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Ask the Expert

Advances in Treating Heart Valvular Disease

Dr. Keith Horvath

Click here to watch a video with Dr. Horvath, "Am I a Candidate for Heart Valve Surgery?"

What are heart valves and what do they do?

 

Heart valves are basically doorways within the heart that keep blood flowing in one direction from one chamber to the next.

 

The heart has four valves: the mitral, aortic, tricuspid and pulmonary. The mitral and tricuspid valves control the flow of blood between the atria and the ventricles (the upper and lower chambers of the heart). The pulmonary valve controls the flow of blood from the heart to the lungs, and the aortic valve governs blood flow between the heart and the aorta, and thereby the blood vessels to the rest of the body.

 

Valves that are functioning normally ensure that blood flows with proper force in the proper direction at the proper time. With valvular heart disease, the valves become too narrow and hardened (stenotic) to open fully, or are unable to close completely (incompetent).

 

How do you diagnose a heart valve condition?

 

Symptoms of valvular heart disease include shortness of breath and wheezing after limited physical exertion; swelling of the feet, ankles, hands or abdomen; palpitations or chest pain; fatigue; dizziness or fainting; fever; and rapid weight gain. During a physical examination, your doctor will listen for distinctive heart sounds, known as heart murmurs, which indicate valvular heart disease. Your doctor may then order an echocardiogram or another diagnostic procedure to evaluate your heart function.

 

What types of valve conditions require treatment?

 

Two of the most common valve conditions requiring surgery are mitral valve regurgitation, the leaking or backflow of blood between the upper and lower chambers of the heart, and aortic valve stenosis, a narrowing that causes an obstruction to blood flow. Both of these conditions increase the workload on the heart and, left untreated, can lead to debilitating symptoms, including cardiac arrhythmia, congestive heart failure, and irreversible heart damage.

 

How do you treat valvular heart disease?

 

The severity of valvular heart disease varies. In mild cases there may be no symptoms, while in advanced cases, valvular heart disease may lead to congestive heart failure and other complications. Treatment depends upon the extent of the disease. Valve surgery to repair or replace a damaged valve may be necessary.

 

How do you decide whether to repair or replace the valve?

 

The undisputed new gold standard of care for the treatment of mitral valve regurgitation is mitral valve repair. Suburban Hospital’s NIH Heart Center is currently leading the region in mitral valve repair, achieving a nearly 100 percent success rate in repair versus replacement, well above the national average of 55 percent.

 

If a patient is suffering from aortic valve stenosis, a narrowing that causes an obstruction to blood flow, then replacement of the valve is necessary in most cases. A stenotic valve can be repaired in only about 5 percent to 10 percent of cases.

 

What does aortic valve replacement surgery entail?

 

Traditional aortic valve surgery involves an open-chest procedure, which takes approximately two to three hours. The patient’s heart is stopped, the aorta is opened, and the aortic valve is removed and replaced. The use of a heart-lung machine is required for this surgery.

 

In some cases, the use of a minimally invasive procedure is an option. Minimally invasive techniques have made these operations safer and less traumatic, which also increases the number of patients who are candidates for surgery.

 

What materials are the new valves made from and how do you decide which material is appropriate for which patient?

 

Replacement valves may be mechanical (artificial valves) or biological (made from animal tissue). The type of replacement valve selected depends on such factors as the patient’s age, condition, and the specific valve affected.

 

The biggest advantage of mechanical valves is that they last forever, so they don’t require replacement. The disadvantage of mechanical valves is that the long-term administration of anticoagulants (e.g., Coumadin) may be necessary because prosthetic valves are associated with a higher risk of blood clots.

 

The biggest advantage of tissue valves (made from pig and cow tissue) is that patients are not required to be on blood thinners for the rest of their lives. The disadvantage of tissue valves is that they may only last about 10 years, possibly requiring a repeat surgery down the road. These valves are less likely to be recommended for a younger patient for this reason.

 

Whether the patient receives a mechanical valve or a tissue valve, there is a high success rate for valve replacement surgery. The surgery can relieve symptoms and prolong lives.

 

Can you describe some of the surgical innovations in valve replacement surgery?

 

At Suburban Hospital, we are very excited about the future of aortic surgery, which involves the use of a catheter to deliver the new aortic valve into the chest, where it is placed inside the old valve. This is a less-invasive procedure that doesn’t require the chest to be opened or the use of a heart-lung machine. This surgery option is especially promising for patients who suffer from co-morbidities that would make them poor candidates for an open-chest procedure. This surgery, which is being performed in clinical trials in the U.S., requires the use of imaging technology such as x-ray or fluoroscopy. The challenge associated with the use of this technology is that x-ray and flouroscopy have limits to their imaging capabilities and don’t always allow for exact positioning of the valve.

 

You do research at the National Heart, Lung, and Blood Institute of the National Institutes of Health. What type of research are you doing related to valve replacements?

 

At the NIH Heart Center, we are working on a very unique adaptation of catheter-based surgery. We are using intraoperative MRI imaging to ensure the identification of critical structures in the heart, allowing us to perform beating heart valve replacements with minimal trauma and risk for the patient, thereby increasing the success rate of this surgery. The use of MRI technology for valve replacement surgery is not being done anywhere else in the country and we are excited about the success we’ve seen with these studies.

 

We anticipate FDA approval of the use of MRI technology in valve replacement surgery in early 2012, making this surgical option available to Suburban Hospital’s most vulnerable patients, including the frail, the elderly, and those with co-morbid conditions.

 

What outcomes are you getting with valve replacement surgery in terms of readmissions, length of stay, etc.?

 

Valve replacement surgery carries a low risk of complications and there is no risk of rejection of the new aortic valve.

 

Most valve replacement patients are out of bed within a day of surgery and are discharged from the hospital within two to three days. They are driving and back at work within 10 days to two weeks and completely back to their normal routines within five to six weeks.

 

Suburban Hospital’s readmission rate for these patients is very low at about 3 percent or 4 percent. Most readmissions are not related to the valve surgery but to the patient’s overall health prior to the surgery.

 

Heart valve disease is a slow and insidious process. When the diseased heart valve is replaced, patients report that they feel spectacular. Heart valve replacement improves their quality of life significantly.


About Dr. Keith Horvath

Dr. Horvath is chief of cardiothoracic surgery for the NIH Heart Center at Suburban Hospital. He is a graduate of the University of Chicago Medical School. He did his postgraduate surgical training at Brigham and Women's Hospital in Boston.  He also serves as Director of the Cardiothoracic Surgery Research Laboratory at the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Dr. Horvath's clinical investigation interests include mitral valve repairs and aortic surgery.


Dr. Horvath’s office is located at Suburban Hospital,
8600 Old Georgetown Road in Bethesda. The phone number is 301-896-7610.



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