FEED DROP: C4E Presents Garbage Air

WEBVTT
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Welcome to Healthcast.
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where leaders and experts from Stony Brook
medicine come together
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to discuss a range of topics
from leadership and strategic planning
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to patient care and the inner workings
of a successful health care system.
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Hello everyone and welcome to Health cast.
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My name is Doctor Allison McLarty,
and today we're discussing
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heart valve disease and how it impacts
well-being and survival.
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And severity of valve disease increases.
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It can cause a range of symptoms, such
as heart failure like dyspnea or thought,
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Mia arrhythmia or syncope,
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or chest pain,
and ultimately severe valve disease.
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Left untreated, is fatal.
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However, most types of valve disorders
can be treated effectively.
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And increasingly, we're able to use state
of the art surgery to repair patient's
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native valves, which can then restore
their life expectancy back to near normal.
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In a few minutes, we will be speaking with
some of our surgical experts to discuss
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innovative surgical options to treat
aortic and mitral valve pathologies.
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But first, let's speak with Doctor
Smith, our court, who is the director
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of noninvasive cardiovascular
imaging at Stony Brook medicine.
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Accurate diagnosis of valve disease
is critically important,
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and imaging is invaluable in procedural
planning and measuring results.
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Doctor. Court.
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Thank you. Allison.
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So my name is middle course
doctors. Middle quote.
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I'm like you said
the professor of medicine
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at the Renaissance School of Medicine.
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I'm the system director for,
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noninvasive cardiovascular
imaging and echocardiography.
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Animals are co-director
of the valve center.
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Okay, so definitely an expert.
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And that's very helpful for us today.
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So can you tell us,
how heart valve disease is diagnosed
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and what key advances have been seen
in cardiovascular imaging recently?
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So the
key tool that we have for diagnosing
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valvular
heart disease is still echocardiography.
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However the echo that we did today
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is very different than the echo
that I was doing as a cardiology fellow.
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He was in no household.
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So we routinely use now 3D
and 4D for assessment of valve anatomy.
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Also for more accurate assessment
of cardiac volumes.
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Less than regular volume left
actual volume.
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We utilize strain imaging
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as a more sensitive parameter
for assessment of systolic function.
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And we, we have all sorts of formulas
of calculations
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to really assess the degree of severity.
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So when we talk about diagnosing valvular
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heart disease,
obviously we need to assess the anatomy.
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We need to visualize the valve.
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We try to figure out the etiology
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of the of the valve pathology.
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We then assess the hemodynamics
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so we can, quantify the severity
of that particular valve disease.
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We then look at the
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effect of that particular valve disease
on the rest of the heart.
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So we really need a very accurate
assessment of, LV size, Lar
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size assessment of the right side
pressures,
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as well as systolic function
and diastolic function.
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So this is how we essentially start
with the trans thoracic echocardiogram.
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Oftentimes we perform stress echo.
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So we put a patient on or a person
on the treadmill.
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And we get echo pictures
before as well as after.
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And we compare them.
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And that's extremely helpful for either
patients who have exertional symptoms.
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We really try to see what happens
with their father function
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as well as their LV function
with exertion.
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And and it's also extremely useful
for patients who have discrepancy
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between our resting images
and their symptoms.
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So if we have a patient
that is very symptomatic,
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but their resting echocardiogram
is naturally demonstrating,
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severe enough pathology
to explain their symptoms,
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we exercise them and we see
what happens to their valve disease,
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what happens to their,
peer pressures with exercise.
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Likewise, if
we have patients who have moderate disease
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and we want to see how they're going
to be doing under stress.
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So we have seen many patients at Stony
Brook with much less noses.
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And the question is,
are they going to be able to get pregnant?
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And how well are they going to be doing?
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Do we need to intervene before pregnancy?
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We put those patients on a treadmill
and we can see
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what's going to happen to their peer
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pressure is what is going to happen
to the gradients close to valve.
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And that gives us an indication
in terms of how well they're going
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to be able to tolerate pregnancy
or any other, stressful event.
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That's amazing.
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That definitely is a huge change
from the way it was.
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And I was training also.
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So a lot has happened in the last
10 to 20 years with echo.
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So with such a, comprehensive examination
like that,
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how long would a patient expect
to be on the echo table for your team
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to complete such, such a thorough study?
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So our lab is an accredited lab.
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So we really go by national guidelines,
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and we get pretty much between 45 minutes
to an hour.
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For going to get all that done.
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And I can tell you that we typically do
utilize for, valvular patients.
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We, we do perform all the,
quantification and all the calculations.
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Oftentimes, like I said,
we do add 3D, measurements as well.
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So it takes about an hour to perform
a trans thoracic echo on these patients.
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Trans
echo, which is a whole other modality
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still utilizing echo, but, with,
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with the additional, probe.
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That's extremely helpful, especially
for assessment of the microbiome.
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So we, performed 3D echo with all of our,
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TS and,
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for the mitral valve, really
get the surgical view of the matter valve.
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So we can really look at this.
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The valve the same way that you look
at the vowel in the O.R..
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And, and this way we can really,
look at the pictures together,
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and we can have very meaningful
conversation about the anatomy,
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the pathology,
the hemodynamics, what needs to be done.
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So transfer echo is extremely helpful.
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And, and we use quantification as well.
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When we perform transfer. You know.
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Yeah, I know that,
it has been extremely valuable for,
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us as surgeons to sit with you
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as, cardiologists and, and choreographer
so that, as you said,
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we're looking at the images together
and we're looking at the valve,
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the way that we would see it
in the operating room.
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And that way we can really pin down
what the pathology is.
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And then in the operating room, we can try
to address that pathology specifically.
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And also, in the operating room
for some of our procedures,
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having yourself and members
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of your team present during
the procedure is also very critical.
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And this is especially so
in some of our percutaneous
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therapies, like the,
the mitral valve edge to edge repair.
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So talk to us a little bit about what
that kind of echo work is like
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in the operating room when we're trying
to get a valve percutaneous closed.
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So our doc should take a step back
because before we even
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bring the patient to the hybrid O.R.,
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we have to make a decision
about the timing of intervention.
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So we start by really, assessing
is there a valvular disease?
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What it is, the severity of it,
how it affects the rest of the heart.
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And,
and then make a decision about the timing,
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because we do not want to intervene
too early yet
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we do not want to wait too long before
there is a damage which is irreversible.
