347 - Heart Valve Repair vs. Replacement (Dr. Richard Kettelkamp)

Heart valve disease affects millions of people, yet treatment isn’t one-size-fits-all. When surgery becomes necessary, doctors may recommend repairing the existing valve or replacing it entirely. In today’s episode, Dr. Richard Kettelkamp, medical director for St. Luke’s Heart Care Services, returns to the podcast to break down each option, discuss how doctors decide which approach is best, and what it means for patients and their quality of life. 

To learn more, visit unitypoint.org/cr-heart. 

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

Dr. Arnold: 0:00

This is LiveWell Talk on Heart Valve Repair versus I'm Dustin Arnold, Chief Medical Officer at UnityPoint St. Luke's Hospital. Heart valve disease affects millions of people in the States, yet treatment isn't one size fits all. When surgery becomes necessary, doctors may recommend the valve or actually replacing it. In today's episode, Dr. Richard Kettelkamp, Medical Director of St. Luke's Heart Care Services, returns to the podcast to down upon each, discuss how doctors make this decision with their patients, and what is the best approach. Dr. Kettelkamp, welcome back.

Dr. Kettelkamp: 0:34

Thanks for having me, Dr. Arnold.

Dr. Arnold: 0:35

So when we say repair versus replace, you know, I know get into the TAVR of which we've spoken before, etc. But take us through what is a mitral valve, not just mitral valve, but what is a repair.

Dr. Kettelkamp: 0:52

Sure. So and and you bring up a valid point, not all valves can be repaired. Right. And so so it actually happens that the mitral itself for repair in some cases, right? So there are certain sort of disease state, so to speak, that lends itself for a repair. So let's say a patient has uh one of the two the mitral valve that's made up of two little flaps tissue. Uh let's say that that that valve flails, one of the goes past its normal stopping point. Oftentimes that can be surgically repaired. And so, and it's actually there's a preference to do you know, for reasons we can talk about. Um but the mitral valve tends to be that that valve that that is maybe lens itself for repair. Um, stenosis is another example.

Dr. Arnold: 1:45

Narrowing.

Dr. Kettelkamp: 1:46

A narrowing of the valve. And oftentimes we can balloon that open and make it uh function basically back to normal.

Dr. Arnold: 1:54

Because when it comes to the aortic valve, I've never, you know, eat valveoplasty in that replacement, right? Right.

Dr. Kettelkamp: 2:01

There's no there's no uh definitive repair of the valve. The aortic valve is either is replaced, and like you uh balloon valveplasty would be an option, but That's a temporary fix. Once in a while we'll do that in a patient with aortic valve stenosis, who we have to get through And I'll see this scenario in a patient, maybe they they break their hip. They we find that they have severe aortic valve and sort of sort of palliate them, get through through through the hip surgery, we'll do balloon and then deal with the valve after after recovery.

Dr. Arnold: 2:35

So let's talk about the mitral valve for this time. Sure. It's on the left side of the heart, it uh mitral valve and that was a rage during the 80s. Right. Um tell them what how how do you determine whether or not, oh, we're gonna repair this, we're gonna replace this. Sure.

Dr. Kettelkamp: 2:54

Um, so there's different processes at play. So you could have a leaky valve, so they call that mitral valve regurgitation is an example. You could have a valve that is stenotic, which means doesn't open well. And in both of those situations, uh, you could either at repair or replacement. A lot of times repair would be well, generally, if can repair the valve, if if structurally the valve that's the preferred method. We're kind of regardless of the patient's age or medical problems. If you can repair the valve, that tends to have a uh longevity. You know, the if you repair a mitral valve regurgitation for a functional abnormality of the valve, arguably that'll stay repaired forever. Uh, whereas a valve replacement will eventually wear out one rip for one reason or another. So ideally, you could have your valve repaired. Now there are times when the valve can't be repaired. It's just uh, you know, it's thickened, it's what we myxomatous, where it's just the the leaflets are no longer pliable. Right. Um, and you know, we just gonna need to put in a new one.

