Valve Disease and Treatments
After a webchat on heart valve disease and treatments, Dr. Grant Reed and Dr. Deborah Kwon review common questions such as what tests are needed to diagnose valve disease, how to determine the best treatment , what patients should know about aortic and mitral valve disease - when surgery is needed or when transcatheter valve replacement is an option, and treatment of tricuspid valve disease.
Valve Disease and Treatments
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Dr. Kwon: Hi, I'm Dr. Deborah Kwon and...
Dr. Reed: Hi, this Grant Reed.
Dr. Kwon: We just had a really great web chat about valve disease and treatment options. Grant and I thought first we'd start off with just talking about how we diagnose valvular heart disease. Typically, the baseline study is with an echocardiogram, and it's very important that you get a very good high quality echocardiogram because this is the basis on which we diagnose disease.
Typically, people think that all echoes are created equally, but actually it's very dependent on how well-trained the sonographer is in terms of really going after the valves and getting a comprehensive evaluation. That's really the very first and foremost thing that we highly recommend, that you get a very good baseline echocardiogram.
From there, whatever diseases diagnosed, your symptoms really guide what further testing, evaluation and treatment is needed. If the disease is in the moderate to severe range, that's typically when we start to think about when treatment should be determined or considered. Some of the advanced imaging techniques that we offer to further evaluate these are stress echocardiography, transesophageal echocardiography, cardiac MRI and CT scanning.
Dr. Reed: Another common theme of the questions that we had asked were, how is transcatheter aortic valve replacement performed? What are some of the indications for that and what are treatment options? Just as Dr. Kwon said, once you have a thorough evaluation for whether it be aortic valve disease or any other valve issue, then the next step is determining how best to treat it.
Medications are often very effective for patients. However, with either valve stenosis or valve regurgitation, that'd be an aortic, mitral or any other valve, eventually it comes to a point that surgery may be needed or a catheter treatment may be needed, and when is it appropriate to do so. In general, it's appropriate to have valve stenosis regurgitation treated with a surgery when patients start becoming symptomatic, when the heart starts to dilate, or when the heart function starts to go down. Those are some indications that we consider every day when we evaluate patients.
If it's decided that we need a mechanical treatment either with surgery or another catheter therapy, then we as a team will discuss this together. One of the great things about being at the Cleveland Clinic is that every physician, they have some other physician to ask questions to, and our team-based approach helps us to come up with the absolute best approach for every patient's care.
For the issue that I deal with mostly which is aortic valve stenosis and transcatheter aortic valve replacement, we have a meeting every week where we discuss every patient that's a candidate either for a catheter-based aortic valve replacement, TAVR or surgery, and we come up with a plan. The tests that are usually needed prior to transcatheter aortic valve replacement are an echocardiogram, a CAT scan, or an MRI scan, a heart catheterization, and a few other tests really to stratify patients for surgical risk.
In patients that are medium or high risk, and those are patients that will typically have the option of having either surgery or TAVR. Patients that are low risk right now are currently being evaluated with a clinical trial which we can offer here at the Cleveland Clinic as well. TAVR is a very exciting field I think, it's something which will continue to evolve and change, and it has been transformative in this area. We're a very high volume center, and in the context of that our outcomes are outstanding.
We encourage anyone who wants a second opinion about their aortic valve disease or wants to consider an evaluation for this to come in and have that done here, because even if it isn't TAVR, ultimately what you end up getting, we end up moving them in the right direction either towards surgery or medical therapy if that's what's best for the patient. That was a very common question that we got asked about as well.
One of the question which is another really nice example of bridging the gaps between specialties and within cardiology and surgery especially, is mitral valve disease. This is something which the patients are very interested in, and what are the new and upcoming treatments for mitral valve disease with with catheter therapies. The surgical outcomes for treatment of mitral valve disease are in general excellent. The patients that are good candidates for a surgery, then it's usually what we recommend for patients unless there's a good reason why they can't have surgery.
Maybe Dr. Kwon can speak a little bit about what goes into your decision making in terms of is a patient ready for mitral valve surgery or not, and should they get a repair, a replacement. That's a very common question that patients ask.
Dr. Kwon: Yes. Here at the Cleveland Clinic, the most common cause of mitral regurgitation is mitral valve prolapse. Patients who have significant mitral regurgitation will be followed serially with clinic visits and echocardiograms to see if their mitral regurgitation is progressing. Because our surgical outcomes here at the Cleveland Clinic are so good, we do recommend surgery if the valve can be repaired, and if the patient has severe mitral regurgitation even if there aren't symptoms. This is because we feel that this will improve the patient's outcomes and prevent the likelihood of the patient developing heart failure and complications related to that.
