Transcription:
Minimally Invasive Valve Surgery

Melanie Cole (Host):  UVA is among the few hospitals in the region offering mini valve surgery. What patients with heart valve disease could benefit from this minimally invasive surgery? My guest today is Dr. Gorav Ailawadi. He is a board certified surgeon whose specialties include heart valve disease. Welcome to the show, Dr. Ailawadi. What is cardiac valve disease? 

Dr. Gorav Ailawadi (Guest):  Thank you for having me. Well, our heart has four main valves. Their job is to open without restriction and close completely without leaking to allow blood to really move forward between the different chambers of the heart out to the lungs and to the body. When a valve is tight, we call it stenotic, and what it does is it restricts blood flow out of the heart. When a heart valve leaks, we call it regurgitant, and then blood ends up going backwards. Either way, when a valve doesn’t work properly, it can lead to symptoms that cause congestive heart failure, which includes things like shortness of breath, fatigue, chest pains. People can feel pretty bad. Valve disease can really span a lot of different types of causes and things like that. 

Melanie:  What are some of the causes of valve disease, and who is at most risk? 

Dr. Ailawadi:  Well, really, anybody can get valve disease. It’s not related to things that we consider to cause other heart disease, like smoking and diet. Those don’t actually lead to valve disease as much as they lead to other diseases of the heart. But there are many different ways that the valve can have problems. We probably ought to think about the two most common valves that are affected because there are four valves. The two most common valves are the aortic valve and the mitral valve. The aortic valve is the main valve between the main pumping chamber of the heart called the left ventricle and the body. This valve most commonly gets stenotic or tight, more so than leaking. When this valve gets tight, again, it restricts blood flow out of the heart to the body. There are few general disorders, such as disorders that people are born with that put people at higher risk for aortic stenosis, and those are people that have a bicuspid aortic valve. That’s where the valves have two parts in the valve instead of three. These patients have a higher risk to get aortic valve problems early on in their life. The other causes of aortic stenosis really are not genetic. It’s really more just related to other things that happen in their life. For example, rheumatic valve disease can occur when someone has had rheumatic fever, typically as a child. That can lead to aortic stenosis later on in life. The most common cause for aortic valve disease is really aging and wear and tear on the heart. Just like our back and our knees that have issues as we get older, so does the aortic valve. We get calcium buildup, and that leads to the valve getting tight. The other common valve that is affected is the mitral valve, and that more commonly leaks than gets tight. The mitral valve is a very complex structure. It actually looks like two parachutes side-by-side with little cords. There can be multiple reasons that cause the mitral valve to leak, like an old heart attack or stretching of the valve or cord itself—that’s called mitral valve prolapse. Rheumatic fever can also cause the mitral valve to leak or become tight. There’s a lot of different reasons. There are few genetic reasons, but most of them, a little bit of bad luck, I’d say, and/or wear and tear on the valve. 

Melanie:  Dr. Ailawadi, I understand there are a number of innovative treatment options. Can you tell us about minimally invasive surgical option, and how does it differ from traditional open heart surgery people might have had to have to get these leaky valves fixed and/or replaced? 

Dr. Ailawadi:  Okay. Well, I want to emphasize the goal with any surgery is to do the right thing for the valve, whether it’s to repair or replace it. The second thing we think about is how best to get to the heart. The way we fix the valve depends on what’s their issue. When a valve is stenotic or tight, we usually replace the valve with an artificial valve, whether it’s mechanical or bioprosthetic, which is a tissue or a cow or pig valve. When the valve is leaking, it’s common to try to repair the valve. That typically is a better option, particularly for the mitral valve. Minimally invasive surgeries are really doing the same operation that we do through full incision through the entire breast bone without breaking the breast bone. For example, we could fix the aortic valve through a small or partial opening in the breast bone or adjacent to the breast bone on the right side, while the mitral valve is fixed through a small incision in between the ribs on the right side of the chest without breaking any bones. Again, it really doesn’t matter if we’re repairing or replacing. We can really do both options through either incision. 

Melanie:  Who is eligible for this minimally invasive approach, and who might not be a candidate? 

