Rania Habib, MD, DDS (Host): Thank you for joining us for HeartSpeak, the podcast from Baylor Scott & White Heart & Vascular Hospital in Dallas, Fort Worth, and Waxahachie. I'm your host, Dr. Rania Habib. Today, we will discuss heart valve disease with a specific concentration on aortic stenosis with Dr. Purav Mody. Dr. Mody is a non-invasive cardiologist on the medical staff of Baylor, Scott & White Heart & Vascular Hospital in Dallas, who specializes in the diagnosis and management of complex structural heart disease with a focus on valvular disorders.

He leads the imaging side of the valve clinic that is run by experts across multiple disciplines and performs all requisite pre, intra, and post procedural imaging for patients with complex valve disease. Welcome, Dr. Mody. We're very excited about this topic today.

Purav Mody, MD: Hi, good afternoon and firstly, thank you so much for having me on this podcast.

Host: We are so excited to delve into this topic. To begin, what exactly are heart valves and what is their function? Could you briefly give us an explanation of the anatomy?

Purav Mody, MD: Yes, so heart valves perform a very important function within the heart. As we all know, the heart is known to pump blood all over the body. However, to facilitate this function smoothly, the heart has some unique structural features, so as to speak, and those include heart valves. The primary function of the heart valves is to make sure blood goes in one direction only, and also to make sure it goes in the direction it's supposed to be.

And so, essential heart valve function is very important to make sure your heart does its job properly.

Host: Okay. And how many heart valves are in the heart?

Purav Mody, MD: So there primarily four main heart valves, depending, you know, there are two within the actual heart, and then there are two heart valves on the big blood vessels that supply blood from the heart to the rest of the body, as well as one of the bigger blood vessels that takes blood from the heart to the lungs.

There are four of them, so starting from the right side, there's one which is on the right side, and connects the top and bottom chambers of the heart on the right side. It's called the tricuspid valve. Tricuspid because there are three leaflets. From there the blood goes from the bottom chamber of the heart on the right side to the lungs where it gets oxygenated.

There is valve which is called the pulmonic valve which is within the blood vessel which is called pulmonary artery and this one ensures that blood goes only in one way from the right side of the heart to the lungs. Once the blood gets oxygenated appropriately in the lungs, that is brought back to the left side of the heart and from there it goes from the top to the bottom chamber through what we call the mitral valve. So that is the big dominant valve on the left side of the heart. And finally from the bottom left chamber of the heart, when the heart squeezes, it pushes blood from the heart to the rest of the body through a big blood vessel called the aorta and therein lies an important valve called the aortic valve and this valve ensures that blood goes again in one direction from the heart to the rest of the body versus going back inside the heart.

Host: So heart valves function to pump the heart, and as you said, keep it going in the right direction. So Dr. Mody, what are the most common valve disorders? And could you specifically then focus on aortic stenosis?

Purav Mody, MD: Just taking a step back, heart disease is an important cause of morbidity and mortality in this country. One of the major subsets of heart disease that people experience as they grow older are valvular heart disease, and that's an umbrella term for any issues that can happen with any of these four valves. The problems that happen with heart valves primarily are placed in two primary buckets. One is an issue with the valve not opening enough, or so as to speak, it's called stenosis. and the other bucket in which valves can malfunction is if they open too much or they're unable to close properly, which can then cause leakiness or regurgitation of blood in the wrong direction.

So this two lesions, stenosis and regurgitation can affect all four of these valves in different severities. The most common valve disease that we see is aortic stenosis. That is, the aortic valve, which as we grow older, just doesn't open as robustly as it should. This is then followed by mitral regurgitation, and then a distant third fourth would be disorders of the tricuspid and the pulmonic valve.

Host: Thank you for sharing that very helpful information. So when we specifically talk about aortic stenosis, what signs and symptoms would alert someone to suspect that they might have a problem with aortic stenosis?

Purav Mody, MD: So aortic stenosis, you know, as we just kind of covered, is the most common valvular heart disease. And before I get to the symptoms, just to kind of put it out there for our audience, AS is a disease which becomes more prevalent as people grow old. So it is prevalent in less than 1% of the general population aged under 50 years.

