William’s Story: The Difference Is What You Don't See

Think of what it feels like to hold your thumb over a garden hose. Pressure builds behind your thumb. And a small spurt of water manages to escape – but not enough to give your flowers a good watering.

That’s something like how William Walsh's heart was working. His aortic valve was unable to open wide enough for blood to flow freely to nourish his body.

“He's got a valve that's like a thumb sitting over the garden hose — it takes a lot of pressure behind there to push that fluid out, and it's not coming out in great quantities,” explains John M. Miller, MD, FACS, a cardiac surgeon with Premier Health. “It keeps you alive, but you can't do very much because you can't raise your cardiac output.”

Patients with this condition – when the aortic valve opens less than a centimeter – usually start feeling symptoms such as chest pain, chest pressure, shortness of breath, or lightheadedness. In someone who is younger and healthy, the aortic valve usually opens to about two and a half centimeters.

“As we age, or as there are other reasons for wear and tear on that valve, the leaflets don't open as well. They end up getting calcified,” explains Palaniappan Muthappan, MD, FACC, an interventional cardiologist with Premier Health.

“When you look at it, it actually looks like the barnacles on the bottom of a ship — there are crusty growths, and the valve just can't open. Eventually the valve area as it opens gets smaller and smaller and smaller.”

William didn't feel symptoms right away, so his care team monitored his condition.

“They would keep asking me, trying to check off what symptoms I might have, and at that time I really didn't have any,” he recalls. “Then all of a sudden I had a dizzy spell, which is one of the things to look for.”

“Given his age, we decided that we were going to be conservative and wait until he developed some symptoms,” Dr. Muthappan says. “Then he started developing some light-headedness and a little bit of heart failure, so that was the point at which we decided to fix the valve.”

Transcatheter Aortic Valve Replacement: A Minimally Invasive Alternative to Open-Heart Surgery

Patients who need an aortic valve replacement typically undergo a surgical procedure that involves stopping the heart, opening the breast bone, removing the old valve, and replacing it with a new valve, Dr. Muthappan explains. “That is still the standard of care, but not everyone can withstand that,” he says.

At 87 years old, open-heart surgery was not an option for William.

In 2014, Premier Health's structural heart team became the first in Dayton to perform a transcatheter aortic valve replacement (TAVR), which is minimally invasive, compared to open-heart surgery.

With TAVR, surgeons gain access to the circulatory system through small incisions made near the groin, upper chest, or rib cage and guide an expandable, bioprosthetic replacement valve to the heart through a catheter.

Once the new valve reaches its destination, surgeons inflate a small balloon to expand it into place. The old valve does not need to be removed. Instead, it acts as an anchor for the new valve, which surgeons guide into place while the heart continues to beat.

“In that high-risk population, the surgery is what puts them at risk – not the valve replacement,” says Dr. Miller. “We're able to take the surgery component out and put the valve in still, so they gain all the benefit with less risk.”

Dr. Miller and Dr. Muthappan worked together to replace William's aortic valve in June 2017. While Premier Health's structural heart team is made up of specialists who practice throughout the region, this catheter-based therapy is performed at Miami Valley Hospital.

Dr. Muthappan describes deploying the new valve in a patient as “a coordinated dance” between the cardiologist and surgeon. “The cardiologist will position the new valve exactly where it should go, and then the surgeon will inflate the balloon,” he says. “While the balloon is coming up, the valve can shift up or down, so the cardiologist has to basically push or pull the valve back into position while it's being deployed.”

Patients can feel almost instant relief from their symptoms, and usually return home from the hospital in one or two days.

William says his life has improved since having the TAVR procedure because he's now able to move around as he chooses.

“I certainly wouldn't look forward to having my bones in my chest broken so they could get at it. This of course took the place of that, coming in through the artery,” he says. “It didn't really cause any pain to speak of. The only pain I had was in the aftermath when having to change a bandage at the entry point.”

During William's first appointment with Dr. Muthappan after the procedure, he told Dr. Muthappan that he was able to vacuum the house and complete other housework without any problems.

“He likes what he sees, and I told him, 'If you like it, I like it,'” says William.

The important difference between TAVR and traditional open-heart surgery “is what you don't see,” says Dr. Miller.

“They're up walking the next day, they're home in two days, the valve's open, they've got more cardiac output, and their body doesn't need to have all that physical recovery,” he says.

“It's definitely a game-changer.”

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