Prakash Chandran (Host): Congenital or acquired structural heart disease can be discouraging for patients trying to live a heart healthy lifestyle. But over the years, the options for identifying, treating or undergoing surgery for structural heart disease have expanded, especially catheterization for valve repair or replacement.

Because of the structural heart program at Ascension Illinois, patient outcomes and recovery are progressively improving.

Here with us to discuss is Dr. Anupama Shivaraju, an interventional and structural cardiologist at Ascension Illinois.

Prakash Chandran (Host): This is “HealthCast” the podcast from ASCENSION Illinois. I'm your host Prakash Chandran.

So Dr. Shivaraju, thank you so much for joining us today. I really appreciate it. I wanted to start by asking when people refer to structural heart, what exactly do they mean?

Anupama Shivaraju, MD (Guest): Great question. So, the heart essentially is it's a muscle and it's a pump that collects blood and pumps blood back out to the body. And when we refer to structural heart, it's the internal components of this muscle, or the organ that whenever there's abnormalities pertaining to either the valves that are inside the heart muscle or issues with certain chambers with holes being there, or kind of appendages that need to be closed, these are all kind of fall under the umbrella of structural heart disease.

Host: You know, when it comes to structural heart symptoms, what do patients typically present with in a primary care settings?

Dr. Shivaraju: It depends on the cause to the problem. So let's take, for example, the valvular heart disease. You have four valves in the heart, two on the right side chamber two on the left side of the chambers. If there's issues with either a tight valve or a leaky valve on the left side, usually that translates all of that pressure and volume to the lungs.

So, a lot of people will present with feeling short of breath. You often hear people kind of complaining of feeling tired, and if there are issues with the right sided valves, or even sometimes when the left sided chambers get overwhelmed and things get translated to the right side. Cause one of the most common causes for right-sided heart failure is problems with the left chambers of the heart or the left structures of the heart.

Those patients can often also start noticing swelling in their legs. They'll notice some people will complain a feeling bloating type sensation in their abdomen, dizziness because of inadequate blood flow circulating. So, the more common symptoms are usually shortness of breath, tired. Sometimes with valvular heart disease, you can get chest discomfort, but dizziness, lower extremity edema. These are some of the more common symptoms that you hear about.

Host: Okay. And one of the things that I think a lot of us have heard about is just general heart disease, specifically coronary artery disease. Does this fall into the category of structural heart or is that completely different?

Dr. Shivaraju: So coronaries are arteries that supply blood to the heart muscle. They're usually on the external surface of the heart muscle. And there you tend to see more atherosclerotic type disease where you have plaque buildup because of people that have high risk factors, like high blood pressure, diabetes, tobacco, that ends up leading to blockage in those arteries.

And when you get a blockage in those arteries, you don't get adequate blood flow to the heart muscle and they start getting symptoms of chest pain. And here also you can get symptoms of shortness of breath and tiredness, especially in women and elderly people and people with diabetes. So coronary artery disease does not fall under the realm of structural, but it definitely falls under the umbrella of cardiovascular disease.

Host: Okay, that makes sense. Thanks for the clarification. So when we talk about assessing the severity of structural heart disease, can you talk a little bit about the workup to actually do that?

Dr. Shivaraju: When we talk about valvular heart disease, a lot of time when people present with symptoms, you'll hear whether it's your primary care physician or your cardiologist, when they listen to your heart, a lot of the times they can hear murmur. Whether you have a tight valve or a leaky valve, and that usually will raise enough concern for them to start with an echocardiogram.

Sometimes they'll get an EKG just to see what your rhythm is. If they hear any irregularity in your heart rhythm. Echocardiogram, which is the surface ultrasound, where they put a gel on your chest and they put a probe and they take pictures, that give us images of the internal structures of the heart.

And that tells us well, how well is that heart muscle squeezing? How well are your valves working? Which valve is involved? Is it leaking? Is it tight? So it gives us a wealth of information. And a lot of the times, if we need to determine what the next types of treatment are, or if we want to get a better image quality, they may say that we may want to get a transesophageal echo. What that means is putting a probe with an ultrasound camera at the end of that probe down your food pipe. Cause your food pipe sits very close to the heart, right behind the heart. And it gives us better pictures of the heart valve. So usually a starting test will be a surface ultrasound. Sometimes they may do the transesophageal echo to get better images.

And then finally, and this isn't true for everybody. And finally, like say if we're determining, okay, surgery is the way to go to fix this. They may do an angiogram, which is taking pictures of the heart arteries. Make sure that there's no coronary artery disease. Cause if there is, and you're going to get surgery for a valve disease, they can fix all of it together.

Host: Yeah. So that makes a lot of sense with regards to the workup to assess the severity of structural heart disease. But you know, I've heard of these different valves and you know, you kind of mentioned the valvular heart disease at the beginning, but I've heard of things like the mitral valve and the aortic valve. There's just lots of valves that are involved with this. Can you kind of do a breakdown or maybe unpack some of these for us?

