HeartBeats Episode 6: Heart Valve Disease

Welcome I’m Cathy Murtagh-Schaffer and I am your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program Lee Health, and matters affecting your health. February 22 is national Heart Valve Disease Awareness Day, which is a recognition of the impact that heart valve disease has on the health and well-being of the American public. With us today is Dr. Brian Hummel, cardiothoracic surgeon with Shipley Cardiothoracic Center, and an expert in the surgical treatment of valve disease. Thank you Dr. Hummel for being here. We know that each year 25,000 people die of untreated or poorly treated heart valve disease, perhaps we can begin with a short anatomy lesson for our listeners.

Where exactly are the heart valves and why are they so important?

Well first of all thank you Cathy for having me and as you pointed out February really is Heart Month. It begins with Valentine's Day and ends with other valves that might be broken. It’s a good month and you're absolutely correct, the heart is a complex structure, it contains 4's distinct valves which when operating normally are one way in their efficiency. That being from a pump standpoint, the valve opens when the pressure below it exceeds its opening dynamics and it closes when the pressure above the valve exceeds that from below the valve. So, each of these four valves function to separate their particular pumping chambers from the one above it or the body. The first valve that blood encounters as it returns from the body and goes into the heart is the tricuspid valve. This valve is important in that it is frequently affected by endocarditis. We see this in a large number of patients, unfortunately, that have become addicted to intravenous drug use and this is one of the valves most frequently affected by that. It is very common for us to have to deal with those problems. The next valve is the pulmonary valve that separates the right ventricle, which is the pumping chamber that pushes the blood out towards the lungs and fortunately, pulmonary valve is very rarely affected by either endocarditis or natural disease. The most common defect of a pulmonary valve is that of a congenital abnormality and pediatric surgeons, a pediatric cardiac surgeons are frequently involved in repair or replacements of those valves. For us adult surgeons, that's a very uncommon valve for us to be involved in. The next valve that the blood returns from the lungs and enters the heart again is the mitral valve and again that separates the left upper's chamber from the ventricle which is the main pumping chamber of the heart and it is a valve that is involved occasionally and endocarditis, or in infections. More frequently, it is a valve that becomes insufficient as a consequence of just fibrous changes within the body. There's a kind of a disease called myxomatous degeneration of the valve, occurring most frequently in women that also men can have as well and the valve quite frankly just becomes very floppy and it does not close appropriately. The courts can be elongated and not allowing the normal apposition of the two leaflets to close tightly and thus leakage back to the upper chamber occurs when the heart beats. That is a valve that we repair very frequently, in terms of repair work of valves, this is our most commonly repaired. Finally, the last valve in the trip of the blood through the heart is the aortic valve that’s separating the main pumping chamber, the left ventricle, from the body and again that should be a one-way valve. Unfortunately, this valve can be involved in endocarditis which we've seen a fair amount of but more often it is the valve that wears and I don't want to use the word senile but it is just called senile sclerosis or is the valve gets difference, differs overtime, it becomes calcified and doesn't want to open all the way or doesn't want to close all the way. It is the most common valve involved in surgery and that we take care of as cardiac surgeons.

(host) Something you said you see endocarditis as a result of IV drug abuse, are there other reasons for endocarditis?

Absolutely, patients can unfortunately have a minor abnormality of a valve and the mitral valve being one that comes to mind most often in this but simple things such as dental work or abscesses elsewhere, skin abscess that may allow bacteria to enter the bloodstream. It circulates through the heart and the bacteria attaches itself to an abnormal point on a functioning valve and so endocarditis as a consequences of just normal living and just having bad luck is a common issue

I think as patients go through this process of being evaluated they hear different terms one of them being AI, aortic regurgitation, mitral stenosis, MAC, calcified mitral valve. Can you explain some of those terms a little bit so that patients would understand what they mean?

