Melanie Cole, MS (Host): This is BayCare HealthChat, another podcast from BayCare Health System. Welcome to BayCare Health Chat. I'm Melanie Cole, and here to talk with me about aortic stenosis is Dr. Joshua Rovin. He's a cardiovascular surgeon and director of the center for advanced valve and structural heart careCenter for Advanced Valve and Structural Heart Care at Morton Plant Hospital, a part of BayCare. Dr. Rovin, it's a pleasure to have you join us today. This is such a great topic. Can you start by giving us a little physiology lesson? What is aortic stenosis?

Dr. Joshua Rovin: Well, good afternoon, Melanie. Thanks so much for having me. Aortic stenosis is one of the most common valvular abnormalities in the heart. You of course have four valves in the heart and the aortic valve is one of the valves that's between the left ventricle, which is the left sided pumping chamber and the aorta.

Typically the aortic valve has three leaflets and when those leaflets are normal, they open and close with the beating of the heart. But when they start to develop calcium on them, they become stiff and rigid, narrow. That opening narrows, and we refer to that as aortic stenosis.

Melanie Cole, MS (Host): What a great definition are there different types of aortic valve stenosis?

Dr. Joshua Rovin: Aortic stenosis is kind of the end term, but the real question that people ask me a lot is how did I get aortic stenosis? Or why do we get aortic stenosis? Most of the time, the majority of aortic stenosis that we see fits in the category of senile calcific aortic stenosis. And basically what that means is as we get older, we develop plaque and calcium on our aortic valve.

And we really don't understand exactly why that happens, but it tends to happen as we get older. So with each decade of life, we see a higher incidence of aortic stenosis.

Melanie Cole, MS (Host): So does it always produce symptoms? We always think of valve disease and calcification and atherosclerosis and all of these things as causing pain or fatigue or difficulty breathing, shortness of breath, any of these things, does it always produce symptoms? And if so, what are they?

Dr. Joshua Rovin: Right. So the majority of the time, what we're talking about is patients who have symptomatic, critical aortic stenosis. Aortic stenosis is a disease process that takes years and years, decades to develop in people with a tri leaflet valve. And so a lot of times people are really unaware of the fact that they have aortic stenosis. And it's usually most commonly picked up at an examination. So one of their doctors or nurses or nurse practitioners is listening and says, did you know that you have a murmur?

And that murmur is the sound of the turbulence of the blood across the aortic valve narrowing. And typically when that happens, they get sent to their cardiologist who listens and then gets an echocardiogram, which is a soundwave study of the heart. And it's on that study that we're able to make measurements to determine the severity or the significance of aortic stenosis. So there's a whole range of aortic stenosis.

And early on with mild aortic stenosis, most patients are asymptomatic. And then as it progresses over years to moderate, still patients may be asymptomatic. And most of the time patients don't become symptomatic until that narrowing becomes significant. And so that's something that's managed by following with your doctor and having serial echocardiograms. Occasionally someone will present with heart failure in the later stages of aortic stenosis.

And that's when it gets picked up toward the end. And most of the time, those are patients who present with shortness of breath, swelling of their legs, inability to lie flat. They could have chest pain, they could have passed out, but these are advanced stages of aortic stenosis.

Melanie Cole, MS (Host): As you were talking about how long it takes to build up this kind of calcification. First, I'd like you to tell the listeners if this is preventable? If living a healthy lifestyle, watching our cholesterol, getting plenty of exercise, if behavioral things can prevent aortic stenosis and valve disease from happening? And if so, what? But also, who's at risk? Are there certain risk factors? I mean, I assume you're going to say things like smoking and high cholesterol and such, but speak about those risk factors because if we can prevent it, it's great to start to try while we're in our younger ages.

