HeartBeats Episode 18: Heart Valve Disease Pt 2 - Medical Management of Valve Disease

Host:

Welcome, I'm Cathy Murtagh-Schaffer, and I'm 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 22nd was National Heart Valve Disease Awareness Day, which is a recognition of the impact that hear valve disease has on the health and wellbeing of the American public. Today, we would like to continue our series on valve disease by discussing the medical management of valve disease with one of Lee Health's newest cardiologists, Dr. Steven Deutsch. Thank you, Dr. Deutsch for being here today. Perhaps we can begin by having you tell us a little bit about yourself, your career and how you came to Lee Health.

Dr. Deutsch:

Thank you so much for having me. So I've had quite the journey doing training across the country. I initially started off with my residency at Tampa General Hospital with the University of South Florida. And then from there, I went to California and most recently, New York. I always wanted to find my way back to Florida, somehow having family here and just really enjoying the state, the beaches and the weather. And I found a Health Park and Shipley, and it had everything that I wanted, great talent, a lot of patients to take care of in the community. So it was a perfect fit.

Host:

Yeah, it sounds like it, you really have had an adventurous trip through your training. But how nice to be able to experience all the different parts of the country.

Dr. Deutsch:

Absolutely. It was a great experience, you know, throughout training, they always talk about how they do things different on the west coast than on the east coast. So I was able to train on both coasts and hopefully take the best form each

Host:

From each side. That's great. We know that each year, approximately 25,000 people die of untreated or poorly treated heart valve disease. So let's start with just a simple anatomy lesson for our listeners, where exactly are the heart valves and why are they important?

Speaker 2:

Well, the heart valves, like any other valve try to prevent flow of blood from, or I guess in any device that you have prevent backflow. So in the heart, when you're pumping blood forward, you don't want it to leak backwards because that can cause shortness of breath if it goes into your lungs, swelling in your legs and discomfort in your abdomen, if you become volume overloaded. The valves that we particularly pay attention to are the aortic valve and the mitral valve. This is because they're on the left side of the heart and the left side of the heart I kind of think of as more important side because it's the one that's pumping oxygenated blood to the rest of your body. So these are the ones that I particularly pay attention to, and you have two other valves on the right side, the pulmonic valve and the tricuspid valve, which are also important, but don't tend to cause as much symptoms as if you have disease in the mitral and aortic.

Host:

What types of diseases affect the valves and are they preventable?

Dr. Deutsch:

So for the most part, the diseases that are affected or that affect the valves are stenotic valves, which aren't opening, prohibiting blood flow from going forward or leaky valves that allow blood to backflow into the lungs and the rest of the body instead of going forward. This can cause shortness of breath as I mentioned earlier, swelling in the legs, not so much preventable, the disease, but there are some things that we can do to help, I guess, slow down the process of disease. One of the most important things is monitoring your blood pressure and making sure that it's not running too high. I always think of blood pressure as a silent killer. You may not know that you have high blood pressure, you're feeling fine, but you know, as increased pressures are hitting these valves over time, you can imagine that it can destroy them. And then there are some other bacterial infections that can affect the valves as well, and then less common are rheumatic mitral diseases that we aren't really seeing as much anymore. Mostly especially in our community, a disease of the elderly is aortic stenosis, which we're most, more often running into now.

Host:

Aortic stenosis, my understanding is a degenerative disease and aging is probably the primary cause of AS.

Dr. Deutsch:

Yes, age is one of the primary causes of it. In the past it was hopeful that we thought that statin therapies may decrease the progression of this disease because a lot of the times the valve won't open, like if you imagine a valve as a door, a door not opening allowing enough people to go out, it's the same thing. The valve doesn't open blood,can't go forward and oxygenate to the rest of your body. This can be caused by calcification. Unfortunately, the studies with cholesterol medications, the statins didn't really prove that it decreases the progression of this disease. There are also genetic variables that can affect the valve. Some people are born with two cusps instead of three, so they'll have symptoms earlier in life, usually around, you know, 60 to 70 years old, as opposed to people with three leaflets on their valve, which tend to be older seventies, eighties, up to 90 years old.

Host:

Is there a hereditary component to this? If my mother and father had AS will, should I think about having AS?

Dr. Deutsch:

If you have the bicuspid aortic valve, yes, that is a genetic predisposition to it, but, there hasn't really, really been a genetic defect found for aortic stenosis with the tri leaflet valve.