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So that's a big part of what we really do.
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And, and this is when we use
all those other tools like strain imaging,
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getting a stress test done
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so we can really look at the patient's
hemodynamics, their exercise tolerance.
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We put it all into that, equation
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and, and have a discussion
typically among all members of the team
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as well as the patient
and their family member.
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So we can all make a decision together
about the best timing.
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So, before we actually bring the patient,
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once we decide that the patient
would benefit
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from intervention, we need to decide
what kind of an intervention.
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And here at Stonybrook,
we have all options available.
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And we're going to hear more
from the surgeons
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and the interventional cardiologist
about the various options.
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But we do have both surgical as well
as non-surgical options for the patients.
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And within each one of them,
we do have multiple different options.
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So we try to make that decision before
we bring the patient for the procedure.
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And we utilize echo.
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We utilize CT.
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It's extremely helpful
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to, reconstruct the heart with,
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the new device or the new valve in place
so we can actually see what it's going to
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look like.
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And based on that,
we can recommend some additional,
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procedures and additional devices
that can be used to really make the,
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procedure
more feasible and safer for the patient.
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So then we can present the patient
with all that information.
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And, and by the time
the patient shows up in the O.R.
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or hybrid O.R., the operator knows exactly
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what is the planned procedure
and have everything available
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in their disposal
to be able to perform that procedure.
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So now that we are in the hybrid O.R..
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So. And actually so I. And.
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Yeah,
before we actually get into the hybrid, or
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are you going to tell us what that's like?
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I just want to emphasize what you said
about the pre procedural planning
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and the exhaustive steps
that are taken to make sure
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that the diagnosis is accurate,
the extent of disease is accurate,
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and that we are very clear
on what pathology needs to be fixed.
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And I think a very important part
of what we offer here at Stony
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Brook is the power
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of the multidisciplinary team,
because, as you said, you know, we,
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the team which involves yourself
and interventional cardiologist
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and surgeons and so on, you know,
we meet regularly to review these patients
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and it's very much,
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a matter of measuring 3 or 4 times
and then cutting wants to make sure
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that when we actually do our procedure,
we do it precisely, and we do it right,
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and we do it. We do it just once. Yes.
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So so I think it is really exciting that
we have all these therapeutic options.
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We have the diagnostic
options, but we also have
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lots of,
therapeutic options for our patients.
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But we do needs to choose the best one,
the optimal one for this specific patient.
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And it is really tailored
to the individual patient.
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And this is why all these Stem
interactions are really, really critical.
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Yep. So now we're in the hybrid
or the hybrid O.R.. Yes.
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And or the final procedure.
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And and in the O.R.,
I were the head of the
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interventional echocardiography,
which is a field within cardiology
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that clearly did not exist
when I was a fellow.
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But,
essentially the way to describe that niche
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is that I'm essentially the eyes
and the GP's of the procedure.
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Yeah.
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So I use, sweetie,
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sometimes with additional eyes,
intra cardiac echo as well.
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And, in which
we utilize those to guide the procedure
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so I can visualize all the wires,
the catheters.
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I look at the valve again,
assess the pathology
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and guide interventional,
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in terms of where to place the device.
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And, and if it's a valve
that is being repaired or replaced,
00:12:53.139 --> 00:12:57.810
then where exactly the,
repair needs to take place.
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You mentioned Tavira.
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You mentioned the magical Calypso
were clip supposed to be, placed.
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And we have the advantage of actually
00:13:08.287 --> 00:13:12.424
assessing the fact of,
let's say, clip before we deployed.
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So that's when I get my images.
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I, do my calculations and measurements
and assess
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the amount of residual,
like if there is any the, the gradients,
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because the valve is the valve
now becoming too tight,
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or do we have the ability
to use more than one clip.
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So again,
this is not something that we can
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we kind of have an idea before we go in.
00:13:41.987 --> 00:13:46.592
But oftentimes
this is the, the fine tuning
00:13:46.592 --> 00:13:50.696
that is being done based on real time
imaging in the hybrid O.R..
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Right.
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Which is critically important
00:13:52.631 --> 00:13:55.734
because without the eyes,
we can't see what we're doing,
00:13:55.734 --> 00:13:57.503
and the procedure
is not getting done properly.
00:13:57.503 --> 00:13:59.071
So it's really important.
00:13:59.071 --> 00:14:03.809
And then once a valve has been
successfully repaired or replaced,
00:14:04.109 --> 00:14:08.180
what kind of surveillance is necessary
after surgery to make sure that
00:14:08.180 --> 00:14:09.748
patients continue to do well?
00:14:11.016 --> 00:14:14.620
So the goal is always for the patient to,
00:14:15.054 --> 00:14:18.490
outlive the device
or the valve, the to put in place.
00:14:18.858 --> 00:14:22.361
So the first thing that we need to do
is establish
00:14:22.361 --> 00:14:24.463
a first baseline for the patient.
00:14:24.463 --> 00:14:29.034
So that's the full echo that we do
just prior to discharge from the hospital.
00:14:29.034 --> 00:14:32.838
And typically the patients
stay here overnight just to monitor them.
00:14:32.838 --> 00:14:35.774
So before they go home
they get a full echocardiogram.
00:14:35.774 --> 00:14:39.078
We assess not just a valve
that was repaired or replaced,
00:14:39.078 --> 00:14:42.648
but we really look at everything
because affecting one
00:14:42.648 --> 00:14:46.218
valve or treating one
valve can affect the rest of the heart.
00:14:46.619 --> 00:14:50.723
So we reassess their LV function
and the RV function,
00:14:50.723 --> 00:14:54.760
and we measure the pressures
and we assess for any
00:14:54.760 --> 00:14:57.763
residual leak, any stenosis.
00:14:57.930 --> 00:15:01.166
And this is now becoming the new baseline
for that patient.
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And most of our patients
stay within the system.
00:15:04.403 --> 00:15:07.139
So they come back to us for follow up
echos.
00:15:07.139 --> 00:15:09.241
And we look for progression.
00:15:09.241 --> 00:15:12.945
We also need to keep in mind
that with the percutaneous
00:15:12.945 --> 00:15:17.182
or transcatheter procedures,
we typically address one valve at a time.
00:15:17.182 --> 00:15:18.717
We don't really it's not like
00:15:18.717 --> 00:15:22.021
an open heart surgery
that we fixed everything that is abnormal.
