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Bill Klaproth (Host): When it comes to heart valve disease, there's a lot to know. And the better informed you are, the better you'll be able to make the right decisions on your heart health. So, let's learn more about heart valve disease with Dr. Amit Vora, Associate Medical Director of Structural Heart UPMC Heart and Vascular Institute in central PA.

This is Healthier You, a podcast from UPMC in central Pennsylvania. I'm Bill Klaproth. Dr. Vora, thank you so much for your time. I really appreciate it. So what is it that you do first off as Associate Medical Director of Structural Heart at UPMC Heart and Vascular Institute.

Amit N. Vora, MD (Guest): Thanks very much Bill, for having me on. It's great to be here and to talk to the audience about what we do at UPMC Heart Vascular Institute, and so I am a structural interventional cardiologist. And what that means is that I spend my time treating folks using the most minimally invasive approaches that we have to treat structural heart disease. And so while I do regular interventional cardiology, which includes placing stents in folks that have narrowings or blockages in their heart arteries, my partner, Dr. Hemal Gada, spend most of our time treating valvular heart disease, and we really try to do this in the most minimalist way possible.

Host: Okay, so valvular heart disease. And you said you try to do this in the most minimally invasive way as possible. Well, that leads us to aortic stenosis. One of the things that I'm sure you find commonly in people. So exactly, what is that for someone listening? What is aortic stenosis?

Dr. Vora: So, aortic stenosis is narrowing of the aortic valve. And the aortic valve is the main valve that connects the main pumping chamber of the heart out to the rest of the body. And so when this valve narrows, you can imagine that it just significantly increases the amount of work that the main pumping chamber of the heart has to do. The main pumping chamber of the heart or the left ventricle can tolerate that up to a point, but eventually it essentially just wears out. And when it wears out, patients can sometimes develop heart failure, and it gets to the point where they can really become symptomatic drom this.

Host: So speaking of symptoms, when the valve starts to wear out, what are the symptoms then of aortic stenosis?

Dr. Vora: So the most common symptom is shortness of breath and shortness of breath typically occurs with activity. And so what we most commonly hear are patients that have been doing very well, but then have slowly noticed increasing shortness of breath, particularly when walking up a hill or when climbing a flight of stairs.

The other things that people generally describe include chest discomfort often, occasionally often with activity. And then also sometimes people feel dizzy or lightheaded, or have a sensation of passing out or sometimes they do pass out. I think these are the classic symptoms of aortic stenosis.

Host: So then how is this treated?

Dr. Vora: Historically the way that aortic stenosis was treated was with open heart surgery. In essence, this is a mechanical problem. There is a valve that is not working the way that it should be. And when that happens, the valve needs to be replaced. Now for the last 50 or 60 years, the way that this had been done was with open heart surgery, where a surgeon would put you on heart lung bypass, would cut out the old valve would stitch in a new one and then close the chest again. But thankfully over the last 15 years, we've developed minimally invasive approaches to treat this condition.

Host: So not having to do major open heart surgery is that the big difference then for patients between surgery and less invasive transcatheter treatments for aortic stenosis. Can you explain that to us?

Dr. Vora: Yep. Absolutely. And so transcatheter approaches generally mean that we can do our work using catheters or plastic tubes that we insert from one of the large blood vessels that's generally in the leg. And so most of the work that we do is done through needle puncture. It does not require any incision, doesn't require stitches or anything like that. And the biggest advantage for patients is that it significantly reduces the amount of recovery time.

Host: Right. So this TAVR or transcatheter aortic valve replacement, as it's known, it's called TAVR, if I'm not mistaken.

Dr. Vora: That's correct. Your absolutely right.

Host: So how many then TAVRs does the structural heart team in central PA perform each year? Has this become the preferred method?

Dr. Vora: The way that we approach this is really on a very individualized manner. We really try to find the best therapy, the most appropriate therapy for particular patients. That being said, we do quite a number of these procedures. So, we do probably close to just under around 400, for the last few years, which really puts us in probably the top 5% of centers across the country by volume.