But with every decade of life, it increases in prevalence to the point that by the time somebody is in their eighth decade of their life, the prevalence of aortic stenosis in the general population hits about 10%. So almost one in 10 person age 80 or older will have some degree of aortic stenosis and this is why recognizing the symptoms of aortic stenosis is so very important. Symptoms can be very general in the sense that people will, start experiencing chest pain. This is chest pain or chest discomfort, as I would like to say, that they would notice once they start exerting themselves, start doing strenuous, heavy, heavy activities.

Other symptoms include swelling of their ankles, feeling dizzy. lightheaded. Most of these symptoms tend to occur with exertion, but with progression of aortic stenosis, some patients might even experience these symptoms at rest.

Host: Some patients are referred to a cardiologist by their primary care provider, but other patients are seen by a clinical cardiologist first. If a patient is experiencing any of the signs and symptoms, which you went into detail about for heart valve disease, should they seek care from their primary care provider or should they self refer to a cardiologist? Can you walk us through that difference?

Purav Mody, MD: So, these symptoms that I just highlighted chest pain, feeling dizzy, lightheaded, you know, getting exhausted with less activity than usual; these are very general, non-specific symptoms. So it's very common that these patients actually present to a primary care provider first before they see a cardiologist. As a part of any clinical visit with a primary care provider, a thorough examination is a must. Most patients with aortic stenosis will have, some signs and symptoms. The primary care provider can look for swelling of their ankles. And most importantly, they can auscultate or listen to the patient's heart.

Patients with aortic stenosis have a very distinct heart murmur which radiates to the neck or to the cardis, to speak more technically. Usually, we'll have primary care providers who, when patients give this history and have examination findings such as swelling of their ankles or a distinct heart murmur, that usually is a referral to a clinical cardiologist to investigate further. And that's how patients end up coming to see me for further evaluations. Every now and then, because of the symptoms of chest pain and dizziness, we'll have patients who will self refer themselves, especially patients who are very well educated or patients who are very self aware of their health would like to see a cardiologist first, which is completely fine.

And then on my exam, it would not be uncommon to pick up a heart murmur or the other signs of aortic stenosis.

Host: Thank you for that very detailed distinction. If a patient now comes to you or the primary care physician with this concern that they might have heart valve disease, what are the common diagnostic tests that might be ordered that would further evaluate and help manage specifically aortic stenosis?

Purav Mody, MD: The advancements in diagnostics has come a long way, especially over the last few decades. The most common test that we would do is, usually most patients get an EKG, but the most helpful specific diagnostic test that we do is what we call an echocardiogram, which simply put is an ultrasound of the heart. And in that study, we can clearly see all the heart valves, especially the aortic stenosis. We can take a good look at if the valve is opening or not, if there's any abnormal calcium deposition, and more importantly, we can assess the function of the valves in terms of how much it is opening.

And this can be done non-invasively. So there's no invasive test. A patient just has to come in for his appointment, which the study would take about 20 to 30 minutes, a simple ultrasound and those images that are then uploaded for review. That is the gold standard diagnostic test for aortic stenosis.

Host: Are there any other emerging imaging or tests specifically for diagnosis that we're seeing on the horizon?

Purav Mody, MD: Absolutely. There will always be certain patients whom echocardiogram is not enough or this might not be sufficient to confirm the diagnosis of aortic stenosis. More importantly, when we're doing these tests and assessing valvular heart disease, not only are we trying to diagnose whether somebody has aortic stenosis or not, we are also trying to quantify the severity.

So, most valvular heart diseases are usually placed, if present, in three buckets; mild, moderate, and severe. To really find out if somebody has severe aortic stenosis or not, most times ECHO is sufficient. But every now and then you'll have patients who are a little more challenging, a little more complicated.

In the last five to 10 years, cardiac CT has really emerged as a good alternative in terms of assessing severity of aortic stenosis by a few different things. It can assess the amount of calcium that is present on the valve with more calcium suggestive of a more severe valve. They can also help with assessing how much the valve is opening, looking at slightly different pictures than what we see on echocardiogram. So cardiac CT is definitely one of the newer diagnostic imaging modalities that has gained traction. And then lastly, in very, very small percentage of patients, if the diagnosis is still unclear, doing a cardiac catheterization, which is a more invasive test, can sometimes help to really decide if somebody has severe aortic stenosis or not.