00:15:22.588 --> 00:15:25.024
We make a decision about
00:15:25.024 --> 00:15:29.895
what is really the most, critical valve
that needs to be addressed.
00:15:29.895 --> 00:15:30.829
Forest.
00:15:30.829 --> 00:15:35.100
We addressed that with the hope that may
be for going to address one valve.
00:15:35.701 --> 00:15:38.504
The other valves may improve in function.
00:15:38.504 --> 00:15:40.873
So we do need to bring those patients
back.
00:15:40.873 --> 00:15:45.844
And we look at the other valves
and and look for either
00:15:45.844 --> 00:15:49.415
progression or improvement
in the function of those valves.
00:15:49.815 --> 00:15:53.052
And we also look for progression
or deterioration of the new valve
00:15:53.052 --> 00:15:56.588
that we put in place,
or the new device that we put in place.
00:15:57.089 --> 00:15:59.591
The follow up is extremely,
extremely important.
00:15:59.591 --> 00:16:03.195
Is there anything else that you'd like to
add before we wrap up before we finish?
00:16:03.195 --> 00:16:03.929
Yeah.
00:16:03.929 --> 00:16:07.766
So we typically talk about people
that have valvular
00:16:07.766 --> 00:16:10.769
heart disease and how we address them
and how we diagnosed in.
00:16:10.769 --> 00:16:15.474
But I really want to emphasize
that it is also very important
00:16:15.741 --> 00:16:19.378
to at least
get an echocardiogram on people
00:16:19.378 --> 00:16:22.448
that are at risk
for developing valve heart disease.
00:16:23.082 --> 00:16:26.685
And very important,
those would be either people
00:16:26.685 --> 00:16:30.389
who have family members who were diagnosed
with level of heart disease.
00:16:30.389 --> 00:16:32.925
The most common one would
be bicuspid aortic valve.
00:16:33.892 --> 00:16:35.761
Also, people that
00:16:35.761 --> 00:16:40.733
have none valvular heart disease
like cardiomyopathy is ischemia can be
00:16:40.966 --> 00:16:45.637
cardiomyopathy is can have
secondary effects on on the valves.
00:16:46.405 --> 00:16:50.609
Also patients who have other systemic
systemic disorders like,
00:16:51.677 --> 00:16:54.747
hematological disorders,
those patients are at risk
00:16:54.747 --> 00:16:56.115
for developing valvular heart disease.
00:16:56.115 --> 00:16:59.618
So it is really important,
especially for primary care physicians,
00:17:00.152 --> 00:17:06.158
to, really think about those people and,
and refer them to us
00:17:06.158 --> 00:17:09.161
whenever they're at risk
for developing valve.
00:17:09.361 --> 00:17:13.432
What are the triggers
in terms of age of patient,
00:17:13.432 --> 00:17:16.435
for example,
that such a referral should take place.
00:17:16.869 --> 00:17:22.875
So for, family members,
if you have, a patient at any age,
00:17:23.375 --> 00:17:27.646
that's a family member,
first degree family member was diagnosed
00:17:27.646 --> 00:17:32.451
with either congenital heart disease
or with a known valvular.
00:17:32.451 --> 00:17:35.120
How this is like a make us video
tick valve.
00:17:35.120 --> 00:17:38.223
You really want to gather
all the first degree
00:17:38.223 --> 00:17:41.527
relatives
and send them for one echocardiogram?
00:17:41.627 --> 00:17:46.331
And hopefully that would be sufficient
to basically exclude the presence
00:17:46.331 --> 00:17:51.336
of any other congenital anomalies
or the presence of a bicuspid valve.
00:17:51.537 --> 00:17:54.239
And that would be
the first and last echo for them.
00:17:54.239 --> 00:17:57.910
But if you do find it, you really want to
then follow them up.
00:17:57.910 --> 00:17:59.611
Hopefully you would,
00:18:00.746 --> 00:18:01.680
diagnose them
00:18:01.680 --> 00:18:04.683
early
enough so they would have no symptoms.
00:18:04.850 --> 00:18:09.188
And, and maybe we can intervene before
there is any deterioration
00:18:09.188 --> 00:18:10.589
or any symptoms development.
00:18:10.589 --> 00:18:13.192
So that's a very valuable,
piece of information.
00:18:13.192 --> 00:18:17.429
And I think, something
that many people don't consider
00:18:17.729 --> 00:18:22.067
the importance of screening for this
where there are elevated risk factors.
00:18:22.067 --> 00:18:24.403
So thank you very much for that.
00:18:24.403 --> 00:18:26.105
Absolutely.
00:18:26.105 --> 00:18:27.806
We'll be right back with doctors price.
00:18:27.806 --> 00:18:30.776
And you mean to continue our conversation.
00:18:38.984 --> 00:18:40.285
Welcome back everyone.
00:18:40.285 --> 00:18:43.255
Now that we understand
how valve disease is diagnosed.
00:18:43.255 --> 00:18:45.324
Let's turn to how we fix it.
00:18:45.324 --> 00:18:49.194
And for this we are going to speak
with our surgical experts.
00:18:49.595 --> 00:18:52.631
We're fortunate to have with us today
Doctor Jonathan Pryce,
00:18:52.631 --> 00:18:55.634
who is the co-director of the center here
at Stony Brook.
00:18:55.734 --> 00:18:59.605
And Doctor Monoamine, who is the director
of Adult congenital surgery.
00:18:59.905 --> 00:19:01.406
So, Doctor Pryce, let's start with you.
00:19:01.406 --> 00:19:06.145
We heard from Doctor Kort earlier
about how we diagnose valve disease.
00:19:06.311 --> 00:19:08.914
Can you speak a little bit
about how we fix it?
00:19:08.914 --> 00:19:10.048
Sure. Surgically.
00:19:10.048 --> 00:19:14.286
So I think once you have a valve problem
diagnosed by your doctor,
00:19:14.286 --> 00:19:17.689
it's important to know that there are
two broadways to address it.
00:19:17.890 --> 00:19:19.491
One is to repair the valve.
00:19:19.491 --> 00:19:20.926
One is to replace the valve.
00:19:20.926 --> 00:19:22.361
I think the most important thing
to remember
00:19:22.361 --> 00:19:24.563
for the patient
is that at the end of the day,
00:19:24.563 --> 00:19:28.500
whatever you have to have, it's
to make your valve work
00:19:28.667 --> 00:19:31.036
and to make your heart pump better
and more efficiently.