Host: Right. So then you said you do about 400 of these a year. What ways does your team strive to make the TAVR if you will, safer?

Dr. Vora: The most important thing is that everything that we do is through a heart team approach. And so that means that when patients come to see us in the office, we really bring the entirety of our resources to bear, to find the appropriate treatment strategy for the right patient. And so that involves making sure not only I, but one of my heart surgery partners sees and evaluates the patient, and in this way it allows us to work very carefully to select the right therapy. There are certain patients for whom surgery is probably the best option. If there's somebody who's very, very young. If it's somebody that has, for example, a number of blockages in the heart arteries, it may be that traditional surgery is the best approach. But for other patients, and especially for folks as they get older and older, it may be that a less invasive approach that allows patients to recover relatively quickly may be the best approach. One of the things that we do for almost all patients that are eligible for the procedure is use a special device to reduce the risk of stroke. And so, as you can imagine, one of the concerns of replacing the valve is that small bits of calcium or debris can flick off of the valve.

And if they happen to go up to the brain that can potentially result in a stroke. And in general stroke rates tend to be similar between patients that undergo these less invasive catheter based approaches as well as surgery. One of the things that we do for our TAVR procedures is we use a device called the Sentinel cerebral protection device.

And that's a device that we insert through the right wrist. It has two baskets that cover the blood vessels that go up to the brain and what these baskets do is they catch any of the debris that may have flicked off of the valve while we're doing our work. And so we feel that this is one of the strategies that we can use to do the procedure as safely and as comfortably for our patients as possible.

It is important to note that this is not the standard of care across the country. And so probably only about a quarter of sites across the country use this device, but at least right now, we believe in the device in terms of lowering the potential risk of stroke for patients that we tend to use that on almost all patients.

Host: Well, it's comforting to know you use this at UPMC to try to reduce the risk of stroke. So, let's talk about the mitral valve as well. So we hear about this mitral valve regurgitation. Can you explain that to us?

Dr. Vora: Absolutely. So the mitral valve is the other heart valve on the left side of the heart. And the mitral valve connects the top left chamber of the heart called the left atrium to the main pumping chamber of the heart called the left ventricle. One of the issues that can happen with the mitral valve is that it can leak. And when it leaks significantly, that's called mitral regurgitation. The important thing to know about mitral regurgitation is that it is essentially a catch all term for a lot of different ways that the valve can leak. The mitral valve just structurally is a little bit more complex than the aortic valve. It's not only the actual leaflets of the valve, but then there's a ring that the valve sits in as well as parachute like cords that connect to the valve, to the main pumping chamber of the heart and dysfunction in any one of these parts of the valve can result in significant leaking.

Host: So, what are the symptoms of mitral valve regurgitation or this leaking of the valve?

Dr. Vora: Patients that have mitral valve regurgitation, also significantly complain of shortness of breath. The shortness of breath is caused by something a little bit different, but in general, the vast majority of patients describe increasing shortness of breath that kind of occurs slowly over time.

Host: Okay, got it. As people age is part of this mitral valve regurgitation, I've heard of this before, is it fairly normal as people age, but just when it gets really bad, that's when you start having the symptoms, is that correct?

Dr. Vora: Yep. So with all of these valve conditions, we generally break it down into trivial or trace kinda mild, moderate or severe. And so the vast majority of people to be honest, have some small degree of leaking of the mitral valve. And in general, it tends to be sort of in the trivial or mild category. When it gets to be severe, and then not only when it gets to be severe, but patients start to become symptomatic, is when we really start to get concerned.

Host: Okay. Thank you for that. And then how is mitral valve regurgitation treated?

Dr. Vora: So unlike with aortic stenosis, there are medications that can treat mitral regurgitation. For the vast majority of patients, cardiologists will place them on two or three medications that can help control blood pressure, and that can also help to reduce the amount of leaking. Unfortunately, for a select number of patients, however, it's still, again, is a mechanical issue. And for that reason, once medicines have done everything they can, we really need to start to look for more invasive options to treat mitral regurgitation.

