Valve Disease Awareness Day

Podcast Transcript

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Dr. Christine Jellis:
Morning everyone. Welcome to valve disease awareness week. I'm Christine Jellis. I'm a cardiologist within imaging section here at Cleveland Clinic in the Heart, Vascular and Thoracic Institute. And I'm thrilled to welcome Dr. Paul Cremer, who is an expert in valvular heart disease, to talk with us further this morning. Paul, could you expand on your roles within the institute because I know you wear several different hats.

Dr. Paul Cremer:
Thanks, Christine, and good morning, and it's good to be doing this again with you. I'm a cardiovascular imager here at the Cleveland Clinic. I also am the Associate Program Director for our cardiovascular training program and the Associate Director of our cardiac intensive care unit.

Dr. Christine Jellis:
So Paul is certainly well qualified to giving us some advice this morning. So I think let's start with a definition. What is valvular heart disease?

Dr. Paul Cremer:
Right. Yeah. So it's a good question to start with and what is valve disease? Well, I think we think of the valves really as being the doors between the heart chambers simply so that blood is flowing in the correct direction. So if those valves, if those doors, become diseased, primarily it occurs in two ways. The valve can become stenosed or narrowed, and that is a sort of some obstruction or limitation to the blood flow, through the valve, through the door, to the next chamber of the heart or blood vessel. Or secondly, the valve can become regurgitant or leaky. So the blood is going backwards instead of forwards. So those are the broad categories that we think about in valve disease, is of course, what valve is involved. And then generally speaking, is that valve narrowed, is it stenosed or is that valve leaky, is it regurgitant? So that's a general framework that I use when I talk to patients. I don't know how you think about it as well, Christine.

Dr. Christine Jellis:
No, I absolutely agree. I think the concept, narrowing and leakiness, is one that's easy to get our heads around. I think it's really amazing when you think about it that are very thin pliable valves that really control all that blood flow through the heart, and that is all done based on pressure. There's really no other mechanism to it. So I think the pump of the heart is really an incredible thing. And what we do is try and analyze that to figure out what's going wrong with that pump so that we can determine why people are starting to get symptoms or perhaps need intervention on the heart.

Dr. Christine Jellis:
I know that there are certain conditions that we can't predict. It's a bit of luck of the draw. But there are some conditions where folks may be more at risk for valvular heart disease. And a question is always, "How can we be proactive? What can we do to prevent it?" So, Paul, do you want to expand upon who might be at risk for valvular disease? And then we can think about if there's anything we can do to try and prevent that. Although for this condition, it can be difficult.

Dr. Paul Cremer:
Yeah, that's great. Thanks Christine. And as you said, we really think of the valve disease as it effects the patients in kind of two big buckets, is this something you were born with or is this something that was acquired? So if we think of valve disease that people are born with commonly would be a bicuspid aortic valve, so that's an aortic valve that has two leaflets instead of the usual three. That affects about 1% of the population. And first degree relatives of people with bicuspid aortic valves also have an increased risk of having the valve with two leaflets. It's about 10% or so of first degree relatives. The other valve problem that we see commonly that people are born with is mitral valve prolapse. So the connective tissue is a bit stretchier in these patients, and that can lead to those valves developing leaks over time.

Dr. Paul Cremer:
So that's one category, you're born with a valve disease and then as you age over the decades that can manifest into valvular disease. Again, either in a narrowing in the valve or leaking of the valve. What about things that are acquired? Well, like a lot of things that cause buildup of cholesterol, which can result in build up of calcium, that can also lead to deposits on the valves. So that can affect the aortic valve, causing it to be narrowed, causing it to be stenosed. As people get elderly, we also see buildup of calcium on the mitral valve, especially around the annulus, the ring of the mitral valve. So those would be acquired valve lesions. And there really it's just that the things that you need to do for your general health, control your blood pressure, control your cholesterol, live a healthy, active lifestyle, don't smoke cigarettes.

