Joey Wahler (Host): They're greatly benefiting patients. So, we're discussing minimally invasive heart procedures. Our guest is Dr. Ravi Ramana. He's an interventional cardiologist. This is Silver Cross Hospital's iMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Ravi Ramana, DO: Hello there. Thanks for having me today.

Host: Great to have you aboard. We appreciate the time. So first, in a nutshell, what does an interventional cardiologist like you do?

Ravi Ramana, DO: So, an interventional cardiologist is a subspecialty of cardiology. And not only do we see patients in clinic or in the hospital on rounds, but we also often perform procedures, procedures that we're trying to get more information about the heart of our patient, trying to diagnose disease states and potentially treat them with less invasive techniques.

Host: Gotcha. So, what do we mean by the term minimally invasive heart procedure?

Ravi Ramana, DO: There's a continuum when we talk about medicine and the procedures that we do. There are large surgeries like brain surgeries or open heart surgeries, and there are smaller procedures like getting an appendix taken out.

Minimally invasive cardiac procedures or minimally invasive heart procedures are somewhere in between. Typically, what we're trying to do is treat disease states for the heart that often in the past has been treated with open heart surgery. So, less invasive techniques often mean smaller incisions, may be shorter procedure times, easier recovery, and hopefully less side effects or risks of the procedure as well.

Host: And which procedures are now minimally invasive compared to, say, five or 10 years ago. What are the most common ones?

Ravi Ramana, DO: The birth of interventional cardiology really occurred with a procedure that is very common, and that's an angiogram. And those are cardiac angiograms, where we place specific catheters or IV lines either in the patient's wrist or in their groin and used small tubes up to the heart to take pictures of their heart arteries and, if there's blockages, maybe fix them with balloons or stents. Those procedures have been around for decades.

What really has changed over the last decade or so has been something called structural heart procedures, and that is even more so trying to treat the heart and disease problems with the heart, typically valves or maybe irregular heart rhythms that in the past were treated with very invasive open heart surgeries with less invasive techniques, again, either using IVs from the groin or from the wrist. These types of procedures now are very commonplace. They've been done around the world for over 25 years. They've been done in the United States, at least under research with the FDA over 15 years and have been done in commercial stating, meaning it can be done at most hospitals over a decade. Those include things like transcatheter aortic valve replacement, or TAVR or less invasive techniques to treat leaky heart valves, like a MitraClip procedure or a tricuspid regurgitation procedure, and also with less invasive techniques to try to reduce the risk of stroke in people with atrial fibrillation. Those procedures are called left atrial appendage occlusion device procedures. These are all procedures that are done by an interventional cardiologist, and sometimes alongside a heart surgeon to be done together as a multidisciplinary heart team. But these are all ways that we can more or less invasively treat patients.

Host: You mentioned earlier, a moment ago, some of the benefits for patients. In terms of their overall long-term health once these procedures are behind them, how does going about it in a minimally invasive way change their long-term outcome, if at all?

Ravi Ramana, DO: A lot of times patients will ask not only how is the procedure done, but how will I feel afterwards, right? These procedures we do not just to treat something that has gone awry, but hopefully in a way that can help patients feel better and potentially live longer lives. So when we do a less invasive therapy, if the procedure goes smoothly, patients typically have a much quicker recovery. Patients undergoing a less invasive TAVR valve procedure often are up and walking around within four or five hours from the procedure and may even go home the next day. This is in comparison to open heart surgeries where patients are typically in the hospital for four or five, maybe seven days as they recover from a larger incision and more side effects from the procedure.

That being said, it's still important to note that there's room for both procedures. And the over 10 years that I've done these procedures, over thousands of people I've met, I've never met anyone that wanted the more invasive open heart surgery. Everyone wants the less invasive procedure, but it's our job as a multidisciplinary heart team to decide not only what procedure is wanted, but what we can do safely and effectively for the patient.

Host: I'm going to ask you in a moment, Doc, about how you go about making that determination. But first, just to go back to something you mentioned a moment ago that these patients often after these procedures can go home the very next day. When you take a step back for a moment, that's really pretty amazing, isn't it?

