Addressing Structural Heart Disease

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Samir Kapadia, MD:

Hello, everyone. We are very excited to be here today. I am Samir Kapadia, Chair of Cardiology here at Cleveland Clinic. I have with me Dr. Amar Krishnaswamy, who is the head of our Interventional Section, cath lab, and he has been also in the past head of our interventional fellowship. So, today we are going to talk about how we treat structural heart disease.

Structural heart disease is a disease where something is wrong in the anatomy of the heart, whether it is the valve, holes in the heart, or dysfunction of the valve that is leaking or narrow, and how we replace the valve. With that broad overview, I just want to ask, Amar, can you just highlight what are the key things that, currently, we are doing and what our team comprises of?

Amar Krishnaswamy, MD:

Sure. Thanks, Dr. Kapadia. It’s a pleasure to be here on this podcast. I think the important thing for us in Cleveland Clinic is that we have had an involvement in the treatment of structural heart disease for decades now. Since the 1990s, we've been using catheters to treat problems such as mitral valve stenosis and aortic valve stenosis. Over the aughts and the teens, those therapies have evolved to include catheter-based valve replacements and valve repairs in the mitral valve, in the aortic valve and most recently in the tricuspid valve.

With decades of experience, we've been able to really evaluate what we do and to provide the most optimal results for patients. We're involved in publishing those results and educating operators throughout the country and throughout the world to try to bring this kind of world class care to everyone that seeks treatment for structural disease.

That obviously takes a large team and includes us as interventional cardiologists. It includes our cardiac imagers who specialize in CT scanning and echocardiography to help us understand the disease at hand and how we can treat it with a catheter-based therapy. Of course, it involves a number of other cardiologists to help manage the medical cardiac conditions that are necessary.

Finally, the cardiac surgeons with whom we collaborate on many of these patient assessments and treatments, so that we're really bringing the team aspect to the optimal therapy for these patients.

Samir Kapadia, MD:

I agree, I think the key thing to understand is the Cleveland Clinic for many years, the last 50 years, has been involved in valvular heart disease treatment.

There is expertise from physicians, imagers and cardiac surgeons who champion many different repair procedures, replacement procedures, and innovated different valves. Then came this revolution of breakthrough devices, where we have all these different valves that are available that can be done without opening the chest, going through the groin or going through sometimes the neck. All these procedures are done in such a way that you cannot even see the incision.

This is a tremendous, in my mind, at least, a tremendous improvement or evolution of treatment, where the same things that our surgeons have been doing, we are able to do without opening the chest. With that introduction, just to say that, over the last 25 years or so, in 2003 or 2004, we started repairing and replacing the valves.

Before that, as you rightly pointed out, in the 1990s, we were still doing balloons to open the valve, but these are now definitive treatments because we are replacing and repairing the valve. Maybe you can tell us about the aortic valve, which is the key valve, the main valve through which the blood goes to the rest of the body. How has it evolved? What is the current status of aortic valve replacement percutaneously?

Amar Krishnaswamy, MD:

Aortic valve stenosis, most commonly patients might experience exertional fatigue or exertional shortness of breath, sometimes exertional chest discomfort as well. If any of these symptoms ultimately lead to an ultrasound or an echocardiogram and a diagnosis of aortic valve stenosis, historically, patients used to have a cardiac surgery. In the mid-aughts, Doctor Kapadia and other interventional cardiologists and cardiac surgeons here at the Clinic really were involved in pioneering transcatheter aortic valve replacement.

So, as Doctor Kapadia mentioned, we put a small catheter at the top of the right or the left leg, and we go up with that catheter to the heart and are able to actually replace the failing valve with the new one.