Host: Okay. And then I've got just kind of a curious question. Since the heart is a muscle, if you were to be active and really start working on your cardiovascular and strengthen your heart, would it be possible to reverse some of this valve degeneration?

Dr. Vora: No, unfortunately not. That being said, it is incredibly important, I think that increasing physical activity is one of the best things that folks can do for their long-term cardiovascular health. Unfortunately for most valvular heart disease, valves just tend to wear out over time. Aortic stenosis is a condition that affects folks primarily as they get older in their seventies, eighties and beyond. Similarly with mitral regurgitation, the vast majority of folks that we treat are generally in their late seventies, eighties, and nineties. And we've actually even treated a couple of folks that have been a hundred and 101 years old.

And so it really is for that reason why it's so important to have these less invasive options. If this were a condition that affected mostly young people, then it would be nice to have less invasive options, but it really would be important to have an incredibly durable treatment that patients could tolerate, recover from and then get on with their lives. Unfortunately, what an 80 or older patient can deal with, you know, with everything else that they have going on maybe a little bit less.

Host: Right. That makes sense. So then what is the difference for patients between surgery and less invasive transcatheter treatments for mitral regurgitation?

Dr. Vora: So, catheter-based therapies for mitral regurgitation are a little bit more complex. And the main reason for that is something that I had alluded to before, which is that it's really important to get to the bottom of exactly what the issue is, what part of the mitral valve is not working so that we can direct our treatment accordingly. Historically, the gold standard for invasive mitral valve treatment was open-heart surgery and one of our surgeons would essentially try to repair the valve if they could. And as I said, Dr. Mumtaz, Dr. Lauren, Dr. Amersham, our team, really are expert at trying to repair the valve if at all possible. But if the valve cannot be repaired, then it needs to be replaced. It's a similar sort of thing on the catheter-based side of things. The main treatment that we have right now, that's FDA approved is something called the MitraClip. And what the MitraClip does is it really tries to grasp the two leaflets and bring them together to reduce the amount of leaking.

There are a number of other platforms that are currently undergoing clinical trials to expand the number of treatment options that we have available. But unfortunately right now, this is a field that doesn't have as many commercially available treatment options as we have for aortic stenosis.

Host: So you were talking about where we currently are in the therapies for these conditions. What about in the future? Are there new transcatheter therapies that are coming for valvular disease?

Dr. Vora: Absolutely. Even just for the mitral valve, it really is a burgeoning field of new technologies that are coming, almost on a monthly basis. And so I mentioned before, right now, the only commercially available treatment that we have available is called the MitraClip. There are a couple of transcatheter mitral valve replacement platforms. So instead of trying to repair the valve, we would essentially just replace ,the valve with a brand new valve. We are a clinical trial site for a couple of those options. There are also other technologies that can work to repair some of the other parts of the mitral valve, such as those parachute like cords, or the ring. These are all therapies that will be coming down the pike very, very soon.

Host: So might we see the day where there is a full mitral valve replacement and you just go in, put the new valve in and you're done mighy that day come?

Dr. Vora: ABsolutely. And those platforms currently exist right now. And we've done those procedures at UPMC Pinnacle at Harrisburg Hospital. They currently are not FDA approved and so those technologies are primarily available as part of clinical trial offering. And so one of the advantages of coming to receive your care at the UPMC Heart and Vascular Institute is that we are a site for a number of clinical trials. And so the options that we have available, not only include traditional surgery or the traditional commercially available options, but then also really the cutting edge treatments that are not available at the vast majority of sites across the country.

Host: Wow. Really interesting. That is really good to know. So in the future, mitral valve replacement may become as common is the TAVR is now, is that another way to say it?

