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A new chance at life
Overlake Hospital and Group Health have partnered to provide a recently Food and Drug Administration approved heart surgery to patients of severe aortic valve stenosis.
Tuesday morning, a team of nine physicians met to perform their sixth transcatheter aortic valve replacement on an 87-year-old man. He’s an energetic man and a dancer, but the narrowing of his heart valve has brought on symptoms like shortness of breath and chest pain that, left unchecked, will mean the end of his active life.
“We certainly look for improving a patient’s length of life, but we also look at improving their quality of life,” said Dr. Scott Haugen, an interventional cardiologist from Group Health. Haugen is co-medical director of the transcatheter replacement program, with cardiologist Dr. Ronnier Aviles of Overlake.
Aviles noted that, because of the advanced age of many of the candidates for transcatheter replacement, improved quality of life was of greater concern.
“We have patients that have lived independently for their entire lives,” Aviles said. “(With the symptoms of stenosis,) they’re looking at giving up independence for one disease process.”
Valve clinic coordinator Valerie O’Mara, a physician assistant monitoring the patient’s surgery from an adjacent control room, noted that he seemed more than a decade younger than his numerical age.
“He doesn’t look or act 87,” she said. “But he will tomorrow.”
Like others who have undergone this procedure, he’s been rejected as a candidate for an open heart valve replacement by two cardiothoracic surgeons due to risk factors for mortality or morbidity – complications resulting in a decrease of quality of life – from open cavity surgery. Calcification of aortic tissue, for example, can be so severe as to prevent its recovery from surgical breach. Such issues can be more common in elder patients, who have been typical of the team’s patients thus far.
“Most people die within two years of a(n untreated) diagnosis,” O’Mara said. But transcatheter replacement requires no opening of the patient’s chest cavity and results in a faster recovery time. The surgical team nicks into an arterial pathway, at the groin or elsewhere, and runs an intravenous line to the heart. A collapsed replacement valve is then run through the path and placed directly into the damaged valve, where the replacement expands and reopens the regular flow of blood. The procedure is only approved for severe symptomatic cases with a traditional surgery risk factor greater than 8 percent, O’Mara said.
Tuesday’s surgery was complete in a matter of hours. X-ray monitors – one live feed and another capable of playback – showed the pathway the surgeon’s tubes had made to the patient’s heart. For much of the time, they appear as stray hairs in a gray abyss. Periodically the heart materialized on screen, briefly and ethereally, under the influence of medical dye. The specter guides the team to the exact location of the damaged aortic valve, so their replacement expands where it should.A balloon valvuloplasty opened the valve.
“This is gonna be it,” a voice said over the surgery room’s intercom.The lights went down and the team eyed the x-ray monitor. On screen, the replacement valve appeared as a constricted tube, traveling through the surgical sheath closer and closer to its destination. Then, the moment of truth.
“In one fell swoop, we inflate the replacement valve inside the damaged valve,” Haugen said after the surgery.
They counted off – one one-thousand, two one-thousand, three one-thousand – and began the process of ensuring their success. They noted leakage down the center of the valve – normal, O’Mara said – and were satisfied there was no paravalval leakage around its edges.
The patient would need to be monitored after surgery, but if all went well, he would be able to walk out of the hospital in a matter of days, not weeks, Aviles said. Previous patients of successful replacement had experienced a marked improvement in their symptoms soon after the procedure.
Transcatheter aortic valve replacement is still in its early days, but Aviles said he expects medical research in Europe to advance the procedure. The next steps would include FDA approval of the procedure’s use in patients of only moderate risk for traditional surgery, he said.