Dr. Paul Cremer:
These are sort of the usual things that we all know when we're seeing our primary doctors, that we need to take care of. And those are also I think benefits in that type of acquired valve disease. The other category of acquired valve disease, if the valve gets infected. And as you said, oftentimes, that can just be bad luck. But oftentimes it does occur also in people who are born with valve that's not quite normal. So if you're born with a bicuspid valve instead of a tricuspid aortic valve, you may be more likely to get an infection on that valve. And then that infection can cause destruction of vascular tissue. And again, cause it to either leak or to be narrowed. But in that situation, there's not a whole lot you can do to prevent that outside of a lot of these infections can come from the mouth. So we always encourage people to maintain the best oral hygiene and dental care as possible.

Dr. Paul Cremer:
So that's how I generally think about those categories, Christine, is this something you were born with or is this something that was acquired or is this something that happened on top of something that was congenital, something that you were born with.

Dr. Christine Jellis:
I love the way you think about it, Paul. And I also liked the fact that you're also thinking about other things we can do to prevent cardiovascular disease, which is important for prevention of heart attacks and strokes. I think just general health, maintaining good oral hygiene, maintaining a healthy weight, minimizing risk factors like smoking is so important. And it's actually reinforcing for us to be talking about that that may have an impact on valvular heart disease, as well as the other areas. I often get questioned on whether mouth hygiene or going to the dentist is necessary, particularly at the moment during the pandemic where people are a bit hesitant to follow up with their dentists. And I would strongly encourage people to keep doing that. I think the dentists are doing a great job at maintaining safety in their clinics. And it's important as you said, to look after our mouth and our gum care, because those bugs that live in our mouth, once they get in the bloodstream, in the right set of circumstances, can certainly cause infection of the heart valve.

Dr. Christine Jellis:
So good for folks to be aware of that. Extra motivation to go to the dentist, even though for those of us who may not be so keen to go to the dentist on the best of days. I think one other group of patients that we don't see quite so much anymore are those with rheumatic heart disease. And so some people may be aware of that connection. And I just throw that out there, because I think we could include that in the group of acquired disease that people should be aware of, although it's becoming less frequent that we see it.

Dr. Paul Cremer:
Yeah. Thanks. That's an excellent point. The rheumatic heart disease of people without an infection, that then causes issue with the valves. I think the other acquire condition that isn't as common, but that we should keep in mind is people who've had prior radiation therapy. In particular, if it was in decades past where there wasn't as much regulation, if you will, in terms of the radiation that people received. So that often can be something acquired on the valves, is radiation induced cardiac damage.

Dr. Christine Jellis:
So I think for our patients Paul, most of us like to be proactive about screening. So if you have a history of perhaps Hodgkin's disease with radiation to the chest, there can be a hangover or a lag effect where we don't see the manifestation of that valve disease until years later. So if you happen to be in that group, obviously that was the treatment that you needed at the time. But it's good to be linked in with a cardiologist for followup of some possible long-term effects of that radiation. We've touched on valvular disease, coronary artery disease, carotid disease, conduction disease. Unfortunately, there are multiple manifestations of this, but I think Paul, the two of us have a particular interest in this and I know others do as well. And I think my take on this is see someone who has an interest in that area, because they're often more in tune with all the things to be looking out for. What are your thoughts on that?

Dr. Paul Cremer:
Absolutely. I couldn't agree more. I think, especially in radiation associated heart disease, you need to be seen somewhere where people are seeing a lot of those patients, they understand the complex issues that arise. If surgeries or interventions are warranted, you want people, who've had a lot of experience doing them and thinking of the planning of what's best to do, not just for the outcome next month, but in the years and decades to come. And that's where I think there's a big advantage to being seen at a center that sees a lot of those patients is because there really is that thought into what's the long-term best approach for the patient.

Dr. Christine Jellis:
Absolutely. It has to be a step-wise consideration, doesn't it? Lastly, I think the one group that perhaps we could also mention with respect to causes of valvular disease are those who have leakiness or regurgitation of the valves as a consequence of something else. So I'm thinking about folks who have leakiness of the aortic valve, perhaps because they have a aortic aneurysm, which has stretched those leaflets apart, or someone who has tricuspid regurgitation because of the leaflets being stretched apart by a dilated right ventricle.

