Dr. Michael Smith (Host): Welcome to Meaningful Medicine, a Novant Health podcast. I'm Dr. Mike, and with me is Dr. Lance Lewis, an Interventional Cardiologist, and today, we're going to discuss structural heart disease and hopefully shed some light on its complexities and treatments. Dr. Lewis, welcome to the show.

Dr. Lance Lewis: Well, thank you so much for having me. I appreciate this opportunity to be with you.

Host: Hey, to start, what's structural heart disease?

Dr. Lance Lewis: Well, you know, we like to think of it as it's kinda like oftentimes we talk about interventional cardiology and we talk about the pipes that feed the house. With the structural portion, we're really talking about the portions of the house, like the doors like a carpenter would work on instead of a plumber. This would be more like carpentry work.

Host: So doors and windows, that kind of stuff, the pipes, all that, that's what you're focused on. Oh, when we say structural heart disease, there's something wrong with that. There's a window that don't open.

Dr. Lance Lewis: Exactly. It either open, it's either too open or it's too closed, and we

Host: Right. That's great. That's great. A lot of people, I think they know a little bit about this when they hear about the hole in the heart of like a newborn or something like that. Is that kind of what we're talking about?

Dr. Lance Lewis: Exactly. So we're talking about those holes in the heart, the valves that are malformed at birth. And then we're also talking about the valves that are acquired malformed. And that is to say, we call it kind of like diseases of so many birthdays, as it were. So people that have wear and tear, breakdown of the valve.

Host: How serious is that? Because I, that is a common thing the lay audience hears about a lot.

Dr. Lance Lewis: Absolutely. So it's one of our most common congenital heart diseases. And the hole in the heart is something that we can fix percutaneously, not all of them. Some of them need open heart surgery. So the structural cardiologist can help guide which of those procedures are appropriate to be done with a less invasive means and then we have wonderful cardiac surgeons that can also take care of it when it necessitates.

Host: With structural heart disease, how often is it found in early life versus say our age, you know, adults. Is this something that you di, this is diagnosed way earlier.

Dr. Lance Lewis: Typically not for an adult structural cardiologist. So there are many congenital diseases that there are pediatric interventional cardiologists that are structurally trained that take care of these things. So there's different subsets, but there is a lot of acquired disease that occurs in folks later in life.

Sometimes they're born with it. The majority of what we see, however, is something that is acquired over time and kind of breakdown of the valve through its use over the many cycles that it has to pump.

Host: Yeah, so for adults that develop structural issues, how do you know if I am like, what are, either some symptoms or what's going on that may help me come to you and say, help.

Dr. Lance Lewis: Absolutely. So typically there are symptoms. Typically people will, develop symptoms of shortness of breath. People can have chest pain. Some people can go into different rhythms because of this. So what you and what you're hearing from me are common symptoms that people have. So most people do not have a structural problem that causes these, but seeing your primary care physician and then seeing a cardiologist for an evaluation of this when they do imaging, most of these are found on echocardiograms, and most of those are the echocardiograms that are done through the chest wall.

So it's a very benign procedure. It's similar to when a mother has an ultrasound on a baby. We just move it up and take pictures of the chest and we can see most of these abnormalities and then help determine how they need to be treated.

Host: So with adults, are we mostly talking about valves? Is that the issue? And if so, help us understand what are the valves, what are they supposed to do and what goes wrong?

Dr. Lance Lewis: Absolutely. Good question. So, typically with adults, it's valves. And the valves are, as we discussed earlier, they're like the doors through which blood moves through the heart. So these open and close, and they open to allow blood to go from one chamber to the next so that blood can move along on its pathway.

And then when the heart squeezes, one valve closes to keep blood from going backwards and the other one opens to allow it to move forward. So either that valve that opens to allow it to go forward can be stenosed, that is to say not open well, and cause a gradient and a backup of pressure and blood in the chamber of the heart or that valve can work fine, but the one upstream of it can leak blood backwards, such that we're kind of recirculating that blood in the system. And those can both lead to similar symptoms, but they're treated very differently.

Host: What causes these problems?

Dr. Lance Lewis: Usually, the majority of the patients that we treat, it's secondary to the heart becoming weak and enlarged and frequently that will stretch the valve such that it no longer meets in the middle and closes and it leaves a little gap, an opening in between and blood leaks backwards. So that's with the leaky valve, although people can be born with abnormalities like mitral valve prolapse, where the valve comes back into the top chamber and over time it just stretches and then becomes very leaky.

Now with stenotic valves, it's typically, it's like having a car and that valve in the car gets a buildup of things on it just from moving through it over time. And if that valve then thickens and starts to not move well and open well, we call that in the heart, and in human beings, we call that stenosis. And then we can treat that by putting a new valve inside of it, which now we can do minimally invasively with small punctures in the groin for most of the valves.

Host: I definitely want to get into treatment, but before we do, so when you're talking about a valve that may be stenotic, it's hard to push through it versus a leaky valve. At the end of the day, what's happening to the heart?

