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Ep. 106 - LiveWell Talk On...Transcatheter Mitral Valve Repair (Dr. Aref Bin Abdulhak)

episode 106

Ep. 106 - LiveWell Talk On...Transcatheter Mitral Valve Repair

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Aref Bin Abdulhak, cardiologist, St. Luke's Cardiology

Dr. Arnold:
This is LiveWell Talk on transcatheter mitral valve repair. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Typically patients with mitral valve issues in the heart, must undergo open-heart surgery for repair. A new minimally invasive procedure performed at St. Luke's is now available. Joining me today to discuss this procedure is Dr. Aref Bin Abdulhak, a cardiologist with St. Luke's Cardiology Clinic. Welcome.

Dr. Bin Abdulhak:
Thank you. Thank you for having me.

Dr. Arnold:
Always good to see it. We go back, you worked at the hospital's program back in the day, and we were always happy to have you here. So what exactly is, I mean, for people listening or watching. The mitral valve is a valve in the heart named after the Mitre, like the Pope's hat, the shape of it. But what causes the valve to be diseased? And then, kind of give us an overview of what the repair entails. And then during this broadcast, we'll have some pictures of just some graphics of what it looks like. So that'll be a little bit easier to describe with those. So, just take us through why the does this valve become diseased?

Dr. Bin Abdulhak:
Sure. So, as you said, the mitral valve is one of the four valve of the heart, and it's the valve that connect the left upper chamber of the heart to the left lower chamber of the heart. The blood is coming from the lung to the left upper chamber of the heart, and it gets pumped through the mitral valve, to the left lower chamber of the heart. Then from the left lower chamber of the heart, to the rest of the body, through another valve. So it's one of the major valve in the heart. It has two leaflets and it can get diseased primarily due to two main, what we call them, pathologies, or two main processes. One of them is the degenerative change in the valve. And the second most important process that the valve gets diseased, is when the left lower chamber of the heart gets dilated from whatsoever other disease processes. And the valve will also be separated and the valve leaflet itself will not come together, then the valve will start leaking. And at that point of time, the patient may have trouble because of the leaky valve.

Dr. Arnold:
Okay. And what are some of the symptoms that a patient might experience?

Dr. Bin Abdulhak:
Typically shortness of breath, like symptoms of congestive heart failure. Shortness of breath, fatigue, tiredness, they are not able to get into their usual activity, they will be easily tired, and easily short of breath.

Dr. Arnold:
I used to always, when I would see patients and they were born before the advent of penicillin, then you can almost assume that they probably had some degree of rheumatic fever and more susceptible to vascular disease, correct?

Dr. Bin Abdulhak:
Correct.

Dr. Arnold:
Yeah.

Dr. Bin Abdulhak:
Rheumatic fever, it can certainly affect the mitral valve to some degree. It usually causes a narrowing of the valve, but regurgitation or a leaky valve can happen due to romantic view for as well. Or, can happen due to the consequences of the rheumatic fever, after the valve leaflet itself gets some sort of calcium on the valve and they do not get approximate together. Then the valve will start leaking, but that's very correct.

Dr. Arnold:
So, I mean, the issue here is you have a valve that is supposed to close to allow blood to move forward in the circulatory system. And it's not closing.

Dr. Bin Abdulhak:
That's right. When we are talking about the mitral regurgitation or leaky valve, that's the simplest term to describe the process.

Dr. Arnold:
And you have a way to fix it without cutting the patient open. Tell us about that.

Dr. Bin Abdulhak:
That's right. And it's, as you say, it's a minimally-invasive procedure, we do it here at St. Luke's. And typically we go from the groin, the patient will be completely asleep. With the catheter, we cross from the right side of the heart to the left side of the heart, then we'll deploy, what we call the clip, the mitral clip. And it's basically just to get the two leaflets approximated together to decrease the amount of leak. It typically takes somewhere between one hour to two hour procedure. Typically they spend the night in the hospital and they can go home next day. And in very rare instances, they may go home the same day if we're able to do the procedure super early in the day. But typically we prefer to keep them one night or two night in the hospital.