Dr. Arnold: 4:05

Um are you seeing an increased incidence of microval

Dr. Kettelkamp: 4:10

It seems to be, yeah. Yeah. Um, and and a lot of that's driven by the onset of heart failure. So, you know, people are surviving longer now that we doing all these things to, you know, to bring people from a heart attack and they live longer because of all these heart procedures we're doing. And then a person will eventually develop heart So we're seeing a bigger incidence of that. And as the the left ventricle and heart failure dilates and weakens, that actually pulls the leaflets apart the mitral annulus, this ring that holds the valve leaflets kind of stretch, and then those leaflets pull apart, and then they and then it becomes leaky. And so in a person who has heart failure, a leaky valve actually makes it harder to manage. And so we see recurrent emissions for that. And if we can pull those leaflets together in a process called transcutaneous mitral valve repair, we stave off the heart failure, even make the heart pump

Dr. Arnold: 5:14

Because the thought at one point was that rheumatic fever associated with mitral valve disease, you know, and with advent of antibiotics. Penicillin first used in C rapids is in 1944. Yeah, that people would be treated for rheumatic fever, and then subsequently we'd see less. Right. But that really hasn't turned out to be true. So the all the mitral disease that we blamed on rheumatic uh, which made sense, right? Probably wasn't the case.

Dr. Kettelkamp: 5:45

That that's probably that could be the case. I mean, I think you're you're right, or or maybe we fully understand it, because you you'll see this valvular disease now, and it tends to be, you know, got these thickened calcified leaflets uh that affect the mitral and the uric valves. And when you see that combination, you start oh, this is a rheumatic disease. Right, right. And uh, and you're right, the process maybe wasn't an you know, strep throat or something like that, but it was you know some other process that we don't fully understand. Some kind of inflammatory process of some sort a long-term effect on the valve. Uh, and so rheumat valvular disease, especially as it the mitral valve, often can be treated with balloon which is a position uh a device that's placed inside the left ventricle, pulled back into the opening of the valve and expanded to stretch the um what we call the of the mitral valve to open it up to make it less And that is a rheumatic process. As rheumatic changes occur, the leaflets get thickened, and then and then a repair like that is an od isn't an option.

Dr. Arnold: 6:59

So take us through the if we okay, we've now we decided gonna replace, we're gonna repair the valve. Let's start with that. Uh how can that be done non-invasively?

Dr. Kettelkamp: 7:10

Uh so there's different options without opening Without opening stuff basically. Sure. So so there are options to do it with the catheter There are options to do it uh surgically, and so if you have a um you have microbial regurgitation of the valve, and it's because of a uh functional of the valve. Let's just say a prolapsing leaflet, right? The leaflet isn't stopping this normal spot. If you're a surgical candidate, your your best long-term outcome is to fix that with surgery. And that could be open, it could be less invasive, but it would still require opening. They there are sort of minimally invasive approaches they'll make a little uh incision in the sidewall chest to access or get to the mitral valve. So they can do it in a minimally invasive way, but it's still open, it's still cardiothoracic surgery. So your best bet if you're a surgical candidate for valve repair with regurgitation is a surgical repair. And that could be done in different ways. There are cases where a non-functioning or poorly mitral valve could be fixed with a catheter-based something called, again, transcutaneous mitral valve which would be a clip procedure or something like that pulls those leaflets together with a little of sorts, and that can make the valve less leaky. Those patients tend to be high risk for surgery. Maybe not non-operative, but but high risk, better to uh try to fix it pretty easily.

Dr. Arnold: 8:56

Functional capacity afterwards, it's a mitral valve

Dr. Kettelkamp: 9:00

Yeah, so what you're doing a little bit is you're um mitral valve regurgitation for a little bit stenosis, right? So you're pulling the leaflets together to make them leaky, but you're also making the valve by that uh uh not open quite as much. And typically that's imperceptible, you know. But there is a stopping point. You you really can't, in some cases, the valve is to clip because it'll cause too much mitral valve which is not opening. Um people do very well. Did a procedure yesterday, she's doing great. Her ejection fraction was was uh low, around 20 15 to 20 percent, um a dilated mitral annulus, and and then subsequent turbulent mitral valve regurgitation, heart failure admissions. We put one clip, pulled those leaflets together, we dropped her rigurgitation from severe down to we've already seen her left ventricle shrink and pump improve in remodels.

