
Surgeon goes over options for treating aortic valve disease
Transcript
[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The aortic valve in our heart helps keep the blood flowing in the correct direction through the heart. A damaged or diseased valve can affect blood flow to the rest of the heart and body. Here to discuss aortic valve repair and replacement is Dr. Callista Ditah, an assistant professor of surgery at Upstate, specializing in thoracic, or chest, surgery. Welcome to "The Informed Patient," Dr. Ditah.
[00:00:37] Callistus Ditah, MD: Thank you. Thanks for having me. It's a pleasure for me to be here today.
[00:00:43] Host Amber Smith: Can you please start by telling us about the aortic valve? Where is it in the heart?
[00:00:49] Callistus Ditah, MD: The aortic valve is located between the left ventricle, which is really the heart's main pumping chamber, and the aorta. And the aorta is the largest artery in the body. The aortic valve ensures that oxygen-rich blood flows from the heart into the aorta, which is then distributed to the rest of the body.
[00:01:15] Host Amber Smith: How big is this valve?
[00:01:18] Callistus Ditah, MD: In normal people, it's about 2.5 to 3.5 centimeters in diameter. There's some slight variations that go with that depending on the person's body size. But typically it's about 2.5 to 2.5 centimeters.
[00:01:36] Host Amber Smith: And, and what is it made of?
[00:01:39] Callistus Ditah, MD: The valve consists of three thin but very strong leaflets, so something that we call cusps. It's made up of connective tissue that's covered by endothelial cells. And in some people, the valve may naturally have two cusps instead of three, which is called a bicuspid aortic valve. And this is thought of to naturally occur at about 1 to 2% of the population.
So if you go to a Syracuse game, you can expect that there are about 1,000 people sitting in the stands with this bicuspid aortic valve.
[00:02:17] Host Amber Smith: Interesting. So, does the heartbeat dictate when the valve opens and closes?
[00:02:26] Callistus Ditah, MD: Yes, it does. So the heart is normally thought of as beating in two cycles. When the left ventricle contracts, which is what it's normally thought of as systole, the valve opens to allow blood to flow out. When the ventricle relaxes, which is called diastole, it closes tightly, to prevent blood from flowing back into the heart.
So in a sense, it's a one-way valve that allows blood to flow forward to the rest of the body. But then the second function is not to allow blood to flow back into the heart.
[00:03:07] Host Amber Smith: Now, how would a person know that something was wrong with their aortic valve?
[00:03:14] Callistus Ditah, MD: Oftentimes, there are really no symptoms until late in the disease process. There are some people with certain anatomical features, sort of like the ones we just talked about, like a bicuspid valve, that should have their heart monitored more on a regular basis to catch some of these things early because we know that for people who have this bicuspid aortic valve, the valve deteriorates at a much faster pace. And there can be a host of issues with it. So those people should get their valve monitored over time.
For the rest of the people, common symptoms of aortic valve disease include things like chest pain, shortness of breath, fatigue, fainting, or what we call syncope, if you get heart palpitations. When it gets really severe, you can start having symptoms of heart failure, which will be noted as swelling in your legs.
[00:04:11] Host Amber Smith: So what are the main types of aortic valve disease? You mentioned the bicuspid, where there's two leaflets instead of three. Are there others?
[00:04:22] Callistus Ditah, MD: Yeah. And just to be clear, bicuspid valve in itself is not a diseased valve. A bicuspid valve, however, changes the flow dynamics across the valve that exposes it to a faster deterioration when compared to people who have a normal pre leaflet or tricuspid valve. So just having a bicuspid valve is not an issue that needs to be addressed per se, but then we need to watch you a little bit more closely to make sure that you don't develop issues or to make sure that when you do, we catch them early enough that this can be fixed.
Now to discuss the other main types of aortic valve diseases, there's something called aortic stenosis, which really just refers to narrowing of the valve. If you remember that diameter that we talked about. This is something that happens over time, and it restricts the amount of blood that can go through this valve.
There's something called aortic regurgitation, or aortic insufficiency. When you heard me talk about the valve preventing blood from flowing back into the heart, a leaky valve is essentially what we call aortic regurgitation, and that in itself is an issue.
Then we talked about the bicuspid aortic valve as well, but there's another thing in this bicuspid aortic valves. Because of the change in the flow dynamics, patients are thought of as being exposed to sometimes developing aneurysms in the ascending aorta because of those changes in how blood flows to a two leaflet valve as opposed to a three leaflet valve. And some of those changes makes it so that you may need your ascending aorta replaced. But that is a separate issue from the valve, but it's an issue that the valve can lead to.
[00:06:22] Host Amber Smith: Are these aortic valve diseases, are they genetic? Do they run in families?
[00:06:27] Callistus Ditah, MD: We, we think so, especially on the bicuspid aortic valve. We do know that they do run in families. Now, there are other issues like the aneurysms that we know for sure run in families.
And things like aortic stenosis, we also see them running in families, but we haven't delineated any genetic factors that we can put our finger on to say that it leads to this.
