Heart valves

Replacing weakened heart valves without surgery



Two years ago, when she started feeling out of breath and slight chest pains, Minna Blander went to see a cardiologist, who explained that the aortic valve in her heart, the gatekeeper for the blood her body needed, was not doing its job.

Blander, then 95 and remarried just five years earlier, would probably be dead in a year, a doctor told her family.

What Blander didn’t know is that doctors in clinical trials around the country, including at the University of Miami, had been testing a new kind of non-surgical valve replacement procedure that could save the lives of people considered too frail or elderly to survive the grueling hours of conventional open-heart surgery.

The procedure, part of a growing trend to repair the heart in non-surgical ways, uses a catheter to slide a new valve into place. It can take just two hours to perform, and if all goes well, patients go home in about two days.

“The thing that’s interesting about her, other than being a spry 96-year-old lady full of life, was that she was slowly dying from aortic stenosis,” said Dr. Harold Roberts, the Holy Cross Hospital thoracic surgeon who performed the procedure. “In the past, these patients have been left to die basically.”

Advances in non-surgical procedures using catheters has meant not only easier procedures for patients with less complicated medical conditions, but help for those whose only option was medicine that could sustain, but not cure them.

Over the years, improved imaging and better catheters have staked out new territory. By making them in different sizes and varying stiffness, catheters can now be manipulated to perform not just cardiovascular procedures, but neurovascular, gastrointestinal, urological and ophthalmic.

“At 2:20 this afternoon, I had a perfectly healthy 56-year-old guy who decided to have a heart attack. And 28 minutes later, 100 percent of the blockage was fixed,” said Dr. Howard Bush, assistant chief of staff at Cleveland Clinic Florida, where doctors use an incision in the wrist to insert catheters and deploy stents, reducing the risk of bleeding and making recovery easier.

“I started my training 30 years ago and that patient would have been in the hospital for two weeks recovering. Now he’s in the hospital for two days.”

Catheters got their big break working inside the body in 1953 when Swedish radiologist Dr. Sven-Ivar Seldinger used one to inject dye into the heart to get a better angiogram. Now, Bush explained, they can be used to clean blocked carotid arteries that can cause strokes; holes in the heart, through which deadly pieces of plaque or blood clots might escape to the brain; and aneurysms in the aorta, the main vein highway that ships oxygenated blood throughout the body.

The technique used on Blander — in medical jargon called the transcatheter aortic valve replacement — was approved in 2011 and is reserved for the frailest patients because traditional aortic replacement is still less risky, Roberts said. It is now performed at a number of hospitals in South Florida, including UM, the Cleveland Clinic and Baptist Cardiac & Vascular Institute, which has teamed up with the University of Heidelberg to get a jump on the latest medical treatments in Europe, where methods are more progressive.

Like Blander, Janice Carlson was last summer feeling out of breath, but also tired and dizzy.

“I felt like a drunken sailor. But I didn’t have any pain. It was just creeping up on me,” said Carlson, 82. “So I went to my regular doctor and ... he said there’s something going loopy with your heart.”

It turns out Carlson was suffering from aortic stenosis, which is most commonly caused by simple aging. Over time, the aortic valve, which has three flaps that open and close in unison as blood is pumped into and then out of the heart, can calcify. A 2002 study by the New England Journal of Medicine estimates that 2 percent of the population has it, although Roberts pointed out that only about half the patients with symptoms — shortness of breath, chest pain and fainting — have anything done. Once you have symptoms, he said, there is only a 50 percent survival rate of 18 months.

While neither women felt pain, they knew they were slowing down. But neither was ready. Carlson, a mother of five, had been selected from 400 residents at her assisted-living facility in Venice to be an ambassador to new residents.

“There’s a lot of stuff going on if you choose to be a part of it,” she said. “OK, it’s a little different lifestyle than when you’re raising children and have your own home, but life moves on and if you don’t move with it, you’re going to be a very unhappy person and I choose to be a happy person. I think, hey, I only travel this road once.”

So when her doctor suggested the valve replacement procedure, Carlson was game. Plus, a previous doctor had given her only 10 days to three months to live. And Carlson was having none of that.

“He said don’t wait too long on this. Get on your horse and gallop,” she said.

Dr. Niberto Moreno, chief of cardiothoracic surgery, and Dr. Ramon Quesada, medical director of interventional cardiology and cardiac research, performed the procedure on Carlson at the hospital’s Cardiac and Vascular Institute.

“When I came to, it was like I was a different person,” Carlson said. “I woke up and my head was clear as a bell.”

Doctors typically perform the surgery by inserting a wire through the groin, into the femoral artery and up into the heart, Quesada explained.

The catheter is then slid over the wire with a balloon to open the valve. The replacement valve — a metal ring is then forced onto the damaged valve.

Doctors use ultrasound and CT imaging to follow what they’re doing on monitors mounted around the operating room, which can be crowded with 10 to 12 people from both the surgery and cardiology departments, Moreno said.

In some cases, femoral arteries are blocked, so doctors go in through a small incision in the chest, said Dr. Mauricio Cohen, an associate professor and medical director of the Sussman Cardiac Catheterization Laboratory at the University of Miami Hospital.

UM, which participated in the trials beginning in 2008, has performed more than 300 of the procedures, Cohen said.

“We’re used to treating other types of things — coronary disease and we treat heart attacks. But we have never been able to cure or treat or reverse conditions such as severe aortic stenosis,” he said. “Even though these patients are old, they’re very functional and have a meaningful life.”

Indeed. Blander remarried after her first husband died. Alone in Plantation, where she’d lived for 31 years, her son and daughter convinced her to move to Boca Raton to be close to them. About three months after she moved into her Century Village apartment, a gentleman knocked on her door and invited her to see a show. Not knowing how to respond, she called her daughter.

“I hadn’t gone out on a date with anybody in the six years [my husband] was gone and she said, ‘Mom, if you don’t go out with this gentleman, because he’s so nice, I’ll never talk to you again. Life is for the living. Go.” So I did and we were married a year and a half later,” Blander said.

And in February, they booked a two-week spring cruise to the Caribbean.

“He said to me one day, ‘You go through this, you get well and if the doctor says yes, we’re going on a cruise.’ And that’s what happened.”

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