Redefining heart care with advanced solutions

We live in times when age has little to do with heart diseases. According to a report by The Lancet, more than half of cardiovascular disease (CVD) deaths in India in 2016 were in people younger than 70 years. And of all CVDs, after coronary artery disease, heart valve disease is the second most common type that affects people of all age groups. A new-born can have narrowed heart valve requiring emergency intervention sometimes on the first day of the life. Also, there can be a patient in the age group of 90 – 100 with either leaking valve due to disruption in any part of the mitral valve leading to an abnormal reversal of blood flow. Dr. Kaushal Pandey, Consultant Cardiac Surgeon, Hinduja Hospital, Mumbai share details that everyone should know.

 

You can have another patient in the same age group with critical narrowing of aortic valve. This is called critical aortic stenosis and is not uncommon in this age group. Both these conditions in any age group are amenable to intervention giving the patient a better quality of life. Unfortunately, often diagnosis of heart valve disease is made in the advanced stage as the disease progresses insidiously and patients remain asymptomatic for years. Hence, people should stay vigilant of any symptoms, maintain a healthy lifestyle, and visit a doctor for regular check-ups.

 

The heart has four valves that keep the blood flowing in the right direction through the chambers of the heart (one way valve). These valves are the tricuspid valve, pulmonary valve, mitral valve and the aortic valve. During each heartbeat, the valve mechanism flips open or close, depending on whether the chamber is filling or pumping out the blood. Sometimes, the valves do not open and close the way they should, disrupting the blood flow to the body through the heart. This problem may be present at birth or it can occur in adults due to infections and other heart conditions or due to ageing (degenerative valve disease). 

 

For decades conditions like degenerative aortic stenosis(AS) and mitral regurgitation (MR) were treated with open heart surgeries. AS is a condition in which the aortic valve opening becomes narrow. This results in decreased blood flow across the valve and the left ventricle having to contract with far greater force. The outcome is that there is decreased blood flow to various organs in the body. When the brain does not receive adequate amount of blood the patient gets fainting attacks. MR is a condition in which the heart's mitral valve does not close tightly which allows blood to flow backwards. This means the contraction of left ventricle results in significant leakage of blood into the left atrium and the lungs. This results in dilatation of the left ventricle and decreased blood supply to the body and flooding of blood in the lungs. 

 

Exertional chest discomfort and breathlessness, easy fatigability and lack of energy, acute onset of breathlessness, air hunger, waking the patient from sleep, excessive cough and blood in sputum are some of the common symptoms of heart valve diseases.

 

 

Diagnosis of heart valve disease is made on thorough clinical examination. Once a cardiologist has made a clinical diagnosis, it is confirmed by tests like ECG, chest x-ray and 2-D echo cardiography. If the patient’s age is above 40 years, coronary angiography and cardiac catheterisation are also performed.

 

A doctor may suggest replacing the affected heart valve with artificial heart valve in severe cases. These operations are open heart surgery procedures which are performed through a midline sternotomy or a small right chest incision. The heart is stopped, the diseased heart valve is removed and a new artificial heart valve stitched in. Artificial heart valves are classified into three categories: mechanical heart valves, tissue or biological heart valves and TAVI / TAVR valves.Mechanical heart valves are durable but require lifelong blood thinners such as oral anticoagulation like Warfarin / Acitrom. Tissue or biological valves have superior central blood flow and require blood thinners for only four to six months but are less durable in younger patients (10-12 years durability).

 

In patients above the age of 60, these tissue valves last longer, sometimes even upto 20 years. Problem with mechanical and tissue or biological heart valves is that the former requires lifelong blood thinners such as oral anticoagulation with warfarin and the latter is less durable in younger patients. Patients with both these valves always have a possibility of a redo surgery. The mechanical valve may thrombose; necessitating urgent redo valve replacement. The tissue valve may degenerate; necessitating elective valve replacement. 

 

With advancement in technology, we now have less invasive treatment options such as trans arterial valve implantation/replacement (TAVI/TAVR). These technologies aid in treating elderly patients less invasively, leading to reduced pain and improved quality of life. In the past, these patients because of age and other co-morbid conditions were not offered surgical intervention. TAVI/TAVR is a good alternative for these high risk group of patients.

 

 

Developed in the last decade, TAVI/TAVR is a new technology for patients who are suffering from heart valve disease but cannot undergo an openheart surgery. They are unfit for surgery because they are too old, frail and have multi organ dysfunction (co-morbid conditions). TAVI/TAVR is a less invasive procedure in which aortic valve is implanted using a narrow tube called catheter. The valve is mounted on the catheter tip.  The catheter is inserted through a small incision in the chest or into a large blood vessel in the groin. This is guided across the diseased aortic valve.

 

The valve is then balloon dilated or there is self-expanding device. Once the new valve is successfully implanted, the catheter is removed. This valve is made of natural tissue like the calf pericardium. These valves are durable for 7 to 10 years. This procedure is less invasive. It requires shorter hospitalisation and quick return to normal life. However, TAVI/TAVR valves are expensive. 

 

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