Joey Wahler (Host): They're making a difference treating structural heart disease. So, we're discussing transcatheter therapies. Our guest from Southwest Healthcare Temecula Valley Hospital is Dr. Niraj Parekh. He's an interventional and structural cardiologist, as well as Interventional Cardiology Fellowship Program Director.

This is the Health and Harmony podcast from Temecula Valley Hospital. Thanks so much for joining us. I am Joey Wahler. Hi there, Dr. Parekh. Welcome.

Niraj Parekh, MD: Thank you. It's nice to be here.

Host: Great to have you with us. We appreciate the time. So first, in a nutshell, what are transcatheter therapies and what patients do they apply specifically to when we talk about structural heart disease?

Niraj Parekh, MD: Transcatheter therapies is a pretty broad term. But when it comes to cardiovascular and structural heart, it applies to patients that have valve diseases that cannot be taken care of through traditional open heart surgery mechanisms.

Host: And so, what would some of those conditions be actually?

Niraj Parekh, MD: So, that would be conditions such as mitral regurgitation where the mitral valve leaks backwards into the lungs, and patients have symptoms of heart failure and shortness of breath. It's literally where, you know, the patients feel like they're drowning with fluid. It's like aortic stenosis, which is a very common disease process where calcium builds up on the valve, the aortic valve. And after some time, the valve is restrictive, so it doesn't open well. And that limits blood flow that the heart can pump to the rest of the body and thus causing symptoms again of heart failure and angina.

Host: So that being said, a transcatheter aortic valve replacement, also commonly known as TAVR, simply put, how does that work? And for whom is that suitable here?

Niraj Parekh, MD: Yeah, great questions. These are therapies that we offer patients that are not candidates for traditional open heart surgery. Over 12 years ago, the only way to treat these disorders was to open somebody's chest, cracking the chechest open, performing a sternotomy, putting them on a heart lung machine, and replacing the valve.

Now, over the last decade or so, patients that are older, frailer, have multiple comorbidities such as being on dialysis, having COPD, these type of disease processes, having weak hearts, they wouldn't be optimal candidates for an open heart surgery. And for these reasons and for much more that we found where they have chronic therapies where they need steroids and so forth where they wouldn't recover well from an open surgery, we're able to offer replacing the valve just through the femoral artery. And it's gotten to the point now where it's completely minimally invasive. You don't even have general anesthesia. It takes about 30 minutes. And patients will go home the next morning.

Host: Wow. So, how do these transcatheter procedures compare to traditional open heart surgeries in terms of recovery time and, of course, what everyone wants to know most of all patient outcomes, right?

Niraj Parekh, MD: Correct. That's a great question as well. So with Cardiology, everything is done with large amounts of literature and data to support it. And so, thousands and thousands of patients have been studied nationwide and worldwide comparing open surgery to transcatheter therapies. And when this first came out, it was only done on the highest of highest risk patients. So, two surgeons would have to deem a patient a nonsurgical candidate, they would've to be too sick to do anything else, those are the patients that we initially enrolled. When that trial came out, we found that those patients did well with transcatheter therapy. But again, they were sickest of sickest patients.

Once that trial was successful, we started do those patients that were very sick. Over the last ten years, we've now studied patients that were intermediate risk as well as lower risk patients. And even now currently, the most recent literature supports even asymptomatic severe aortic stenosis patients. And that literature all supports that the outcomes are comparable to open heart surgery with actually a lower risk of stroke, lower risk of other complications, such as pneumonia. And then, the hospital length of stay average is one day now compared to seven to ten days with open heart surgery.

Host: That's a huge difference indeed. And so when we talk about the end result, what can patients expect?

Niraj Parekh, MD: So, there's two stages that I've seen over the last 10 years. There is some immediate improvement and gratification of patients' symptoms. They feel that almost instant improvement with the new valve opening. As far as their symptoms of how they can breathe, how they feel energy, their heart failure symptoms, they're able to offload that volume, extra fluid. And then, over the next few months, they continue to feel better, because now they're actually able to walk more and do more in rehab. And so, we traditionally send patients to cardiac rehab, where they actually have focus on getting stronger and recovering from all these months and years of having a valve that wasn't helping them do the things that they normally would be able to do.

Host: And speaking of which, tell us please, Doc, a little bit more about that in terms of the symptoms and the turnaround here, because these are people that typically have really been very stagnant, immobile, unable to do the "quality of life" things that so many of us enjoy and often take for granted until they're no longer available.

