In the past, we’ve talked about the risks of valvular disorders and enlarged hearts. Recently, a study was released which further examined whether or not dilated hearts return to normal size after heart valve surgery. Interestingly, the study considered this post-operative objective from a male and female perspective.

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Since having my aortic valve replaced via the Ross Procedure in 2005, I’ve received a number of questions about this unique double heart valve replacement. One of the most common questions is, “Isn’t that operation more risky as two valves are replaced?”

I have to admit, that is a very fair question. I remember thinking the same thing when both Dr. Trento and Dr. Starnes suggested this relatively uncommon surgical approach. However, as I did my research on the Ross Procedure, the benefits started to outweigh the risks.

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Recently, I was extremely lucky to observe Dr. Saibal Kar and his team perform its 103rd MitraClip procedure on a patient with severe mitral regurgitation at Cedars-Sinai Hospital in Los Angeles, California.

Dr. Saibal Kar And Me In The Cath Lab At Cedars-Sinai

While I expected to watch the procedure from a gallery – much like an episode of Grey’s Anatomy – I quickly found myself inside the cardiac catheter lab wearing scrubs and a lead suit used to protect me against x-ray exposure from fluoroscopy.

For the next three hours, I had front-row access to Dr. Saibal Kar’s team as they cared for the patient and deployed the new MitraClip device. Yes… This was much, much, much better than an episode of Grey’s Anatomy.

Although the MitraClip has yet to receive FDA approval in the United States, Dr. Kar has been using the device to treat mitral valve regurgitation without causing any physical trauma to the patient’s sternum or ribs. As previously discussed, the results of the MitraClip clinical trials have been encouraging.

A few minutes before the procedure began, I was very surprised to see a familiar face enter the cardiac catheterization lab. Doctor Alfredo Trento, the Chief of Cardiothoracic Surgery at Cedars-Sinai Hospital, quietly assumed a position to left of Dr. Kar.

Dr. Kar (Cardiologist) and Dr. Trento (Cardiac Surgeon)
Work Side-By-Side During A MitraClip Procedure

“This has got to be somewhat unique,” I thought to myself, “Given the distinct nature of their specialties and some of the skepticism surrounding the MitraClip from the surgeon community, I can not imagine this is common.” (I would later learn that, so far, only a handful of cardiac surgeons have taken a serious clinical interest in this non-invasive procedure used to treat mitral valve regurgitation.)

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In 2009, many public figures, including Barbara Bush and Robin Williams, needed aortic valve replacement due to heart valve diseases including aortic stenosis. One might think that their successful results and the improvement in mortality rates would inspire patients and the medical community to view heart valve surgery as a blessing.

However, fear about the risk of surgery is among the reasons half of eligible patients are not getting aortic valve replacement surgery, according to a study by physicians at the University of Michigan Health System.

The study, published in Circulation: Cardiovascular Quality and Outcomes, found that 66% of patients who did not have aortic valve replacement were suffering symptoms such as shortness of breath that would have improved if they had the surgery.

“Aortic valve replacement not only treats the symptoms, but also saves lives,” says lead author David S. Bach, M.D., professor of internal medicine at the U-M Medical School and cardiologist at the U-M Cardiovascular Center.

Aortic stenosis, a narrowing of the aortic valve opening, is common among older adults. In those age 75 and older, as many as 5 percent have the heart condition. Over time, the heart thickens as it tries to pump blood through the small valve opening which can lead to heart failure.

David S. Bach – Professor Of Internal Medicine, Michigan

The study also suggests that more than a handful of patients were denied surgery. Researchers identified 369 patients from three Michigan hospitals who had aortic stenosis. They had been screened by electrocardiogram. Among them, 191 did not have their aortic valve replaced.

The lack of referrals for surgery occurred in a variety of settings – whether patients saw a community physician or one affiliated with a university or veterans hospital – which suggests a widespread lack of awareness about the benefits of surgery, or overestimation of the risks associated with the surgery.

A review of patient charts showed the most common reasons for not referring for surgery was surgical risk and presence of other major health problems. But surgical risk scores for patients who did not have surgery were lower than doctors had predicted, according to surgical risk guidelines created by the Society of Thoracic Surgery.

Surgery is considered the best treatment for aortic stenosis and the consequences of waiting or passing up surgery are substantial. According to the report, only 66 percent of the patients who did not undergo surgery survived 12 months later.

Keep on tickin!

I was just reading the New York Times when I came across a very interesting study about the use of “off-pump” techniques for heart surgery.

The study, just published in the New England Journal of Medicine, suggests that use of heart-lung machines may actually provide enhanced surgical outcomes (inclusive of pumphead) when compared to beating heart procedures.

The highlights of the study, which evaluated 2,203 patients that were randomly assigned to have bypass surgery on-pump or off-pump, were:

• One year after surgery, patients who had had off-pump surgery had poorer outcomes.
• Off-pump patients were more likely to have needed a repeat operation.
• Patient that did not have the heart-lung machine used were more likely to have a heart attack or die.
• Off-pump patients were no less likely to have had strokes or difficulty thinking (cognitive problems following surgery).

Dr. Eric Peterson, a Duke cardiologist who wrote an editorial accompanying the paper, stated, “This is a big one… It’s a good study and the fact that it did not find superiority [for off-pump procedures] was key.” Dr. Peterson added that he, like many cardiologists, expected off-pump procedures to be superior.

So you know, bypass surgery is one of the most common operations in the world. Today, as many as 20 percent of bypasses in the U.S. are being done off-pump. That said, this new study could affect a lot of procedures.

The study also suggests that patients who had their surgery “off-pump” did have fewer blood transfusions but spent slightly longer time in the operating room.

Also, the study indicated that there were no significant differences between the two patient groups specific to (i) the time patients spent in intensive care after surgery, (ii) how long patients were on a ventilator and (iii) the length of patient hospital stay.

Pretty interesting study, right?

Keep on tickin!