Dr. Arnold: 10:07

So why this is I don't know the answer this question. I know that surprised you because we know everything I just about everything, but so the mitral valve when it's let's say mechanically, you know, the degree of aptic is of graver or more serious for that to be regulated the aortic.

Dr. Kettelkamp: 10:31

Why is that? It's flow velocity, so um and heart pump function plays a role too, but the flow velocity through the mitral and it's bigger as well, is low, right? So um it's it's going from a low pressure chamber, left atrium, to uh, you know, uh uh you're basically your left ventricle relaxes, it's sort of sucking blood through the right left atrium into the left ventricle. That's how left ventricular filling occurs. And that flow velocity is quite slow. But when the heart squeezes, it's pushing blood out of the aorta at a meter per second, so it's very fast high velocity flow. And if you have stenosis, it's gonna be up to four per second or even higher. So so the flow velocity is what keeps the aortic from becoming thromogenic, basically. Okay.

Dr. Arnold: 11:27

Alright, that makes sense. You know, you always someone has to be up there into for a day or two with an aortic mechanical valve. Wait, don't worry about it. Don't worry about it. But I know Micro, we take that seriously, and I have to I guess, yeah, I never really understood. I knew to do that, but I didn't really understand why. That totally makes sense, full velocity across there. Well, now I officially do know everything now that that been answered. Thanks. I'm glad I can. So I think that's that's an important achievement today for the podcast. Uh JAMA four weeks ago, uh just that tricuspid regurgitation fixed uh catheter approach that and followed those for a couple years. It was very uh successful. Right, right. Triclip event. Have you done one of those?

Dr. Kettelkamp: 12:17

Haven't yet. We're gonna embark on that this year. So we're gonna start. We have several patients, they do do much better. You know, you'll see patients with dilated right or left, which is an impressive outcome of what they at for all those patients.

Dr. Arnold: 12:31

It's huge. So when we talk about heart valve replacement, right? What when when do we go with mechanical made of plastic and metal versus bioprosthetic? Well, how does that decision made?

Dr. Kettelkamp: 12:46

Sure. Um often patient age is a is a big player in that. So so a mechanical valve made of plastic and metal, big the big advantage to that is that it's gonna last arguably. With rare exception, it'll never wear out. Um the downside to a mechanical valve is that uh it's um requires antiquation. Gotta be on blood thinners. So uh most people do fine. Yeah. But uh if you're on it for a lifetime, there'll be a at some point. Right. Um the the other downside to a mechanical valve, kind depending on the position you're putting it in, You're putting it in the mitral position, you're putting it in the ear to position, you have to put it in with heart surgery. There's no other way to get it in there. The bioprosthetic valve is tissue valves, right? Often made of beef or pork tissue, maybe it's tissue, there's there's different types. Um the big advantage to the bioprosthetic valves is that they don't require anticoagulation. And in many cases, they don't require open heart surgery to put in, such in the case of TAVR. Now, in the mitral position, that there are to do that, and it's advancing technology, and I imagine in the next few years we're gonna see that a valve can be placed in all comers in the mitral

Dr. Arnold: 14:13

That'll come, it's you know, it's a few years off. But there are circumstances now where we can do a mitre proposition with a catheter-based approach. And that requires anticoagulation afterwards?

Dr. Kettelkamp: 14:30

No, and that's the big advantage to be like a TAVR, It'd be a TAVR valve.

Dr. Arnold: 14:34

Yeah.

Dr. Kettelkamp: 14:35

So a bioprosthetic valve doesn't require Right. And the downside again for a bioprosthetic tissue is that they don't last forever. Hopefully 10 years, and maybe 15. We're seeing pretty good longevity with the with the valves. They tend to be actually they tend to have more at least in the aertic position, um, because they're

Dr. Arnold: 15:00

What are those leaflets made of?

Dr. Kettelkamp: 15:02

Uh beef or pork. On the TAVR. Uh-huh. Both bovine for the Edwards valve, and it's porcine for the for the Medtronic.

Dr. Arnold: 15:09

And how do they just is is one better than the other? The beef for pork?

