According to the American Heart Association, about five million Americans are diagnosed with heart valve disease each year.
Harold Dauerman, MD, cardiologist at UVM Medical Center, talks about what heart valve disease is and new treatments for it. Dauerman is a professor at the Larner College of Medicine at UVM.
What are heart valves and what do they do?
Harold Dauerman: The heart’s a pump in your chest. It is divided into four chambers, and each chamber has a valve. There are four valves that allow the blood to move in one direction through your heart.
So, blood flows back from your ankles to your heart, through the right side to the lungs, then from the lungs to the left side, and from the left side out to your hands, your arms, and your head. To keep the blood moving all in one direction, you need four valves that open and shut at the right time. Most of the patients we see at the UVM Medical Center acquire wear and tear on two of these valves, the aortic and mitral valves, over the course of decades.
As these valves start to wear and tear they either block and get clogged like your kitchen drain so that – just like in your sink, the water can’t get out – the blood can’t get out. Or, they wear and tear and they get leaky, and everything starts backing up in the wrong direction. Either of these problems usually leads to syndromes like shortness of breath, chest pressure, and can be fatal if they progress too far.
What causes heart valve disease?
Dauerman: The most common valvular heart disease that we treat is called aortic stenosis. This is a blockage of the aortic valve, which is normally the size of a quarter.
All blood flows from your heart, on the left side, out to your hands, your body, your brain – everything – through the aortic valve, which has to open and close. For three percent of people over the age of 80 that quarter shrinks down to the size of a dime. That’s called aortic stenosis. As the aortic valve shrinks down to the size of a dime, your heart squeezes out blood with difficulty like a sink trying to drain through a clogged kitchen drain. It can’t get all the blood out, so it backs it up into the lungs. This causes shortness of breath or congestive heart failure.
If that dime keeps shrinking to the point where the blood can’t get forward to your brain and your legs and your arms, you can die from the disease.
What causes aortic stenosis? We don’t know. We don’t know why these three percent of people over 80 get it. The normal heart valve has the soft feel like the bottom of your thumb. As it gets diseased, it gets calcified or hardened like your fingernail. Normally, there are three leaflets that need to open and close and be soft and compliant. When they’re hard like your fingernails, they get stuck and they get clogged up. That’s what causes people to need interventions in order to open up that blocked aortic valve.
What is the average age of a person with heart valve disease?
Dauerman: The average age is around 80, but we see people in their 70s, and we even see people in their 50s and 60s.
There are some people who are born with an abnormal aortic valve, and they can live with it for five or six decades. The usual aortic valve has three pieces that move together, three leaflets. But, some people are born with two leaflets. And when the two leaflets try to do the work of three, over decades, they wear out more quickly. So, those people who have what we call bicuspid aortic valves,and will come in in their 50s or 60s with the same disease as an 85-year-old.
It’s less common than what we call the degenerative, calcific form of aortic stenosis, but we do see that. Often those people will know they have a heart murmur – they have had it ever since they were born or since their teenage years. The doctor may have told them that they have a bicuspid aortic valve.
What are the symptoms of heart valve disease?
Dauerman: The two most common valve diseases we see are the 1.) aortic valve diseases, which are either a plugged aortic valve, aortic stenosis or, a leaky aortic valve (which you call aortic regurgitation), or 2.) a completely different valve called the mitral valve, also on the left side of the heart, getting leaky.
All of those conditions usually result in a heart murmur. If somebody’s seeing a primary care doctor or a cardiologist they will often be told they have a murmur, which sounds like a harsh loud sound in their chest in between the normal closure sounds of the valves.
Often people don’t find out about it until they start to have symptoms. The most common symptom is shortness of breath. They didn’t feel short of breath a year ago when they went up flights of stairs. Over time, they might start a process of restricting their climbing of stairs or walking to get to the mailbox, instead sending someone else. They have decreased activity tolerance, more shortness of breath, and they’ll eventually present to their primary care doctor and then, hopefully, a cardiologist as a next step to evaluate why they’re more short of breath. A valve blockage or leak is one of the possible causes.
How do you treat heart valve disease?
Dauerman: The first treatment is medical therapy. If someone has fluid in the lungs medicines can help relieve the amount of fluid. Some of these medicines are similar to blood pressure medications. Aortic stenosis, the blocked aortic valve, is not preventable medically, meaning you can treat some of the symptoms, but it’s going to progress, and inexorably cause death without an intervention.