Dr. Deutsch:

What are some of the more common symptoms of heart valve disease and why is heart valve disease so deceptive?

Dr. Deutsch:

So some of the common symptoms are shortness of breath, chest discomfort, as I described earlier with aortic stenosis, if the blood can't go forward, you're not oxygenating your organs in your body. So some people will get increased fatigue, if they exert themselves, they'll get chest discomfort, lack of energy, and once again, shortness of breath. This also is true with a regurgitant valve disease where blood's not going forward it's going backwards so you're not getting as much oxygen as you should. It's deceiving because you may not realize that it's your valve, that's the issue. Why would you, unless you're seeing a cardiologist who can diagnose it. So you may just think that you've been getting something with age or now more fatigued because you got older and you just don't have the energy and stamina you once used to when you were 20 years old. But since it's such a slow progression, people get used to this and they don't realize how truly affected they are and they stop pushing themselves physically as much as they used to in the past, because over time the valve has slowly deteriorated.

Host:

It was not an uncommon thing for me to hear when talking to patients, I thought it was just my age and sure enough, that they had progressively worsening, aortic stenosis.

Dr. Deutsch:

Absolutely. I see it all the time in my clinic. People are coming to me, they think their thyroid is maybe acting up or, you know, it's just COVID and they're feeling more tired. I put my stethoscope up to them and I hear an abnormal heart murmur and right away, I know that it's likely there arctic valve that's causing issues. I recently had a patient who states that he was riding his bike eight miles a day, and that he has no issues and he didn't want to replace his valve, put him on a treadmill and you see his blood pressure tanks and he gets crazy heartbeats, dangerous rhythms, and he definitely needed the valve replaced.

Host:

Im surprised he wasnt fainting .

Dr. Deutsch:

Exactly, and that's my biggest concern because, you know, once you get to severe aortic stenosis, it's you know, a disease, almost like a cancer, your prognosis is poor unless it's fixed. This guy ended up, uh, being evaluated by the staff at Shipley and myself, and got a new valve and he couldn't believe the pressure that was taken off his chest that he's been living with for the past, however many years.

Host:

Amazing! Talk a little bit about mitral regurge.

Dr. Deutsch:

Yeah. So mitral regurgitation of mitral valve is the valve that separates the top chamber on the left from the bottom chamber on the left end. It allows blood flow, oxygenated blood to go into the left ventricle and out to the rest of your body. Now, if you can imagine that the oxygenated blood isn't going forward, and it's going back up into your lungs, you can get short of breath for multiple reasons. You have increased fluid in your lungs, and you're not getting enough oxygen out to the rest of your body to perfuse your organs, your brain, your heart, and the rest of the organs in your body. So, people, the most common symptoms from this are going to be shortness of breath and fatigue as well.

Host:

And edema.

Dr. Deutsch:

Yes, edema as well, absolutely.

Host:

I see a lot of patients with excessively large ankles and swelling in their legs because of fluid overload.

Host:

So people shouldn't just that their symptoms are a natural part of aging. They should consult their doctors when they start to feel symptoms such as increasing fatigue, shortness of breath, or a racing heart. When a patient comes to see you, what should they expect when they first come in for these types of symptoms? What tests would you recommend?

Dr. Deutsch:

Well, I think the best test of first is a good physical exam. I don't think anything can beat that first, getting a good history. A lot of the times patients may think that their legs are swollen because they're coming from the Midwest down to Fort Myers and they're not used to the Florida humidity. When a lot of the time it's not the heat and the humidity it's, you know, their valvular disease. So I think nothing trumps a good physical exam. And then I always like to start with a minimally invasive test and the echocardiogram, which is basically an ultrasound of your heart can give me and the patient invaluable information on the anatomy of their heart valves, the function of their heart, the squeeze, the relaxation, in just the correlation with what symptoms they may be having; If there's a stenotic valve that's not opening enough, or if there's a leaky valve for a valve that's not closing correctly and prolapsing.

Host:

An EKG is something pretty basic that most physician offices can do in their office. But these other tests such as a TEE echocardiogram, chest x-ray and cardiac cath, they all need to be done in special labs and a TEE and cardiac cath are invasive procedures. So when should a patient expect that these types of tests would be recommended? I mean, obviously you don't start with a TEE or cardiac cath unless the symptoms call for it.