Well AI, the actual word being aortic insufficiency. Insufficiency or regurgitation are the same thing, simply meaning the valve is no longer acting as a one-way valve, there is leakage back through the leaflets of the valve. The mitral valve is a two leaflet valve, the pulmonary valve, the aortic valve, and the tricuspid valve all have three leaflets and so whatever the design of the valve, if it is leaking it is regurgitating or insufficient. Sclerosis, just means thickening of the valve and the thickening can cause reduced mobility of the valve, thus leading to different terms of stenosis. Stenosis being that the valve does not open adequately all the way so the motion is so restrictive that blood is being forced through a narrowed area and thus the pumping chamber below or above if it's the left atrium trying to go through a mitral stenosis, that is forced to work harder, then becomes thicker and less sufficient and leads to the complications and problems that these patients have.

So basically what I'm understanding you to say is that most valve disease if prolonged leads to a reshaping of the heart and not for the better and the pump becomes weaker because of that reshaping.

Well it certainly becomes less efficient. Interestingly if you think about the bodybuilder and somebody who does muscle curls, bicep curls to build up their bicep, all they're doing is working that muscle against resistance. If you take the same concept of the heart being a muscle and it's trying to push blood out a narrowed opening it's the same thing as lifting weights, so that heart muscle affected, the pumping chamber becomes thicker and thickness that does not mean health. (host) not in the case of the heart anyway. And unfortunately, as it gets thicker it may not grow an adequate blood supply to the new thickened muscle and so then it susceptible to injury or heart attack. The blood cannot be supplied to meet the demands of this thick muscle and so you get this imbalance and damage to the heart muscle. The other thing is if the valve is regurgitant or insufficient and the chambers are working overtime they think that they've pushed enough blood out but the reality is the blood simply going back up and then coming back through so it's a very inefficient system and in those instances you begin to see dilation, or enlargement of the chambers, again an unhealthy situation.

What are the most common symptoms of heart valve disease and why is it so insidious?

Well a lot of things that people tribute to just daily things, fatigue, shortness of breath, they say oh I'm out of shape or I've gained weight or whatever and in reality for most people that's actually the case but it can be a sign or symptom related to a heart valve disease. If we went down the most common list of things that people display when they have valvular heart disease it would be shortness of breath, fatigue, leg swelling, chest pain, lightheadedness or actually fainting or palpitations. Now, we've all experienced some of those symptoms at various times in our life but if you start noticing amount of recurring basis or it becomes a something that suddenly is developed and you hadn’t noticed it a month before but now you're having it frequently, that needs to be investigated.

Does atrial fibrillation play a role in the symptomatology of heart valve disease?

well a Afib is much more common in patients with mitral valve disease. Either, regurgitation or stenosis because the left atrial muscle mass changes shape, it dilates with your regurgitation or stenosis either from volume or pressure so that as the chamber dilates the muscle fibers become elongated and are more prone to the fibrillatory excitement of the electrical system and thus those patients have a higher incidence of afib.

What you're saying is instead of people just assuming it's a natural part of aging they probably should talk to their doctors when they start feeling those types of symptoms such as fatigue or a racing heart or shortness of breath? And when they go to see their doctors what should a patient expect when they first approach their physician with these types of symptoms what tests do you think will be recommended?

Well before they get into any testing obviously there's going to be a history taken and if the patient is displaying evidence of infections such as fever or whatever that's going to point the doctor into questions regarding dental work or drug use or infections elsewhere, skin infections as I mentioned, so that'll be the direction taken. If it's palpitations then the questions will be centered upon, does it occur with activity? Does it occur at rest? Does this wake you up? These sorts of things but once you kind of get past the history and focus in on a thing, some of the common things that are going to be done is, one is an EKG, EKG wall an age old device that is very telling in number of things that can be determined and so that will be one place to start the other thing that is developed and become really acutely in finely tuned is echocardiogram. The images that we can now get in the information we can lean from echocardiogram is tremendous and quite frequently that provides definitive answers as to what's going on. Now, there will be other tests that may be involved including cardiac catheterization, cat scans, etc. but between those two things, an EKG and an echo, most of the information really to home down and find detail is there

So we know that cardiologists are the experts at treating heart valve disease with medication but when does heart valve disease evolve into a surgical issue? How does a patient know when they've crossed that boundary between medical care and now needing surgery?