Dr. Lance Lewis: Great question. So the heart, if it's stenotic, typically what happens is the heart has to build up more muscle to get blood through there. Now you'd think, okay, that sounds good. I want to be like Arnold Schwartzenegger. Well, you actually don't want that with the heart. Thicker the heart muscle gets the less well it works, it functions.

So we really want it to be distensible so it can receive the fluid, and then also to be able to contract in a normal fashion. So when it gets thick, we run into problems. Now that's with stenosis. With leaky heart valves, what happens is we start to dilate the heart and that dilation of the heart then begets, more leakiness, and then it dilates further, and then it leaks more, and then it leaks more. It dilates further. It's this cycle that we get into that we need to try to stop.

Host: So big biceps, not big heart. Is that a good way?

Dr. Lance Lewis: Correct. Exactly. You can do all the big bicep workouts, but you don't want to extra workout the heart. You do want to work it out aerobically, but you don't want to work it out trying to get big, thick muscles. If that makes sense.

Host: It does. And so, what about infections? Can infections cause some of these valvular problems?

Dr. Lance Lewis: Another great question. Yes, absolutely. Now, most of the time when infections cause these problems, we need to treat people with antibiotics because they kind of tend to degenerate. It's one of these acquired degenerations of the valve, and frequently, not all the time, but frequently, those kind of issues with valves, and it's usually leakiness, not stenotic when they get infected because it kind of breaks down the integrity of the valve and doesn't make it stenotic or stiff, but it makes it leak. So when that occurs, typically patients need surgery to have it fixed after a course of antibiotics, although there's some indications where patients just cannot tolerate the surgery.

So we have done some minimally invasive treatments for those patients as well. But yes, infection can certainly occur. That's why people when they go to see their dentist, if they have certain problems, will need to take antibiotics. That has changed a lot, so you need to talk to your primary doctor or your cardiologist about when it is prudent to take those antibiotics.

Host: So let's move into treatment now. In the past, I think it was more invasive surgeries and procedures is how you dealt with this stuff, right? But how have things changed over the last, say, even 10 to 20 years?

Dr. Lance Lewis: Absolutely. Great question. So, we started our structural heart program here 11 years ago, and that's around the time that the first minimally invasive valve was approved, and that's the TAVR valve. That is a transcatheter aortic valve replacement. And we talked, we juxtapose that with surgical aortic valve replacement.

So over 40, 50, 60 years, we've been doing open heart surgeries where we have wonderful surgeons. They open the chest, cut out the old valve, and put in a new valve. Well over the last 10 years, transcatheter aortic valve replacement where we can make a small incision in the groin, take a catheter up, deliver a small, or I should say a stent that is in a small condition.

We then put it over a balloon and we blow up the balloon that has the leaflets mounted on it and to deliver it in its enlarged state once it's inside the body. We now, that is now the number one way aortic valves are replaced in the world, and in this country. Because of its minimally invasive nature and the fact that most of the people having the procedure are in their seventh and eighth decade of life, although we certainly have people much younger and we have people even in their ninth and people that are a hundred or more getting this so at the extremes. But we do have those folks that previously could not be treated.

Host: We are living a little longer, you know, here and there with moderate medicine. And so I'm sure you're seeing that. Just so the audience, the listening audience understands, when you talk about the procedure here, you're talking about you're finding the artery in the groin, right? And then you're running it up, and you have things that visualize this for you into the heart and into that valve. Is that correct?

Dr. Lance Lewis: Absolutely, and it's a really a team of us. So we have special anesthesiologists, we have special imagers. We work hand in hand with our surgeons and we have wonderful cath lab staff. So we are able to find that we go in both the artery for some procedures and we go into the vein for some, it depends on which valve and which side of the heart we're working on.

But we then take our catheter up and across the valve, either retrograde, that is to say backwards across it against the flow of blood or antegrade or forward with the flow of blood so that would depend on which way we get, we go from the vein or the artery, and then we take either our new valve we put across it, or in certain instances like, when we work on the mitral and the tricuspid valve, we tend to use a procedure where we're placing a small clip that helps those leaflets that are leaky, come together more effectively so they don't leak as much as they used to.

So it's not really putting a new valve, it's doing what we would call a valve repair, minimally invasively. In other words, it's more of a procedure than a surgery.

Host: So let's talk about the, I'm going to go back to the valves for a sec. You've mentioned several names here. You've said aortic valve and tricuspid and mitral valve. Can you just real quick, where are these valves in the heart and related to like the upper part, the atrium versus the ventricles and all that kind of stuff?

Dr. Lance Lewis: Yes. So, I'm sorry I wasn't more clear, but yeah, absolutely. So the top chambers of the heart on the left side of the heart, we talk about the left side of the heart. That's the area that has all the oxygenated blood coming from the lungs, it first enters the left atrium, the top chamber of the heart, then it goes through the mitral valve.

And when it goes through the mitral valve, the mitral valve's in between the left atrium and the left ventricle. When the left ventricle fills, it fills through that mitral valve opening and the left atrium squeezing and helping to prime the left ventricle. And the blood goes across that valve, and then the top chamber relaxes and the bottom chamber of the left ventricle squeezes.