Dr. Shivaraju: Absolutely. are a total of four valves. You have two on the right side, which are your tricuspid valve and pulmonic valve. The tricuspid valve is allowing blood to flow from the right top chamber to the bottom. And the pulmonary valve allows blood to flow from the right bottom chamber out to the pulmonary vasculature. The two valves on the left side, your mitral valve and your aortic valve, you mitral valve allows blood to flow from the left top chamber to the left bottom chamber. And the aortic valve allows blood to flow from the left bottom chamber back out to the body. So remember, in the beginning, I told you the heart is a pump.

It collects blood from the body, and then it pumps the blood back out to the body, the right sided chambers collect blood from the body, from there it pushes the blood into the pulmonary circulature, where it picks up oxygen in, as it circulates through the lungs and that oxygen rich blood returns to the left side of the heart.

And then the pump, the heart pumps that back out to the body. And the valves, think of them as kind of doors that are supposed to only open in one direction, allowing blood to flow in one direction. But over time these doors for various reasons, either your born with a congenital abnormality or as we grow older, the valves degenerate. You end up either getting stenosis where it's tight and not opening as effectively as it should, or it gets leaky where you have blood flowing in both directions.

And so in adults, as we grow older, the left sided heart chambers valves are the ones that are affected the most. So the two most common things that we see are mitral valve disease and aortic valve disease, and particularly arotic valve stenosis. And in younger people, you see a lot more of the pulmonic valve. You don't see as much of the right-sided valve issues in, in older patients, unless since the heart, the two chambers are connected in a series, when you have overwhelming left sided disease, whether it's valular the heart muscle on the left side, not working effectively, that all translates to the lungs and that pressure all translates then to the right side.

And you can start getting leaks in the tricuspid valve often associated with either aortic or mitral valve disease. I hope that clarify things a little bit.

Host: Yeah, it does help clarify things. I think I'm going to have to listen to this back a couple of times to really get it crystal clear my head, but, but yeah, no, that's very helpful. So, you know, earlier, when we were talking about the workup to assess things, you talked about, if surgery was required that maybe you'd get an angiogram. You're at Resurrection Medical Center in Chicago. I'd love for you to talk just more broadly about the treatment modalities, including surgery that are available for patients there.

Dr. Shivaraju: You know, so just more thing I wanted to emphasize is that, you know, we've, we focused mainly on valvular heart disease, because that tends to be more common. The two other structural things that we tend to see sometimes not as often as valvular heart disease are, issues with the septum that separates the right and the left chambers of the heart, you can get holes in the two top chambers of the heart or the two bottom chambers of the heart that we can close with devices.

And also people that have atrial fibrillation, irregular heart rhythm. They have a higher tendency to form blood clots in a little pouch called the appendage, that's at the left top chamber. And we have now procedures where we can close off the appendage. So people don't have to be on blood thinners, lifelong.

These are elderly patients and minimize their risk of bleeding. So all of that kind of falls under structural heart as well. Now, to come back to your question, there are very different treatment modalities available in then as technology gets better with time we see a lot more of the minimally invasive procedures coming about to address a lot of these valvular and structural heart diseases as well.

There's, with certain valvular heart disease there are really good medical therapy that we try first, especially in patients who are not really symptomatic, but we tend to kind of listen, we hear a murmur, we decide that we get an echo and we determine that they have a valvular heart disease And in these patients, we can just do medications like beta blockers and calcium channel blockers that we put them on to help improve the strength of their heart muscle, to prevent a process called remodeling, which is a bad thing in the heart.

And we put them on water pill, if they're noticing that they're gaining extra weight, water weight, and they're getting swelling in their legs. Now, open-heart surgery has been around for a long time and people with significant valvular heart disease do really well with the open-heart surgeries, if they don't have a lot of comorbid conditions and they're relatively healthy patients. And lately what we've been able to do is especially with the aortic valve in people that have tight aortic valve, we can replace those valves through catheter. And that procedure is called transcatheter aortic valve replacement. TAVR is the short version for it and that's become quite popular and well-known in the field of cardiology at least.

We can also repair some of the mitral valve leaks with a device called a MitraClip. Coming in the horizon, are there lots of valves currently in trial in the United States and overseas, looking at replacing mitral and tricuspid through catheters with tiny incisions, either coming through the blood vessels in the leg or arm.

So there's a lot of a lot of things, exciting things coming in the horizon. And certainly we do have currently ways we can repair and replace the aortic valve and repair the mitral valve.

Host: It's really amazing to hear just how far technology has come. Related to the last point you just made, what criteria qualifies patients for a valve repair or replacement procedure. And when should they be referred to a structural heart program?