00:19:31.036 --> 00:19:34.540
So both modalities are options,
but it's based on a discussion with you
00:19:34.540 --> 00:19:37.109
and your doctor
about which one is best for you.
00:19:37.109 --> 00:19:38.110
Okay, that's fair enough.
00:19:38.110 --> 00:19:45.551
So, doctor, you mean tell us
why would somebody prefer or or,
00:19:45.784 --> 00:19:48.754
would a doctor prefer to recommend
00:19:48.754 --> 00:19:52.824
valve repair surgery
rather than valve replacement?
00:19:52.824 --> 00:19:55.194
Are the two treatment options equivalent,
00:19:55.194 --> 00:19:58.197
or are there advantages
one over the other?
00:19:58.463 --> 00:20:02.201
So for for certain specific patients,
there is an advantage
00:20:02.201 --> 00:20:06.939
of repairing the valve or what we call
preserving the native valve
00:20:07.806 --> 00:20:12.511
compared to replacing it
with a, either a biologic prosthesis,
00:20:12.844 --> 00:20:17.649
or a animal prosthesis,
or a mechanical properties or metallic.
00:20:18.417 --> 00:20:21.119
If patients receive a metallic prosthesis,
00:20:21.119 --> 00:20:24.189
they have to be on blood thinners
the rest of their life.
00:20:24.656 --> 00:20:28.493
For those who have a biologic prosthesis,
will have, a certain
00:20:28.493 --> 00:20:32.364
lifespan of that prosthesis and might need
re intervention down the line.
00:20:32.764 --> 00:20:36.301
For certain patients
with certain problems,
00:20:36.301 --> 00:20:38.904
we can preserve their native valve.
00:20:38.904 --> 00:20:44.042
And by preserving it, they that valve
could last much longer than animal valve.
00:20:44.309 --> 00:20:48.146
And it doesn't need blood thinners
like a metallic or mechanical valve would.
00:20:48.146 --> 00:20:51.149
So that's where the bigger advantage of
00:20:51.817 --> 00:20:55.621
preserving the native valve or repairing
it comes compared to replacement.
00:20:55.954 --> 00:20:57.456
Okay. So that's very helpful.
00:20:57.456 --> 00:21:01.994
So then Doctor Price, tell us
what are some of the diagnoses that would
00:21:01.994 --> 00:21:05.030
require valve replacement
00:21:05.030 --> 00:21:08.634
rather than even consideration
for valve repair?
00:21:09.001 --> 00:21:12.804
So again in general terms the valve cannot
00:21:12.804 --> 00:21:15.774
be repaired once the tissue of the valve
has been destroyed.
00:21:16.475 --> 00:21:20.279
And in general, for the optic valve,
that would be aortic stenosis.
00:21:20.279 --> 00:21:21.413
When the valve has a very,
00:21:21.413 --> 00:21:25.150
it's heavily calcified
and deposited with sclerotic tissue.
00:21:25.284 --> 00:21:29.087
And the valve is no longer opens properly
in those cases, repairing
00:21:29.087 --> 00:21:30.722
the valve is not possible.
00:21:30.722 --> 00:21:35.093
Similar for the mitral valve
when you have mitral valve, stenosis,
00:21:35.227 --> 00:21:38.363
not every case, but
in most cases of mitral valve stenosis,
00:21:38.363 --> 00:21:41.633
when the leaflets are, heavily
calcified and restricted
00:21:41.633 --> 00:21:45.771
and not moving properly,
those leaflets are not repairable anymore.
00:21:46.772 --> 00:21:47.773
Doctor, you
00:21:47.773 --> 00:21:51.410
mentioned, mechanical prostheses
00:21:51.743 --> 00:21:54.746
and, biological prostheses.
00:21:55.013 --> 00:22:00.752
So can you, make a recommendation on
which one might be better for a patient?
00:22:00.752 --> 00:22:06.658
Like how how does a surgeon decide
which prosthesis to offer a patient?
00:22:06.658 --> 00:22:10.362
And how should a patient think about it
and decide which one to accept?
00:22:10.529 --> 00:22:11.697
That's an excellent question.
00:22:11.697 --> 00:22:14.700
And it's really one for the ages,
because I think that is one of the most
00:22:14.700 --> 00:22:18.937
heavily debated, topics
when physicians speak to each other
00:22:19.137 --> 00:22:22.974
and when physicians speak to patients
and when patients speak to patients.
00:22:23.375 --> 00:22:25.944
And the reason is
because everyone will have an opinion,
00:22:25.944 --> 00:22:29.548
and there is some good data
to guide our recommendations,
00:22:29.548 --> 00:22:32.751
but at the same time, a valve replacement
00:22:33.018 --> 00:22:36.154
and the type of value use really
is dependent on the patient,
00:22:36.521 --> 00:22:41.193
their lifestyle, comorbidities and,
and a lot of other factors.
00:22:41.193 --> 00:22:44.963
So for instance, as doctor,
you mean, I mentioned earlier
00:22:44.963 --> 00:22:49.000
that a metallic valve,
or a mechanical prosthesis
00:22:49.267 --> 00:22:52.237
may not be something
someone is, is interested in
00:22:52.237 --> 00:22:54.806
because they have to be on blood thinners
for the rest of their life.
00:22:54.806 --> 00:23:00.145
However, a mechanical valve has
a, longevity and a likelihood of staying
00:23:00.145 --> 00:23:05.150
patent and lasting and working much longer
than any other type of prosthesis.
00:23:05.150 --> 00:23:06.385
Like how much longer?
00:23:06.385 --> 00:23:08.453
Well, decades.
00:23:08.453 --> 00:23:09.888
Longer, potentially.
00:23:09.888 --> 00:23:13.925
So the the question then becomes,
you know, for a very young patient
00:23:14.126 --> 00:23:17.829
who might need a valve replacement,
is a mechanical valve a viable option?
00:23:18.397 --> 00:23:19.231
And the answer is yes.
00:23:19.231 --> 00:23:20.565
It's a it is a viable option
00:23:20.565 --> 00:23:24.069
because it's still a very good operation
that gives very good results.
00:23:24.302 --> 00:23:28.540
Now, the counter side to that is
that you do have to be on blood thinners
00:23:28.540 --> 00:23:29.708
and not just any blood.