Ravi Ramana, DO: it really is amazing. You know, we've been fortunate here as this team to be a part of some of these technologies from the beginning, from 2012 when we first started TAVR really in America. And back then, they were a little tougher procedures to get through. The procedure wasn't as refined, the technology hadn't improved. And so, we were really just hoping on some basic things to happen to be considered a successful procedure.

One of the exciting things with interventional cardiology is there's always advancements in technology, and that makes it really enjoyable for us practicing. And it makes it exciting to try to stay on top of cutting-edge technology, and bringing it to our patients. And so, to think that we can fix someone's severely narrowed valve that is putting their heart and their life at risk and oftentimes send them home the following day. Yes, it's a very humbling, but very exciting procedure to be able to do for them and their family.

Host: Very well put indeed. So, you've mentioned TAVR a few times. Remind us what would bring someone to needing that procedure.

Ravi Ramana, DO: So, TAVR again is an acronym. It stands for transcatheter aortic valve replacement. And for the most part, we treat patients that have a narrowed valve, a narrowed aortic valve called aortic stenosis. Now, it's very common for patients to have a mild or moderate leak or narrowing to their heart valves. But when the aortic valve, the main valve of the heart becomes severely narrowed, we know that puts way too much pressure on the heart muscle. It can make people have symptoms of shortness of breath, chest pain, feeling weak or passing out. We know then that the heart is under too much strain. And without fixing the valve, without replacing the valve, we know that these patients have a worse prognosis than most cancers. So, to fix the valve, that requires replacing it. And that can be done either with open heart surgery or with the TAVR procedure.

And so, patients often will come to me with these symptoms saying, "I don't feel so good. I get short of breath going upstairs." And then, some of our testing then shows that indeed they have a significantly narrowed aortic valve.

Host: To followup on that, how do you determine what can be done minimally invasively versus the traditional open method?

Ravi Ramana, DO: Well, the key in that really starts with working alongside our heart surgeons. So, now, in this era of cardiovascular medicine, there's something referred to as a multidisciplinary valve team. And that involves nurses, radiologists, interventional cardiologists, and heart surgeons, right? Heart surgeons are the ones that perform the open heart surgery. And the cardiologist, alongside the heart surgeon performs the TAVR. And so, there's certain tests, some basic non-invasive tests that we do on all patients. We do an echocardiogram, which is an ultrasound of the heart. We do a special CAT scan of the heart and blood vessels leading to the heart, and patients being evaluated with a bad valve, and we'll do an angiogram to make sure we understand that there's no significant blockages on the heart arteries.

With those three tests, the patients and their loved ones often will come to a clinic where both the surgeon and the cardiologists are. And we discuss as a team the pros and cons of either fixing it with open heart surgery with TAVR, or sometimes not at all if we feel the patient isn't a candidate for either procedure. At that point, usually from the team's decision, we can make a recommendation to the patient and their loved ones and up to them to accept, and then we proceed by scheduling the procedure at our hospital.

Host: You mentioned earlier about the technology continuing to advance, and you've talked about what's gone on in recent years, of course. How about in the succeeding years to come? How much do you expect this type of a procedure to continue moving forward in terms of what's available?

Ravi Ramana, DO: Well, that's what's exciting. There's things about the procedure that need to get better. There's things about the procedure that have dramatically improved. And just the last 10 or 12 years I've done the procedure, I've been around long enough to know that I feel like kind of the old guy in the group when I get to tell some of the new operation cardiologists, do "You remember when we had to do it this way?" And so, the procedure in 10 years has gotten less invasive. It's gotten more predictable. Um. Risks of the procedure are much less than they were 10 years ago. But inherently, in a heart procedure, there always will be risks. There will never be a 0% risk procedure. There's risks of bleeding or infection or stroke.

So moving forward, there's more research and more technology, looking at how do we make these 2% or 3% risks closer to 1% or 0%, especially when we talk about things like stroke or the need for a pacemaker following, or we talk about how big is the device and how less invasive can we make an already less invasive procedure.