Dr. Christine Jellis:
And I think often there's multiple things going on. And I think that's why when we see patients, as imaging cardiologists, we really rely on some of our testing, our imaging testing in particular, to figure out not only what is the problem with the valve and how bad is it, but what else is going on because that's really important to putting the whole puzzle together. So Paul, perhaps we could start with what symptoms and signs should a patient be aware of that they may have valvular heart disease. And then perhaps we'll start talking about what you and I would do to delve into that and be able to solidify that diagnosis. So what should patients be on the lookout for?

Dr. Paul Cremer:
That's great, Christine. And I think that was well put in terms of thinking about is the problem the valve, or is the valvular issue secondary to something else. It's nice to have these categories when we think about valve disease. So is the valve leaky, is the valve narrowed, is the problem with the valve itself. And if it is, is that because you were born with something or because it was acquired. Or, is a valvular dysfunction related to something else from the heart and it's not really the valve's fault if you will. Either, as you said, that aorta is enlarged. And so then the valve is leaking or the left ventricle is enlarged, so then the mitral valve is leaking. So I think having that framework is incredibly helpful for patients and incredibly helpful for us as imaging cardiologists. And that's sort of the initial things that are going through my mind before I go see a patient, to think about what tests are going to be best for the evaluation.

Dr. Paul Cremer:
In terms of the symptoms, it can be quite insidious. And so I think it's of paramount importance that as healthcare providers, we really take a careful history of what the patient's doing, of their activity level. Because I think as we know, a lot of us adjust our lifestyles. If we're not as active as we have been, people just say, "Oh, I'm just starting to get older. I thought this was normal for my age." And if you dig a little bit, you say, "No, this really goes beyond that." And so that relates to the symptoms. Primarily, often what we see is people getting more short of breath I think, with physical activity. That would be the most common thing that we would see. Certainly there can be many symptoms related to vascular heart disease, getting dizzy or light headed, getting chest discomfort, having fatigue. But I think most often, at least in my experience, the shortness of breath with activity seems to be the most common that's clearly attributable to the valvular disease.

Dr. Paul Cremer:
And that's where you really, as I noted, have to really sit and spend time with the patient and dig a little bit and say, "Okay, what do you do today? How does that compare to what you were doing a year ago or two years ago?" And we know of all the benefits of aerobic exercise and cardiovascular health overall. But it also applies when we're seeing patients with valvular disease, I want them to stay very active because then that's their own barometer, if you will, or measurement stick of what they can be doing and saying, "Okay, you can do that now. You used to run three miles a day, now you're only running half a mile. What's going on?" Yeah, so it can be challenging to sort of tease out whether the symptoms are related to the valve disease. I think in particular, because it can be very slowly progressive. I don't know if you have other thoughts along those lines, Christine.

Dr. Christine Jellis:
No, I completely agree with you Paul. I think I would just add swelling of the ankles as a sign for people to watch out for that. Can sometimes be a clue. But I completely agree that that symptom of additional breathlessness, it's the most likely symptom that most people will present with. And so particularly at the moment where people are being a little bit more sedentary, a lot of us unfortunately addedCOVID pounds, and it's easy to blame that on other factors. So just being in tune with your body, as you said, pick a barometer of that you used to be able to do quite successful, that now perhaps you're struggling with so that we, as your physician, can get a sense of how things have perhaps progressed. And I'll also just, Paul again, it's always nice to have the opinion of a friend or a partner, a spouse, a sibling, someone who can give you a more objective view on what you can do now compared to what you were doing a few years ago.

Dr. Christine Jellis:
And I know that's hard with visitation restrictions and things like that. But most of us are very happy to have a family member on the phone or on FaceTime or whatever it happens to be so that we can get that holistic picture of really what's going on and how is this person? Because I think that once we figure out what the problem, because symptoms will play into our decision-making about proceeding with interventions like surgery and so forth, where we are much more likely to want to do something about it, if the person's having symptoms. So I completely agree with everything that you're saying. So Paul I work at Cleveland Clinic and I know I've gained my few COVID pounds, I'm feeling a little bit more short of breath when I walking. What sort of things would you be wanting to do to really evaluate me further?