00:23:29.708 --> 00:23:32.611
And as of right now,
the only button that's FDA approved
00:23:32.611 --> 00:23:35.447
to be used with a mechanical
valve is warfarin.
00:23:35.447 --> 00:23:39.317
And as most people know, warfarin is labor
intensive and time
00:23:39.317 --> 00:23:41.186
consuming and energy consuming.
00:23:41.186 --> 00:23:44.523
It takes a lot of effort on the
part of the patient and the physician
00:23:44.523 --> 00:23:48.260
to make sure that it's being used properly
and being measured, make sure that it's,
00:23:49.294 --> 00:23:52.330
it's it's being,
effectively use of the patient's blood
00:23:52.330 --> 00:23:55.333
thinner levels are appropriate
for the type of valve.
00:23:55.734 --> 00:23:58.236
That's one thing that you cannot skimp on.
00:23:58.236 --> 00:24:02.274
If you have a mechanical valve,
you need to be on your warfarin
00:24:02.274 --> 00:24:03.642
and you can't take it lightly.
00:24:03.642 --> 00:24:05.610
You have to be checking regularly.
00:24:05.610 --> 00:24:06.878
So does you mean.
00:24:06.878 --> 00:24:10.248
You know, Doctor Price
just said that for a young patient,
00:24:10.482 --> 00:24:16.054
a mechanical valve might be a good option
because it might last for many, many,
00:24:16.054 --> 00:24:19.391
many decades and therefore not necessarily
need to be replaced.
00:24:19.825 --> 00:24:23.128
So for a young patient
00:24:23.662 --> 00:24:27.766
who has a valve abnormality
and is going to need surgery.
00:24:28.133 --> 00:24:31.970
Can you speak a little bit
about the valve repair options
00:24:31.970 --> 00:24:33.572
that might be possible
00:24:33.572 --> 00:24:36.508
that might obviate the need
for a mechanical valve,
00:24:36.508 --> 00:24:40.312
and therefore the need for lifelong
anticoagulation for this young patient
00:24:40.312 --> 00:24:42.781
for many, many, many years. Absolutely.
00:24:42.781 --> 00:24:46.585
I think before going into valve repair,
it's very important to point that,
00:24:46.885 --> 00:24:52.657
as Doctor Price mentioned, every patient
would benefit from different surgeries.
00:24:52.691 --> 00:24:54.726
Some patients have more than one option.
00:24:54.726 --> 00:24:56.695
And we should discuss all options.
00:24:56.695 --> 00:24:59.931
Some of
and then depending on each patient,
00:24:59.931 --> 00:25:02.234
their best option might be different.
00:25:02.234 --> 00:25:05.337
Some patients where if the valve
is repairable, we can offer repair.
00:25:05.337 --> 00:25:09.007
Some patients, especially young ones
who need the replacement.
00:25:09.007 --> 00:25:11.276
Mechanical prostheses are a great option.
00:25:11.276 --> 00:25:13.311
Their logic prostheses
have their limitations.
00:25:14.646 --> 00:25:16.314
If a patient is
00:25:16.314 --> 00:25:19.885
found to be a candidate
for valve preservation or valve repair,
00:25:20.151 --> 00:25:25.156
then it is possible for both aortic
valve and mitral valve disease.
00:25:25.156 --> 00:25:29.995
It's more commonly done for mitral valve
because it's a more common problem
00:25:29.995 --> 00:25:30.629
that we see,
00:25:30.629 --> 00:25:35.066
and it's been there for much longer
time compared to the aortic valve repair.
00:25:35.333 --> 00:25:38.436
But aortic valve repair is also known,
and it's studied
00:25:38.436 --> 00:25:41.673
and has good, long term outcomes.
00:25:41.773 --> 00:25:44.743
We have up to ten years
follow up for the valve repair.
00:25:44.743 --> 00:25:47.746
And usually younger patients would
00:25:47.779 --> 00:25:51.316
with aortic regurgitation
would benefit from it.
00:25:51.683 --> 00:25:55.620
But there are certain strict criteria
for repair,
00:25:55.620 --> 00:25:59.124
which makes some patients,
unfortunately not candidates for it.
00:25:59.124 --> 00:26:02.928
And then we'd have to look into types,
other types of replacements.
00:26:04.162 --> 00:26:06.431
I say okay fair enough.
00:26:06.431 --> 00:26:10.068
Now what about we've heard a little bit,
00:26:10.535 --> 00:26:14.472
about, valve replacement.
00:26:14.639 --> 00:26:18.577
What about the surgical techniques
that one would use
00:26:18.577 --> 00:26:21.880
to achieve either replacement or repair?
00:26:22.213 --> 00:26:23.748
You know what?
00:26:23.748 --> 00:26:28.853
What would, a referring doctor,
be thinking about
00:26:28.853 --> 00:26:33.825
when they're sending their patients,
to us to be, treated.
00:26:34.392 --> 00:26:37.762
So I think, again, it depends
on, the patient.
00:26:37.762 --> 00:26:39.564
It depends on what comorbidities
they have,
00:26:39.564 --> 00:26:41.967
and it depends on what
we're trying to achieve.
00:26:41.967 --> 00:26:45.503
With the,
with the valve replacement, or repair.
00:26:45.770 --> 00:26:47.606
You know, we have many options.
00:26:47.606 --> 00:26:49.574
Open heart surgery is an option.
00:26:49.574 --> 00:26:55.180
Open heart surgery can be done,
with a, not I mean, a full incision.
00:26:55.180 --> 00:26:58.617
It can be done with a mini anatomy
or a, basically a mini incision.
00:26:58.917 --> 00:27:01.586
It can be done through a thoracotomy,
through the ribs.
00:27:01.586 --> 00:27:05.757
So there are different ways to access,
the heart and to get a valve implanted.
00:27:05.757 --> 00:27:08.526
It doesn't always have to be
the traditional way that people most,
00:27:08.526 --> 00:27:10.829
think about when they think of open heart
surgery.
00:27:10.829 --> 00:27:14.966
And again,
depending on what the patient needs,
00:27:14.966 --> 00:27:18.937
many patients would be in, I would say
a candidate for different access points.
00:27:21.406 --> 00:27:22.641
Which is good because as you
00:27:22.641 --> 00:27:26.511
know, the world is moving towards
minimally invasive interventions.
00:27:26.511 --> 00:27:32.017
And, obviously,
if we can minimize, the invasiveness
00:27:32.017 --> 00:27:35.020
of what we're doing to our patients,
we can hopefully accelerate recovery.
