Structural heart disease is the newest field of interventional cardiology to offer hope to many extremely sick patients who are not candidates for surgery while reducing recovery time for those who are candidates.
The field of structural interventional cardiology was first developed with transcatheter balloon dilation of the mitral valve, followed by the introduction of new catheter-based techniques to close congenital defects like atrial septal defects (ASD) and patent foramen ovale (PFO). Since the launch of transcatheter aortic valve replacement (TAVR) therapy around 15 years ago, the field has been in continuous progression. Each generation of TAVR, as well as the continuous development and addition of new technologies, like MitraClip and transcatheter mitral valve replacement (TMVR) for patients with mitral valve disease, keep adding new horizons and offering more hope for the thousands of patients who need urgent and complex care.
By Zaher Fanari, MD, FACC, FSCAI
Medical Director, Structural Heart Disease at Wesley Medical Center
Interventional Cardiologist, Structural & Endovascular Specialist, Heartland Cardiology
Transcatheter Aortic Valve Replacement (TAVR)
TAVR has proven to be a great approach that is superior to medical therapy for patients who are not candidates for surgery. It also provides a less-invasive and equally effective alternative to surgery for patients of advanced age and those with medical problems and defined as high and intermediate risk. Many trials are currently underway to see if TAVR should be used in all aortic stenosis patients. Women with all types of risk profiles are showing especially promising results.
Patients who undergo TAVR usually recover faster and leave the hospital within a few days of the procedure. In most cases, they are able to return home and spend time with family instead of going to a rehabilitation facility. TAVR offers a faster route to get patients back to their normal lives.
Another future development in structural heart disease is the introduction of MitraClip. MitraClip is a new catheter-based procedure that provides an option for patients with severe mitral regurgitation (leaking of the mitral valve). This procedure works by pulling the two parts of the valve together and making the leak less significant. Although MitraClip does not replace the valve like TAVR does, it still offers a great opportunity for patients to breathe better and live their daily lives without having to suffer. In many cases, the MitraClip allows the heart systolic to recover and get stronger.
Transcatheter Mitral Valve Replacement (TMVR)
Another great development, TMVR, is similar to TAVR. TMVR offers a less-invasive approach for valve replacement in patients with severe mitral stenosis and regurgitations.
Even older technologies like PFO closure are again gaining new grounds. After years of controversy about the possible benefit of PFO closure in stroke prevention, many emerging trials now show PFO offers a great potential for protecting patients with TIA or those at higher risk of stroke from recurrent events. Left atrial closure with either WATCHMAN or AMPLATZER Amulet also offer similar hope to protect against stroke in high-risk patients with atrial fibrillation who are not candidates for long-term anticoagulation.
Although many of these procedures are new and emerging without long-term data, they are helping patients on daily basis and offer a chance for improved quality of life or protection from potential disabilities that may worsen it. In many cases these procedures, especially TAVR, offer real lifesaving options.
Despite all the growth in this exciting field, it was estimated in 2013 that only 25 percent of potential patients who may benefit were getting referred. This deprives many patients from important care that is widely available. This deficiency can hopefully improve with better communication between structural programs and the physician referral base. This communication, coupled with the continuous improvement in structural procedures and their outcomes, will hopefully encourage primary care providers, hospitalists and general cardiologists to consider structural clinics as a resource to help deliver much-needed care for vulnerable and complex patient populations.