Dr. Vora: It's possible. That is a technology that is one of the options that is being studied very, very carefully. But for other patients, it's not really clear if repair versus replacement is the best option. As an analog on the surgery side, surgeons really do try to repair the valve as best as they can before they go to replace it. And so on the catheter based therapy side, it's not entirely clear whether all patients should receive transcatheter mitral valve replacement or whether there are some patients that may benefit more from repair. Whether there are other patients that may benefit from other mitral valve technologies that may be a hybrid between the two, it's very early in the field and we just don't have the answers to those questions quite yet. But it's something that we're looking very, very carefully at.

Host: So taking that individualized approach, and like you said, for some people, the repair might be the best thing in place of a replacement.

This is really good stuff, Dr. Vora. So where does your team of structural heart specialists see patients?

Dr. Vora: So our home base is at the our main hospital, a Harrisburg Hospital in downtown Harriburg. But we spent a lot of time doing outreach clinic. And so Dr. Gada and I spend a lot of time every month going to our satellite facilities. And so we go to Chambersburg, we have an office in Hanover, another office in York at the New York Memorial Hospital. We have offices in Lancaster and Lititz as well. And so we understand that patients have to sometimes travel to get their procedures done at Harrisburg Hospital. And for that reason, we really do try to make it as streamlined and as straightforward for patients as much as we can. And for us, the first step for that is coming to, meet patients closer to home for them, to establish the relationship, to kind of talk about what some of the options are. Many of these patients do need to come to Harrisburg Hospital for some advanced testing before the procedure, just because some of the tools that we have really are state-of-the-art and we only have them at Harrisburg Hospital.

And so for that reason, what we do is when we meet patients in the community, we will outline an entire testing plan for them as well, so that they're not having to come back and forth to and from Harrisburg, we'll find a day where we can get all of the testing; it'll be a full day, but we can get all of the testing, have folks meet everyone they need to meet in terms of the rest of our team, in one day. So that the next time that they're coming up to Harrisburg Hospital is for their procedure. The vast majority of our patients go home the very next day. And then we do all of the follow-up at our satellite facilities in the community as well.

And so it is really our hope that patients are coming to Harrisburg Hospital two times total, one time for their testing and to meet everyone on the team. The second time is the day of the procedure, go home the next day. And then all of the follow-up happens locally.

That's really good. And then you mentioned talking about discussing options for treatment among the team. How does the team of structural heart specialists at the UPMC Heart and vascular Institute work together to assess patients?

So one of the biggest advantages of having a valve clinic, a set of office days that are dedicated entirely to patients that have valvular heart disease, is that we have all of our specialists really in the same place at the same time. And so, when patients come to see us at Harrisburg Hospital, they will see not only Dr. Gada or I, as the structural interventional cardiologists, but they will also meet one of our excellent surgeons. So, Dr. Mubashir A Mumtaz, Dr. Dave Lauren, Dr. Reza Abrishamchian; they're the cardiac surgeons that we partner with and work very closely with to ensure that patients are getting the appropriate therapy. The last thing that we want is for patients to get different treatments based on who they see first. And so we really do take a collaborative approach.

The other thing is that we have dedicated imaging specialists as well Dr. Atimansore, Dr. Roberto Hodara spend a lot of time, taking pictures, or using ultrasound to get really good images that are incredibly important for us as we do our work. And so we really rely on them to give us the information that we need as well. Finally, we have a weekly meeting every Friday morning at 6:30, our entire heart team gets together. And we talk about the patients that we've seen in the prior week. And this really allows, it's a meeting that's open to the entire heart team, and it really allows everyone to offer their perspective on what potentially is the best treatment option for individual patients.

Host: Right. Well, this is really been informative. Dr. Vora, thank you so much for your time. We've really learned a lot through this podcast and we appreciate your time. Thank you again.

Dr. Vora: Thank you very much, Bill. I really appreciate being here. Thank you so much for your help.

Host: And once again, that's Dr. Amit Vora. You can schedule an appointment with one of the valve specialists by calling 717-231-8555. That's 717-231-8555. And for more information, you can visit upmc.com/centralpaheart. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Healthier You, a podcast from UPMC. I'm Bill Klaproth. Thanks for listening.