Dr. Shivaraju: Another excellent question. So, in terms of determining repair replacement, we usually, there's a heart team involved in most institutions where they have structural programs, where they offer both catheter-based therapies and open heart surgery. We create a heart team which involves a surgeon, it involves the interventional cardiologists that do the minimally invasive procedures. It involves an imaging physician who do the echocardiograms and CTs, the nurse practitioners, or valve coordinators that are involved. So it's a big team that's involved in every patient. We review the images together. We look at how old are they? What are their comorbid conditions? How are they physically, you know, are they frail? Can they, it can be recover from surgery. So all of these factors go into making the decision between the treatment modalities. Now, whenever people start developing symptoms or there's evidence of valvular heart disease.,I think it's a good idea to get them established with a cardiologist and a cardiologist is anybody that practices general cardiology will know how to manage a valvular heart disease as well. So they will get routine echos or when they come for follow-up visits, kind of determine, are you getting symptoms?

Are you developing any symptoms? Based on kind of the symptoms and how severe the disease is they'll determine, okay, now is probably the right time for you to go meet with the surgeon or meet with this heart team and the structural team to determine what are the next steps of the procedure.

Host: So, you know, just as we start to close here you know, you hear about the modifiable risk factors associated with, for example, coronary artery disease, things like, hey, you know, you shouldn't smoke, you should eat a heart healthy diet. Is it the same for maintaining a healthy heart when it comes to structural heart disease?

Dr. Shivaraju: Very similar. The genetics, there's nothing we can do about it. Right? It's if somebody is born with a congenitally abnormal valve leaflet there's nothing they can do about it. It's something that over time may progressively get worse and get to the point where they need either surgical or transcatheter repair or replacement of the valve. Those that that develop heart failure and secondary to heart failure that develop mitral valve regurgitation, yes, it's very similar. These are just make sure your blood pressure is very well controlled. Make sure you don't develop diabetes. And if you have diabetes, make sure your sugars are well controlled.

Don't smoke. Exercise plays a big component in heart health. We emphasize cardiovascular exercise for a reason is because it's a muscle at the end of the day, and you want to condition that muscle as well. And the best way to condition that muscle is get your heart rate up to your target heart rate level and maintain it for 30 minutes a day, at least three to four days a week. Makes a big difference in, in conditioning, the heart valve.

And I think they then tolerate should they get any progression of these valvular heart disease, they tolerate it better. So, whenever we talk about heart failure, we talk about a compensated state and a decompensated state. And what that generally means is somebody has weakness in their heart muscle or have valvular heart disease, but they're compensated because they're not really accumulating a lot of fluid.

They're not requiring hospitalization. And that comes from just living a healthy lifestyle, lot of the times. And the decompensated state is people that are just getting a lot of fluid accumulation and they're very sensitive to salt and different lifestyle modifiers that end up in frequent hospitalizations for them. And so it's important to maintain the same risk factors that we talk about for coronary artery disease to make sure that all of those things are under control as well.

Host: Yeah, that makes a lot of sense. So, just as we close, is there anything else that you'd like to share with our audience?

Dr. Shivaraju: Heart disease is number one killer in men and women throughout the world. It's no longer just in the United States and heart health is the most, preventative health is the best health. And so starting early, being mindful and it's truly a lifestyle change. And you know, I always tell patients that don't I take any offense when you're at a point when you don't need me and you don't need to come see somebody like me, and we all want that too.

Even though this is what we do for our living. We want everybody to be healthy. We want it. Be able to get to people at the point where we can prevent the disease process from starting. And obviously, even if you have developed these disease process, secondary prevention is also equally important.

So prevention is key. And you know, if not even if for whatever reason we, we get to the point where we have developed these disease, then getting, paying attention, getting the help that you need early on makes a big difference because a lot of the people, especially with a lot of the valvular heart disease, we tend to see that in older patients in their seventies, eighties, nineties, and when they start getting symptoms of tiredness and fatigue and shortness of breath, they have a tendency to just chalk that up to old age.

And I say, don't chalk it up to age. Age is just a number, you know, your functional capacity. If you're an active individual and you notice that there's a change in your functional capacity, that should warrant you to go seek help.

Host: Well, I think that is the perfect place to end. And you know, just a good reminder that we have to be proactive, especially with our heart health. We have to know our numbers, eat right, exercise, all of those things are going to prevent you from seeing Dr. Shivaraju. And clearly she doesn't mind if that happens.

Dr. Shivaraju: A hundred percent don't mind.

Host: All right. Well, thank you so much for your time today, I truly appreciate it.

Dr. Shivaraju: Thank you. I appreciate you.

Prakash Chandran (Host): That was Dr. Anupama Shivaraju an interventional and structural cardiologist at Ascension Illinois. To learn more about the latest heart valve treatment options available near you, visit ascension.org/ILheartvalvecare. Thanks for listening to “HealthCast” the podcast from Ascension Illinois. I’m Prakash Chandran.