Dr. Ailawadi:  It really takes thoughtful consideration for every individual patient, but anybody who has an isolated valve problem—that means they only have one valve that needs to be fixed, they don’t have a second valve or they don’t have a bypass surgery that needs to be done—we consider for a minimally invasive approach as the first option. We start looking at any unusual things that may suggest that traditional open heart surgery may be better for them. For example, they have a lot of calcium buildup around the heart, around the valve, around the aorta that might make minimally invasive surgery more risky. If they’ve had certain types of heart surgery before, it may be safer to do through a traditional incision. But I’d say by and large, the majority of patients that have an isolated valve problem that is just one valve that’s the issue; we’re offering a minimally invasive approach. 

Melanie:  If you’ve had to repair the mitral valve, for example, what is recovery like and what is the outcome? Are they going to have it re-repaired or possibly replaced later on in life? Can they still go into congestive heart failure if you’ve repaired a leak? What’s the outcome like? 

Dr. Ailawadi:  It depends a little bit on how it’s leaking. We’re learning more and more about the mitral valve. There have been large recent studies for what we call ischemic mitral valve regurgitation, when a valve is leaking to a very weak heart. And we’re learning that it might be actually better or at least as safe to replace that valve so that the valve leak should not come back. When we’re talking about mitral valve prolapse, by and large, those valves can be repaired with very good longevity without a need for repeat operation. It’s not to say it never happens, but it’s pretty unlikely and we have data up to 15 years that the valves still work very well once we repair when it’s a mitral valve prolapse. In terms of recovery and the benefits, what we see is there’s a shorter stay in the hospital, like a return to activity and driving. For young patients, that means they can get back to work sooner. In older patients, it means they can get more mobile with fewer restrictions. They don’t need as much help with rehab. I think there is certainly recovery benefits. Regardless of the incision, the outcome and longevity really should be the same. The valve should be repaired with the same efficacy. 

Melanie:  Is there anything you can tell listeners about prevention, or is there anything they can do to kind of keep their valves healthy? As you said, it’s not necessarily lifestyle management, but is there anything else that we should know? 

Dr. Ailawadi:  Again, since it’s not related to really our lifestyle, I wouldn’t say there is any modifications. What I would suggest is if you’ve ever been told you have a murmur -- or certainly ask your doctor when they listen to your heart, “Do you hear anything?” If there’s ever a murmur or you have any history of valve disease, the easiest thing to do is to ask your doctor to get an echocardiogram. That’s an ultrasound on the chest of the heart. That would be a great screening to see do you have any valve disease or not. The other part of it is to really pay attention to your symptoms. When you have valve disease in which you can feel short of breath, particularly when you start exerting yourself or going uphill, that’s usually the earliest sign. And what we find is a lot of patients modify their lifestyle so they don’t do as much, and it’s been very subtle and you ask them and they say, “I do everything I can. I don’t have any issues.” Really, they changed their lifestyle over the last few years. The other thing we hear is palpitations when people feel their heart racing. Those are the things that should tip off your family doctor or other doctor to start thinking about—could it be valve disease, let me listen to the heart, and maybe even push for an echocardiogram. 

Melanie:  Dr. Ailawadi, in just the last minute or so, why should someone come to UVA Heart and Vascular Center for valve disease treatment? 

Dr. Ailawadi:  Well, UVA is really one of the few places, really, in the country that has all the options to treat valve disease. For example, for the aortic valve, we have more than, say, seven different ways to fix the aortic valve from simply ballooning the valve open to a transcatheter valve replacement, which we didn’t talk about. But we can replace the aortic valve in the right patient without an incision by going through the groin, or even through a small incision on the chest without stopping the heart, minimally invasive valve repair, minimally invasive valve replacement, a traditional incision valve repair or replacement. For the mitral valve, we have at least five ways to fix the mitral valve, including a percutaneous mitral valve repair with mitraclip device, minimally invasive mitral valve repair, minimally invasive replacement, traditional valve repair or replacement. We have a lot of different options, and we’re one of the few places that really can offer the full spectrum of what’s available. Choosing the best option for each patient involve our whole valve team, a really multidisciplinary approach with experts, really, from all disciplines working together to provide the best outcome for each individual patient. I think the care is very individualized. Really, finally, our excellent outcomes and reputation, I really think, are world-renowned, and that allows us to get access to, really, the newest techniques and devices that are not available to other institutions. We’ve got some of the newest valves, newest devices that we use to help aid in minimally invasive surgery, and we really have leaders in the field who love to do their job and they love to do it with a smile. 

Melanie:  Thank you so much. And for more information on the UVA Heart and Vascular Center, you can go to uvahealth.com. That’s uvahealth.com. You’re listening to UVA Health System Radio. This is Melanie Cole. Thanks so much for listening.