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CMC's New Advancements in Cardiac Care

Bringing Hope
New tools and procedures may bring about a revolution in cardiac care
by Karen A. Jamrog

This article appears in the Feb 2014 issue of New Hampshire Magazine 

As rampant obesity and unhealthful lifestyle choices take their toll on US citizenry, government officials have intervened on our dietary behalf by taking steps toward banning artificial trans fats and waging war against super-sized sugary drinks. Although we might fret about the future of our beloved cookies, cakes and Big Gulps, the need for such drastic measures should be apparent to even the most ardent junk-food junkies among us. After all, heart disease remains the leading cause of death for men and women in America, and accounts for one in every four deaths, according to the Centers for Disease Control and Prevention.

Not all instances of heart disease are self-inflicted, though, and while we wait to see what the future of the food industry brings, treatment options for heart patients continue to expand, fortunately, bringing choices that are less invasive and, as a result, less risky. For example, transcatheter aortic valve replacement (TAVR) is a new procedure that offers hope to patients who in the past have had limited options.

TAVR is used to treat aortic stenosis, a condition in which the aortic valve does not fully open, leading to decreased blood flow. It can occur at any age, but often appears later in life when calcium deposits narrow the valve. Aortic stenosis can develop over time regardless of a person’s diet and exercise habits.

“The prognosis for aortic stenosis, once it becomes symptomatic and once it becomes severe, is very, very poor,” says James M. Flynn, MD, FACC, the Cardiac Catheterization lab director and director of Interventional Cardiology at Catholic Medical Center’s New England Heart Institute. “It’s a dismal prognosis unless you can replace the valve.”

But some patients, particularly the elderly, are not candidates for valve replacement surgery, usually because they have additional medical problems or a physical condition that likely would be overtaxed by the rigors of open-heart surgery. TAVR is currently targeted at just that subset of patients. Research has shown “a dramatic improvement in survival” in those patients who could not undergo traditional valve replacement surgery, Flynn says, although it’s important to keep in mind that not everyone is a candidate for TAVR, either.

TAVR is almost “like valve replacement without the surgery,” says Paul F. Boffetti, MD, FACC, director of Interventional Cardiology at Lahey Cardiology at the Medical Center in Nashua and a cardiologist at Lahey Clinic in Burlington, Mass. Unlike its traditional surgical counterpart, “[TAVR] is done without splitting the sternum,” he says.

The approach of TAVR procedures varies —  sometimes it begins in the groin area, sometimes with an incision closer to the heart— but all of the approaches are minimally invasive, Flynn says. Whereas conventional valve replacement usually requires opening up the chest, during TAVR, the surgeon makes only a small incision and snakes a catheter along its way toward the heart, where a balloon is expanded in the location of the malfunctioning valve and a pig valve that has been sewn onto metal mesh is left behind to take over the work of the old, narrowed valve. Besides the absence of a big incision, a key aspect of TAVR that contributes to its non-invasive appeal is its lack of reliance upon a heart-lung machine during surgery, says Yvon R. Baribeau, MD, FACS, a cardiac and thoracic surgeon at Catholic Medical Center’s New England Heart Institute. A heart-lung machine is used during some cardiac procedures to do the work of the heart during surgery and can be “very challenging for older people,” Baribeau says. Not having to involve a heart-lung machine during TAVR offers “a tremendous advantage,” he says.

In addition, recovery time following the procedure is typically shorter than what is required after conventional valve surgery, with patients monitored for recovery for up to five days on average, Flynn says. “The toll on the body and the recovery [compared with conventional heart surgery] is dramatically better for the patients. They feel better quicker because they aren’t having their chest opened up.”

The TAVR procedure has “saved a lot of lives,” Flynn says, which alone is good reason to welcome it to the toolbox of Granite State surgeons.

But patients who have undergone TAVR often find that their quality of life changes significantly for the better too. “It’s not only the number of years you add to this elderly population [of patients], it’s also the quality of years,” Baribeau says. “[After TAVR], they can actually walk and dress themselves and see their families, for example.”

At this point, the FDA has only approved TAVR for patients who fall into the non-operable or high-risk category for conventional valve replacement surgery. “It’s not FDA-approved for everyone,” Boffetti says. “The old procedure is so well-established, safe and durable that the new procedure is limited” to those who are believed to be unable to tolerate the open surgical procedure, which “in and of itself can be a little difficult to recover from” for some patients who are very old or have other health conditions, Boffetti says.

But over time, it’s possible that doctors will be able to offer the procedure to other patients, as well. “I think everyone’s feeling is, as time goes by, whether it’s five or 10 years, the population that’s going to be eligible for this procedure is going to expand,” Flynn says. “This is sort of the beginning of a revolution in valve replacement and right now, it looks very promising.”

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