00:27:35.120 --> 00:27:36.921
So, doctor,
you mean, can you speak a little bit
00:27:36.921 --> 00:27:41.226
about some of the very, very minimally
invasive options that are available,
00:27:41.493 --> 00:27:46.131
including things like trans femoral
00:27:46.131 --> 00:27:53.238
percutaneous options for for,
the aortic valve,
00:27:53.238 --> 00:27:56.808
the mitral valve and actually,
no, the tricuspid valve.
00:27:57.475 --> 00:28:02.213
So the percutaneous options,
for different valves
00:28:02.213 --> 00:28:08.319
have gone through different, generations
and advancements and the latest form.
00:28:08.319 --> 00:28:12.657
Now, we know that the treatment
for aortic valve disease,
00:28:12.724 --> 00:28:16.494
that is the, tavor, which is a cutaneous
00:28:16.695 --> 00:28:20.765
that has come a long way and it's become
one of the most common procedures we do,
00:28:21.266 --> 00:28:24.302
along with our, colleagues
from Intervention Cardiology.
00:28:24.836 --> 00:28:27.639
That one is used very commonly for
00:28:27.639 --> 00:28:31.209
to treat aortic valve stenosis
where valve is not repairable.
00:28:31.643 --> 00:28:36.114
And it's a, so it's a procedure
performed through the groin
00:28:36.347 --> 00:28:40.652
with catheters and where the aortic valve
is replaced for the mitral valve.
00:28:40.885 --> 00:28:45.790
There is a mitraclip,
which is another procedure we perform.
00:28:45.790 --> 00:28:50.562
And tricuspid valve, tricuspid clip
where both valves are not replaced,
00:28:50.562 --> 00:28:54.933
but rather, repaired or preserved,
00:28:54.999 --> 00:28:58.570
just in a way to lower the amount
00:28:58.570 --> 00:29:02.741
of regurgitation or backwards leak
that those valve are causing
00:29:02.907 --> 00:29:06.878
to help the patient feel
better and, recover from their disease.
00:29:07.946 --> 00:29:10.148
So, you know, if if I was a patient,
00:29:10.148 --> 00:29:14.452
I would want the most minimally invasive
option.
00:29:14.786 --> 00:29:18.389
So, Doctor Price, tell me, why not offer
00:29:18.690 --> 00:29:22.460
all patients percutaneous options
like the tava
00:29:22.460 --> 00:29:27.565
or the percutaneous,
yeah, valve, mitral valve.
00:29:27.565 --> 00:29:29.367
And tricuspid valve repair is a duct.
00:29:29.367 --> 00:29:34.806
You mean, just describe like,
what might be exclusion criteria
00:29:34.806 --> 00:29:38.843
for not having this minimally
invasive option, because if you can avoid
00:29:38.843 --> 00:29:41.946
an incision in open heart surgery,
then why not go for it?
00:29:42.614 --> 00:29:43.815
Again, an excellent question.
00:29:43.815 --> 00:29:46.918
Because, you know, that is the thing
that people ask us the most.
00:29:47.018 --> 00:29:51.055
Why would I ever want surgery if I could
just have a puncture hole in my groin?
00:29:51.356 --> 00:29:52.157
And the fact of the matter
00:29:52.157 --> 00:29:55.760
is that not every minimally invasive
option is good for every patient.
00:29:56.094 --> 00:29:58.897
Now, us specifically
of what kind of criteria do we look for?
00:29:58.897 --> 00:30:01.699
And it depends on the valves.
So let's start with the aortic valve.
00:30:01.699 --> 00:30:04.135
When you're talking about a Nordic valve
replacement,
00:30:04.135 --> 00:30:07.272
let's say open surgery versus a tava,
which is basically
00:30:07.272 --> 00:30:10.275
a stent with a valve implanted in it
that is inserted through the groin.
00:30:10.575 --> 00:30:14.245
They're both options to replace,
astronautics out
00:30:14.279 --> 00:30:16.080
for the pathology of aortic stenosis.
00:30:16.080 --> 00:30:20.218
However, there are certain pathologies or,
you know, extents of aortic stenosis
00:30:20.218 --> 00:30:21.486
and calcification
00:30:21.486 --> 00:30:25.790
and valve morphology that makes the tava,
less likely to function properly.
00:30:25.790 --> 00:30:29.661
So, for instance, a very heavily
calcified aortic valve, or when the,
00:30:29.661 --> 00:30:33.298
calcium extends off the valve
but down into the left ventricle.
00:30:33.498 --> 00:30:38.469
Those are things that make the
the risk of injury to the heart and or
00:30:38.469 --> 00:30:42.574
a, an improper seal of the valve such
that there is para valvular regurgitation.
00:30:42.574 --> 00:30:43.908
Much more likely.
00:30:43.908 --> 00:30:45.877
And if you're talking
about a young patient
00:30:45.877 --> 00:30:49.047
who is coming to you
for a perfect outcome,
00:30:49.447 --> 00:30:53.918
to trade one pathology for another,
and a young patient seems to be,
00:30:54.219 --> 00:30:58.289
not imperfect and defined young
00:30:58.590 --> 00:31:02.093
because, you know, like 60 is the new 50,
if you will.
00:31:02.093 --> 00:31:03.595
So what's young these days?
00:31:03.595 --> 00:31:08.766
Well, so again, it's it's interesting
because we do open heart surgery
00:31:09.033 --> 00:31:10.301
on people in their 80s.
00:31:10.301 --> 00:31:13.204
We also do taggers on people in their 50s.
00:31:13.204 --> 00:31:17.675
And it really depends on the patient
and their risk profile for surgery
00:31:17.876 --> 00:31:20.845
and whether or not we think
that they will benefit from the surgery.
00:31:20.845 --> 00:31:25.383
Now, in planning for this, you know,
we have a lot more long
00:31:25.383 --> 00:31:28.386
term data with surgical valves
than we do with the tava valves.
00:31:28.653 --> 00:31:31.990
So, you know, the Tava procedure has only
been around for about 20 years now.
00:31:32.223 --> 00:31:35.526
And, you know, being performed here
at this institution in the northeast
00:31:35.526 --> 00:31:38.863
and most of the hospitals in the area for,
you know, a little over a decade.