And when it squeezes, blood then leaves through the aortic valve into the aorta, into the rest of the body, but upstream of, that, it's the mitral valve. And if it's leaking, we lose a lot of our forward blood flow through that leakiness. And obviously if the aortic valve is stenotic, then we end up getting that extra thick muscle in the and the heart doesn't, it, it builds up extra pressure.

Similarly, if we go to, that's all on the left, what we in medical terms, call the left side of the heart. That's the oxygenated side. Now, if we go to the other side of the heart, we have analogous situation. We have the top chamber of the heart, right atrium, and blood comes back from the big veins, and then it goes across the tricuspid valve from the right atrium into the right ventricle. And then similarly, that valve then closes, the right ventricle squeezes and the pulmonic valve opens, and when it opens, the tricuspid valves close so blood doesn't go backwards into the top chamber of the heart and then back into the liver and other things like that. So that's kind of the sequence in the way we think about it.

Host: That's heart anatomy 101. That was great. That was wonderful. And so we've talked about some of the valves there. The tricuspid valve though, I want to go back to. This is that part of the right part, the part that doesn't have the oxygen coming back, all that, right. That valve, there's something new going on there, right? A new procedure or something that is pretty awesome. Can you share that?

Dr. Lance Lewis: Absolutely. Well, first what you should know is that the tricuspid valve's long been known as the forgotten valve. It's been a valve that's not had very good treatments. And the treatments that were there, were surgical. There was not much appetite for fixing it, because while the procedure goes well, patient doesn't do well.

So now we have a procedure called the TriClip procedure where we can do a minimally invasive procedure and we can do a repair on the tricuspid valve to help keep this valve that's long been forgotten and not well treated. We can now get it so that the leakiness dramatically reduces and it can improve patients clinically, how well they feel, how they're doing, get their breathing better, get them to be able to get the fluid off of them, and to have a meaningful procedure, that does not mean days, if not weeks, in the hospital with dubious outcomes. Again, not because the surgery's not done well, but because it's so hard for the heart to recover from open heart surgery when that side doesn't work well.

Host: So this is a new innovation. As the expert in this field, what do you see might be going on the next five, 10 years that you're excited about that's really going to innovate things?

Dr. Lance Lewis: Absolutely. So, the TriClip procedure was approved in April of last year, of 2024, and it has really been beneficial for our patients and it fills a void of an area we have not been able to help folks. Well, now we have a new valve that we can replace the tricuspid area with called the EVOQUE valve. But it is a valve in and of itself, so not just a repair, but a new valve that we can put in. And there are so many, for lack of a better way of putting it, anatomic challenges that we now, that we can't just use the other valves that we used to fix on the other side of the heart, we really needed a specialized valve.

This has now been approved and is being disseminated. And those of us that are in the structural heart space, we're hopeful in the next six months to a year, we're going to have another option. So these will be complimentary. So we'll have some patients that'll benefit from a repair or a clip, and some will benefit from a brand new valve, both done through a minimal incision through the vein that takes a lot less on the recovery side and most people will be able to go home the day after the procedure, if not the day of the procedure, for the repairs. And, if you had a surgery there, and again, not many were done, this was minimum of four or five days in the hospital, but oftentimes longer just because of the challenges in recovery.

Host: That's great news to hear, and I'm sure there's so much more that's coming down the line, which is fantastic. Now, Dr. Lewis, don't get mad at me. You're the expert, but I gotta tell you. I hear all this stuff that you're talking about, how about I just prevent any of this to happen so I never have to see you. Don't take that the wrong way. But what are some of the ways people can reduce their risk of even having these issues?

Dr. Lance Lewis: Oh my goodness. I would love it if folks didn't have to come see us for this. And there are things that we can do, and I think that these are going to be complimentary things. So I mentioned to you before when we started talking about this. Some of these are acquired over time, some of which comes from people that have had heart attacks, and now obviously things are moving forward there.

So when the heart has damage to it from, the valve's not the problem, but the heart becomes the problem. So getting in sooner to get treated for blocked arteries. If you have atrial fibrillation, don't, go see your electrophysiologist because if they treat the atrial fibrillation, which is a rhythm disturbance we hadn't yet talked about, but that causes the left atrium to dilate and the right atrium, when those dilate the annulus or the ring in which these valves sits gets bigger and when it gets bigger it stretches and then the valve doesn't close well. So optimal and appropriate treatment of your atrial fibrillation, of your coronary artery disease, keeping your blood pressure under control, exercising, all of these things can, how should I say, stave off visits from coming, needing to come to see me, which I'd love.

Host: This was fantastic information. Thank you so much, Dr. Lewis.

Dr. Lance Lewis: Well, you're so kind. You were wonderful to speak with and I appreciate you doing this with me.

Host: To find a physician, you can visit novanthealth.org. For more information, you could go check out healthyheadlines. Lot of good wellness information from our experts. This is Meaningful Medicine. I'm Dr. Mike. Thanks for listening.