Dr. Joshua Rovin: Sure. Unfortunately, there really is no direct cause for aortic stenosis and as I referred to it before, the other word we use is idiopathic senile calcific aortic stenosis. And idiopathic is just a fancy word for we don't really understand why it happens. So other than good health maintenance, as you described, watching your cholesterol and your blood pressure and not smoking. Those may contribute to preventing aortic stenosis, but more often than not, this is just a disease process that happens with age.

Now, there is a subset of patients who are born with an abnormal aortic valve. And when I say abnormal, we're talking about two leaflet valves instead of a three leaflet valve. And we call that bicuspid aortic stenosis. And in the United States, about two to three percent of the population is born with a bicuspid aortic valve. And what we know about those valves is that they tend to wear out faster than the three leaflet valves.

So a lot of times the patients that we're seeing who are younger in their fifties and sixties, those patients are presenting with aortic stenosis. And almost always, you can bet that they have a bicuspid aortic valve. And the reason why that's important is bicuspid aortic valve treatment usually requires surgery more often than tricuspid aortic valve.

Melanie Cole, MS (Host): A great educator you are. So as we're talking about diagnoses, and you mentioned idiopathic that obviously we don't always know the cause, unless like you say, it's a cardiogenetic thing that they've had since they were born. How then do you diagnose it? Is it found incidentally? Do they come in because they're having trouble breathing, but not always just shortness of breath on exertion? Tell us a little bit about how it's diagnosed. Are we doing the echo just as a screening? I mean, what don't really use that for screening, right?

Dr. Joshua Rovin: Sure. And I think these patients present two ways. One is the asymptomatic patient who it gets picked up on a physical exam that they have a murmur, then they get an echo. And that starts the process then of serial echo imaging, depending on where you are in that timeline. A lot of times patients have just mild aortic stenosis and they can be followed on a yearly basis with their cardiologist or their family doctor with echoes.

As you progress and have more severe aortic stenosis, they may want to increase that interval follow up to six-month period of time. Now at any point, along the way you start to become symptomatic. And as we touched on a little bit ago, symptomatic aortic stenosis, that's usually is patients who have shortness of breath with exertion. So they used to be able to walk up two flights of steps, now they're getting short of breath after the first flight.

They're noticing that their legs are starting to swell. They're not able to lay back flat. Maybe they have a little bit of chest discomfort with exertion. That group of patients who presents with those symptoms, then when you listen to them, they have a murmur and they get an echo, you may say, wow, you have aortic stenosis and that's what's causing these problems. So most of these patients make it to our structural heart center from their primary care doctors or from their cardiologists who have been screening and following them.

Melanie Cole, MS (Host): So then what is the first line of defense, Dr. Rovin? Are there any medications that can help with aortic stenosis? Do we recommend cardiac rehab to get them to work on some of that exercise tolerance and claudication that you know, the feeling in their legs, that heavy feeling? What is it that you're doing before you would consider a surgical intervention?

Dr. Joshua Rovin: Yeah. So I think, that it's really important to figure out what age the patient is and that's how we make decisions. So I think when we see someone like this who has symptomatic, critical aortic stenosis, it's really a matter of sorting through the process. How old is the patient? What is their functional status? And then they need to go through the workup. So they'll have a heart catheterization to measure the pressures in the heart.

They'll also be able to do a dye study of the coronary arteries to look for blockages. And then an echo of course. And then depending on your age, if you're older, a lot of times we do what's called a functional triage assessment. So we want to figure out how functional is this 86 year old that came to the clinic now with critical aortic stenosis. Many of our patients, particularly here in Florida, are very active.

We had someone who came in who was 94, who told us that they were now having symptoms because they were only playing tennis three days a week instead of five days a week. And that was how they presented to their doctors. So once we understand the anatomy, then it's really a complicated, but straightforward conversation about what are the options and treatment strategies to fix aortic stenosis.

Now you ask a question about medicines and so there really are no medications to treat aortic stenosis. Aortic stenosis is a mechanical problem. As we talked about earlier, where the valve leaflets just don't open or close adequately. So what medicines do in aortic stenosis is they help relieve the symptoms for patients.