00:31:39.163 --> 00:31:43.234
So the fact of the matter is, the long
term data really isn't there to support,
00:31:43.434 --> 00:31:46.671
you know, do you have 10 or 20 years
of longevity out of these valves?
00:31:47.605 --> 00:31:50.642
Now, we do know,
the surgically placed valves,
00:31:50.642 --> 00:31:53.311
especially the bio prosthetic valves,
do not last forever.
00:31:53.311 --> 00:31:55.947
They also have a shelf life,
but we do at least have the data
00:31:55.947 --> 00:31:58.316
to report that with the towers,
we really don't.
00:31:58.316 --> 00:32:01.953
So for a young patient
who were looking for a certain outcome,
00:32:02.253 --> 00:32:05.623
we would likely offer them
surgery over a tava
00:32:05.623 --> 00:32:08.826
because the longevity is not,
not quite clear.
00:32:09.260 --> 00:32:12.263
That being said, certain
other types of valve pathologies,
00:32:12.263 --> 00:32:15.767
like people who have bicuspid valves,
a bicuspid valve causes
00:32:15.767 --> 00:32:18.770
an abnormal geometric
shape of the optic root.
00:32:18.803 --> 00:32:22.373
And when you place a perfectly rounded
aortic valve stent
00:32:22.373 --> 00:32:25.076
in an abnormally shaped root
or an oblong root,
00:32:25.076 --> 00:32:27.478
there is a higher chance
that you will have a parallel leak,
00:32:27.478 --> 00:32:30.815
which again, may not be,
ideal for certain patient.
00:32:31.549 --> 00:32:33.952
So those are things
we all take into consideration.
00:32:33.952 --> 00:32:36.354
When we discuss with the patient
what would be better for them
00:32:36.354 --> 00:32:38.156
because obviously no one wants surgery.
00:32:38.156 --> 00:32:39.724
But at the end of the day,
that actually be the
00:32:39.724 --> 00:32:42.727
maybe the thing that saves their life
and is really the best thing for them.
00:32:43.194 --> 00:32:47.598
And you know, doctor,
you mean so as, as we all know,
00:32:47.865 --> 00:32:50.768
in the early days of the percutaneous
valve therapy,
00:32:50.768 --> 00:32:54.238
especially TAVR,
there was a lot of enthusiasm.
00:32:54.238 --> 00:32:59.677
There were, low risk trials and a lot of
low risk younger patients had tavaris.
00:33:00.044 --> 00:33:03.614
And as as you gentlemen know,
we have seen,
00:33:03.681 --> 00:33:06.884
a spike in patients
00:33:06.884 --> 00:33:11.155
with complications of their tavaris
coming now for open heart surgery.
00:33:11.155 --> 00:33:14.659
Can you speak a little bit
about some of the complexity of trying to
00:33:15.026 --> 00:33:18.196
to deal with a patient with a problematic
00:33:18.463 --> 00:33:21.632
TAVR valve who now needs surgery?
00:33:22.667 --> 00:33:25.103
So, yeah, I
00:33:25.103 --> 00:33:28.573
having
a previous any manipulation to the valve,
00:33:28.740 --> 00:33:32.510
especially with having a new replaced
valve in
00:33:32.944 --> 00:33:35.580
would make the surgery
00:33:35.580 --> 00:33:38.583
for replacement or re replacement
more complicated.
00:33:39.017 --> 00:33:40.184
It's always the case.
00:33:40.184 --> 00:33:42.954
Second time
operation is always more complicated.
00:33:42.954 --> 00:33:46.190
Now we have a lot more experience in
00:33:46.657 --> 00:33:49.627
doing second line operations
00:33:49.627 --> 00:33:52.563
following a previous surgical replacement.
00:33:52.563 --> 00:33:57.235
But as we're gaining more exposure
and experience with the transcatheter,
00:33:57.568 --> 00:34:01.439
we're realizing that it does
cause little more,
00:34:01.873 --> 00:34:06.010
maybe damage to the aorta
around it, to the aortic root.
00:34:06.010 --> 00:34:10.915
And sometimes we find ourselves having
to repair the aorta around the tava,
00:34:11.282 --> 00:34:15.853
valve before we implant the new aortic
valve prosthesis surgically.
00:34:16.120 --> 00:34:19.157
So there's no doubt
that makes it more complicated.
00:34:19.157 --> 00:34:21.225
But it's something
that we've gained experience
00:34:21.225 --> 00:34:25.563
in, and we're very comfortable offering to
our patients if the procedure they need.
00:34:27.465 --> 00:34:28.299
All right.
00:34:28.299 --> 00:34:30.535
So we're going to be winding up soon.
00:34:30.535 --> 00:34:36.841
So, do you have any final thoughts
or, comments that you'd like to make
00:34:36.841 --> 00:34:42.380
about the spectrum of valve care
that we can offer here at Stony Brook?
00:34:42.380 --> 00:34:43.915
And we've heard a little bit about,
00:34:43.915 --> 00:34:48.152
surgery and incisions
and percutaneous options.
00:34:48.586 --> 00:34:53.391
I will just say that what we also have
is an excellent multidisciplinary team
00:34:53.391 --> 00:34:56.594
that we can sit with to discuss complex
patients.
00:34:57.395 --> 00:35:00.865
Anything else that you'd like to highlight
about the services that we offer you?
00:35:00.932 --> 00:35:01.466
Absolutely.
00:35:01.466 --> 00:35:04.635
So I think that's a great point
to bring up the multidisciplinary team,
00:35:04.635 --> 00:35:05.803
because at the end of the day,
00:35:05.803 --> 00:35:09.073
I think the overarching
theme of this entire talk is that
00:35:09.273 --> 00:35:12.210
there are a lot of different options
for valve intervention,
00:35:12.210 --> 00:35:15.746
whether it be a repair or replacement,
and every patient
00:35:15.746 --> 00:35:19.283
deserves an in-depth conversation
to see what is right for them.
00:35:19.584 --> 00:35:22.386
And it's important to know
that that decision is not made
00:35:22.386 --> 00:35:25.389
unilaterally by the surgeon
or a cardiologist.
00:35:25.456 --> 00:35:27.592
Or a referring doctor.
00:35:27.592 --> 00:35:30.995
This is really a conversation
that happens with many, many physicians
00:35:30.995 --> 00:35:34.165
who are each giving their unique expertise
and insight
00:35:34.298 --> 00:35:36.868
to make sure
that no stone is left unturned
00:35:36.868 --> 00:35:39.937
and the patient is really being evaluated
for every single option.