Dr. Kettelkamp: 15:13

Uh for longevity? I haven't seen that. You know, again, we've been doing this. Pork is the other white meat. That's right. So there's some advantages there. It's probably better for your collection. Yes. Um, but the uh the uh you know, we've been doing this 2017, it's been almost you know, close to 10 years, I almost have never seen failure on those tapper valves, which is great. You know, in the surgical valves, we saw failure eight years, you know, where the valve needs to be Now, that's not all climbers, but I think part of that is is because the valve is bigger, so bigger is better in this circumstance, and and that's because doesn't have a sewing ring, and so it it's at least millimeters larger than the you know the same-size base valve because it doesn't require a sewing ring, so in that case, your flow velocities are lower, it less trauma on the leaflets and they last longer.

Dr. Arnold: 16:16

Yeah, so it's good to do it. I mean, I know you watch the sewing ring to make sure it leak around it, etc. over time, right? Correct, right? Yeah, um it's been on other podcasts, and it's been the hospital, the new hybrid OR. Take me through how that will contribute to the uh the of our structural heart program.

Dr. Kettelkamp: 16:39

Sure. Um, you know, the advantages to a hybrid OR is a lot it's space, but it's also imaging equipment. You know, we need to do fluoroscopy to be able to see we're doing. We also have to have the ability to do a lot of times echo, which we're where we're taking pictures of the from the backside with a with a echo probe that is in esophagus, so you know we can see the heart in really detail. So the advanced imaging is a big part of this. Um, it's also a full OR, so we'll probably start seeing a little bit more surgical and catheter-based hybrid procedures. Uh, we recently did a uh a percutaneous valve as an open procedure. So Dr. Whitey uh opened and exposed the left atrium looking down on the mitral valve, and then we placed a balloon valve, a catheter base TAVR valve, in the mitral Um and that was that was uh kind of a newer technique to be able to place the valve in a person who has really calcified circumferential uh mitral When you have all that calcium kind of at the annulus, this this ring that I was talking about, um you can't into it because it's so calcium. So then there is that risk that Dr. Whitey would get in there and he'd want to sew in a valve, and it would you couldn't get it in. You couldn't secure it with sutures. And so this was a great sort of approach that allowed woman to get a mitral valve replacement safely. Uh he put a few guiding sutures in, but then just expansion in the mitral annulus made it work and So previously you would you just couldn't do anything those people.

Dr. Arnold: 18:38

So yeah, I know. I've had patients over the years that that was an issue. Right now they nothing. In there and they really couldn't do anything. Right. I know not invasively you have the skill set to do a valve and valve replacement where you similar to the you know, you put in a valve inside the original valve. Correct. It you can do that on the mitral valve as well, correct?

Dr. Kettelkamp: 19:04

Correct. And actually, there's there's other indications. One of the challenges with putting in a valve in the mitral position is that that annulus, I talking about this annulus, this is this ring that is of cartilage that holds the mitral, the native mitral in place, is pretty flexible, right? And so the big advantage to placing a in the aortic position is that's a pretty solid You can place this valve, it it expands outward, and outward radial force holds it in place. In the mitral position, it's not as stable, right? That ring is flexible and the valve will move and potentially embolize. But there are circumstances and situations where put a catheter base valve in the mitral position, and would be a bioprosthetic surgically placed failing. So you could put that in, that's going to hold the valve in place securely. The other situation is a previous repair that's not, you know, continuing to be stable, and they'll often put a mitral annuloplasty ring in, which is a plastic ring they sew in where the annulus is to cinch the valve the native valve up. And that ring provides enough support to put in a valve. And then there's a third situation if there's enough mitral annular calcification. So the situation that I was talking about with with there's enough calcium in a in a let's say at least 300 degrees of circumferential uh circumferential that'll hold the valve in place. So found so can actually be used to advantage. It can in it in this caffeine-rings approach. It has to it has to be an almost fully circumferential bow. Because if you have, like in this poor lady's situation, she had about 240 degrees of heavily calcified mitral but no significant calcium at that in that uh sort of aspect, and so the valve wasn't going to stay stable. And so um this higher approach in her case was a option. But they call that valve and MAC, valve and ring, and and valve.

Dr. Arnold: 21:24

That's the request. You know, I think I never really thought about you know the mitral valve kind of kind of just sits out there freely, you know, on the anterior aspect of the heart, where valve is really packed into a bunch of other structures provide some support. I never really thought about that before until you describe that. Yeah. Um yeah, the the mitral valve is kind of just out there by itself, isn't it?

