Dr. Rania Habib (Host): The Centers for Disease Control and Prevention estimates about 2.5 % of the U.S. population, or 7.5 million Americans, are living with mitral valve disease. As the population ages, mitral valve disease may become more prevalent in a primary care or clinical cardiologist's practice. Listen to Dr. Yash Chugh address what clinicians need to know for their patients they suspect need a mitral valve specialist.

Thank you for joining us for HeartSpeak, the podcast from Baylor Scott & White Heart Vascular Hospital in Dallas,

Host: Fort Worth, and Waxahatchee. I'm your host, Dr. Rania Habib. Today, we will discuss mitral valve disease with Dr. Yash Chugh. Dr. Chugh is a structural and interventional cardiologist on the medical staff at Baylor Scott & White Heart Vascular Hospital, Dallas and Baylor University Medical Center, part of Baylor Scott & White Health. Dr. Chugh previously recorded a similar podcast on mitral valves for the public, and now this episode on mitral valves focuses on important information for clinicians. Welcome to the podcast, Dr. Chugh. We are excited to have you on for a second time.

Dr. Yashasvi Chugh: Thank you, Dr. Habib. My pleasure. Thanks for having me.

Host: Now as we know, this is a very important topic, but many of us might not remember specifics about mitral valve disease from way back when we were in med school. So to begin, what are the various types of mitral valve disease, and how are they diagnosed?

Dr. Yashasvi Chugh: Yeah. So, that's a great startup question. Mitral valve disease, we club into disease where the valve becomes leaky because there's a distortion of the architecture for some reason, or if the valve becomes too tight. So, we'll talk about a leaky valve or mitral regurgitation. This often happens in two scenarios, scenario one is you're born with floppy mitral tissue. So, this is called as Barlow's disease or fibroelastic disease of your mitral valve. The mitral valve is undergoing so much stress every time it opens and closes, and usually having floppy tissue predisposes you to having your valve actually deteriorate or get damaged earlier on in life. And often, you can have a tear in the mitral valve architecture, similar to a tear in the ropes that hold a parachute together. And that often leads to a leaky mitral valve or mitral regurgitation from something called as a mitral valve flail or mitral chord rupture, these are some technical terms.

The other type of leaky mitral valve is in patients who have congestive heart failure from having either a weak heart that they were born with or heart blockages and heart attacks. Oftentimes, they can develop leaky mitral valves as well because the mitral valve architecture is really dependent on how the left ventricle or the heart pump's architecture is.

Now, the second type or second big spectrum of mitral valve disease is tight mitral valves. So, tight mitral valves can occur when you're young and something called as rheumatic heart disease. This is often a disease in countries like Southeast Asia, Mexico, South America, where there's a high burden of certain bacteria that can cause something called as rheumatic fever. So, we do see a lot of that in Dallas. Especially in immigrant populations, we see tight valves when they're very young.

And then, the second type of tight valves is in older patients. So as a part of aging and degeneration, when something is being used constantly, such as the mitral valve, it gets worn down and often calcium deposits on it, and we develop something called as mitral stenosis. And more specifically, the term we use is mitral stenosis from mitral annular calcification, which is a lot of calcium that deposits and really tightens the valve. So, these are the two broad categories of mitral valve disease.

Host: And where does mitral valve prolapse fit into those broad categories?

Dr. Yashasvi Chugh: So, mitral valve prolapse is a condition that describes that you have a lot of floppy extra tissue in your mitral valve. It doesn't necessarily mean you have a leaky mitral valve, but it just means you have a lot of extra floppy tissue in your mitral valve, which in your lifetime can predispose you to having a leaky mitral valve because of wear and tear.

Now, your last question, sorry, I just want to answer, which was how is mitral valve disease diagnosed? And the answer is very simple. Just a stethoscope can help you listen for a murmur which can often pick up if a valve is tight or leaky, and that is often followed up with an echocardiogram done by a cardiologist, which is an ultrasound of the heart.

Host: Now, once a clinician diagnoses a patient with mitral valve disease, a pressing question that they might have is, should we refer patients with mitral valve disease who are asymptomatic, Dr. Chugh?

Dr. Yashasvi Chugh: Yeah, that's a very important question. And the easy answer is yes. I think all patients with mitral valve disease, even if they're not symptomatic, should be referred. And I look at it as really two reasons. If you have asymptomatic disease, but the disease is bad enough, it will not get better without intervention. And we'd rather catch it and treat it early when the patients are stronger and healthier to withstand procedures versus later on when they can get sicker and more decompensated and develop congestive heart failure, then it becomes harder and riskier to help them.

