Anatomically speaking, the heart and its icon bear little resemblance to each other. A pioneering, second-century Greek physician known as Galen of Pergamon described the organ’s shape as akin to a pinecone. But as we all know, the Middle Ages changed much of what came before, and the iconic history gets convoluted.
The bulbous muscle mass in our chest is equally complicated. Its four chambers function in concert with each other: The right atrium receives oxygen-poor blood from the veins and pumps it into the right ventricle. The right ventricle pumps it to the lungs to load it with oxygen. The left atrium takes in the oxygenated blood and pumps it to the left ventricle. The left ventricle pumps the blood to the rest of the body. The smooth flow of blood involves arteries, valves, and nerve tissue. It’s easy to see that a lot can go wrong if something impairs any part of the symbiotic system.
Fortunately, the cardiology toolbox has grown to make repair work easier on both physicians and their patients. Following are examples of minimally invasive procedures offered by Eisenhower Health to restore heart functions that go awry.
Transcatheter Aortic Valve Replacement
Congenital heart defects, scar tissue from rheumatic fever, and a buildup of calcium deposits can cause a narrowing of the aortic valve (the “door” between the left ventricle and the main artery that distributes oxygenated blood throughout the body). Called aortic valve stenosis, this condition can lead to chest pain, loss of consciousness, heart failure, and even death. In fact, left untreated, 50 percent of people with aortic valve stenosis will die within two years.
Open-heart surgery used to be the standard approach for replacing the aortic valve. In 2012, the U.S. Food and Drug Administration approved transcatheter aortic valve replacement — known by the acronym TAVR — for people at high risk of death or major complications during surgery. The FDA subsequently expanded its approval to include patients at intermediate and low risk of death or major complications during surgery.
Phil Patel, M.D., performs TAVR procedures.
“When we do open-heart surgery, the patient has to be put on the heart-lung machine. For some patients, that confers a very big risk,” says Phil Patel, M.D., president of Eisenhower Desert Cardiology Center. “When we do TAVR procedures, we don’t use general anesthesia. The patient is lightly sedated.”
Accessing the femoral arteries and veins in the patient’s groin, the cardiologist uses a catheter (a flexible tube) to deliver a stent valve to the heart. Once positioned, the device is inflated with a balloon, allowing restoration of normal blood flow from the left ventricle to the aorta. Eisenhower Health’s 100th such treatment, in the fall of 2017, took less than 45 minutes. By the end of 2020, Eisenhower cardiologists had completed 425 TAVR procedures.
Patients return back to their normal life 24 hours after undergoing the procedure. “One of the big things about heart surgery is recovering from all the things that have to be done just to get to the heart and then to get out,” says Khoi Le, M.D. “One of the paradoxes of heart surgery is that the people who need it the most may be the least able to withstand a heart operation. So the direction of cardiac care now is to try to do these things without being so invasive.”
The transcatheter heart valve expands into place in the heart with the help of an inflatable balloon catheter.
Eisenhower Health uses another minimally invasive approach for patients with atrial fibrillation. The Watchman device received FDA approval in 2015.
Congenital defects, high blood pressure, an overactive thyroid, and sleep apnea may tamper with the heart’s electrical system. With atrial fibrillation, the upper (atrial) and lower (ventricular) chambers fall out of sync, causing an irregular heartbeat that in turn creates the potential for blood clots, stroke, and heart failure. Patel points out that 98 percent of strokes come from a blood clot that forms in the upper-left chamber. The standard treatment has been blood thinners and beta-blockers. Unfortunately, blood thinners can result in excessive bleeding or bruising, and beta-blockers present issues for people with asthma and diabetes.
As they do in the TAVR procedure, cardiologists implant the Watchman device — a closure frame of nickel-titanium with a fabric cap — via a catheter inserted in the leg. Patients go home the next day with no restrictions on their activities. After a transitional period, people with a Watchman implant need merely follow a daily regimen of baby aspirin.
Yet another procedure provides a minimally invasive alternative for patients with mitral valve malfunction and at prohibitive risk for surgery. When the door between the left atrium and left ventricle fails to seal, blood entering the heart backflows toward the lungs.
“Among the population over age 75, the prevalence of mitral valve regurgitation may be as high as 10 percent,” says Andrew Frutkin, M.D., adding that the condition can cause irreversible damage in the left ventricle and worsening heart failure. “If you have significant mitral valve regurgitation and heart failure,” he continues, “your one-year mortality rate is probably 20 percent and at five years 50 percent.”
Approved by the FDA in 2013, the MitraClip — a fabric-covered metal clip about the size of a dime — can be delivered to the heart through a catheter in the femoral vein. Although it requires general anesthesia, the MitraClip procedure does not involve open-heart surgery. Patients typically go home within a day or two, compared to a minimum of four days for surgical patients.
Le recalls a 74-year-old woman who had a MitraClip procedure and on a follow-up visit reported, “Well, I get a little tired when I finish playing tennis.”
The MitraClip is an option for mitral regurgitation patients who have too high a risk for surgery.
Patel stresses the importance of staying current on the latest in medical advances.
“Structural heart interventions is one area where cardiology is moving these days,” he says. “Very early on, when people had heart attacks, the only therapy was surgery. Then stent technology came along. Now this is the era of valvular interventions, which is getting better and better. In the electrophysiology world, there’s more and more technology in catheter ablations of complex arrhythmias. We’re able to tackle really stubborn cardiac problems that we weren’t able to tackle before.
“We have to be able to offer patients the latest and the greatest techniques that have been shown to improve their quality of life,” Patel concludes.
Open and Close Cases
Khoi Le, M.D.
The world of cardiology dramatically changed in 1953 with the advent of the bypass machine.
“Surgeons can open the chest, push the lungs aside, cut into the heart and make repairs,” says Khoi Le, M.D. “The downside of cardiac surgery is that it is tremendously invasive. The body is built to protect the heart as much as possible from external trauma. It is a breach of natural defenses that requires a tremendous amount of healing and discomfort. It is a big insult to the body to have open-heart surgery. Paradoxically, the people who most need that operation may not survive the recovery.”
Interventional cardiology became the second game changer for treating heart problems. Medical pioneers discovered ways to reach the heart without opening the chest — through catheter tubes that feed devices to the heart via arteries.
“This is the direction heart care is going,” Le says. “A heart problem threatens not only your life, but also your independence. Let’s say you are one of the lucky people who can have an open-heart operation. You still are looking at an eight-to-12-week recovery. If you are in your 80s, you have a lot of worries: ‘Am I going to spending those weeks in a nursing home? Am I going to be changed from the operation?’ These I think are things that people really worry about.”
In contrast, Le offers the example of an angioplasty using a small vessel in the wrist or base of the thumb — after which a patient can go home four hours later.
“Patients walk out with a Band-Aid on their thumb about two hours after the procedure. It feels like a miracle, and it really is a miracle,” he exclaims. “It is so wonderful, as a doctor, to be able to do this for people and not disrupt their lives.”