Dr. Paul Cremer:
Sure. Yeah, thanks Christine. Yeah. Yeah, as you noted, it begins with a good history to assess how the patient's doing, especially as it relates to their activity level. And then in terms of the testing, the first thing we're going to do is a transthoracic echocardiogram that is after a physical exam, which we of course should also emphasize the importance of people seeing their regular doctors for their regular visits. Again, for all the routine care that's really important, that we know is important, that people have been hesitant to pursue during the pandemic. And unfortunately, I think we're starting to see the consequences of that. So just as a bit of an aside, it is so important to continue to see your general practitioners and internist for your routine health maintenance. And part of that is going to be auscultation and listening to your heart to hear if there's a murmur.

Dr. Paul Cremer:
And so based on the symptoms, based on the heart murmur, the next test going to be a transthoracic echocardiogram or a cardiac ultrasound. And really there, we're trying to define two things broadly speaking. The first is how bad is the valve disease? Is it mild, moderate, severe? And then secondly, what are the consequences we're seeing on the heart related to that valve disease or vice versa, is the heart dysfunction causing the valve disease to worsen. But that's the second thing that we're really interested in, that will guide our decisions about subsequent interventions, is how bad is the valve disease. And usually it's a question of is it severe valve disease or not in terms of thinking of subsequent intervention. And then if it is severe valve disease, what are the consequences to the heart? Is the heart starting to enlarge? Is the heart starting to weaken? And have we reached a threshold where we really need to think about doing something for the valve? So I think that's, as you know, a test that we put so much emphasis and so much importance on for all these good reasons.

Dr. Paul Cremer:
And then secondly, I think getting at the functional status, at least in my practice, if it's difficult to assess the functional status or difficult to attribute whether the valve disease is causing the symptoms, I think having people run on a treadmill and looking at the heart with an ultrasound before and after the treadmill can be very helpful in specific valvular conditions to then inform subsequent management and say, "Okay, yeah, it does look like this valve is or is not contributing to your symptoms." So in terms of valve disease and testing, those are the things that immediately come to mind, is the value of the transthoracic echocardiogram. And if there's a disconnect between what we're seeing in the valve and the report of the patient's functional status and symptoms, then an exercise test to try and further adjudicate that.

Dr. Christine Jellis:
Look, I completely agree. I think we're most of this and then many patients will then at that point, have a pretty solid diagnosis and we can make our treatment plan and give them reliable advice based off of that. I think as you and I both know, often things are not so cut and dry. And so that's where some additional testing like CT scans, MRI scans, even blood tests, like NT-proBNP, which we won't delve into in too much depth today. But for those patients who end up with those tests, they provide us with extra evidence, I guess, about how bad the severity of the valve problem is and what's actually driving that.

Dr. Christine Jellis:
We mentioned radiation heart disease in the past, radiation in the past, which can contribute to valvular disease. And certainly something like a CT scan is valuable in that setting with the calcification of the valve, the aorta, the coronary arteries and so forth. Paul, when we are getting to the point where there things are severe and we may need to intervene on that valve, would you mind just running us through the different options? Because certainly over the last few years, this has really evolved in a really positive way. So we have some less invasive options now and I guess targeting the various options to the right people is an important decision.

Dr. Paul Cremer:
Right. Yeah. Thank you, Christine. And yeah, you put it well in that if we pursue additional testing, it's often to see what are the consequences of the valve lesion and will that test help to inform that in terms of looking at, in certain patients, a cardiac MRI or in other patients a cardiac CT, or inpatients laboratory tests, that's sort of showing downstream effects of the valvular disease. And then if we say, okay, the valve seems to be severe, there does seem to be some consequences related to it, the further testing in terms of intervention is often anatomic based. And so in the sense of we're getting a CAT scan to see, okay, is this someone who is a candidate for a robotic mitral valve repair? We're getting a CT scan to look at the aortic valve to say, "Okay, what's the best approach for this patient? Is it a transcatheter based approach for the aortic valve replacement or is it a surgical approach?" So I think that's the progression that we would generally have, if you will, in the evaluation of the patient.

Dr. Paul Cremer:
How are they doing symptom wise? How severe is the valvular disease? Is there any consequence of the valvular disease? And it doesn't have to be symptoms. We talked about mitral valve repair if you have a flail, sort of a tear, in one of your mitral valve leaflets. In a center like the Cleveland Clinic, there's a high likelihood, a very high likelihood of successful repair. Well, it often makes sense to intervene early. But even in those situations, we often will find that certain of the cardiac chambers have enlarged. So that ends up being a part of the evaluation. But then once we've defined it, okay, it looks like something needs to be done here. Then we're using our testing to give us an anatomic sense of what the best approach is. And that's a complicated topic that we're not going to be able to address in a few minutes. That would be sort of a discussion in and of itself.

