Scripps Memorial Hospital Interventional Cardiologist, Dr. Curtiss Stinis, MD talks about a new technique, called TTVR, that helps heart patients.
Interview conducted by Ivanhoe Broadcast News in 2022.
What is a tricuspid valve?
STINIS: The hardest four valves, and they’re all one way valves. The very first valve in the heart is the tricuspid valve. All the blood that comes from the lower body and the upper body after it has given up all of its nutrients and oxygen as it returns to the heart, goes through the tricuspid valve.
What happens when that isn’t working properly?
STINIS: It becomes a problem. Blood is supposed to go into the heart and not back out of the heart in the wrong direction. So when the tricuspid valve is leaking, blood pressure goes backwards when it’s not supposed to. That can affect primarily the organs in the abdomen, like the liver, the kidneys, the intestines, and the lower extremities. The pressure in that side of the body should be low, not high. When it is leaking backwards, that pressure is elevated and causes a lot of symptoms for patients.
Can it be fatal?
STINIS: It can unfortunately. Sadly, tricuspid regurgitation is one of the most ignored diseases of the heart. Until recently, we really had minimal treatments for it. We can use medications, as well as a couple of open heart surgeries that have been tried. The outcomes with that are not great. It is an ignored problem because there is no solution. Ultimately those patients that have severe tricuspid regurgitation have a worse outcome than people that don’t have it.
What is the age group for people that have this problem? Are they older?
STINIS: Not necessarily. It can affect younger people too. The tricuspid valve can leak for a number of reasons. It can leak because the right ventricle, the pumping chamber has a problem and stretches in size, along with the doors that are coming together perfectly and can be stretched apart when there’s a leak in the middle where the valve can itself be damaged. For example someone could have had a pacemaker placed or had a procedure done where the tricuspid valve was injured. Patients that have had heart transplants need something called biopsies where pieces of little tiny chunks of the muscle are taken to look for evidence of rejection. Sometimes doing those instrumentations can damage the tricuspid valve. Some people are born with tricuspid valve problems where it’s leaking from a very young age. It’s an equal opportunity offender. It can be a younger people, it can be older people. Most of the clientele are the older folks, but not necessarily.
This makes heart surgery risky?
STINIS: Indeed.
Why hasn’t there been a valve replacement for the tricuspid valve?
STINIS: Traditional valve replacement was done with open surgery. As techniques have come about doing catheter based interventions, the aortic valve is a simpler structure. It’s three doors that are passively opening and closing with the heart. The mitral and tricuspid valves are more complex. They have cords attached to them. If you think of a parachute that has strings attached to it, it has chords that are attached to the heart and that keeps the valve from going backwards. It is a more complex structure. The anatomy is more variable and there’s also a lack of structures to anchor a device to. People that have an aortic valve problem, usually it’s a narrowed aortic valve because calcium builds up on the valve so that calcium can be exploited to anchor a device too. But with a tricuspid valve, it typically does not calcify. Trying to come up with a design of a device that anchors appropriately to the tissues, seals the leak, and doesn’t float away is tricky.
Now that you have that, can you tell me about it?
STINIS: It is very exciting. A group of engineers with a company called Edwards Lifesciences, have invented a device that is a valve. It has an anchoring capability where it grabs the existing valve and incorporates that into the seal of the new valve, attaching it to the heart and sealing it to the heart structure. This can all be put in through a tiny incision in the vein and the groin without any type of open heart surgery.
Do you think that this is just giving a lot of people that didn’t have any options?
STINIS: That’s our hope. This is a brand new technology. It is still experimental and we are studying that question and we know that patients that have tricuspid regurgitation don’t do well long term. We know that open heart surgery is very high risk and we know that medicines alone do not fix the problem. It might extend people’s lives for a short time, but ultimately they still don’t do well based on what we know. This is a very exciting time because if this valve pans out and it works, long term it could offer significant hope for patients. Both in reduction of their symptoms and hopefully also in their mortality.
You performed the first one here, on Steve? Can you tell me a bit about that?
STINIS: Steve is an amazing guy. He has had a leaking tricuspid valve for many years and he’s a typical patient that we see in this scenario where there have been minimal options. He has been on medications, he’s been getting by, but not doing well. He has limitations in his activity, he gets short of breath, he gets some swelling of his legs, and over time his kidneys started to worsen, which is typical of what we see. The opportunity to help someone like that and change their long term outcome is huge.
Is there any more risk or less risk than an open heart surgery?
STINIS: It is far less risk than open heart surgery. We know that open heart surgery for isolated tricuspid valve disease does not have a good track record. In fact, smart surgeons avoid the operation because they know it’s going to be a challenge. The risks involved are actually small so far. We are still studying this as part of the trial, but the incision is minimal. The main primary risk involved would be getting caught on the valve. Patients get blood thinners interfering with the electrical system of the heart requiring a pacemaker, but many of these people already have pacemakers. That’s less of a concern, but those are the primary risks. Other than that, it is a safe procedure.
Is Steve off medication? Is he going to be fine? Does he have to come back in?
STINIS: Yes. Time will tell. He is still on medication because he has several health problems, but he did very well after the procedure. He has no leak around his valve for the first time in many years. The way he feels is much improved and we’re hoping that long term he’s going to do very well.
How long does that surgery take?
STINIS: An hour to an hour and a half, and it’s pretty quick.
How much compared to an open heart?
STINIS: Open heart takes a lot longer and patients are in the hospital a lot longer. With this procedure, typically patients are in the hospital a day or two.
How many hours would that be?
STINIS: It depends on the surgeon, but most likely three or four hours. Then they are in the ICU for awhile before they recover. Typically at least a week, possibly longer.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Stephen Carpowich Keith Darce
Carpowich.stephen@scrippshealth.org darce.keith@scrippshealth.org
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