I think the really exciting thing is that when this started, now almost 20 years ago here, it was really reserved for patients who had no other option for treatment. Through very rigorous and well-done randomized control trials with which we've both been involved over the last 15 years, we have demonstrated that transcatheter aortic valve replacement, or TAVR, is equally safe and effective to cardiac surgery and in some ways, in fact, even safer than cardiac surgery, depending on the patient's level of risk. In the most recent year, for example, in the United States, the ratio of TAVR to surgical valve replacement was almost 5 to 1, which means that we're able to bring a minimally invasive therapy to patients to treat a major cardiac condition and send them home the same day of their valve replacement, which is quite exciting.

Samir Kapadia, MD:

It is also important to recognize that some of these patients that, as you rightly pointed out, we select the patients appropriately. If you still look at Cleveland Clinic, we are doing 600 to 700 transcatheter valves and about similar number of aortic valve replacements, isolated maybe 400 and plus other aortic valve replacements that we are doing surgically.

One of the good points about Cleveland Clinic is that, since we all work as a team, it allows us to select the right anatomy, the right patient for the right treatment. We are able to provide this treatment at the highest level, because in the last so many years, our mortality has been less than 1% on 5,000 patients. Stroke rate is less than 1%, pacemaker is less than 3%, which is almost unheard of.

All these things can be done, I think, because we are selecting the patients right. We have an incredible team, other than Dr. Krishnaswamy and myself. Dr. Puri and Dr. Reed are working, plus so many other people are involved. Doctor Yun as a cardiac surgeon. So, this is a very big team.

This is very unique because our ORs (operating rooms) are also incredible, very large. You can do open surgery as well as transcatheter therapy, both at the same time. Many hospitals do not have these kinds of facilities. This also adds to the safety of the procedure that we are doing.

How about the mitral valve? What do you think? Where do we stand with the mitral valve treatment currently?

Amar Krishnaswamy, MD:

The mitral valve is an exciting frontier for therapy for patients from a transcatheter perspective. We've been using the edge-to-edge repair device, the MitraClip, since the device started. Again, Dr. Kapadia was involved in the first procedure done with a MitraClip in the US. In the world, I should say.

Samir Kapadia, MD:

Yeah, in the world, it was Dr. Whitlow and Dr. Rodriguez from Cleveland Clinic. They did go to Venezuela to do the procedures. We did the first here, where it came to Cleveland Clinic. That was like in 2004. So, we have 21 years of MitraClip. Dr. Whitlow, is no longer with us. This also tells us how life moves on, that he pioneered that, but he's no longer. We'll always remember him when we do the MitraClip procedure.

Amar Krishnaswamy, MD:

We've been able to treat a lot of patients who would not have been candidates for a cardiac surgery for their mitral valve regurgitation, with what we call degenerative mitral regurgitation, with the MitraClip. That then evolved to treating patients who have congestive heart failure associated with their mitral valve regurgitation, which is usually not very well treated with cardiac surgery. Frankly, even the cardiac surgeons find that a difficult illness to treat. We have found that the MitraClip therapy can be very effective in these patients. That's become a really big option for patients with what we call functional or secondary mitral regurgitation.

As with the aortic valve, where we started treating patients who had no options and then moved subsequently to patients who were younger and at lower risks for open heart surgery, we're currently in the midst of a similar sort of evolution in mitral valve therapy. The good news, again, with a large center like ours with pioneers and leaders in interventional cardiology, cardiac imaging and cardiac surgery, is that we have the option to bring patients therapies that might not be available elsewhere, through FDA-sponsored or company-sponsored clinical trials.

For the mitral valve, we are involved with an NIH-sponsored trial called PRIMARY. One of the heads of that trial is Dr. Marc Gillinov, who is our head of cardiac surgery. In that trial, we are able to treat patients either with traditional surgical mitral valve repair or edge to edge repair using either the MitraClip I mentioned or a newer device called the PASCAL.

Samir Kapadia, MD:

Wonderful. I think just to add to that, the tricuspid valve, which is on the right side of the heart, and as you know, Dr. Jose Navia developed the first valve here, the NaviGate valve. We were the first in the world altogether, to put the first valve in the patient. This was a big, big achievement, or a lot of fun for us to develop the valve and then put it in the human where it was successful. Then subsequently, we published that.

