Okay, buddy, you’ve done a great job beating every minute of every day for this guy’s 80+ years. Time to take a break, I got this - Barbara Dehn
image by: VA Ann Arbor Healthcare System
Imagine two experienced surgeons working side by side to replace a calcified, stenotic and tired aortic valve within a man’s heart without ever having to cut into the heart muscle. Imagine also, that unlike what was available in the past, this patient will not have to endure having his sternum or ribs broken to gain access to the heart that’s been pumping continuously, lub dub, lub dub, lub dub for over eight decades.
In fact, let’s stretch our imaginations and envision that this man’s heart will not even be stopped. Instead, it will be rapidly paced with a wire placed through a thin catheter placed in his neck vein. At the same time, another wire is threaded carefully up from his leg, through the narrowed and sometimes tortuous twists and turns of the femoral artery and the descending aorta, over which the valve is placed. Every millimeter of that route has been pre planned and mapped out in 3-D.
This is real
It’s not sci-fi. It is one of many Trans-catheter Aortic Valve Replacements (TAVR) done every day around the country. I have watched this in person; have seen a barrel-shaped fine mesh of Nitinol (Nickel Titanium Alloy) with three whisper-thin porcine valves arrive at the heart through a catheter like a parachutist hovering over the landing spot.
I like to think that the new valve is almost a like a Navy Seal, arriving on the scene, dropping in, as it were, fighting the constant pressure of the blood pumping up with each beat. I have an active imagination so — in my mind, anyway — the two valves talk to each other. “Okay, buddy, you’ve done a great job beating every minute of every day for this guy’s 80+ years. Time to take a break, I got this.”
The old, calcified valve is worn out and knows it’s time to lay back against the cardiac muscle and let the new CoreValve get into position. The surgeons, Dr. Ajanta De, interventional cardiologist and Dr. Pei Tsau, cardiothoracic surgeon know that this is a Gold-i-Locks situation. Not too high, not too low; every single aspect must be just right. Precision is a word I hear over and over. They have reviewed every aspect of this case ahead of time and then reviewed it again.
Dr. De is an experienced interventional cardiologist and has just completed her advanced endovascular fellowship under the guidance of renowned interventional cardiologist and innovator, Dr. James Joye. With Dr. De in charge, the nurses are buzzing, “Hey, everyone, hold on a second. This must be the first all-woman TAVR team in California.” History in the making.
Virtual Reality Glasses
Also present is Dr. Christian Assad, the new endovascular fellow. Thanks to the collaboration with VitalMedicals, he is wearing a pair of ODG Smart Glasses, the next generation of virtual reality glasses currently being used by NASA and the Military to demonstrate how you can teach other cardiologists from around the country from within this Cardiac Catheterization Lab. In addition to working as an additional angiographic monitor, the glasses also have the capacity to work as a telemonitoring hub to show doctors exactly what he sees in real time.
This isn’t a sci-fi movie; this is real. Of course, here in the Silicon Valley an ample bit of genius tends to grease the skids between imagination and reality. Innovators and researchers are pushing boundaries and thinking different, especially when the Fogarty Institute for Innovation is across the street.
If they aren’t developing the next generation of medical instruments, valves, or devices, they are involving El Camino Hospital in clinical research in order to place them right here in the OR. My heart’s beating faster as I consider the interplay of technology and health care swirling around this team working to provide a very nice older man more time so he can see his grandkids graduate from college, dance at a few more weddings and maybe enjoy a few more rounds of golf.
Trans-catheter Aortic Replacement
Dr. De has already chosen a CoreValve that will be the perfect size. Precision is everything. She has to determine exactly how much of the valve must be in the heart and how much must be in the aorta. And, she has to ensure that the valve is attached within the heart at precisely the same angle as the patient’s current valve to prevent leaking and congestive heart failure.
Before Dr. De and Dr. Tsau deploy the new valve, they pump up a balloon to push the old valve back and out of the way. They are pacing the patient’s heart fast now, so that the blood pressure drops. Now they can guide the new valve into it’s new home. Ready? The valve is opened partially, the angle is checked, the height, the depth. Double check. Triple check. All good? All Good! I see nods. Then it’s time. They open the valve.
Am I the only one holding my breath? Then I hear the collective exhalations. They look, they check, they check again. Yes, it’s good, it’s good! The valve is perfect. I watch the new valve on the ultrasound monitor. Three little whisper thin leaflets, delicate as a moth’s wing, yet strong enough to open and close just from the pressure created by this man’s own heart beats. Lub dub, lub dub.
The future is here
It’s almost unbelievable, in the past, replacing the aortic valve meant a long recovery of at least 9 -12 months before a person felt like themselves again, yet this man got a new valve in a few hours from a catheter passed up through his leg. He’ll be home in about three days and when he gets there, he’ll be able to walk across his living room without having to stop and reach for a chair to steady himself and take a few deep breaths like he was climbing Mt. Everest. He’ll be able to participate in life and not watch from the sidelines.
It’s only 9:30 a.m., and we’re all donning lab coats, heading to medical offices to see our scheduled patients. I can just imagine everyone considering all the possibilities for the next levels of improvements that will continue steadily because, it’s just another day here in Silicon Valley where medical device innovation continues regularly like a beating heart, lub dub, lub dub. You can count on it. And if it does stop, well, they’ve got a pacemaker for that.
Source: Barbara Dehn, Excerpt from Replacing a Heart Valve Without Opening the Heart, the Blog, HuffPost, June 18, 2016.