The real issue for us is to determine whether or not the valve severity is truly severe, and sometimes that can be difficult in mitral valve prolapse because the mitral regurgitation could be somewhat hard to see, and therefore it's quite common that we get advanced imaging such as stress echocardiography, transesophageal echo, or cardiac MRI to further evaluate the presence of the severity. While we are aggressive in repairing valves that are asymptomatic, they do need to be in the severe range for that to be justified.
On the flip side, if a patient has moderate to severe disease but has symptoms, then symptoms always guide the management in terms of becoming more aggressive with surgery. If it's mitral valve prolapse, the patient is a good surgical candidate and the valve can be repaired, we typically recommend that the patient goes for surgical repair. On the other hand, we also have transcatheter techniques for mitral valve prolapse with severe regurgitation who aren't good surgical candidates, and doctor, we can talk a little bit about that.
Dr. Reed: Sure, that's the perfect explanation. I think that really sums it up nicely is that if patients are candidates for surgery and they have degenerative mitral valve disease due to mitral valve prolapse or flail of their mitral valve, then we generally recommend surgery.
Those patients that can't get surgery for one reason or that they're high risk, then we can consider doing what's called a mitral clip procedure, which is a catheter-based procedure which is not surgery, but is one in which we go in the veins of the body and go to the right side of the heart. Across the right side of the heart with a catheter into the left atrium, and then we'll grasp both leaflets of the mitral valve and attach a clip to it. That generally does a very good job in reducing a mitral regurgitation, especially for patients with degenerative mitral regurgitation.
Currently, patients that have functional mitral regurgitation or regurgitation due to the ventricle dilating, which is generally considered to be not a problem with the mitral valve itself, more problem with the ventricle or the atrium which are dilating and stretching things. Those are patients which we're currently enrolling in clinical trials for mitral valve repair with mitral clip.
There were recently some clinical trial data which is very encouraging, those patients may also benefit from mitral valve clip. I think the future is very bright in this area and we're very excited to evaluate patients with this problem because if it isn't mitral clip that they're suitable for, oftentimes we can come up with an innovative solution or a solution that other hospitals don't have available. That'd be through additional clinical trials or getting them plugged in with one of our surgical colleagues who can do things here which a lot of places would not be able to do. I think the multidisciplinary team-based approach here is just one of the really special things about it.
Some of the other questions that we had were about tricuspid valve disease. We've talked about aortic valve, and we're talking about mitral valve, and now tricuspid valve disease, and what are the treatment options for that. From our perspective and my perspective as being an interventional cardiologist and what catheter-based options are there for tricuspid valve disease right now. At this point it's all in clinical trials. However, there are some surgical options for patients that do have severe tricuspid valve regurgitation. Maybe Dr. Kwon can talk a little bit about what goes into the evaluation of a patient with tricuspid valve disease and when do you consider doing a surgery for those patients.
Dr. Kwon: Tricuspid valve disease is a little bit more tricky in the sense that it's not as a clear cut indication when we send patients as it is for left-sided disease. Obviously, if a patient is having symptoms such as increasing fatigue, bloating, weight gain, lower extremity edema in a setting of significant tricuspid regurgitation, surgical therapy can be considered. However, it's also important to determine the etiology of the tricuspid valve disease.
For instance, if a patient has significant pulmonary hypertension that's not reversible, then it's thought that tricuspid valve intervention will likely not be successful because the increased pressure on the pulmonary side will result in back pressure on the tricuspid valve and cause the valve to leak again. Determining whether or not tricuspid valve intervention is necessary, again, as a multidisciplinary approach. Typically, we'll evaluate the tricuspid valve, the presence of pulmonary hypertension, and then discuss whether significant success is likely. If that's the case, then we would then proceed with doing surgical intervention.
Dr. Reed: Right. I think that's a pretty good summary of most of the questions that were asked. There were some others about heart stenting and such that... maybe I'll not discuss any further right now given the focus of this being on valvular disease, but I hope this was informative. I hope that this aids to improve your health in some way. If there's anything that we can do at the Cleveland Clinic to either give you a second opinion or a first opinion about your valve disease, please don't hesitate to reach out because we see patients from the simple problems all the way to the most complex. I think we can almost always in every case, help patients improve their health in some way.
Dr. Kwon: Thank you for your time.
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A Cleveland Clinic podcast to help you learn more about heart and vascular disease and conditions affecting your chest. We explore prevention, diagnostic tests, medical and surgical treatments, new innovations and more.