Host: So once you diagnose a patient with aortic stenosis, and as you said, there's all these different imaging tests that you can choose as the cardiologist, and you put them into their bucket of mild, moderate, or severe, could you review with us the treatment options for aortic stenosis?

Purav Mody, MD: Yes, and this is actually where the most exciting developments have been occurring. About I would say, 10 15 years ago, the only treatment for severe aortic stenosis used to be what we call SAVR, or Surgical Aortic Valve Replacement. This is a major heart operation where somebody has their chest open and the valve surgically replaced with a new valve.

However, as we also know that aortic stenosis is a disease that becomes more prevalent as people grow old; and also presents an interesting dilemma or dichotomy in the sense that patients tend to be sicker, more frail, and might not necessarily be low risk enough to safely undergo cardiac surgery. And those patients did not have an option until about a decade ago.

However, there's a whole new technology called Transcatheter Valve Replacement or Aortic Valve Replacement, and in short it's called TAVR, where patients can actually get their aortic valve replaced through a procedure where experts go in through their leg and enter where the aortic valve is and percutaneously using catheters, replace the aortic valve. And all the equipment comes out after the procedure is done, which usually takes about 30 to 45 minutes, and patients are monitored overnight, and if they're doing okay, and everything looks okay, they go home as soon as the next day. And that has really been a game changer in the sense that aortic valve replacement is now available to a wide variety of patients regardless of what their comorbidities are.

Host: That is really fantastic news, Dr. Mody. What are the newer emerging treatment options that we see on the horizon for the treatment of aortic stenosis? Is there anything beyond the new TAVR replacement that you're referring to?

Purav Mody, MD: The advancements in TAVR are significant in the sense that we have come a long way in the last 10 years, in terms of reducing the safety and complication profile of this new technology, and heart valves that are implanted through this technique are getting more and more individualized and personalized so that there are more options for patients to obtain a valve which seems most appropriate for their anatomy and their underlying disease condition. The other technology that is emerging is we have valves that are being developed now that can be implanted. So if a patient has a TAVR valve done, but let's say 10 years from then the valve is not functioning as well, then there's always an option to go in the same way and place another valve within the pre existing valve, thereby saving the patient another sternotomy or saving them a major cardiac surgery operation. These are obviously very nuanced discussions, which are best handled at specialized centers with extensive valve clinic experience dealing with these patients.

But there is an option for doing what we call valve in valve, replacing valves within valves if needed, which is also becoming more and more popular.

Host: It is so wonderful that you guys are able to really customize the type of valve surgery that these patients undergo, and I love the fact that this technology has really allowed you to take care of those really difficult patients when the patients are sicker and more elderly. So thank you for sharing this exciting new development.

We're getting near to the podcast, Dr. Mody, so are there any take home points that you would like to leave with our audience, specifically about aortic stenosis?

Purav Mody, MD: Yes, as always, lead a heart healthy lifestyle, which would include, you know, exercising regularly, eating the right kind of diet, and most importantly, listening to your body. If you start noticing symptoms where you feel like you're getting more fatigued or tired than, doing activities that previously seemed not an issue to you, go see a primary care provider.

Try to investigate if something is going wrong. This is always best if it's done earlier and with the newer treatment options. There are treatment modalities which can help you feel a whole lot better in a safe and effective manner, and a very, very fast and rapid way.

Host: Thank you so much for joining us today, Dr. Mody. It was a wonderful discussion.

Purav Mody, MD: Thank you so much. It was a pleasure to be talking with you about something that's near and dear to my heart.

Host: That's Dr. Purav Mody, a cardiologist on the medical staff of Baylor Scott & White Heart & Vascular Hospital in Dallas. To find a cardiologist, please call 1-844-600-2342. That's 1-844-600-2342. Or visit bswhealth.com/heartdfw. I'm your host, Dr. Rania Habib, wishing you well. Thanks for listening to Heart Speak, the podcast from Baylor Scott & White Heart & Vascular Hospital in Dallas, Fort Worth and Waxahatchee.

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