Clinician-to-Clinician Update Clinician-to-Clinician Update

Catheter-Based Treatment Options for Valvular Heart Disease Patients

February 2015

Valvular heart disease is an important public health concern, with a prevalence of 0.3-0.7% among those 18- to 44-years-olds increasing to 11-13% among those 75 years of age and older. 1  Although mild-to-moderate valvular heart disease may be managed medically or with watchful waiting, surgical intervention is often indicated for severe disease. Unfortunately, up to 30% of patients with valvular heart disease are not candidates for traditional, open-chest surgery because of frailty, advanced age, or co-morbid conditions.2 Historically, such inoperable patients had no option other than palliative care.

The University of Minnesota Heart Care team continues to improve outcomes for these complex patients through the use of catheter-based procedures and leading-edge medical devices. Our multidisciplinary team-based approach is allowing many patients previously considered inoperable to undergo successful, catheter-based procedures. Two key examples of this strategy are percutaneous mitral valve repair and transcatheter aortic valve replacement (TAVR)3.

Catheter-Based Mitral Valve Repair

The natural history of degenerative mitral regurgitation (MR) is characterized by progressively worsening left ventricular failure, pulmonary hypertension, atrial fibrillation, and death. 4 In late 2013, a novel, catheter-based option for percutaneous mitral valve repair was approved for use in patients with severe degenerative MR who are not candidates for traditional surgery. The MitraClip® device (Abbott Vascular, Menlo Park, California, USA) allows the mitral valve leaflets to be clipped together, rather than sutured as they are with open-chest surgery.5

In a randomized controlled trial comparing percutaneous mitral valve repair using the MitraClip device to surgical repair, percutaneous repair was found to be somewhat less effective at reducing mitral valve dysfunction. However, it had a superior safety profile to that of traditional surgery, and 12-month improvements in left ventricular size, functional class, and quality-of-life measures were similar across the groups. 6 In a study tracking high-risk patients, the percutaneous procedure was associated with improved clinical outcomes, better quality of life, and an increased survival rate at 12 months compared with nonsurgical standard of care.7 Since May 2014, the University of Minnesota Heart Care team has performed 15 MitraClip procedures, with positive patient outcomes. The procedure is currently available for selected high-risk patients at our medical center.

TPF5591-TAVR-and-provider-443x411
— Surgeons prepare to conduct a TAVR procedure.

Transcatheter Aortic Valve Replacement

Valvular aortic stenosis (AS) is a progressive disease for which, when severe, there is no effective medical management. Three classic symptoms of the disease are exertional angina, syncope, and heart failure, but symptoms are frequently insidious at the onset and can be highly variable, even among patients with a similar degree of valve stenosis. 8

Aortic valve replacement is indicated in most patients with severe AS, and in those deemed suitable candidates, openchest surgery is associated with very good patient outcomes. 9

For patients for whom open-chest surgery is a high or prohibitive risk, a new option was approved in 2011: TAVR with either a balloon-expandable valve or a self-expanding valve. The replacement valve is most commonly introduced using a percutaneous transfemoral approach, but it can also be introduced via a chest-wall incision. In both clinical studies and postmarketing experience, outcomes are good even in a typically frail, elderly, and co-morbid patient population. 10

University of Minnesota Heart Care physicians were among the first to provide this groundbreaking treatment for patients whose health status makes open-chest surgery too prohibitive or high a risk. Our team has performed over 140 TAVR procedures since 2011, with a 30-day survival rate of about 98%. Patient evaluation is available at Fairview Southdale Hospital and University of Minnesota Medical Center. Procedures are performed at the medical center.

References

1. Nkomo VT, et al. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368:1005-1011.

2. Nishimura RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 ;63:e57-e185.

3. Iung B, et al. Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur Heart J. 2005;26:2714-2720.

4. Iung B, et al. Valvular heart disease in the community: a European experience. Curr Probl Cardiol. 2007;32:609-661.

5. Feldman T, et al. Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol. 2009; 54:686-694.

6. Feldman T, et al. EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364:1395-1406.

7. Glower DD, et al. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study. J Am Coll Cardiol. 2014;64:172-181.

8. Lindman BR, et al. Current management of calcific aortic stenosis. Circ Res. 2013;113:223-237.

9. Schwarz F, et al. The effect of aortic valve replacement on survival. Circulation. 1982;66:1105-1110.

10.Fearon WF, et al. Outcomes after transfemoral transcatheter aortic valve replacement: a comparison of the randomized PARTNER (Placement of AoRTic TraNscathetER Valves) trial with the NRCA (Nonrandomized Continued Access) Registry. JACC Cardiovasc Interv. 2014;7:1245-1251.

When to refer

Patients with exertional angina or fatigue, shortness of breath, or syncope are appropriate for consultation with the Heart Care team. Each patient’s unique case is evaluated by our TAVR team, which consists of interventional cardiologists, echocardiographers, imaging cardiologists, cardiovascular surgeons, vascular surgeons, anesthesiologists, and core staff from the cardiac catheterization laboratory and operating room.

TAVR Referrals: 612-273-TAVR

When you call, you will connect with a structural heart care coordinator at one of our locations.

University of Minnesota Medical Center 

Evaluation and Surgery Center

Deb Dempsey, RN, Structural Heart Care Coordinator

Fairview Southdale Hospital 

Evaluation Center

Deb Dempsey, RN, Structural Heart Care Coordinator

Collaborative Care

Primary care physicians and regional cardiologists play a critical role in identifying and referring patients for prompt medical and surgical intervention. When you refer your patient to our program, we are committed to partnering closely with you to obtain the best possible patient outcome. We value our relationship with you, your patients, and your office staff. We work hard to keep you informed of your patients’ care by providing detailed reports, from diagnosis to treatment and followup. Our goal is to provide you with prompt service and communication for the patients that you refer to us.

Physician Outreach Program

The Heart Care Outreach Program is designed to provide education and facilitate knowledge sharing between our team and the medical community.

To schedule a physician meeting or to visit to one of our facilities, contact Brendan Cassidy, Cardiovascular Outreach Manager. Phone: 651-269-2634; bcassid1@fairview.org

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