00:35:40.171 --> 00:35:43.107
And at the end of the day, when there are
multiple options and the patient has
00:35:43.107 --> 00:35:46.110
all of the data and all of the information
available to them,
00:35:46.277 --> 00:35:48.279
they can choose
what they think is best for them.
00:35:49.614 --> 00:35:50.114
Right.
00:35:50.114 --> 00:35:54.185
And I think being able to offer patients
choice is important.
00:35:54.385 --> 00:35:56.154
Sometimes too much choice gets confusing.
00:35:56.154 --> 00:35:59.524
So I think we do need to be able
to at least give them some structure
00:35:59.524 --> 00:36:02.527
within which to make decisions.
00:36:02.693 --> 00:36:05.263
So, on the heels of, of,
00:36:05.263 --> 00:36:08.499
of talking
about multidisciplinary decision
00:36:08.499 --> 00:36:12.904
making and selection, perhaps, doctor,
you mean we could end with you
00:36:12.937 --> 00:36:18.442
just describing a little bit about one of,
the more complex decision
00:36:18.442 --> 00:36:22.180
making options for patients,
which is the introduction of something
00:36:22.180 --> 00:36:23.381
called the RA procedure.
00:36:23.381 --> 00:36:24.882
Tell us a little bit about it
00:36:24.882 --> 00:36:29.020
and why a patient might be a candidate
for this kind of valve surgery.
00:36:29.554 --> 00:36:35.193
So the Ross procedure, is a procedure
that was initially performed
00:36:35.193 --> 00:36:39.263
and invented for congenital aortic
valve disease
00:36:39.263 --> 00:36:43.201
or it happened in neonates or kids
with aortic valve disease
00:36:43.201 --> 00:36:46.437
where they cannot fit in a prosthesis
00:36:46.437 --> 00:36:49.540
that is,
either the metallic or the, the biologic.
00:36:49.774 --> 00:36:55.346
So, it's a more complicated procedure
where the pulmonary valve or the,
00:36:56.847 --> 00:36:58.482
one of the other valves in the heart
00:36:58.482 --> 00:37:03.120
is moved to the aortic position
to replace the aortic valve.
00:37:03.120 --> 00:37:07.525
And in kids it was shown to work,
exactly like an aortic valve.
00:37:07.525 --> 00:37:10.528
And it grew with these patients,
to adulthood.
00:37:10.795 --> 00:37:13.764
So that had been,
00:37:14.765 --> 00:37:16.767
applied to adults with aortic
00:37:16.767 --> 00:37:20.104
valve disease,
especially those in the younger age group.
00:37:20.104 --> 00:37:24.508
So in fact, it's actually considered
in the American College of Cardiology
00:37:24.508 --> 00:37:28.446
and the American Heart Association
as the procedure as a possible option
00:37:28.446 --> 00:37:31.782
for patients who are younger than 50
to 55 years of age.
00:37:32.450 --> 00:37:35.386
It has the benefits of,
00:37:35.386 --> 00:37:39.357
not having a metallic prostheses
or mechanical.
00:37:39.357 --> 00:37:41.225
So no anticoagulation.
00:37:41.225 --> 00:37:45.229
It certainly last much longer
than a aortic valve.
00:37:45.296 --> 00:37:49.433
That is, bioprocess or biologic
or animal based prostheses.
00:37:49.834 --> 00:37:53.671
The, the only thing is
that it's a more complicated procedure,
00:37:53.671 --> 00:37:57.708
so it cannot be offered,
in all institutions, only
00:37:58.676 --> 00:38:01.679
institutions
with good experience, with it.
00:38:01.946 --> 00:38:06.951
So we're, you know, very proud to be able
to offer this here at Stony Brook.
00:38:07.218 --> 00:38:12.790
And, it's definitely more complicated
to decide on doing this procedure
00:38:12.790 --> 00:38:16.160
and the technicality of the procedure
is more complex
00:38:16.160 --> 00:38:20.364
than in a other,
aortic valve replacement, but it's it's
00:38:20.364 --> 00:38:23.501
very well described, and it's been there
for more than 30 years now.
00:38:25.236 --> 00:38:29.006
But yet it adds to the complexity
and especially as, as Doctor
00:38:29.006 --> 00:38:32.943
Price was saying earlier that the age
group plays a major role in deciding which
00:38:33.411 --> 00:38:36.414
which prostheses or which choice to
to make.
00:38:36.781 --> 00:38:39.817
The guidelines
do help us by saying that if you're
00:38:39.817 --> 00:38:42.853
less than 65, you should have
00:38:42.853 --> 00:38:45.990
the surgery considered, even though
travel might still be an option.
00:38:45.990 --> 00:38:50.394
But as you move further younger than 65,
00:38:50.394 --> 00:38:54.465
as you get closer to the 50s
or even the younger than 50, that's when,
00:38:55.099 --> 00:38:57.668
Ross versus mechanical,
00:38:57.668 --> 00:39:01.439
possibly biologic becomes
more of a conversation to have.
00:39:01.906 --> 00:39:04.175
Okay. All right. That's very helpful.
00:39:04.175 --> 00:39:06.844
And that's all the time we have today.
00:39:06.844 --> 00:39:09.613
Thank you very much to all our panelists.
00:39:09.613 --> 00:39:12.616
And thank you to all our listeners
and viewers.
00:39:13.050 --> 00:39:16.354
As we've heard, Stony Brook Medicine's
Heart Institute offers
00:39:16.354 --> 00:39:19.357
the full range of treatment options
for heart valve disease,
00:39:19.590 --> 00:39:23.127
and we prioritize repairing native valves
where possible
00:39:23.361 --> 00:39:26.464
to confer the greatest long term
benefit to our patients.
00:39:27.064 --> 00:39:30.968
Our outstanding multidisciplinary team
will care for you or your loved one
00:39:30.968 --> 00:39:35.339
with valve disease from diagnosis
to discharge, and provide state of the art
00:39:35.339 --> 00:39:38.442
treatment to get you back on your feet
in a timely fashion.
00:39:39.276 --> 00:39:41.779
For evaluation by one of our team, please
00:39:41.779 --> 00:39:46.016
call (631) 444-1820.
00:39:46.617 --> 00:39:49.920
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helpful or informative,
00:39:50.221 --> 00:39:53.090
please
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