That's kind of the art, if you will, of medicine. There are sometimes when it's very clear, if you have a badly infected valve from, let’s say endocarditis, it's not responding to antibiotics, then some sort of surgical intervention is most always going to be indicated. If you have a valve not opening all the way, a stenotic valve, that valve may indeed ultimately need surgery but perhaps can be watched for a period of time and the patient followed very closely for development of symptoms outside of what they presented with or having echo evidence that the valve has progressed and then need surgery. There's some criteria we used for echo, say for aortic stenosis, now when we see enlargement of the chambers that can be a sign that the valve needs to be attended to whether the patients having symptoms or not. There are there are a number of things that can point one to at least consider surgical intervention. The patient may or may not know that they've crossed a line.

What surgical options are available to patients and can you talk about Shipley’s various approaches to valve replacement? For example, open surgical versus transcatheter versus hybrid and even valve sparing rings and the vacuum procedure?

Well we're very fortunate and I say this with a great deal of pride we can offer virtually any sort of valve intervention in this institution, that's available anywhere in the country. We’re apart of a national trial for FDA for minimally invasive valve replacements, particular valve the mitral valve. To kind of summarily answer your question, every patient offers a different and unique situation. So we have available, minimally invasive approaches either from small incisions in the right chest to small incisions and the upper sternum to deal with valve pathology, we have catheter based therapies that we can replace valves with at the end of the catheter, we can repair valves through very small incisions, we can, in cases of large vegetation’s (describe the vegetation is just a big infection) Abscess, if you will, on top of a valve, we can apply a device much like a vacuum cleaner and eliminate a great amount of that infected material thus making it easier for the antibiotics to do their job. (host) it's like de-bulking that infection. It’s reducing the infectious load in the valve. All of these things are possible and again each patient is unique and what we offer depends on the clinical situation but we are not limited by any one thing and how we approach valve. (host) It’s is such an excellent program

The first augmented reality knee replacement was done recently and augmented reality for our listeners is a technology in which digital pictures and physical realities converge giving surgeons a very technical and precise vision of the operative field this technology provides them with information in real time through computerized images that overlay the surgical site seen through special glasses that the surgeon wears. Think Terminator or Iron Man vision. Do you see augmented reality eventually playing a part in surgical valve replacement?

Actually I do, in lung surgery which we do a lot of here. There's also the ability to overlay cat scans where nodules are identified out in the peripheral lung sac and you are seeking to get a biopsy of that particular nodule, which can be very difficult to identify, we're doing this robotically or minimally invasive, we can overlay those cat scans with real time imaging in the operating room and ensure that we were getting that nodule. Now that's a little different than what you're describing but I foresee in the not too distant future where we will take echo images of the valve and say OK here is where this regurgitation is occurring and overlay our planned repair say OK will this work. Interoperable, we get echoes we do everything to assess our repairs or replacements but to be able to predict ahead of time that you need X number of stitches here, will be a benefit to us. I see that coming I think it's a really incredible piece of technology coming.

So what parting advice do you have for patients with heart valve disease?

Well one, don't ignore it! That’s first and foremost. If somebody tells you you've had a murmur and many of us through our lives have been told “oh you have a murmur don't worry about it, it's benign”. For the most part it probably is, but don't ignore it. It should be checked periodically to ensure that it is benign and not something that is becoming a problem as we age. If you're having symptoms that we describe such as lightheadedness and increasing shortness of breath doing the normal daily activities or you notice your legs are now starting as well or whatever, those things should be evaluated and investigated and it's not hard to get in to see a cardiologist, particularly in this area. We have lots of great cardiologist in town and in the area and I would encourage our listeners to seek out their expertise if they feel they are having a heart problem, if there if their primary physician is unable to evaluate it or they seem unavailable to them, then they should seek out a cardiologist.

Well as always doctor Hummel this has been a fascinating discussion is there anything else you want to add before we sign off?

I would encourage all of our listeners to take care of their hearts, particularly here in heart month and enjoy what God's giving you and cherish it take care.

(host) yeah we get one lifetime don't wait that's right

Thank you so much doctor Brian Hummel for being with us on National Heart Valve Disease Day to discuss heart valve disease and Shipley’s innovative surgical heart valve program until next time I'm Cathy Murtagh-Schaefer and this has been heartbeats, Shipley Cardiothoracic Centers podcast dedicated to bringing research innovation an education to our patients and the community