Heart valve replacement: What are my options?
Some people may hear the words “valve replacement” and automatically assume it means open heart surgery. This misconception could be one reason why people choose to delay treatment for valve disease, which can allow the condition to worsen and cause permanent heart damage, according to Dr. Michael Firstenberg, a cardiothoracic surgeon with affiliate The Medical Center of Aurora in Aurora, Colorado.
Open-heart surgery is how doctors have traditionally repaired or replaced faulty heart valves. But in recent years, newer options for valve replacement, including some less invasive alternatives to major surgery, have become available.
If you need a heart valve replacement, you may have pre-conceived thoughts about what you think is best. It’s important to understand that this is a complex decision based on many individual variables. Your doctor—and possibly other specialists, otherwise known as a ‘heart team’—will help you determine the most appropriate therapy for you.
We spoke with Dr. Firstenberg to learn more about heart valve replacement and some of the risks and benefits of existing treatment options.
Q: Are there alternatives to open heart surgery for patients who need valve replacement?
A: Many people may be familiar with traditional open heart surgery, which involves getting into your chest, putting you on a heart-lung machine, stopping your heart, opening it up and either repairing or replacing a valve to deal with the problem at hand. Over the past several years, catheter-based therapies that require smaller incisions have been developed. This approach typically involves accessing a faulty or diseased valve through some of the larger arteries and veins in the body. A replacement valve is secured to the end of a thin tube, or catheter,
which is threaded to the heart. The rapidly-growing trend is partly driven by the desire to make any type of intervention as minimally invasive and safe as possible.
Q: In recent years, one catheter-based procedure in particular, called transcatheter aortic valve replacement (TAVR), was approved by the U.S. Food and Drug Administration as an option for high- and intermediate-risk patients who are unable to undergo major surgery. Aside from how you access the heart, how is TAVR different?
A: A fundamental difference between the two procedures is that during traditional open heart surgery, you go in and you take out the existing diseased valve. You clean it out, and you put a new valve in. During TAVR, you basically put a valve in whatever residual hole there is and expand it. So, the old valve isn’t taken out. It just gets pushed to the side.
Q: Are there any concerns about leaving an “old” heart valve in place?
A: One issue that people get very concerned about are paravalvular leaks, which occur when there is a space between the existing heart tissue and the replacement valve. When you put these transcatheter valves in, and you just expand them against the existing valves, there clearly is an increased risk of having leaks in those areas. There’s more and more data coming out to suggest that those leaks are not exactly benign and may cause problems down the road. There is also a significantly increased risk for needing a permanent pacemaker due to problems with the electrical system of the heart. The short-term and long-term risks of needing a pacemaker are also not minor.
Q: Are there any other specific risks associated with catheter-based therapies?
A: One obvious question involves the durability of transcatheter valves. We’re just starting to get three, four and five-year data, and some limited data beyond that. Accessing a heart valve through the femoral vessels, or the arteries and veins in your groin, also isn’t risk-free. There’s risk of injury to the vessels. There are nerves in those areas that could also be bruised for a while. These are all part of the trade-offs and that’s why each case needs to be individualized. We are also still trying to understand some of the additional risks and benefits of each procedure, including bleeding, infections, heart attacks, the need to be readmitted to the hospital and strokes—not only during the first few weeks or months after the initial procedure, but also years down the road.
Q: There is some recent research which suggests that TAVR may actually be appropriate for younger, healthier people. Could this eventually become the new standard of care?
A: Time will tell. Catheter-based valves have been available for about seven to 10 years, depending on where you are. Many places in the United States have only been doing this procedure for three to four years at most. So, people are still gaining experience with it and working to identify the ideal patient population.
Two recent studies looking at the one-year outcomes among patients who are considered relatively low-risk suggest that TAVR may be just as good as, or in some cases, superior to traditional open heart surgery. But there is still a lot of criticism of the data across the board, both by surgeons and cardiologists. Even though the technology is getting better and safer and people are getting more used to dealing with it, some potential problems and complications—especially when we start looking at expanding this to younger patients—are not trivial.
Q: Some people might assume that a less invasive procedure is always better. How would you respond to that idea?
A: Most people do not want surgery. That’s understandable. I think that there’s a lot of fear and apprehension. There is a natural tendency to think that because something is less invasive, it is inherently safer or better. I think it’s important to keep in mind that this is not always the case. The key is that you have to get the therapy that’s going to be best for you in the short and long term. All of these therapies have advantages and disadvantages. Nothing is perfect.
