Medical science has advanced to a great degree in the last two decades, and techniques, processes, and systems have evolved to a large extent these days that almost all patients are assured that they will get the best treatments for most diseases and conditions.
This is especially true with diseases of the heart. Surgery, medication, and minimally invasive procedures have allowed more and more patients to access critically important treatments, extending lifetimes and improving quality of life. To aid doctors, equipment and facilities, such as the cathlab, have been developed and refined to an extent that a doctor can see right into a patient’s heart without making even a single cut.
At Apollo Hospitals in Chennai, Dr. Y Vijayachandra Reddy, and the other Cardiologists are especially skilled at providing the very best of modern heart disease and heart attack management procedures to a large section of the population.
One very important procedure that Dr. YVC performs, is the Trans-Catheter Mitral Valve Replacement, or TMVR.
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The Mitral Valve is a critical unit of the heart. It is situated in the left ventricle of the heart, and regulates the flow of blood between the left atrium (upper left chamber of the 4-chambered heart) and the left ventricle (the lower left chamber of the heart). The blood must flow from the upper chamber to the lower chamber, that is, from the Left Atria, to the Left Ventricle, from where the blood is pumped into the main aorta which then supplies the rest of the body. Any change in the way the valve opens and closes, or any leaks and gaps in it, could be fatal.
As with many other heart ailments, the Mitral Valve loses its elasticity or ability to open and close properly, due to aging, or due to stenosis - deposits that collect over the valve. Additionally, long term diseases such as Rheumatic Fever or Rheumatic Heart Disease could affect the Mitral Valve, causing it to develop leaks or regurgitations.
This could lead to severe breathlessness, fatigue, heart murmurs, palpitations and heart racing. And must be immediately fixed.
TMVR - The next stage of evolution in treating Mitral Valve
Surgery was the only treatment available for Mitral Valve repair. Complicated and risky procedure, it required doctors to open the patient up, make a huge cut in the rib cage to allow access to the heart, and then repair the valve, or in many cases, replace it.
However, advances in surgical procedure has meant that Mitral Valve replacement can be done with minimally invasive cardiac surgery (MICS). At Apollo, MICS is extensively practiced, allowing for better patient outcomes.
A further evolution in the MICS procedure, is the Percutaneous Coronary Intervention (PCI) based Transcatheter Mitral Valve Replacement. This procedure involves absolutely no surgery or cuts, with doctors making only a small needle entry in the femoral artery (near the groin) and accessing the heart via catheters.
Once the wires reach the heart, and the valve, Dr. YVC deploys a replacement valve that will take over the functions of regulating blood flow. Doctors will then check to see if everything is working as they should be, and satisfied, will remove the catheters, and seal the opening.
“The Transcatheter Aortic Valve Replacement (TAVR) has been a routine, now well accepted procedure around the world since 2002. But the Transcatheter Mitral Valve Replacement procedure is very different. Because this valve, a natural valve may not be suitable for a replacement,” says Dr. YVC.
But since 2013, few refinements in the procedure, and newer technologies and valve models, are allowing doctors to consider this as a viable procedure.
However, Dr. YVC cautions, patients have to be carefully selected, and all options must be discussed with them so they know the risks, the benefits, the costs, and are able to arrive at a well-informed decision.
The TMVR procedure is suitable only to replace a valve that has already been replaced, says Dr. YVC.
That is, a patient who has already undergone a surgical mitral valve replacement or a minimally invasive mitral valve repair or replacement procedure, who now faces a situation when the repaired or replaced valve is beginning to malfunction again, may be advised to go for a TMVR.
Only a few 100 such procedures have been performed worldwide, in the last 4 years. “The technology is still in evolution. There is one group of patients where it is well accepted. If someone has been given a bioprosthetic (tissue) valve in an earlier surgery, and that also is degenerated, then TMVR is an option,” he says.
Two choices, one result: longer life
There are two kinds of replacement valves available. The bioprosthetic or tissue valve, and the mechanical valve.
A bioprosthetic valve is made out of animal tissue. Bovine pericardium, or porcine aortic valves are the two most commonly used bioprosthetic valves. The tissue valves usually last for up to 10 or 15 years, but will begin to degenerate after that point. This means, patients who receive bioprosthetic valve replacements will need to go back to the doctor for a newer valve.
Mechanical valves are constructed out of a pyrolytic carbon leafs, or other alloys that are safe for human bodies. While the mechanical valve is enduring and will last the lifetime of the patient, it requires the patient to go on anti-coagulant drugs or blood thinning drugs. Mechanical valves could have blood clots forming inside them, which can then be transported into the heart, or to other parts of the body, causing strokes or death. Careful use of anticoagulants and life-long care must be taken for patients with mechanical valves. “Any error in anti-coagulant use or mismanagement, is fatal,” he says.
Dr. YVC takes especially great care to give his patients all this info. For younger patients who have already gone through surgical mitral valve replacement, he advices a mechanical valve replacement during the TMVR process. 10-15 years of life for a bioprosthetic valve does not make sense, he believes.
“The first, and major advantage in TMVR,” says Dr. YVC, “is valve in valve replacement.” In this process, a new mechanical or bioprosthetic valve is deployed over the existing valve and positioned over it accurately. This is especially useful and has good results, for middle aged and older patients who may not be suitable for surgery.
“The first case of TMVR was done by us,” says Dr. YVC. There are two further techniques in the TMVR procedure. Totally Percutaneous Transseptal technique, and the Transcervical technique. In the latter process, a surgeon makes a small incision in the chest of the patient, and places a “purse string” suture around it. Through the opening, doctors introduce guide wires and catheters, which then deploy the replacement. Once the replacement valve is set in place, the wires are removed, and the purse strings are tightened to seal the opening.
In the transseptal procedure, doctors approach the heart through a needle entry in the groin, and enter the heart through the right side, and access the mitral valve through the septum puncture.
Whatever the option a patient finally chooses, TMVR is an important, and life-saving procedure that allows patients to get a new lease of life.