Fortunately, for us and the team, we've been a part of a lot of this research, this cutting-edge research that's also done under the supervision of the FDA. So, we're a part of driving that technology forward in bringing that to the area.

Host: A couple of other things. As you know, as well as anyone, heart conditions, especially heart surgery, can be awfully scary for patients. How do you and yours go about reassuring people that they're in good hands here?

Ravi Ramana, DO: I think the first thing that's important to do is when we spend time with our patients, to have them understand that we're here and connected to them for a specific reason. We know very well this is scary for them, and I often will tell my patients if they get scared or nervous for a procedure that that's normal. I almost prefer them to get nervous because then I know they know how serious this is.

But the only thing more serious than not looking or identifying or treating this, the only thing that's more scary to me than that is ignoring it and trying to pretend like this doesn't exist and not being evaluated when we notice we're not feeling very well, when we're having chest pain or we get short of breath when we're mowing the lawn and that we didn't do last year. The scarier part to me is not knowing.

So once we know what it is or maybe what it's not, maybe it's not the heart, but if it is the heart, then to be able to look around and find a team with a lot of experience in being able to deal with this, a lot of good results, the heart surgery team here is magnificent. We've worked with them decades. So, it's great to have a good team that care about not only fixing the problem, but again, back to what you said before, returning the patient back to the quality of life that they want to have.

Host: You led me beautifully there, Doc, into my next question, which is when you talk about the magnificent people doing this work at Silver Cross, what would you say Silver Cross Hospital's main strength regarding interventional cardiology as where patients are concerned? What do you really hang your hats on, so to speak?

Ravi Ramana, DO: I think there are some hospitals that are known for certain things, just like some sports teams are known for certain things. But I think at Silver Cross, we have the luxury of having a lot of good healthcare professionals. That's not only doctors, but that's surgeons, that's nurses, that's administrators that are really focused on trying not to have a weak spot in this system. And so, that allows us to have good cardiology. There's a great heart imaging center here. Interventional cardiology, I'm biased, I think we're pretty good here and really can treat most of the disease states out there. Our electrophysiology team, meaning the heart rhythm specialists here, are fantastic, and do some of the best work in the Midwest area.

So, I think it's the fact that the team is focused on being good at what we are, trying to get better, and also trying to add procedures that at some point in the past were only available at the really large centers. And we can—and we have—brought that to Silver Cross, where we're doing essentially the same work that anybody in the area, anybody in the country is doing when it comes to heart care.

Host: And then in summary, Doctor, what would you say is most rewarding about the work that you and yours do? What's a good day at the office for you as they say, when you go home and it's all behind you?

Ravi Ramana, DO: I mean, all days are busy days, right? That's the way it is for everyone working. I think, on the days that I go home and I feel that I have made a difference or I've been part of a team that has made a difference. And sometimes that's helping people live and sometimes that's helping people respectfully die. But I think when we can do procedures that not only make people live longer, but more importantly allow people to live a better quality of life. We've all been around people, we've been around loved ones. They get older over time. And none of these people, whether they're 50 or 60 or 90, very few of them are asking about, "Can you make me live to be 110?"

Most people want to know, "While I'm here, can you make me live a good life? Can you allow me to travel and do the things I want? Can I go see my kids? Can I go see my grandkids? Can I go see my great-grandkids play little league?" That's really what this is about. And when we can participate in a care that allows people to do that better and enjoy life, that's where the gratification from this job comes from.

Host: Yeah, I can definitely appreciate that. Well, folks, we trust you are now more familiar with minimally invasive heart procedures. Dr. Ramana, keep up all your great life-extending and life-saving work. And thanks so much again.

Ravi Ramana, DO: Great. Thanks for having me.

Host: Absolutely. And for more information, please do visit silvercross.org/advancedheart. Now, if you enjoyed this podcast, please do share it on your social channels and check out the entire podcast library for topics of interest to you. And thanks so much again for being part of iMatter Health, a Silver Cross Hospital podcast.