More than five million Americans have moderate or severe heart valve disease. Left undiagnosed and untreated, their condition can cause
progressive deterioration in heart function, which can result in heart failure and premature death.
Kendra Grubb, MD, MHA, FACC, discusses the latest heart valve disease treatment options available at Emory HealthCare.
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The Latest Heart Valve Disease Treatment Options
Featuring:
Learn more about Dr. Kendra Grubb
Kendra J. Grubb, MD, MHA
Dr. Kendra Grubb is the surgical director of the Emory Structural Heart and Valve Center. Prior to joining Emory, Dr. Grubb was the director of minimally invasive cardiac surgery and the surgical director of the heart valve program at the University of Louisville. Dr. Grubb is a champion for women's heart disease, and is dedicated to improving the lives of all patients, both male and female, through innovation and by building collaborative teams to promote a patient-centered approach to the treatment of cardiovascular disease.Learn more about Dr. Kendra Grubb
Transcription:
Bill Klaproth: Five million Americans have moderate or severe heart valve disease left undiagnosed and untreated. Their condition can cause a progressive deterioration in heart function, which can result in heart failure and premature death. Here to talk with us about the latest heart valve disease treatment options is Dr. Kendra J. Grubb, surgical director at Emory Structural Heart and Valve Center at Emory Healthcare.
Thank you for your time. Why do they call heart valve disease “mystery killers?”
Kendra J. Grubb, MD, MHA, FACC: Often times, patients don’t realize that they have valvular heart disease until its very progressed to the point where that they have symptoms that are really interfering with their life. Some of these patients, the valvular disease results in the actual heart muscles starting to fail, and those patients are particularly vulnerable.
Bill: How would someone know if they have heart valve disease? You mentioned symptoms. What should we be looking for?
Dr. Grubb: Some of the common symptoms of valvular heart disease are simple things like shortness of breath or pain in the chest called angina or dizziness when you stand up. In the advanced forms of that, patients may have an actual syncope where they pass out and certainly things like leg swelling would clue people in. When a patient sees their doctor, they should be asking about their heart and asking questions like ‘do I have a murmur?’ The murmur is the sound that the valve makes when it’s diseased.
Bill: How do you diagnose heart valve disease?
Dr. Grubb: At the doctor’s office, often times while the doctor’s listening to the chest with the stethoscope, a murmur can be heard and the murmur is turbulent flow pattern through the valve itself. Instead of hearing the typical lub-dub, there may be a swooshing sound during that usual lub-dub. The physician would then be able to hear it. After a murmur is identified, then an echocardiogram or what's more commonly thought of as like an ultrasound of the heart is done where we can actually visualize a heart valve as well as the pumping chambers of the heart and be able to see the actual pathology of the valve.
Bill: Is this something you're born with or can people develop this over time?
Dr. Grubb: There's actually both. Some patients are born with valve disease. Those patients we term ‘congenital’ and so there are patients that could have a bicuspid valve from the time that they're children. Their bicuspid valve is normal for them but not normal for an adult, so those patients, their valve will wear out sooner rather than later. Often times, their valves will be replaced when they're in their 40s or 50s. Some patients have calcium deposits on their valve leaflets as they age and it’s more of a wear and tear process and the valve starts to get stenotic, or tight. As the valve tightens, the heart muscle has to work harder in order to pump the blood out of the pumping chambers into the rest of the body.
Bill: How do you generally treat this? Is it reversible?
Dr. Grubb: Unfortunately, for valvular heart disease, there is no medicine that can fix it. Medicines are the first line to treat the symptoms so we control the blood pressure, we try to control any signs of heart failure like swelling by using diuretics. We try to start the medicines that make the heart be more efficient but nothing is going to stop the actual process of the valve degeneration whether it’s a leaky valve called insufficiency or regurgitation or the opposite, a stenotic valve, where the valve is too tight, it's a progressive disease. The only treatment is either a repair or a replacement. Traditionally, the only option was open heart surgery where we would open the breastbone, go on the heart-lung machine, stop the heart, stop the lungs and either replace the damaged valve or repair the valve. Now there's newer technology and so for patients who are high risk or patients who are even intermediate risk for aortic stenosis, we’re able to use catheters and wires to put a new valve inside of the old valve and there's a tremendous amount of research being done on this type of technology for the various valves in the heart. There are actually four different valves in the heart. The transcatheter valves are only at this point approved for the aortic physician. Aortic stenosis can be treated with what's called a TAVR, a transcatheter aortic valve replacement.
Bill: That’s very interesting. Is that becoming more commonplace, the TAVR procedure?
Dr. Grubb: Yes, very interesting. The initial studies were done on patients who were high risk or inoperable. They were too old or too sick for traditional open heart surgery, but had developed aortic stenosis over time. The catheter valves were an option because we really didn't have anything that we could help them with in terms of surgery. After the results of the initial trials were so positive and the patients did so well, then we started looking into lower risk groups. Now, what we call intermediate risk patients are able to choose the TAVR valve and even patients who are low risk can participate in ongoing trials to answer the question of whether low-risk patients are better served with open heart surgery or with a transcatheter aortic valve replacement. Similarly, there are some technologies in mitral repair called a mitral clip where we can help patients with mitral regurgitation, but those patients are still in the high risk or inoperable category. That’s not beyond those patients yet.