[00:06:58] Host Amber Smith: Now we talked about stenosis and regurgitation. What about connective tissue disease? Does that affect the aortic valve?
[00:07:06] Callistus Ditah, MD: It absolutely does, in certain ways. So for patients who have connective tissue diseases like Ehlers Danlos (Syndrome), Marfan (Syndrome), or Loeys-Dietz (Syndrome), those patients basically have what is a weakened aorta, and a lot of them can develop what we call aortic root aneurysms. Now you wonder what's the aortic root. I think for the purposes of this conversation, the aortic root is often thought of as the business end of the aorta where your coronary arteries leave.
It's where the aortic valve lives. It's really that transition from the ventricle to the aorta. So if you have an aneurysm in that area, as you're going to imagine, as the aorta dilates, those leaflets that have to come together to prevent blood from going back into the heart, they can't touch because the aorta, they've been pulled apart by the dilation of the aorta.
So that's what we call aortic regurgitation. So most patients will have connective tissue disorders and have an issue with their aortic valve. It often presents itself in the flavor of aortic regurgitation. And those are the patients where it's absolutely critical for us to do things like the David operation, where I can go in and fix that aneurysm but keep their own valve by taking it and implanting it in some sort of a tube graft and preserving a function in that sense.
[00:08:43] Host Amber Smith: I know we'll talk more about that David operation. But first, let me remind listeners that this is Upstate's "The Informed Patient" podcast with your host Amber Smith. My guest is chest surgeon, Dr. Callistus Ditah, and we're talking about the aortic valve.
So how is valve disease diagnosed? Is there testing that has to be done?
[00:09:05] Callistus Ditah, MD: There's a number of tests that we can do to determine whether you have valve disease. The first and the very simplest thing that we use is an echocardiogram, which is essentially an ultrasound of your heart that looks a little bit closely at this valve. That's really the gold standard for evaluating a the valve function.
But we can also do a CT scan or an MRI, which is a different kind of imaging to look for calcifications, because this is what leads to aortic stenosis. And we can also look at the valve anatomy and look at the aorta surrounding that.
Then there's something called cardiac catheterization, which is where we inject some dye, either in your coronary arteries, so the arteries that supply blood to the heart, or we can inject this diet directly to the opening of that aortic valve to measure some pressure gradients and see how it's working.
And then lastly, we can also do a stress test, which is really to examine and really interrogate the response of the heart to physical exertion when we test this.
[00:10:18] Host Amber Smith: Let's talk about treatment options. Does aortic valve disease always mean surgery?
[00:10:24] Callistus Ditah, MD: No, It doesn't always need surgery. There's some surgical and non- surgical treatments that we target for the aortic valve.
Now, on the non-surgical side, there are medications like diuretics, beta blockers, if you've of these medications. They call them metoprolol or carvedilol. And they often are thought of as some afterload reducers that may manage symptoms, but never really fix the valve. Lifestyle changes can also help in early stages, but severe valve disease typically requires surgical or procedural interventions.
[00:11:07] Host Amber Smith: So for those who do end up needing surgery, can you compare the aortic valve repair versus the aortic valve replacement?
[00:11:18] Callistus Ditah, MD: It's often taught in our field that any time you can repair the valve that you were born with successfully, that's unanimously the better thing to do. We know that for patients who get their valves replaced, meaning you take a valve off the shelf, and there are two that we can get into later, those patients have, depending on what you use to replace that valve with, some of them may need to be on anticoagulation for the rest of their lives, something called warfarin. Or if you put in what we call a tissue valve, those patients, if they're young enough, they often need to come back and get surgery. So anytime you can repair the patient's own valve, that's what we would like to do.
Now for patients who have aortic stenosis, by definition your valve is bad. It's got calcium on it, and you can't really repair those. But for patients who have a leaky valve or they have an aneurysm, which is in that area where the valve is, we can often do an operation called a David procedure. For surgeons who are a little bit more sophisticated with the aortic valve, we can do that kind of operation to sort of repair it.
[00:12:38] Host Amber Smith: And is that an open surgery or minimally invasive?
[00:12:43] Callistus Ditah, MD: All of the options, the surgical options that I've described so far are open heart surgery, the way that we think about it, where in most cases we kind of split your sternum, get down to the heart, put your heart on what we call a bypass machine, and then arrest it to do all of this work. Then we start it at the end of the work.
[00:13:07] Host Amber Smith: So if you're able to do a repair, how long does the repair last?
[00:13:12] Callistus Ditah, MD: It really depends. If your valve, if I meet your valve in a pristine condition, this repair can last you your entire lifetime. If I can catch and reverse the condition before it deteriorates, it basically restores your life expectancy to the normal population.
Now if I go in there, and your valve is sort of mediocre to start with, there's nothing I can do to reverse the condition of the valve itself. I can arrest that process of deterioration, but I can't reverse what already happened. And some of those patients may need something done down the road, but having the valve that you were born with for 10 to 15 more years is also better than replacing it at that time.
