Advancements in Minimally Invasive Open Heart Valve Surgery Including Valve-in-Valve Procedures

S. Christopher Malaisrie, MD discusses recent advancements in open heart valve surgery, including minimally invasive access for cardiac surgery. His podcast also includes topics related to improvements in both tissue and mechanical valves, the indications for valve-in-valve procedures, and the benefits of enhanced recovery after surgery (ERAS).
Advancements in Minimally Invasive Open Heart Valve Surgery Including Valve-in-Valve Procedures
Featured Speaker:
Christopher Malaisrie, MD
S. Christopher Malaisrie, MD is a cardiac surgeon at Northwestern Medicine, associate director of the Center for Heart Valve Disease at Bluhm Cardiovascular Institute, co-director of the Marfan Syndrome and Related Disorders Program, and co-director of the Thoracic Aortic Surgery Program. He is a professor at Northwestern University Feinberg School of Medicine. Dr. Malaisrie's special interests include Marfan syndrome and related connective tissue disorders, bicuspid aortic valve, aortic aneurysms/dissections, chronic thromboembolic pulmonary hypertension, and mitral valve disease. In addition to complex aortic surgery encompassing valve repair, valve-sparing aortic root replacement, aortic arch reconstruction, thoracoabdominal aortic repair and endovascular stent grafting, Dr. Malaisrie performs minimally invasive valve repair, transcatheter valve replacement, and pulmonary thromboendarterectomy. Dr. Malaisrie is board certified by both the American Board of Surgery and the American Board of Thoracic Surgery. He completed his thoracic residency at Baylor College of Medicine and completed his cardiac surgery fellowship at Stanford University.

Learn more about S. Christopher Malaisrie, MD
Advancements in Minimally Invasive Open Heart Valve Surgery Including Valve-in-Valve Procedures

Melanie:    Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and I invite you to listen in as we discuss recent advancements in open-heart valve surgery.

Joining me is Dr. Christopher Malaisrie. He's a cardiac surgeon and Associate Director at the Center for Heart Valve Disease at the Bluhm Cardiovascular Institute at Northwestern Medicine. He's also a professor of cardiac surgery at Northwestern University Feinberg School of Medicine.

Dr. Malaisrie, it's a pleasure to have you here. This is such an interesting topic. First start by defining minimally invasive cardiac surgery for us. What are the benefits in patients with heart valve disease?

DR Christopher Malaisrie: Minimally invasive cardiac surgery is open-heart surgery through incisions that are substantially smaller and less traumatic than the standard approach through a median sternotomy. Often our patients think of a long vertical incision measuring eight to ten inches and a complete division of the breastbone when they think of open-heart valve surgery. What many people don't know is that open-heart surgery can be performed through incision between the ribs measuring only three to four inches. Minimally invasive cardiac surgery allows patients who require aortic valve replacement or mitral valve repair to have shorter recovery time and fewer physical restrictions. No sternotomy, then no sternal precautions, and most importantly, no sternal wound infections.

Our younger patients appreciate a surgical scar that is away from the midline and often not noticeable, even with low cut shirts and dresses. It's important to note that everyone is not a candidate for a minimally invasive of cardiac surgery, however. And your surgeon may require additional imaging, such as CT scan to determine suitable anatomy.

Melanie: Isn't that fascinating? What an exciting time to be in your field, Dr. Malaisrie. So then speak a little bit more, expand on that newer cardiac access, that vertical access, and then we'll get into the actual valves themselves. How did this cardiac access come about?

DR Christopher Malaisrie: Well, minimally invasive cardiac surgery came about because we wanted to minimize the trauma from cardiac surgery for our patients. And what many surgeons soon realized that in order to do an isolated valve procedure such as aortic valve or mitral valve, that we in fact do not need to see the entire heart. So hence we looked for incisions that are smaller than what's traditionally used. And because we use these smaller incisions, there's less trauma and patients are able to return to normal life a lot quicker than they would otherwise.

Melanie: Are the latest tissue valves getting better? Are bioprosthetic heart valves preferred over mechanical valves? And is it because they have a lower risk of thrombosis or they don't last long? Tell us a little bit about why you would choose a bioprosthetic heart valve versus a mechanical valve. And any new advancements you'd like to mention in the valve world?

DR Christopher Malaisrie: Tissue valves otherwise known as bioprosthetic valves are used to replace diseased valves, such as the aortic valve are indeed getting a lot better. Tissue treatment for the valve leaflets, which can be either from a cow or a pig, so either bovine or porcine, reduces the risk of valve degeneration due to calcifications. The science is complex, but advanced treatments either inhibits or blocks binding of circulating calcium in the bloodstream to the valve leaflets. This in turn ensures that the valve remains soft and pliable, but strong enough to resist tearing. In fact, we now expect that older patients can see a durability of 15 to 20 years with these new tissue valves.

Melanie: Well then, does the size of that valve matter when patient's next procedure might be in 15 or 20 years? And then tell us a little bit, if they do have to have that, what's valve-in-valve?