Dr. Deutsch:

Absolutely. You always want to go, I think with a non-invasive study first after we would get that echocardiogram and get a good look at the valves. For instance, you were talking about mitral regurgitation. We need to look which leaflets maybe are flapping backwards and not coming together as they should. So then we'll go with a more invasive study, such as a transesophageal echocardiogram or TEE where we can take a better look, a closer look at the heart valve and better distinguish which part of the valve is maybe not acting appropriately and how we could move forward to either fixing it surgically or, more less of an invasive approach with a mitral clip.

Host:

So patients shouldn't expect to just come into your office and do a one-time visit.

Dr. Deutsch:

No, I think once you come into my office, it's more that if you have cardiac disease, it's going to be a lifelong relationship with me. It's something that needs to be followed and even without having an initial diagnosis of a valvular problem, you come into my office,we'll work together to hopefully prevent coronary disease and the progression of valvular disease. A lot of patients come in and they may not have severe aortic stenosis or severe mitral regurgitation, but we need to survey them either biannually or annually or, whatever the guidelines may recommend in that patient's circumstances.

Host:

I know you're working very closely with the Shipley surgeons doing transcatheter procedures to replace valves. Has the evolution of these procedures influence how you medically manage patients. And when do you consider it time to refer a patient for surgical management?

Dr. Deutsch:

Yeah. I worked very closely with the Shipley heart Institute. They're very talented individuals, in each respect they have their own talents with Dr. Gigiorgi doing minimally invasive disease and Dr. DeFrain and Dr. Hummel placing TAVRs with Dr. Muppala, I believe they just recently completed or are finished doing 1500 plus, which is quite a feat, especially in Fort Myers, Florida with when you're competing with places like LA and you know, Manhattan. But yeah, the TAVR procedure has completely changed the game, patients who were, you know, weren't candidates for open-heart surgery can now come in, have a valve replaced, minimally invasively without general anesthesia and sometimes walk out of the hospital within two days with a brand new valve. What once was considered a deadly disease that couldn't be treated, now we're treating patients over a hundred years of age.

Host:

Yes, we've done. We've done some fairly elderly folks and they've done well and it's changed their lives.

Dr. Deutsch:

It's a complete game changer. They don't realize that, you know, once again, you may be a 100 year old patient blame your fatigue and lethargy to age, but once you get one of these new valves in you, it completely opens the door to allow blood flow to the rest of your body, and you get energy like a 80 year old.

Host:

I love that. So at what point do you refer patients for surgical management?

Dr. Deutsch:

Well, you know, there are a lot of criteria that we look at with either the echocardiogram or transesophageal echo. A lot of physics is involved to gradients and velocities across the valves, how large the regurgitant flow is the velocities of the flow, and the size of, I guess, the regurgitant flow not to get to too much detail. That's why I say when, you know, a patient comes and sees me, it might be a long-term follow-up until they meet this criteria. And even once they meet certain criteria, you know, we'd like to see them be symptomatic or,you know, hopefully catch it before there are signs of heart failure and by heart failure, you know, like I said before, your heart's a pump. If it's not pumping correctly, we want to try to treat the disease before it gets to that point and it fails.

Host:

What advice do you like to give patients that will help them manage their valvular disease?

Dr. Deutsch:

Keep a follow-up with your cardiologist and cardiothoracic surgeon,stay on the medications we prescribe. It's, you know a disease that is fixed, but we need to survey the valve. We make sure that there aren't any changes in symptoms, and we need to make sure the blood pressure is managed well. And, you know, certain valves are going to require you to be on anti-platelets and aspirin and something like a super aspirin. So you, you may need to be on this three to six months and aspirin likely the rest of your life. And like I said, you have to maintain contact with your primary care physician, and most importantly with your cardiologist and have regular follow-ups, make sure there aren't any changes on physical exam that warrant us to further evaluate that new valve that you just got.

Host:

Thank you so much, Dr. Steven Deutschfor being here today. Is there anything else you'd like to add before we sign off?

Dr. Deutsch:

Yeah. Come see your cardiologists. If you have any concerns, get a good checkup. Preventative care is the best care, it's better to see me in the office than in the hospital.

Host:

Yeah, I agree. Are you taking new patients?

Dr. Deutsch:

I am taking new patients. Absolutely.

Host:

Good. Good. Thank you so much for being here today to discuss heart valve disease and Lee Health innovative heart valve program until next time I'm Cathy Murtagh-Schaffer, and this has been HeartBeats, Shipley Cardiothoracic Centers podcast dedicated to bringing research innovation and education to our patients and the community until next time.