Bill: What is involved in the TAVR procedure? That’s done in a hospital, but I would imagine the recovery time, etc., is much less.
Dr. Grubb: That’s absolutely right. It’s certainly the most minimally invasive approach. When I think of minimally invasive aortic surgery, I think of small incisions, but basically the same operation. This is different. This is when a patient would go and often times the procedure can be done in a cath lab and doesn't even require an operating room. At Emory University, we're able to even have the patient awake throughout the procedure in a twilight sleep called conscious sedation, so the patient is talking to us but they're very comfortable. They've been given a small amount of pain medication, a puncture in the groin often times with a wire that's then threaded backward through the anatomy and across the aortic valve that’s damaged. Over that wire, we’re able to put a new valve on a very sophisticated delivery system and using a complex x-ray and echocardiogram or that ultrasound I mentioned before. We’re able to position the valve and then deploy the valve either on a balloon or on a special memory metal that expands on its own and then the valve is seated in place, pushes the old valve off to the side and the new valve in the aortic position holding on by radial force and friction. It’s amazing technology. Most of the patients do not require the intensive care unit. They just go to a recovery room and the majority of the patients are able to go home as early as the next day.
Bill: When it comes to treatment, can you tell me about the structural heart and valve team at Emory Healthcare?
Dr. Grubb: The structural heart and valve team is a very robust multidisciplinary team. It is really a collaborative effort, traditionally cardiologists and cardiac surgeons referred patients back for but there was not necessarily a collaboration. The structural heart and valve team has really transitioned this patient-centered care with a focus on this specific patient and their valvular heart disease. When a patient comes to the clinic, they're seen by both a cardiologist, often times two surgeons, by a nurse practitioner, a valve coordinator. If they require a nephrologist or a neurologist, we have all of those people integrated into the system so the patient is really getting a multidisciplinary team that’s deciding what is best for them at this stage in their life and based on their risks for the various options. Often times as you can imagine, although a patient may be older, they could be low risk or vice versa, they could be a young patient but have other comorbidities that make them high risk. The multidisciplinary team is able to look at the entire picture of the patient and then have shared decision making with the patient so they understand here are my options and here are the risks and benefits of each of those options. The nice part about the multidisciplinary heart team is that we continue to follow these patients for their lifetime. Initially, we’re going to talk about their valve implantation, but then we're going to make sure that we continue to follow them on at least an annual basis to make sure this new technology continues to be working well and they haven't developed any other problems. Our goal is, of course, to make sure the patient still keeps the relationship with their referring cardiologist and their primary care doctors. The structural heart and valve center is the place where they go for their valve for the rest of their life.
Bill: Really important information. Thank you for sharing that with us and thank you so much for your time today. For more information, please visit emoryhealthcare.org/heart. That’s emoryhealthcare.org/heart. You're listening to Advancing Your Health with Emory Healthcare. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth: Five million Americans have moderate or severe heart valve disease left undiagnosed and untreated. Their condition can cause a progressive deterioration in heart function, which can result in heart failure and premature death. Here to talk with us about the latest heart valve disease treatment options is Dr. Kendra J. Grubb, surgical director at Emory Structural Heart and Valve Center at Emory Healthcare.
Thank you for your time. Why do they call heart valve disease “mystery killers?”
Kendra J. Grubb, MD, MHA, FACC: Often times, patients don’t realize that they have valvular heart disease until its very progressed to the point where that they have symptoms that are really interfering with their life. Some of these patients, the valvular disease results in the actual heart muscles starting to fail, and those patients are particularly vulnerable.
Bill: How would someone know if they have heart valve disease? You mentioned symptoms. What should we be looking for?
Dr. Grubb: Some of the common symptoms of valvular heart disease are simple things like shortness of breath or pain in the chest called angina or dizziness when you stand up. In the advanced forms of that, patients may have an actual syncope where they pass out and certainly things like leg swelling would clue people in. When a patient sees their doctor, they should be asking about their heart and asking questions like ‘do I have a murmur?’ The murmur is the sound that the valve makes when it’s diseased.
Bill: How do you diagnose heart valve disease?
Dr. Grubb: At the doctor’s office, often times while the doctor’s listening to the chest with the stethoscope, a murmur can be heard and the murmur is turbulent flow pattern through the valve itself. Instead of hearing the typical lub-dub, there may be a swooshing sound during that usual lub-dub. The physician would then be able to hear it. After a murmur is identified, then an echocardiogram or what's more commonly thought of as like an ultrasound of the heart is done where we can actually visualize a heart valve as well as the pumping chambers of the heart and be able to see the actual pathology of the valve.
Bill: Is this something you're born with or can people develop this over time?
Dr. Grubb: There's actually both. Some patients are born with valve disease. Those patients we term ‘congenital’ and so there are patients that could have a bicuspid valve from the time that they're children. Their bicuspid valve is normal for them but not normal for an adult, so those patients, their valve will wear out sooner rather than later. Often times, their valves will be replaced when they're in their 40s or 50s. Some patients have calcium deposits on their valve leaflets as they age and it’s more of a wear and tear process and the valve starts to get stenotic, or tight. As the valve tightens, the heart muscle has to work harder in order to pump the blood out of the pumping chambers into the rest of the body.