Niraj Parekh, MD: That's right. And so with this therapy, as I mentioned, everything is transcatheter, so everything is through the femoral artery and the femoral vein,. We pre-close and pre-stitch everything. So, there's no tubes or anything like that left in. Patients have minimum bed rest time, like four to six hours. But the next morning, physical therapy is already working with them and giving us recommendations as to what their needs are at home. And we set these patients up from the get go with home physical therapy and then we transition that to a cardiac rehab program. And so really, we give them like the best jumpstart, restart back to their normal quality of life.

Host: And when you talk about that quality of life, what are a couple of the things that, from your experience, patients typically are most thankful to be able to get back to as a result of this procedure?

Niraj Parekh, MD: First and foremost, they're thankful that they're not in the hospital every other week with heart. And they actually can be at home with their family and their friends and their, you know, significant others. So, that's the first thing. The second thing is that they're just able to enjoy, as you mentioned, the everyday things of life, walking, golfing, swimming, things that we day-to-day take for granted that we are able to do and they were not able to do for months or even years sometimes if they were underdiagnosed.

Host: When we talk about, especially older patients, it seems is often one of the activities that's at the top of that list. "Let me get back out to golfing and I know I'm good," right?

Niraj Parekh, MD: That's right. Yes, that's right.

Host: That's great to hear. So, how about lifestyle changes, improving outcomes after undergoing a transcatheter heart procedure? What has to happen once the procedure is over and done with so that whatever positive changes have resulted can stick?

Niraj Parekh, MD: We give some medicines to help the valve stay open and not to let the body have platelets stick to it. So, we give them some great simple medicines to help with that. We have very close followup with patients too, and we check their heart, we check their valve the next day, in a month. These type of procedures are very closely monitored by registries. And so, we have a while team just to get these patients kind of get ready for their procedure. There's a team of physicians and coordinators and nurse practitioner involved in the pre- part. And the same team follows these patients in the post and after care and to help really facilitate, because every patient is very different. Some people need more, some people need less. And so, these are really tailored treatments and therapy plans for individual patients based on what their needs are. Some people bounce back right away and they catch it early. Now, we're able to catch these patients much earlier. So, it's becoming a little bit more of a smoother transition.

Five or six years ago, we were only seeing the sickest of sickest patients. And so, it took a little bit of a longer time to get them back to that lifestyle that we were talking about. But the key is educating, doing these types of talks and getting the word out that we can take care of them earlier. Low risk, intermediate risk patients are approved, and asymptomatic as they're approved. So if you hear a murmur, get them to us so we can diagnose them earlier and treat them earlier so they can really get back on the horse much faster.

Host: Switching gears a little bit. How about telling us, please, what mitral valve disease is and what are the latest advancements in transcatheter therapies for that?

Niraj Parekh, MD: So, mitral valve disease is a little bit more complicated of a valve disease process, and where you could have mitral regurgitation, where the valves backwards, you could have mitral stenosis where calcium builds up and it restricts the flow from one chamber to the other chamber or you could have a mixture picture where you can have a little bit of both. If you have purely regurgitation where the valve leaks backwards, we have something called transcatheter edge to edge repair. It's what the surgeons used to do, they used to do an Alfieri stitch where they would repair the valve with a stitch. We're able to replicate that stitch with a transcatheter edge to edge repair, and that repair also known as a mitral clip and some common terms will basically do the same functional job as a stitch would do and it would cinch the spot where the maximal leak is, creating two orifices instead of one orifice, and therefore now eliminating that regurgitation.

So, that's been around for several years now, and it's been shown to reduce heart failure admissions, shown to improve quality of life outcomes, as well as we do these questionnaires of how much they can walk, how their symptoms are and what the difference they've seen since the procedure. Overall, they seem to do much from a quality of life, reducing hospitalizations as well as their questionnaire of how they feel we've changed their life.

 In addition to that, as far as outcomes, we've studied these therapies, these transcatheter edge to edge, we call them TEER, kind of like we call that TAVR. So, this is called TEER therapy for mitral regurgitation. And you have to really treat eight patients to get one improvement in their mortality or outcome. Whereas some of the medicine and defibrillators, you have to really, like, treat 30, 40, 50 paitients before you get an improvement. So, it really a powerful impact of their mortality and their outcomes.

The newest stuff coming out now is for this mixed picture and the mitral stenosis. That stuff has still been in trials and literature, but now we just have some valves coming out this year and the next year to actually help with this mixed picture. And so, there'll be new valves that are being implanted transcatheter, going through the septum from the right side to the left side and actually putting a new valve inside the old mitral valve. So, that's the latest and greatest that's going to be pretty much approved later this year.