Dr. Kettelkamp: 21:51

It's kind of no man's life. And it's the new, it's sort of the new um, you know, where I think a lot of focus is going to happen here in the next, like I was saying, in the next few years about how can we enhance our minimally invasive opportunities for mitral valve procedures. You know, clip is being one of the most commonly used catheter-based mitral valve procedures. We've been doing that roughly five years, maybe like five or six years. Yeah. Um and but I but I do anticipate here in the relatively near future that we'll probably be doing more mitral valve replacement procedures. With with there's there's a relatively new device, called the Edwards M3 valve, that there it places a on the inside of the the native mitral valve uh to pre provide some structure for the valve to re to be adhered to. But it also protects the anterior leaflet of the mitral valve from being pushed into the left ventricular tract. Because that's the biggest risk of uh valve in um replacement, is that you'll you'll push that fairly large anterior leaflet into what we call the left alpha tract or the LVOT, and that causes obstruction, then you you have no outflow in the systole out of the aortic valve. Yeah, and that's uh fatal. So you have to address that anterior leaflet, and you have to tear it or you have to um you know somehow cauterize it so that you can open it up to be able to put that mitral valve in in the place. And so this M3 device, which again hopefully will the market relatively soon, captures that and creates a structure to put the valve in. So I imagine we'd be saying this.

Dr. Arnold: 23:52

Isn't that uh SAM or whatever when that my anterior moves?

Dr. Kettelkamp: 23:57

That's when you have a big you know, Holcum hypertrophic obstructive cardiomyopathy where your septum is and and that can create obstruction uh to the left alphabet tract. So it's the same process. Yeah, you know, you'll see this in you know the the of the causes of sudden cardiac death in young is is Holcum hypertrophy. Absolutely a little bit different story, but the same L VO2 obstruction.

Dr. Arnold: 24:22

Yeah. Uh while we're talking about valves, one last question. You know, with the the GLP1s and weight loss. Uh remember the fenteramine. Right. And that there's all the concern about heart valve disease. And we've ever really seen that kind of present where we these uh patients presenting in their 60s and 70s with that may have been related to penteramine.

Dr. Kettelkamp: 24:50

You know, I don't think that's really played out. Yeah, that's been my experience. And and you know, it was it was focused kind of kind of on the pulpit valve, which is interesting. You know, it was that was the big thing. And it was kind of the in-vogue. Yeah, you know, it was like microvile prolapse in the This this fin fin thing was you know really big in the early, you know, you know, the early 2000s, and everybody was going after. In fact, there were lawsuits. Oh, yeah, yeah, yeah. And it it I don't think it's played out, you know. Um you we go off topic a little bit, but the GLP a really interesting topic, and and I and I don't want to you know circumvent your podcast, but but a drug that came out uh probably probably 30 years ago that was a revolutionary drug that that was cardiovascular risk more than any other drug on the at the time. That was a statin. So lipidord came along, and all of a sudden it cardiovascular risk. There has not been a drug until now that's had the same impact on cardiovascular risk until the GOP along. And that's because they they do a multiple multitude of effects to lower risk, and that's you know, lowers lowers blood pressure, uh, it lowers you know metabolism, improves sugar metabolism, um, sleep apnea uh you know enhances that uh obviously activity is but it's also has an inflammatory effect, effect.

Dr. Arnold: 26:20

Yeah, it and actually the and maybe that's a good idea for future podcasts. The in Europe, the effect on alcoholism. Oh, interesting. And the cravings for alcohol and nicotine go down with the GLP ones. Interesting. That you know, there's trials going on now for smoking For for alcoholism interesting uh to abate that. Very cool. Yeah, I didn't know that. Yeah, it's fascinating stuff. Um, and that's a good topic for future podcasts. There you go. Dr. Kettelkamp, thanks for joining me and sharing with our about heart valve repair versus replacement. Once again, this is Dr. Richard Kettelkamp, Medical Director for St. Luke's Heart Care Services. To learn more, visit unitypoint.org backslash CR Heart. Thank you for listening to Live Well Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a review and tell your family, friends, neighbors, about our podcast. We're available on Apple Podcasts, Spotify, Pandora, or you get your podcast. Until next time, be well.