Also, not all mitral valve disease needs to be treated. Really, we want disease to be severe and we treat disease that is severe. So, it's important for us to follow patients even with moderate disease, either moderate mitral regurgitation or moderate mitral stenosis. It's important for us to follow these patients in our Valve Center of Excellence so that when the time comes and they do become severe, they're in the right place at the right time.

Host: That's fantastic to know that you guys can offer those services. Now, speaking of that, when you receive referrals for patients with mitral valve disease to the Center for Valve Disorders at BHVH in Dallas, could you tell us a little bit about what patients can expect at their visit?

Dr. Yashasvi Chugh: Yeah, definitely. So, our goal has been to be very patient-centric. So, what usually the flow is when the referral is received by coordinators, our coordinators then contact patients. Usually, we have testing and visit all in one day. So, we have a bunch of tests that we need, which we do in the first half of the day. And then in the second half of the day, the patients meet with our team members, all our physicians. So, our sort of our practice has been that we will come to you. So, four physicians who are different specialists evaluate all patients with mitral valve disease at the same time. So, we visit with the patients so they don't have to go and visit four different specialists at four different times.

Our team includes a mitral valve surgeon who does open heart surgery; a cardiologist whose expertise is in doing imaging, which is echocardiograms and things like that, and helps us diagnose patients with severe valve disease and helps us come up with treatment options. We also have a heart failure specialist, so that's a cardiologist who is specializing and helping people with weak hearts and who have congestive heart failure. And then finally, myself, who is an interventional cardiologist and I, again, can offer procedures to patients that our surgeons may be reluctant to offer or think maybe too high risk to offer. So, we have a pretty robust team that will give the patients sort of a patient-centric treatment all in one day during their visit.

Host: That's wonderful. I mean, the fact that you're doing diagnostic and all the four specialists are there at one time is a very unique opportunity for that patient to work with a multidisciplinary team.

Dr. Yashasvi Chugh: Yeah, it definitely is. And I think we're probably one of the few centers in the country who do it this way. And, you know, we've really gotten great feedback from our patients, because they don't have to go to four different appointments at four different times. Here, four physicians can see the patients together and come up with a plan right there and then. So, they really tend to like it.

Host: Oh, that's fantastic. I want to go to a visit like that. Now, Dr. Chugh, we know that treatment options have evolved over the years. Could you discuss the treatment options from least invasive to the patient who might be a candidate for open heart surgery and just give us a brief refresher?

Dr. Yashasvi Chugh: So, I think our rule usually is if you're young and healthy, you should get open heart surgery, whether that is repairing your valve, or if the valve cannot be repaired, then replacing the valve. If you're older and you cannot get open heart surgery or the risk of open heart surgery is too high, and then we have treatment options where we can go through the groin with special catheters and devices, and we can repair your valve by putting clips and oftentimes we can even replace your valve and give you a new valve by going through the groin.

So all those things, at least the catheter-based technologies right now, the technologies to repair your valve with clips is available. The technology that is to replace your valve through the groin is limited to access only via research. But certainly, there is a promise in the future that this technology will be available for our sickest patients.

Host: That is fantastic. Now, you mentioned that there are different procedural options based on how old the patient is and their comorbidities. So, could you just touch base a little bit about why open heart surgery is more geared towards the young patients and why the clip variation of the catheter procedures are reserved for the older patients?

Dr. Yashasvi Chugh: Yeah, definitely. So I think standard of care really for someone with a leaky valve, and they're young and healthy and strong, they should really get a good surgeon at a high-volume center like ours, who does a lot of these procedures to get a good surgical repair. So, you can basically repair the valve, sort of patch it up, so it functions as it was designed to function. And I think we have data out there that if your valve is repaired by a good surgeon, you will continue to live a good life or your life expectancy really doesn't change.

Now, on the contrary, if you're older and we think your risk of surviving an open heart, going on the heart-lung machine, and then being in the ICU, then your scars and the wounds on your sternum have to heal, if that becomes a problem, if that's challenging, and then often we notice becomes challenging in the seventh, eighth, and ninth decade of life, and then at that time, we think that it's certainly much better to offer patients procedures through the groin using less invasive approaches, such as the MitraClip. So, the clip, or it's called a transcatheter edge-to-edge repair is the procedure, and MitraClip is one of the commercially available devices that we can use to help relieve leaky or treat leaky valves.

Host: Okay. So, I'll challenge you, why not use the less invasive, I think you were mentioning the TEER, for younger patients?