Host: A couple of other things, Doc. What risks or complications are associated with transcatheter therapies and how do you manage those?

Niraj Parekh, MD: Sure. So, they sort of depend on which therapy we're talking about. So for transcatheter aortic valve replacement or TAVR, the risk is because have large-bore access in the artery, like a large tube that we put into the artery to help facilitate the valve to kind of go through that tube, the risk are of bleeding complications at the entry point, in the femoral artery. So, those can range from 1-2%. You can get a hematoma, you can get bleed where you have to put a stent in or, you know., worst case scenario, you need a vascular surgeon to repair the artery, if it really gets injured. That's not common.

The more common thing, which is not really a complication, I would call it more of like a side effect of getting a transcatheter valve in the aortic valve position is when we put a valve in, we're basically expanding a valve on a preexisting calcified aortic valve. So, we're pushing against the conduction system. So, some patients can require a permanent pacemaker after. The national average is about 7-8%. Our program is about 3% of patients after transcatheter valve replacement needing a pacemaker.

Outside of that, you know, it's really any type of risk of stroke, which is similar to doing an angiogram, similar to getting open heart surgery. That ranges in the 0.1-0.3%, and that's really because we have large catheters and valves going across aorta to the heart. So if there's calcium, these patients are in their 70s, 80s and 90s, have a lot of calcium built up in their aorta, and so there's, you know, a risk of that happening as well.

Host: When we talk about minimally invasive surgery these days, it seems in all areas of medicine, one of the main advantages is the greater precision that you and yours can work with. Why is that so important here when we talk about the effectiveness of these heart valve replacements?

Niraj Parekh, MD: What we've learned over, you know-- medicine is ever-changing and ever-evolving, but what we've learned is we know how to plan these procedures to the T, you know, plus or minus a few things. We do a lot of prep work. This involves the heart team approach. You know, many people may have heard of it, but this is not just, you know, Dr. Parekh saying, "This is what we're going to do and this is how we're going to do it." This is interventional cardiologists and structural heart cardiologists, such as myself, as well as one or two heart surgeons. We have cardiac anesthesiologists. We have cardiovascular nurse practitioners as well as cardiovascular coordinators, all working together to work this patient up, do their planning. They get angiograms, they get CAT scans. So, the day of the procedure, it's precisely timed. We know which access to do, we know which valve size is going to go in, we know any pitfalls along the way. And our job is to get in. Be in there for 30 minutes to 40 minutes and get out. That's how we get this precision. This is all planning. It's all imaging.

Imaging has changed Cardiology and Interventional Cardiology, drastically to the point where we know, we see the valves, we know where to look out for, we know where the exact of leak is because we image these patients that have mitral regurgitation prior with transesophageal echocardiograms. So, we know what size repair clip we're going to place, we know where we're going to put it. We know how many the patient will need. So, it's a very planned procedure. Probably, the most planned procedure in Cardiology.

Host: Finally, Doctor, in summary here, what future developments in this transcatheter therapy world should patients and healthcare providers as well be aware of, do you think?

Niraj Parekh, MD: I think that there's still a lot of work to be done and a lot of work that's continuing to be done because we just touched the tip of the iceberg here. As I mentioned, we have mitral stenosis and then mixed mitral valve diseases that is coming out soon. We just have started doing tricuspid valve therapy, so a different valve that leaks that is really challenging to treat with medicines. It's the right-sided valve. And when that leaks, it's hard to really balance the water pill and effect on the kidneys and effect on the heart. And so when we really tapped out resources, we didn't really have any options and surgeons were taking patients to the OR for one valve, especially the right-sided valve. So now, we have actually ways to repair that valve as well as replace that valve. We have other pathologies in the valve where the valve leaks, like the aortic valve can leak. We don't have a great answer for that. That's being studied currently. We also have other transcatheter therapies that help patients that have weak hearts that will help support their hearts. just some transcatheter mechanism, so they can actually walk around, they're not hooked up to a machine. And then, in terms of carrying it, they're able to walk around the floors, potentially even go home at some point. So, there's a lot of things to look forward to with Interventional Cardiology in the near future.

Host: Folks, we trust you're now more familiar with transcatheter therapies. Dr. Parekh, keep up all your great work. It all sounds very exciting, including what's headed down the road in the future. And we thank you so much again.

Niraj Parekh, MD: Thank you.

Host: For more information, please visit tvheart.com. If you found this podcast helpful, please do share it on your social media. And thanks so much again for being part of the Health and Harmony Podcast from Southwest Healthcare Temecula Valley Hospital.

Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians.