It’s a complicated issue, and unlike other heart conditions, isn’t caused by diet, smoking or even genetics.

Patients with structural heart conditions typically need the care of multiple heart specialists who can collaborate from their own viewpoints to arrive at a comprehensive care plan. Combining the skills of cardiothoracic surgeons, interventional cardiologists, electrophysiologists and imaging cardiologists into the same team brings more experience to bear and a more convenient treatment path for the patient.

“Patients are fast-tracked for evaluation, diagnosis and treatment, and those who need surgery or minimally invasive procedures are scheduled within four weeks,” said D. Sean Stewart, M.D., structural heart disease and interventional cardiologist with the Norton Heart & Vascular Institute Structural Heart Program.

Patients can schedule multiple appointments in one visit on the Norton Audubon Hospital campus. A nurse navigator can assist patients in finding their way through their care, with help ranging from explanations about the patient’s condition and care to navigating insurance, planning aftercare and any home-care needs.

Norton Heart & Vascular Institute has been treating structural heart conditions for more than 10 years and adopted the multiprovider approach more recently to support patients through diagnosis, treatment and recovery.

Understanding structural heart disease

All four of the heart’s valves — aortic, mitral, tricuspid and pulmonic — need to open wide, then shut tight in a precise rhythm for blood to keep moving forward to the lungs and out to the rest of the body.

“Heart valves may not close all the way — regurgitation — or open sufficiently —  stenosis. These conditions can develop over time and often don’t need treatment. Sometimes invasive treatment is necessary to fix these issues. In these instances, if left untreated, structural heart disease can lead to serious complications,” Dr. Stewart said.

The mitral valve is particularly prone to begin to leak over time. As it regulates the blood flow into the heart’s powerful left ventricle, this leakage can lead to serious and even life-threatening issues.

If left untreated, mitral regurgitation can lead to heart failure and arrhythmia.

Likewise, the aortic valve is prone to become narrow over time. Valve stenosis happens when a valve becomes narrowed or stiff and doesn’t allow enough blood to flow out of the heart to the rest of the body. The result is typically shortness of breath and chest discomfort.

In some instances adults were born with structural heart conditions. They need continuing specialized care throughout their lives from congenital heart defect specialists as children, then adult congenital heart disease specialists as they grow older.

Regardless of the type or cause of the valve issue, the specialists across Norton Heart & Vascular Institute can meet patients’ treatment needs.

Treatment options for structural heart disease

“What was once treated with open heart surgery and required a multiple-day stay in the hospital is now considered minimally invasive. Patients often go home the next day,” Dr. Stewart said.

With the help of the latest technology, structural heart disease specialists use minimally invasive treatments that use tools threaded through blood vessels to the diseased valve to make repairs or even replacements. A tiny incision in the groin or an alternative site allows the physicians to access blood vessels, while advanced imaging helps them guide a catheter to the valve causing the condition.

Structural heart disease treatments include transcatheter aortic valve replacement (TAVR), transcatheter tricuspid valve repair or replacement, transcatheter pulmonic valve replacement, left atrial appendage closure (Watchman) and transcatheter mitral valve repair or replacement.

“Rest assured, the structural heart team at Norton Heart & Vascular Institute has the experience and expertise to treat you and your loved one with these conditions,” Dr. Stewart said.

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For many, the left ventricular assist device (LVAD) option offered an alternative to a heart transplant.

Ten patients received an LVAD through Norton Heart & Vascular Institute’s Advanced Heart Failure & Recovery Program during its first year of inception. The program also provides care for another 11 patients whose LVADs were implanted at UK HealthCare (UKHC) through a collaboration established in fall 2020 with UK Gill Heart & Vascular Institute in Lexington, Kentucky

“For these patients, quality of life was impacted. Because their heart is not working properly, it is causing their breathing to be labored; they have severe swelling in the legs and feet and are just exhausted. Their everyday activities were limited — even the basics of grocery shopping, doing their hobbies or caring for loved ones,” said cardiologist Kelly C. McCants, M.D., executive medical director of the Advanced Heart Failure & Recovery Program and executive director of the Institute for Health Equity, a Part of Norton Healthcare.

Ventricular assist device pumps most commonly are used to treat patients with left-sided heart failure Patients eligible for LVAD consideration have reached the fourth stage of heart failure — severe limitations even while resting.