Dr. Yashasvi Chugh: That's a very good question. So, you know, I think, number one, there's not enough data. There's not enough data. The device was really studied and the studying started about 10 years ago in clinical trials in patients who were older and sicker and could not undergo surgery. Really, it's hard to get a valve to function normally or work normally with clips. It certainly cannot beat a good surgeon that sort of reconstructs the mitral valve and does surgical repair.

In terms of longevity and durability, that's someone who's 40 who comes to me, I have to make sure I give him a solution that lasts him until he's in his 80s. But if someone comes to me in their 70s, my goal may not be to give them a durable solution for 40 years, because they won't be around for 40 years. So, you know at that point my job is to make sure I give them the safest possible procedure that I think will get them "to the finish line", which may be another 10, 15 years. And I want to ensure that they don't have any complications from a major surgery in their 7th or 8th decade of life, if we have options that are less invasive and catheter-based.

Host: No, thank you for clarifying. That makes complete sense. Now, you did mention failed surgical valves. So, what treatment options are available for a patient with a failed surgical valve or failed surgical mitral repair that was done maybe a decade or 15 years ago since we know they typically last about 10 to 15 years?

Dr. Yashasvi Chugh: Yeah, that's a great question. And I think our population is really living longer than we were maybe 20 or 30 years ago. So, we're seeing a lot of patients who've had their first surgery, they continued, they've sort of outlived their valve and now we're stuck with a dilemma. And the dilemma usually is should our surgeons go in again and take this failed valve out and give them a new valve, which comes with risk, especially when you have to invade someone's body a second time. Sometimes that's the right thing to do, especially if the patients are still young.

Oftentimes again, it goes to how healthy the patients are, how old they are. But certainly, I think someone in their 80s, we would probably shy away from offering them a second surgery if we had options. And really, the option now that we have is we can put valves through the groin. And we can bring them to the level of the mitral valve and sort of put our new valve inside the old valve, sort of like a Russian doll that's stacked inside each other. And we avoid opening their chest. The patients go home the next day and they can resume their quality of life that they were missing because their tissue valve wasn't functioning appropriately.

Host: And what is the name of that procedure?

Dr. Yashasvi Chugh: It's transcatheter mitral valve inside a valve or mitral valve-in-valve. And we do also have the expertise to do procedures where we can put valve inside rings. If you've had a surgical repair in your lifetime, then the surgeons usually leave you with a ring. Again, like I said, they leave you with as little hardware as possible when they're repairing the valve and when those fail in some instances, we can certainly just put a valve inside there through the groin as well.

Host: That's fantastic. You're really giving patients, options for minimally invasive surgery to really help prolong their life and minimize complications. Our final question is what information should referring physicians consider when helping patients choose the appropriate specialist for mitral valve disease?

Dr. Yashasvi Chugh: Yeah, I think choosing the right team is important. So, a team that has experience in all spectrums of mitral valve disease, as I mentioned, and a team that is not only good with doing surgery, which is, like I said, I would still say gold standard for young patients with leaky valves, but I think teams that are equally good in doing catheter-based procedures with good outcomes for older patients and sicker patients. Also, teams that are multidisciplinary, such as our team where we have four different specialists evaluate each patient and decide what is the best procedure for them, tailored to their needs, their life expectancy, and the kind of problems they have. So, I think a team that is truly patient-centric and also is well-versed with surgical and catheter-based treatment options is your go-to team.

Host: And it's wonderful that you guys have that team specifically at Baylor Scott & White Heart and Vascular Hospital.

Dr. Yashasvi Chugh: Yeah, we're very lucky. I'm very lucky to be able to participate in the team and help our patients.

Host: Well, thank you so much, Dr. Chugh, for joining us today. We appreciate your time and expertise.

Dr. Yashasvi Chugh: Thank you very much, Dr. Habib.

Host: That was Dr. Yash Chugh, a structural and interventional cardiologist on the medical staff at Baylor Scott & White Heart and Vascular Hospital. For more information about mitral valve disease, diagnostic and treatment services at Baylor Scott & White Heart and Vascular Hospital, please call 214-820-3604. To refer a patient, please call 1-844-600-2342. Again, that's 1-844-600-2342, or check us out at bswhealth.com/heartdfw. I'm your host, Dr. Rania Habib, wishing you well.

Thanks for listening to Heart Speak, the podcast from Baylor Scott and White Heart and Vascular Hospital in Dallas, Fort Worth, and Waxahatchee. If you found this podcast helpful, please share it on your social channels and be sure to check out our entire podcast library to find topics of interest to you.

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