Dr. Arnold:
I think the first question that you're going to get after this is, did they have to take blood thinners after this procedure?

Dr. Bin Abdulhak:
Not the classic term of the blood thinner. Typically we would like them to be on what you call them, anti-platelet, like an aspirin and additional antibiotic therapy for variable amount of time. But if they are taking a blood thinner, say for something else like an abnormal heart rhythm, we tend also to continue that because they will need it for other indication.

Dr. Arnold:
Okay. And that would require that they have antibiotic prophylaxis with dental procedures, correct? This is if they have a mitral valve clip?

Dr. Bin Abdulhak:
That is correct. It's a still debatable issue, but we tend to treat the mitral valve like a tougher procedure. When they are going to a dentist, we will typically ask them to take an antibiotic prophylaxis.

Dr. Arnold:
And I mean, I've been in practice almost 25 years now, and I've seen that pendulum swing from 2007 and beyond of yes, you need antibiotics. No, you don't. All it takes is one patient in your career that had dental work, had a prosthetic knee that gets infected. And you know, then you're stuck the rest of your career because of that one case. You don't want to let that miss. So, now the valve that wasn't closing and allowing this blood to go backwards, now it's approximating or coming closer together, if not completely closing appropriately. What benefit would the patient feel to that?

Dr. Bin Abdulhak:
Well they will feel better, or that's the prospect that we would like them to feel better. And most of them, they will feel better. More importantly, or almost as equal as important to feeling better, their quality of life will be better. They may gain some additional years of life, what you'd call a survival benefit for this procedure. The landmark trial, the co-op trial has shown that this procedure adding additional years of life to the patient. So it's not only about—which is extremely important symptoms and control, as well as improving quality of life. This procedure may have an additional benefit of survival, adding survival to the patient's life.

Dr. Arnold:
And what patients are going to benefit? I mean, are there patients that you're going to see in clinic and go: No, we have to do it open traditional valve replacement, which requires surgery. Or, do you say: Hey, I think we can do the mitral valve clip. How do you break those two?

Dr. Bin Abdulhak:
It's typically a team approach. We tend to see the patient with the surgeon. Side by side with the surgeon, and we decide who goes for surgery and who goes for mitral clip. Typically those with what you call it, secondary mitral regurgitation, or those that they have the leaky valve due to a problem in the left lower chamber of the heart or the left ventricle, we would prefer to do those by the minimally invasive procedure, which is the mitral clip. That's the substrate, or those are the subjects or the population of the patient that we have from the co-op trial. Now, if the valve is diseased due to a degenerative process, typically we send them first to be seen by the surgeon before contemplating the clip. And for whatsoever reason, if they are high-risk for surgery for too many reasons, then we will try to treat the valve with the clip.

Dr. Arnold:
And is there timing here? With like with aortic regurgitation and leaky aortic valve, you know, there's— You don't want to wait too long. Is that the same with the mitral?

Dr. Bin Abdulhak:
That is correct. You don't want to wait too long and you don't want to act too soon, too. So for example, patients with secondary mitral regurgitation due to heart failure, like the valve leaflet itself, they are not diseased, but they are not approximating together because the left lower chamber of the left ventricle is dilated and they are separated because of that process. We would like them to be on optimal medical therapy, followed by a cardiologist in their clinic. They are very much optimized by the medication. And if they remain symptomatic despite all of this, then we will contemplate the mitral clip procedure.

Dr. Arnold:
Well this is really great information. And I think there'll be more to come with the structural heart program here as technology advances. That that's been one of the—I think any physician that gets, you know, after 20 years in practice and as they near, you know, the late years of their practices, are always just amazed at the progress that happens. You know? And we're glad to have you here to bring that technology to the forefront. Thanks for taking time to talk about this new procedure and technology. Again, this was cardiologist Dr. Aref Bin Abdulhak with St. Luke's Cardiology Clinic.

Dr. Bin Abdulhak:
Thank you for having me.

Dr. Arnold:
Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.