DR Christopher Malaisrie: Oh yeah, of course, tissue valves don't last forever and will eventually degenerate over the long-term. And this is really important for our younger patients. So while repeat open-heart surgery remains an option for patients with a failing tissue valve, now many patients can be considered for the transcatheter valve-in-valve procedure or just the valve-in-valve procedure for short.

This procedure is similar to the TAVI procedure, transcatheter aortic valve implantation procedure, where a transcatheter valve is delivered through the groin and deployed within the failing tissue valve without removing the old valve. A new valve is anchored with a rigid stent of the old valve by radial force. And that's what allows it to keep it in place.

Recovery from the valve-in-valve procedure is much faster than repeat open-heart surgery since general anesthesia is not required and there is no incision on the chest. However, not all patients with a failing heart valve after previous aortic valve replacement will be candidates for valve-in-valve. And again, you will need to see your specialist to determine whether or not anatomy is suitable for this procedure.

Melanie: Doctor, speak about the expertise and experience involved. How does this experience of the physician play into successful outcomes, since this is a newer way to do these procedures?

DR Christopher Malaisrie: Expertise is important for the valve-in-valve procedure. It is a new technology with multiple devices that can be used, so experience does matter. However, having said that the procedure itself has been simplified and become very standard so that many operators can do this procedure. I think the most important part about valve-in-valve versus reoperative surgery is the decision-making that has to be made before the procedure.

Some patients will do better with a repeat open-heart surgery. Some patients will do better with the valve-in-valve procedure. We'll only know by looking at the patient and also determining the suitable anatomy based on preoperative imaging. So I think it's both decision-making prior to the procedure and then the procedure itself.

Melanie: Well, then speak about ERAS or enhanced recovery after surgery and how that is helping these procedures to have better outcomes?

DR Christopher Malaisrie: So enhanced recovery after surgery or ERAS for short is multimodal perioperative care pathways designed to achieve early recovery after major surgery. This is done by maintaining preoperative organ function and reducing the stress response following surgery. Because ERAS is patient- centered, pathways and protocols are designed with optimizing recovery from the standpoint of the patient. Benefits to the patient include decreased postoperative pain, rapid return of bowel function, so no nausea and shorter length of hospital stay. Overall, eRAS has been shown to improve patient satisfaction after open-heart valve surgery and also reduce post-operative complications.

Melanie: Doctor, tell us about your multidisciplinary team and how this approach really helps for better outcomes.

DR Christopher Malaisrie: All of our patients are seen by a multidisciplinary team, which includes a cardiac surgeon, a cardiologist, an interventional cardiologist, and also behind the scenes, a skilled radiographer who is skilled at looking at CT images, echocardiograms and angiograms. We decide after we see all patients which procedure is suitable for that particular patient and what the approach will be. So I think this multidisciplinary team is important. Patients will notice that it can be a long day because there's imaging involved and seeing multiple doctors, but we aim to get all these images and consultations done within the same day in order to give an answer to the patient as soon as possible.

Melanie: As we wrap up, Dr. Malaisrie, is this newer way to perform these procedures a game changer? How do you see it affecting the world of cardiovascular medicine? Or is it just another tool in the cardiology medicine world? And give us any examples that you see for broadening the spectrum of procedures like this by using minimally invasive cardiac surgery.

DR Christopher Malaisrie: Yeah, there is one other technology that we haven't talked about and that is the technology with mechanical valves. And mechanical valves are also used for aortic valve replacements and also getting better. Now, newer generation mechanical valves are constructed of high-grade carbon, which are both durable and more resistant to clotting.

In fact, low dose warfarin, which everyone knows is a blood thinner, which has its risks as well, has been tested and improved for the newest generation mechanical valves. That means that patients can be maintained at a lower level of warfarin, which reduces the risk of bleeding complications. Moreover, I want our clinicians to know that we are currently enrolling patients in investigational trial involving warfarin alternatives, the novel oral anticoagulants, which have proven to be safer than warfarin in the treatment of other conditions, such as blood clots and atrial fibrillation. We hope that these warfarin alternatives can be an option for patients who had an aortic valve replacement with a mechanical valve.

Melanie: When do you feel it's important that physicians refer their patients to Northwestern Medicine?

DR Christopher Malaisrie: Well, first, we talk about valve choice with our patients. I think that's the first important thing that has to be established before anything else. Does a patient wish to have a mechanical valve or do they wish to have a tissue valve? Knowing not only the current guidelines, but also future possibilities with newer technology, newer drugs, that's the most important decision to be made.

Then we go on to discuss the approach and the approach can either be the transcatheter procedure, so-called TAVI procedure, or open-heart surgery, which can now be done with minimally invasive cardiac surgery as we discussed earlier. And these incisions, I think, provide a patient with early recovery that is associated with transcatheter procedure while still gaining the benefits of open-heart surgery, where we actually cut out the old valve and able to implant a brand-new valve in its place.

Melanie: Absolutely fascinating. Thank you so much, Dr. Malaisrie, for joining us today and sharing your incredible expertise. To refer your patient or for more information, you can call (312)-NM-HEART or you can visit us at to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.