[00:14:03] Host Amber Smith: So if you did have a repair, and it lasted 10 or 15 years, could you potentially get a replacement later if you needed it?
[00:14:12] Callistus Ditah, MD: Absolutely. It just means going back to do the operation again, another open heart surgery. If you already have a valve that's in there, the valve that you were born with, we just go back in there, we cut it out and then put in a valve off the shelf. So there are no bridges burned in doing a repair if it -- obviously, there's risk associated with open heart surgery. It's a major operation -- but outside of those you can always go back and replace a valve that we repaired earlier.
[00:14:42] Host Amber Smith: So let me ask you about valve replacement. What is the valve replaced with?
[00:14:50] Callistus Ditah, MD: It's often thought of as using two different kind of valves. There's what we call the biologic or tissue valve, which usually comes from a cow or some sort of a pig skin. And then there's what we call the mechanical valve.
Now, with the biologic valve, we reserve this for patients who are older, that we often think of their life expectancy to be in the order of 10 to 15 years. Because this valve, usually, that's usually the shelf life. Now, the benefits of getting a biological valve is that you don't have to take any kind of medication for the rest of your life. But if you're someone who's younger, let's say you are the age of 50 and you get this valve, you can expect that at about 65 years old, you're going to need to have something done. Either through a TAVR (Transcatheter Aortic Valve Replacement) valve. You can have that done through the groin, or you may need another open heart surgery to go and replace that valve again. But if you get that valve, and your life expectancy is more than 10 to 15 years, be prepared to have something done again, and just think about what that backup option would be.
Now there's the other side of this, which is the mechanical valve. With the mechanical valve, we often think of this as lasting the entire lifetime. The catch with a mechanical valve is that you have to be on a blood thinning medication that's known as warfarin or Coumadin for the rest of your life. There are obvious implications for being on a medication like that. Your blood oftentimes has to be at least 2.5 times thinner than that of the normal population, which means if you scratch yourself, if you go hiking, if you're someone who likes to go snowboarding, or if you fall and hit your head, that's a big deal. So some patients, for those reasons, will oftentimes shy away from getting the mechanical valve.
So you can, you know, it's pick your own, depending on your lifestyle. If you, prefer something that allows you to do all the things that you love and you are a very active individual, maybe the biological valve works for you. But if you're someone who has a desk job, you don't really enjoy getting out in the woods and things like that, maybe the mechanical valve works for you in that case.
[00:17:28] Host Amber Smith: With the mechanical valves, can you hear them clicking as they work?
[00:17:34] Callistus Ditah, MD: That's a very good question, and what I usually tell patients is that about a third of the patients who get a mechanical valve will not hear it at all. A third of them will hear the valve clicking, and it wouldn't bother them. A third of them will hear the valve clicking, and it will drive them absolutely nuts. So that's just something that goes with it. And you can think about the rule of thirds as how you know, to deal with this.
[00:18:03] Host Amber Smith: So let me ask you about the biological valves then. Do you ever have a patient whose body rejects the the tissue?
[00:18:13] Callistus Ditah, MD: That's another good question. The biological valves are what we call decellularized valves. So the human components, or the components that we react to are completely removed, so people don't react to these valves at all. You don't have to take any kind of medication to dumb down your immune system to tolerate this valve because all the elements that are immunologic are removed from these valves.
[00:18:42] Host Amber Smith: How do you tell patients to prepare for aortic valve surgery? It is a major surgery.
[00:18:50] Callistus Ditah, MD: It is a big operation. And what I usually tell my patients of things that they can expect, going something like this: I tell them that they're going to come out of the operating room, and in most cases, with a breathing tube in. We usually take that breathing tube out the night after their open heart surgery. They stay in the ICU for about a couple of days, and then after that I send them to what we call a step down unit where they spend another five days there or so. And then they get to go home.
Usually, when I get them home, if it's an operation that I was able to do through the breast bone, I put them six weeks on light duty, just so that depthe breastne can heal up.
[00:19:37] Host Amber Smith: So after those six weeks, can they get back to normal activities, or are there going to be limitations to what they can do, since they've had heart surgery?
[00:19:48] Callistus Ditah, MD: Most of my patients actually get back to work in about two to three weeks, after open heart surgery. It just needs to be a desk job. You can't be lifting heavy things. And what I usually tell them is you can't lift more than a kettle of water for those six weeks after your operation. Again, it is just time for that breast bone to heal.
After those six weeks, I tell them to get back to the things that they enjoy doing. If it's running, if it's climbing, whatever it is, get back to it. Just pace yourself and ramp it up. But after that time, you are essentially signed off.
[00:20:27] Host Amber Smith: Very interesting. Well, Dr. Ditah, thank you so much for making time for this interview.
[00:20:33] Callistus Ditah, MD: It's, it's my pleasure. I really enjoyed talking to you this morning. Thanks for giving me the opportunity to discuss the valve I really love.
[00:20:40] Host Amber Smith: My guest has been Dr. Callistus Ditah. He's an assistant professor of surgery at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please invite a friend to listen. You can also rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.