In their own words, these patients described how having an LVAD has improved their quality of life.

• Deandre, 42, from Radcliff, Kentucky, “… couldn’t do anything before getting the LVAD; now I can play with my kids more.”
• Bill, 68, of Westview, Kentucky, said the “best advice is not to wait to get the LVAD; all you are doing is suffering, and I’m not suffering anymore.”
• Christopher, 65, of Greenville, Indiana: “I was fighting for my life before; now I am celebrating my grandchildren’s birthdays.”
• Derrick, 68, of Shively, Kentucky: “I’m able to do the things that most people do every day like shopping and cleaning. I have more energy.”
• Patricia, 50, of Hardinsburg, Kentucky: “I’m now able to do more with my 11-year-old daughter and enjoy spending time with her.”
• Charles, 60, of Louisville, Kentucky: “With the LVAD I am breathing better and getting back to doing the things I love to do.”
• Mark, 74, of Louisville, Kentucky, “At just three months in the recovery process, I am still healing and hoping to get back to my everyday activities.”
• Conte, 46, of Shively, Kentucky: “I’m looking forward to doing more with my kids. Just a few months into my recovery and I can already tell a difference.”
• Dave, 58, of Louisville, Kentucky, is “just a few months into my recovery, and I am not hurting as much. I’m really starting to feel better.”

Building the team with the expertise needed to launch a certified VAD program has been a huge undertaking, especially during the COVID-19 pandemic, according to Dr. McCants. The program has been accredited by DNV Healthcare and the Centers for Medicare & Medicaid Services.

“We have a dedicated multidisciplinary LVAD team led by two outstanding cardiothoracic surgeons, Steven W. Etoch, M.D., and David H. Rosenbaum, M.D., in addition to a host of advanced heart failure cardiology providers and staff who really are the backbone of this program,” Dr. McCants said.

Physicians, advanced practice providers, nurse VAD coordinators, pharmacists, nutritionists, therapists, social workers and others provide crucial support to make a VAD program successful. Moreover, everyone who may interact with a patient during the hospital stay must have proper education and training in case an emergency arises.

Once considered solely a way to keep patients alive until a donor heart becomes available, a VAD is now often an alternative to a heart transplant. Two-year survival rates approach 90%. The devices are readily available, while transplantable donor organs are very limited.

The VAD is implanted during an open heart procedure, which typically lasts four hours and requires a hospital stay of at least 14 days. The 10 Norton Heart & Vascular Institute VAD patients in 2021 had an average hospital stay shorter than the national benchmark.

Following surgery, specially trained cardiac nurses and VAD coordinators monitor the patient, focusing on safety and education of the family and caregivers. Then the patient can go home and start resuming daily activities. Before and after surgery, advanced heart failure cardiologists including Bassel Alkhalil, M.D., and Srikanth Seethala, M.D., provide weekly and monthly care.

“Our mission is to assist these patients along their heart failure journey, whether it is medical management of heart failure, providing mechanical circulatory support, or collaborating with established heart transplant programs like the University of Kentucky. Our goal is to provide excellent care close to home as we continue to build on our outstanding program,” Dr. McCants said.

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“I never expected to hear anything serious from my exam,” Barry said.

His primary care provider, Alice H. Johnson, M.D., an internal medicine specialist at Norton Community Medical Associates – Audubon East LL2, listened through her stethoscope and didn’t like what she heard — atrial fibrillation or A-fib. The upper chambers of Barry’s heart, the atria, were out of sync with the lower chambers, the ventricles.

Dr. Johnson referred Barry to Wayne M. Shugoll, M.D., cardiologist with Norton Heart & Vascular Institute.

“I was shocked. I had no idea there was something major going on,” Barry said. “I had been feeling tired, but I thought that was because I was getting old. Had I not gone to the physical, this probably would not have been detected and I wouldn’t be here today.”

Dr. Shugoll ordered tests and imaging that showed Barry had a bicuspid aortic valve that was causing his A-fib. A valve in Barry’s heart that regulates blood flowing out to his body had two flaps instead of three. It’s a condition he inherited and that often goes undetected until adulthood.

With a bicuspid aortic valve, blood doesn’t move through the heart as easily and actually can flow backward. Sometimes surgery is needed to repair the aortic valve.