We have come a long way in tricuspid valve therapy also, because now we are able to put clips, we are able to replace the valve. The most exciting part of all this is that these patients can go home the same day after this major surgery. Dr. Krishnaswamy wrote these papers to say that we can send the patient home after the aortic valve replacement, mitral valve therapies, tricuspid valve therapies, home the same day. This is like a fiction to say that we are repairing something inside of the heart, replacing a valve, and patients are 80, 90 years old, and they are frail, but they are still able to go to the hotel or home and then come back the next day just to say hi to us. This is a tremendous achievement, not just for us, but in the entire world, that we are witnessing.

I want to ask you a question, how do you see the field going forward? If you are a patient and if you're trying to decide what should we do, whether they should travel, whether they should stay in the local area? What are the pluses and minuses of different therapies and how should people be able to evaluate this?

Amar Krishnaswamy, MD:

I think this is a complicated question. I think traveling for care is a tough situation for many patients. There is a financial commitment that patients and families have to make to come from where they are to Cleveland. That might require also staying in a hotel for a number of days. That's something to consider. Also, for recovery, oftentimes having an infrastructure in their own home may be more comfortable than being away from home.

To the second point, I think the fact that after so many of our transcatheter therapies, patients are back up on their feet within 6 or 7 hours after the procedure. The recovery aspect is often still taken care of at home if patients need physical therapy or rehabilitation. I think that is often less of a hurdle.

Primarily, I think patients have to decide whether or not to travel based on the access to care that they have locally. Oftentimes, the procedures that we offer are not ones that can be undertaken locally, because it might be part of a particular clinical trial. It may be that local interventional cardiologists are not trained in the procedures that we're doing. So, coming to Cleveland may really be their only option for the treatment that they need.

For patients that have an option locally and an option with us, of course, there's a number of different factors that go into that decision. I would never try to make ourselves look good by making someone else look bad. All I would say is that we're fortunate that since we take care of so many patients every year as an institution, we tend to have a very high volume. Also, in these types of transcatheter procedures, often the more that we do anything, the better that we can be, the better we have the ability to analyze our experience and how we can make things better moving forward.

That's a lot of where our research comes in and how we're able to advance the care of transcatheter therapies, generally speaking.

Samir Kapadia, MD:

I agree, I think it is not just the physicians, because it's also the nurses, the OR physicians, people taking care of them afterwards, how we follow patients, all of these things get better with volume. All of these things get better with how many patients you treat effectively. I think that adds to it.

I also think that our fellows, our trainees and our mentors, Dr. Tuzcu, Dr. Svensson, a lot of people worked on all these different areas. This adds a level of comfort, a level of expertise that allows very difficult things to be done in a very safe manner with a lot of safety nets.

This is, I think, our advantage. We are lucky that we are here and we are able to do all these things. But this is something to consider when you are evaluating your options. Especially, the amount of time that you are investing in travel and coming back is not that much because the recovery is fast. You are able to go back to work or go back to your home fairly fast. This is the reason why the paradigm may be changing a little bit, that patients may be able to travel depending on their resources and their abilities.

Amar Krishnaswamy, MD:

I think the other thing that I would mention specifically to patients and referring physicians in this regard is, we take a lot of effort to keep everyone in the loop. If a patient comes from elsewhere, their referring providers and caregivers know what we thought, what their procedures were, what our imaging studies showed, so that everyone can be taking care of that patient with the same information. We make that a collaboration.

Samir Kapadia, MD:

Many times, referring doctors come to us along with the patients to see how we treat. We are very happy to train them too. And our trainees are everywhere. This is another positive thing that if they want to find some people who are trained with us, that is another very good option.

Amar Krishnaswamy, MD:

Thank you very much for joining us for this podcast. For more information on heart care at Cleveland Clinic, please visit clevelandclinic.org/heart. That's clevelandclinic.org/heart. Thanks again for listening to Love Your Heart and look forward to having you on another podcast.

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