentrating on. But, I think it also go to internists. I think that a majority of patients around are seen by internists, not necessarily a cardiologist. So, I think our education has been within cardiology and cardiac surgery. My opinion is is that we need to really branch that out and diversify that out into the community of internists, also, because a lot of them are doing transthoracic echocardiograms in their offices.
Host: What are some of the more advanced technologies or techniques that patients can find at MedStar Heart and Vascular Institute that they maybe they couldn’t find elsewhere in the community?
Dr. Thourani: That’s something that we are very proud to note, that we have all the newest technologies to treat valvular heart disease. So, for example, when a patient comes in, we evaluate them for a regular surgery, for a sternotomy where we do go through the front of the chest, but on top of that we are now offering minimally invasive surgery, so we don’t have to go through the entire chest in order to fix their valve problems, and sometimes we don’t even need to go through the front of the chest at all. We do it minimally invasive through the side. So, that’s surgically that’s advances we’ve made and we have all of those available to us. The rapid growth of what we call transcatheter valve technologies has really exploded and we’re fortunate at the institute to have all of that technology available to us. We’re the only site in the surrounding 50 miles or so in the greater DC area that can provide all the new technologies for aortic valve, for the mitral valve and the tricuspid valve. So, quite honestly, we’re in a position to treat all the valves, sometimes without ever opening the patient up, and they can go home the next day or within two days. So, we do have a lot of technology that we’re also leading, and we’re the national investigators for many of the new technologies coming out, so we’d like to provide all the services for this area, and we believe that we can do that.
Host: What has you excited right now, either in looking forward in heart and vascular care, or in any research that you’re conducting with your colleagues?
Dr. Thourani: So, the thing that excites me the most are the people here. I think that we have put together a team of highly knowledgeable, very caring physicians who really have the patient as our primary focus. That’s really what I’m the most proud of, and to be one person within this large team is personally very gratifying for me. What we are leading is incisions or the lack of incisions for mitral valve disease and aortic valve disease. We’re actually the national leaders for two or three new trials in which there are only four or five centers in the entire United States who actually have this new technology. So we’re very fortunate to be able to have that here and we’re very fortunate to be able to bring that to the patients in the surrounding 7 million of us in the Northern Virginia, Maryland and DC area.
Host: Could you share any patient treatment success stories? Any outstanding care that was provided or outcomes you didn’t expect?
Dr. Thourani: So, recently, we had a patient who was in her 80s, very pleasant, literally like the grandmother that we wish we had. Very high risk, someone that was not a surgical candidate, and really was mentally as sharp as can be, so we really wanted to help her. And what we were able to do is after all of our testing, we thought that she would actually be benefitted by repairing her mitral valve with never opening her up. So, with a little needle stick in the femoral vein-- it’s a very easy procedure as far as getting access to. Through the femoral vein, we were able to repair her mitral valve, and she went home the next day. So, here’s someone who had lost all hope and wanted to spend more time with her grandkids, and we wanted her to do that, and she was completely depressed by this and kind of now bound at home. And we were able to give her another lease on life, so someone who had given to our community for over 80 years--now we were giving her back a little bit to let her enjoy the remaining parts of her life with her kids and grandkids. So, to me, that was just, it’s a fabulous story because it does show that we do have technology sometimes that somebody doesn’t know about until they come and see us, and I think that that’s something that we want to educate more people on.
Host: Could you describe that surgery in lay terms? Maybe start with where the femoral artery is?
Dr. Thourani: So, this procedure for the mitral valve, is done actually through the femoral vein, and so even a less risky procedure. So, we perform this in the cardiac cath lab. The patient is asleep, and we do put probes down their throat so that we can monitor the heart the whole time. And the femoral vein is actually located right in your groin area. If you feel your groin area, there’s a pulse. Just next to that is your vein. And we’re able to have a little needle stick there with local lidocaine and we’re able to perform the entire procedure. And so, when you’re completed with the procedure, which takes about an hour to hour and a half, there’s actually zero incision, and so you walk away with valve surgery with no incision. I think that’s pretty remarkable.
Host: I’d say. So, you can replace the entire valve via catheter?
Dr. Thourani: Yeah, you can replace it and you can repair it. And so, I think it’s something that has really grown within the last decade, and we’re fortunate that the institute was one of the earliest sites, within the first five sites in the United States, to have this technology, and so we’ve really perfected it in the last 12 years of having the technology.
Host: Thank you for coming today, Dr. Thourani.
Dr. Thourani: Absolutely. Thank you for the invitation.
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