Since the invention of the heart bypass machine, the standard of care to treat valvular heart disease like aortic stenosis has been open heart surgery: Open the chest, cut out the valve, sew in a new valve, then close the chest. This is a successful, life-saving procedure. Our surgical colleagues have perfected it to the point that it is a low-risk procedure for the right patient. But, with aortic stenosis there are many patients who are between the ages of 80 and 95, who may be sicker and less able to tolerate open heart surgery.
In that case we have a second option called Transcatheter Aortic Valve Replacement, which we’ve abbreviated to TAVR. In Transcatheter Aortic Valve Replacement, we go into your right groin area where the femoral artery or leg artery is, we make a three-millimeter incision, and we go up from there with a straw or a catheter up to your heart, and we put a giant stent inside the diseased aortic valve. We sew pig tissue or cow tissues into that giant stent. The tissue has the three leaflets that open and close, soft like the bottom of your finger. Doing that, you get back the quarter-sized hole which you’re supposed to have, with unidirectional flow from the left ventricle out to the aorta. Instead of blood backing up to your lungs it’s going forward to the rest of your body the way it should.
How many patients have gone through the TAVR procedure?
Dauerman: We’re approaching 1,000 patients at UVM Medical Center. We started the program in February 2012, and we currently do about five people a week. We’re the only center in Vermont; every other state has at least two centers performing this procedure.
How do you talk to patients about their options?
Dauerman: We ask patients to first understand the disease process and that medications alone for aortic stenosis won’t prevent it from progressing. If they’re highly symptomatic now, it’s only going to get worse. If they’re thinking about doing something to fix it, now’s the time – not waiting another year or two when things could be too far progressed.
Once they have an understanding — and I usually talk about the clogged kitchen drain with them and how it’s a mechanical problem, and we need to open up the drain – they t may want to proceed with therapy. I tell them the risks of the TAVR procedure. There is a 3% risk of death or stroke in the first 30 days, there is an 8% risk of ending up with a pacemaker because we disturb the wiring of the heart, and there’s an 8% risk of a bleeding complication in the groin that could require a transfusion, or stent. I tell people you have a 90% chance that you will undergo this procedure without any complications, be up walking around the next day, and go home.
You do have an excellent alternative of open heart surgery. The recovery time is much longer. But, the outcomes are excellent with open heart surgery. Every patient sees a cardiac surgeon as well as an interventional cardiologist to discuss these options and then the patients choose what they prefer.
What does life look like after the TAVR procedure?
Dauerman: A day later patients are usually up walking around and can go home.
I tell them for the first four or five days to take it easy at home. Even though it’s only a three-millimeter incision in the groin, there is a little bit of a bruise there sometimes, and I like to make sure they’re all healed up.
After four or five days, I tell them to do whatever they normally do in life. We will want to see them four weeks afterwards to find out if they’re feeling better. For 90 percent of people, their breathing improves within days of the procedure, and we want to confirm that. If, for some reason, their breathing is not better by one month that means something else is going on and we need to investigate other problems that might cause shortness of breath, like blocked heart arteries or lung disease or anemia.
So, sometimes it’s a complex process getting people back to how they felt ten years prior, but if it’s really only the aortic valve then often we will see dramatic improvements within days.
What does the future of treatment for heart valve disease look like?
Dauerman: We’re expanding the therapies that we’ve developed with the aortic valve to the other valves. For example, two years ago we started fixing the mitral valve, which traditionally only had the options of surgery or medical therapy, and doing it again with a catheter-based approach. In this case we’ve found techniques where we come up through a vein in the leg, puncture through the septum or the dividing part of the right and left heart, and we put a clothes pin on the leaky leaflets of the mitral valve.
The risks are very similar to the risks of TAVR. And, very similarly, 80% of patients will have significant improvement in their breathing by the time we see them again in 30 days. That program, the MitraClip program, is one that’s rapidly expanding. As we see more indications and more improvements in that technology, I see the aortic valve and mitral valve generally having a more and more solid, minimally-invasive option than it did ever before.
What would you say to someone who is concerned that they or their loved one might have heart valve disease?
Dauerman: We’re fortunate to have beautiful technology to figure out what’s causing a heart murmur with a noninvasive procedure of an echocardiogram. Just like you can see the fetus now better than ever before, we can see the heart in a lot of detail with the exact same technology. We just move the ultrasound up from the belly to the chest.
Our expert echocardiographers here and in Plattsburgh and in Montpelier have technology that should be able to make this diagnosis very simply and quickly. And I would say anybody who has a heart murmur, especially if they’re having any shortness of breath symptoms, should get an echocardiogram as the first step.