Q: How do patients decide which valve replacement procedure is best for them?
A: When patients visit their doctor with a valvular problem, there will be a whole team of specialists—very similar to what’s done in the cancer world—participating in a work up. In other words, the team will collect data, analyze it and determine what, if anything, needs to be done. The members of this heart team will then strategize and make treatment recommendations based upon their areas of expertise. It’s our obligation to provide patients with as much objective data as possible so that they can make a good decision.
Q: Can you talk about some of the variables that go into this treatment decision?
A: Patients must have anatomy that is suitable for any type of valve replacement. In addition to ultrasounds and cardiac catheterizations, patients often undergo CAT scans, which provide a picture of their arteries and veins. These images help determine the course of treatment. We also investigate patients’ other medical problems and how those play into decision making. The current line of thinking is that if somebody is at very high risk for surgery—they’ve had previous open heart surgery, they are frail, they’ve had cancer and radiation to the chest or they have other major health concerns which would make recovery after surgery difficult—then there is a trend towards offering those patients catheter-based therapies.
Q: Are there unique considerations for younger adults who need valve replacement?
A: Valvular disease, for a variety of reasons, affects people of all ages. Yesterday, I did two valve replacements. One of them was in a 70-year-old and the other was in a 34-year-old. For someone who’s a little bit younger with a life expectancy that could be measured in decades, I think it’s important to be honest with them about therapies that have stood the test of time, like open heart surgery. Although we only have limited data, some of the complications that we see with the transcatheter valves are not trivial. When you start extrapolating that risk over the patient’s lifetime, they could be potentially significant. That’s why I think there’s a reluctance to be very aggressive with newer types of procedures in younger patients that may have a reasonable life expectancy to begin with.
Q: For those who undergo open heart surgery, there are different types of replacement valves available—tissue valves and mechanical valves. So, are there additional pros and cons to consider?
A: Mechanical valves have the advantage of durability. While nothing lasts forever, for most patients they will last the rest of their lives. The downside is that these patients will have to take a blood thinner, called Coumadin [warfarin], every day afterwards. And there are concerns and risks associated with being on a blood thinner for the rest of your life.
On the other side of the coin, tissue valves—which are predominantly made out of pig or cow tissue—are limited by their durability. You do not necessarily have to be on a blood thinner for a tissue valve, but the offset is that the valve may wear out over time. Younger people tend to wear out their valves sooner than older people. That’s why the early decision-making process is so important. These are lifelong decisions and people need to make sure that whatever they decide right now is something that they can live with down the road.
Q: What about TAVR? What type of valve is used for this catheter-based therapy?
A: Currently, all of the TAVR valves are tissue valves. It has to be this way to coil them up for the delivery before they expand within the existing valve. The inherent issue with tissue valves is that they wear out. And the younger patients are, the more quickly the valves tend to wear out. So, if someone is 70-years old, a tissue valve may last 10 years but that same valve may only last six or seven years for someone 20 years younger. Complicating matters, the risks of complications associated with valve replacement are additive, so they increased with each additional procedure.
Q: Following a heart valve replacement, what type of recovery time is involved and what can people expect?
A: Recovery varies by the individual. It also depends on how healthy patients are going into the procedure. Overall, for most elective open heart valve replacement surgeries, people spend between five and seven days in the hospital. For transcatheter valves, people are usually hospitalized for two to four days, depending on the circumstances. There’s no doubt that open heart surgery can be a little bit more painful. You also have to let the bones heal. A week or two down the road, we talk to all patients—including those who had a transcatheter valve replacement—about getting into a cardiac rehabilitation program. If they’re doing well, people also usually start to drive within a couple weeks, and then we start negotiating with them about when they can get back to work. We really try to get patients back to a quality of life as quickly as possible.
Q: Are there consequences for putting off valve replacement?
A: There are patients out there who, for a variety of reasons, say, “You know what? I can live with this shortness of breath. It doesn’t bother me. I’m just going to wait.” What they don’t realize is that shortness of breath and chest pain is their heart struggling for oxygen and blood. Over time, that can result in substantial damage. Some of that damage is irreversible. You don’t want to be in denial because these problems don’t go away. They just get worse. The longer you wait to treat the condition, the greater the impact it will have on your longevity and the quality of your life. Heart valve disease is almost like ‘cancer of the heart.’ The longer you wait, the worse it gets and the more damage it can do you your body.
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