Dr. Paul Cremer:
But I think broadly speaking, that's what we're looking for, is this a patient who's a candidate for a less invasive approach based on their anatomy and risk factors, or is it a patient who's not, but still needs something done? I guess what I would emphasize and what I say to my patients is once the decision is made to do something for your valve, something needs to be done. And then it's really just about the subsequent testing to figure out what the best approach is for you. So sometimes you have to be understanding that when we do subsequent testing, the best plan for the patient may change based on that testing. And we're always thinking about not what the best outcome is for you next week, but in the years to come, that's what's going to give you the most durable result. So anyway, those are just a few thoughts in terms of how I think.

Dr. Christine Jellis:
No, I think we're on the same page there. I would only add, and I know you practice like this, Paul, is that if they're really individualized patients approach, so there's no one size fits all. Gather all that data together, we really then need to circle back, sit with the patient, figure out what their expectations are and their wants, present all the different options and then in conjunction with our colleagues, obviously, and our interventional colleagues find what the best option is for that particular patient.

Dr. Christine Jellis:
I think we're fortunate now that we have more options that we can offer. And so we have the benefit of being able to look forwards and be planning for decades in advance because whatever we do at this point in time, we're really starting the clock on what we're going to have to do down the line. Because as we both know, most of these bioprosthetic type valves that are put in for either percutaneous or surgical replacement are going to last roughly about 10 to 15 years. So it's really important that we're making the right decision now to set that patient up for success in the future. And hopefully you and I will still be here to help them out if they need that in decades to come. But I think we really want to set everyone up for success with a long term lifetime plan of what to do for their valvular disease.

Dr. Paul Cremer:
Yeah, that's great, Christine. And I agree with that completely and I think that is something that's worth emphasizing again about the patient with valvular heart disease, that this really is a lifelong management plan. So you may have a patient who has moderate dysfunction of the valve, and that's something that you plan to follow for the patient for some years. And again, I think it's important, as we've touched upon, is to really encourage people not to forgo some of their necessary appointments during the pandemic. It is so important to get your routine care. And so in patients with valvular heart disease, it is a lifelong relationship. And so there may be some patients where they are going to follow them or plan to follow them for years before something is done. And then when something does reach a threshold where there should be an intervention, what is the best intervention here to give the most optimal result, thinking about what is this patient going to be like in their eighties, nineties, et cetera. And that's what we do every day in clinic.

Dr. Christine Jellis:
Yeah, absolutely. It's really beyond the scope of our time today to delve into all those individual options. But needless to say, they cover mechanical valve replacements, bioprosthetic valve replacements, our patients will have had the percutaneous approaches like TAVR, mitral clip, increasingly, tricuspid clip, percutaneous mitral valve replacement. The sky is really the limit, it's a very exciting area to be working in. And also for our patients to now have a real smorgasbord of different options that we can tailor to them. Maybe that's a talk for another day, Paul, cover all those different options.

Dr. Paul Cremer:
I agree, and I think that's what makes it exciting for us and great for our patients that every year we do this, the options have increased. And so it's amazing to think back even five years ago, what we're able to offer our patients now compared to then.

Dr. Christine Jellis:
Absolutely. And I think it becomes a real team approach. We bring that valvular expertise to the table, but we really enjoy working with the other physicians involved in patient's care to really develop that lifelong plan. So I completely echo Dr. Cremer's thoughts about encouraging people to make sure that they have their regular health checks throughout this pandemic, particularly related to cardiac disease. But obviously, also all those other preventative things that tie into those risk factors that we mentioned earlier. So Paul, I think that brings us to the end of our session today. It's been wonderful to speak with you again. Hopefully we get to do this next year. But once again, to wish everyone a happy valve disease awareness week is the phrase, and we hope that everyone's doing well.

Dr. Paul Cremer:
That's great. Thanks Christine.

Dr. Christine Jellis:
Thanks Paul.

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