READ MORE: Study of atrial fibrillation (A-fib) and alcohol shows chance of an episode increase dramatically within hours of drinking

Dr. Shugoll brought in cardiothoracic surgeon Steven W. Etoch, M.D., a colleague at Norton Heart & Vascular Institute.

Barry also had a large aortic aneurysm. The bulge in his aorta could cause internal bleeding and burst, leading to death.

From an annual checkup to open heart surgery

In November 2019, Barry underwent open heart surgery to contain the bulge in his aorta with a sleeve. Surgeons also etched a maze of scar tissue onto the outside of his heart to interrupt the irregular heart rhythm (the A-fib). That would be enough to address his condition without having to go inside his heart to address the bicuspid aortic valve.

Barry is feeling like his old self again. His wife, Robin, is glad she encouraged Barry to get his annual exam.

“Scheduling an annual visit with your primary care provider allows us to catch issues as quickly as possible,” Dr. Johnson said. “Patients often underestimate the importance of these exams. We want to get ahead of issues. Preventive care is always the goal.”

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TAVR is an option now for nearly all patients.

“With TAVR, we’re able to place the new valve by entering through an artery, much like we would a stent,” said D. Sean Stewart, M.D., interventional cardiologist with Norton Heart & Vascular Institute. “Patients eligible for this minimally invasive approach often go home after an overnight stay.”

TAVR is now an option even for patients for whom open heart surgery for valve replacement would be low risk. The procedure was at first only for those who faced high risk if they underwent open heart surgery, then expanded to include those with intermediate risk.

Open heart surgery is still preferred for younger patients, those with congenitally malformed valves and other specific cases.

Aortic stenosis means the valves have narrowed, become calcified and rigid. One in 2 patients with untreated symptoms of severe aortic stenosis will die within an average of two years.

TAVR vs. Open Heart Surgery

TAVR: Interventional cardiologists access the damaged valve through an artery — usually in the groin. The new valve is collapsed and placed on the end of a catheter or tube that is threaded through the blood vessels to the aortic valve.

There, the new valve is expanded and pushes the leaflets of the damaged valve aside to take over regulation of blood flow. The TAVR valve leaflets open and close with each heartbeat, just like the person’s heart valve did when it was healthy.

After more than a decade of data, the durability of the valves used in TAVR compares favorably with surgically implanted valves, Dr. Stewart said.

Avoiding open heart surgery means there are fewer risks, and patients typically recover much faster and with a shorter hospital stay.

Open heart surgery: Surgical aortic valve replacement involves an incision in the chest to provide access to the heart. The surgeon stops the heart and turns over circulation to a heart-lung bypass machine.

The damaged valve is removed entirely and replaced with a new one.

The procedure has been performed for more than 50 years. Patients should be healthy enough that they have a very strong ability to withstand the trauma of open heart surgery.

After surgical aortic valve replacement, patients usually stay in the hospital about a week, with at least a few days in intensive care.

The Heart Valves’ Functions

The valves make sure blood keeps moving in the right direction. Between heartbeats the aortic, pulmonic, mitral and tricuspid valves close to prevent blood from flowing backward. If a valve isn’t working right, your heart needs to work harder to keep the blood moving in the right direction.

The interventional cardiologists at Norton Heart & Vascular Institute use two kinds of aortic replacement valves for TAVR: the Edwards Sapien valve and the Medtronic CoreValve. The Edwards Sapien valve is made from cow heart tissue and is supported by a cobalt and chromium frame. The Medtronic CoreValve is made from pig heart tissue and has a frame made from a flexible nickel-titanium alloy.

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Interventional cardiologists and cardiothoracic surgeons at Norton Heart & Vascular Institute team up to conduct a TAVR procedure. Performed though a catheter, it requires only a short hospital stay – often just one night. Many patients report improvement in symptoms including shortness of breath and improvement in leg swelling.

At Norton Heart & Vascular Institute, our board-certified and fellowship-trained specialists sometimes use TAVR as an alternative to open-heart surgery. The procedure treats aortic stenosis – a narrowing of the aortic valve – that prevents the valve from opening fully. One in two patients with untreated symptoms of severe aortic stenosis will die within an average of two years.

The TAVR procedure does not remove the damaged valve, but rather implants a replacement in the valve’s place. Once the new valve is in place, it pushes the old valve tissue out of the way and takes over.

Reviewed by Arpit Agrawal, M.D., cardiologist with Norton Heart Specialists.

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