Bill: How do you generally treat this? Is it reversible?
Dr. Grubb: Unfortunately, for valvular heart disease, there is no medicine that can fix it. Medicines are the first line to treat the symptoms so we control the blood pressure, we try to control any signs of heart failure like swelling by using diuretics. We try to start the medicines that make the heart be more efficient but nothing is going to stop the actual process of the valve degeneration whether it’s a leaky valve called insufficiency or regurgitation or the opposite, a stenotic valve, where the valve is too tight, it's a progressive disease. The only treatment is either a repair or a replacement. Traditionally, the only option was open heart surgery where we would open the breastbone, go on the heart-lung machine, stop the heart, stop the lungs and either replace the damaged valve or repair the valve. Now there's newer technology and so for patients who are high risk or patients who are even intermediate risk for aortic stenosis, we’re able to use catheters and wires to put a new valve inside of the old valve and there's a tremendous amount of research being done on this type of technology for the various valves in the heart. There are actually four different valves in the heart. The transcatheter valves are only at this point approved for the aortic physician. Aortic stenosis can be treated with what's called a TAVR, a transcatheter aortic valve replacement.
Bill: That’s very interesting. Is that becoming more commonplace, the TAVR procedure?
Dr. Grubb: Yes, very interesting. The initial studies were done on patients who were high risk or inoperable. They were too old or too sick for traditional open heart surgery, but had developed aortic stenosis over time. The catheter valves were an option because we really didn't have anything that we could help them with in terms of surgery. After the results of the initial trials were so positive and the patients did so well, then we started looking into lower risk groups. Now, what we call intermediate risk patients are able to choose the TAVR valve and even patients who are low risk can participate in ongoing trials to answer the question of whether low-risk patients are better served with open heart surgery or with a transcatheter aortic valve replacement. Similarly, there are some technologies in mitral repair called a mitral clip where we can help patients with mitral regurgitation, but those patients are still in the high risk or inoperable category. That’s not beyond those patients yet.
Bill: What is involved in the TAVR procedure? That’s done in a hospital, but I would imagine the recovery time, etc., is much less.
Dr. Grubb: That’s absolutely right. It’s certainly the most minimally invasive approach. When I think of minimally invasive aortic surgery, I think of small incisions, but basically the same operation. This is different. This is when a patient would go and often times the procedure can be done in a cath lab and doesn't even require an operating room. At Emory University, we're able to even have the patient awake throughout the procedure in a twilight sleep called conscious sedation, so the patient is talking to us but they're very comfortable. They've been given a small amount of pain medication, a puncture in the groin often times with a wire that's then threaded backward through the anatomy and across the aortic valve that’s damaged. Over that wire, we’re able to put a new valve on a very sophisticated delivery system and using a complex x-ray and echocardiogram or that ultrasound I mentioned before. We’re able to position the valve and then deploy the valve either on a balloon or on a special memory metal that expands on its own and then the valve is seated in place, pushes the old valve off to the side and the new valve in the aortic position holding on by radial force and friction. It’s amazing technology. Most of the patients do not require the intensive care unit. They just go to a recovery room and the majority of the patients are able to go home as early as the next day.
Bill: When it comes to treatment, can you tell me about the structural heart and valve team at Emory Healthcare?
Dr. Grubb: The structural heart and valve team is a very robust multidisciplinary team. It is really a collaborative effort, traditionally cardiologists and cardiac surgeons referred patients back for but there was not necessarily a collaboration. The structural heart and valve team has really transitioned this patient-centered care with a focus on this specific patient and their valvular heart disease. When a patient comes to the clinic, they're seen by both a cardiologist, often times two surgeons, by a nurse practitioner, a valve coordinator. If they require a nephrologist or a neurologist, we have all of those people integrated into the system so the patient is really getting a multidisciplinary team that’s deciding what is best for them at this stage in their life and based on their risks for the various options. Often times as you can imagine, although a patient may be older, they could be low risk or vice versa, they could be a young patient but have other comorbidities that make them high risk. The multidisciplinary team is able to look at the entire picture of the patient and then have shared decision making with the patient so they understand here are my options and here are the risks and benefits of each of those options. The nice part about the multidisciplinary heart team is that we continue to follow these patients for their lifetime. Initially, we’re going to talk about their valve implantation, but then we're going to make sure that we continue to follow them on at least an annual basis to make sure this new technology continues to be working well and they haven't developed any other problems. Our goal is, of course, to make sure the patient still keeps the relationship with their referring cardiologist and their primary care doctors. The structural heart and valve center is the place where they go for their valve for the rest of their life.
Bill: Really important information. Thank you for sharing that with us and thank you so much for your time today. For more information, please visit emoryhealthcare.org/heart. That’s emoryhealthcare.org/heart. You're listening to Advancing Your Health with Emory Healthcare. I'm Bill Klaproth. Thanks for listening.