And we may be able to tune patients up with some medications and make them feel better. But the actual disease process or the actual process of the aortic stenosis requires a mechanical intervention.

Melanie Cole, MS (Host): What does that entail? Can you tell us a little bit, because I mean, really, it's a very exciting field that you're in Dr. Rovin with TAVR and all of these valve disorder treatments that are coming around. And I mean, it's really an exciting time. So can you speak about some of the treatment options that you would offer people and really what that's like for patients?

Dr. Joshua Rovin: For sure. Yeah. the discussion has become more and more complicated. 20 years ago, even 10 years ago it was a very easy conversation because we only had one treatment strategy, which was open heart surgery. And so let's start with that, open heart surgery involves, stopping the heart, opening up the aorta, and looking down and cleaning out the aortic valve.

So we actually remove the leaflets by cutting them out and using instruments to remove all of the calcium from around that aortic anulus, which is the portion of the anatomy where the leaflets are attached to. And then we sew in a new valve, whether it's a mechanical valve made of metal or a bioprosthetic valve, which is a valve that's made out of animal parts.

So that's a surgical aortic valve replacement. Most of the time when someone has that operation, they're in the hospital for four or five days, and then the rehabilitation process after that takes weeks. And sometimes even months before people are back feeling a hundred percent. So obviously most patients would love an option that isn't that invasive. So the second option, which is a great option for many patients, but not everyone is called a TAVR.

A TAVR is a transcatheter aortic valve replacement. And in most patients, we're able to use the artery in the leg or the shoulder to deliver a catheter valve. That's a valve that is attached to a stent. And we actually put the valve inside of the old aortic valve. So it's inside of your own old narrowed aortic valve. And when it opens up, it pushes your own leaflets out of the way.

So unlike in a surgical valve replacement, where we remove all of that old tissue, in a TAVR, the TAVR valve actually pushes the old tissue out of the way. And when that stent expands the new leaflets, which have been sewn on to the stent start to work. So a TAVR is much less invasive and most patients go home the next day and are back doing their regular activities within a week or two. Having said that a TAVR is not for everyone.

It was designed for patients who have tri leaflet aortic valves. So it wasn't designed for bicuspid aortic valves. And initially it was only for patients who were too sick to have an operation. And over time with all of the studies and trials over the last decade plus, we've determined that this is a good option for most patients with good anatomy that allows us to place a TAVR valve.

Melanie Cole, MS (Host): Isn't that fascinating, what you can do and the way you just described a valve replacement, it is so interesting to me, and I know it is to our listeners as well. Before we wrap up, Dr. Rovin, what would you like people to know about valve disease and specifically aortic stenosis and really your best advice and what you can do for them at BayCare?

Dr. Joshua Rovin: So aortic stenosis. I think the most important thing to know is that it's treatable in most patients. And so we know that aortic stenosis, if left untreated and you're having symptoms, 50% of patients will be dead within two years. So it's not something to play around with. It's definitely something that needs to be evaluated and addressed by your doctor and hopefully referred to a structural heart team, which is a multidisciplinary team made up of cardiologists and cardiovascular surgeons to help decide the best treatment option. And so like I said, the good news, in 2022 is that we have several options to help patients. You just want to be at a place that has a very experienced multidisciplinary heart team to help walk you through the different choices and help you with that shared decision making about what is the best treatment strategy for your individual aortic stenosis.

Melanie Cole, MS (Host): What great information, what a great educator you are, and it is so important as you say, for shared decision making. Thank you so much, Dr. Rovin, for sharing your incredible expertise with us today. To learn more about treatments and prevention for aortic stenosis, please visit our website at BayCareHeartValve.org for more information, and to get connected with one of our providers. That concludes this episode of BayCare HealthChat.

Please always remember to subscribe, rate and review this podcast and all the other BayCare podcasts. I'm Melanie Cole.