11 minute read
heart valve therapies
Expanding the Field of Transcatheter Heart Valve Therapies at Cleveland Clinic Florida
By Emad Hakemi, MD, MS
Until recent years, open-heart surgery has been the standard of care for most patients with valvular disease, including aortic stenosis. However, minimally invasive procedures such as transcatheter aortic valve replacement (TAVR) and MitraClip™ have emerged as safe and effective minimally invasive alternatives for patients with advanced and complex valvular disease. Through Cleveland Clinic Florida’s Structural Heart Disease Program and Multidisciplinary Valve Clinic, our team of interventional cardiologists provides innovative, multispecialty care and access to the industry’s most advanced technology and procedures, including the use of balloon-expandable transcatheter valve bioprosthesis for patients with degenerated mitral valve bioprosthesis or failing mitral valve repair.
Figure 1: Transcatheter aortic valve replacement in patient with severe aortic valve stenosis.
Figure 2: Transcatheter aortic valve replacement in patient with degenerated prior aortic bioprosthesis.
Transcatheter Aortic Valve Replacement (TAVR)
In recent years, the minimally invasive TAVR procedure has revolutionized the management of valvular heart disease. A multitude of studies has shown TAVR to be a safe and effective alternative to traditional valve replacement. TAVR is available for patients of all risk levels with severe aortic stenosis, including those with degenerative aortic bioprosthesis stenosis or regurgitation.
At Cleveland Clinic Florida, TAVR is routinely performed using a minimalistic approach. With the patient under local anesthesia and mild sedation, a new valve is inserted within the diseased valve through percutaneous transfemoral access. This approach provides patients with an expedited recovery with early discharge at one to two days. Our specialists have more than 10 years of experience with TAVR procedures, and the center performs among the highest volume of implants in Florida. Our expertise in structural heart disease combined with an extensive experience in TAVR translate to the best possible patient outcomes.
Transcatheter Mitral Valve Edge-to-Edge Repair
The transcatheter mitral valve edge-to-edge repair procedure has evolved to become an important solution for patients with mitral regurgitation for whom medical therapy fails. Initially approved for non-surgical candidate patients with severe degenerative mitral regurgitation (MR), this therapy is now also available for those with functional mitral regurgitation. In the multicenter randomized COAPT trial of patients with severe functional MR, this therapy resulted in marked improvement in survival, hospitalizations and heart failure class. MitraClip™ is presently the only FDA-approved transcatheter therapy for this indication. The procedure is performed under general anesthesia using 3D transesophageal echocardiography. Following transeptal access, the MitraClip is delivered to create a double orifice mitral valve that reduces the severity of the mitral regurgitation. One or more clips may be necessary. The device has been shown to provide benefit and improvement in survival and quality of life when used in patients with reduced heart function.
Figure 4: Transcatheter mitral valve replacement in patient with degenerated mitral valve bioprosthesis. Figure 3: A transcatheter implanted clip improves coaptation of the mitral valve leaflets.
Transcatheter Mitral Valve Replacement
The use of balloon-expandable transcatheter valve bioprosthesis has been broadened to cover patients with degenerated mitral valve bioprosthesis or failing mitral valve repair.
This groundbreaking minimally invasive procedure is done under general anesthesia, and the femoral vein is used to advance a transcatheter bioprosthesis through the inter-atrial septum into the left atrial cavity. From there, the valve is positioned and deployed within the degenerated mitral valve bioprosthesis or mitral valve ring. Patients benefit from the less invasive nature of this therapy with a faster recovery in comparison to the extensive surgery that had traditionally been performed, which required repeat sternotomy for redo mitral valve replacement.
Dr. Hakemi hakemie@ccf.org
Coronary Bypass Surgery in a Beating Heart
By Mariano Brizzio, MD
Coronary artery bypass grafting (CABG) surgery was developed more than 50 years ago. Rene Favaloro, MD, a pioneer of the surgical technique, published the world’s first reported CABG in 1968 at Cleveland Clinic. CABG surgery withstands the test of time: Few other therapies have long-term outcomes for report 20 to 30 years later.
Good results in CABG surgery in selected centers are a function of appropriate patient selection and a systematic approach to the surgical technique that is based on meticulous construction of a conduit-coronary anastomosis and efficiency in the management of the operation.
Expeditious and accurate performance of coronary anastomosis was imperative at a time when the best a surgeon could do to minimize myocardial injury was to reduce the period of ischemic time. The introduction of the systematic use of cardioplegia combined with retrograde delivery techniques in the 1980s leveled the playing field. These techniques allowed surgeons the opportunity to operate using the cardiopulmonary bypass machine in an arrested heart, thereby eliminating the pressure exerted by the original techniques. In this context results improved, and the operation was accepted, making it a significant treatment in the management of patients with coronary disease.
Benefits of off-pump CABG surgery
However, CABG surgery was impacted in the late 1990s by the introduction of off-pump techniques – performing coronary bypasses without the utilization of extracorporeal circulation. Later, a few publications including randomized clinical trials have shown no difference in results between off-pump and conventional coronary bypass.
Still, there is a select group of patients for whom off-pump CABG techniques are a better option.
Many publications have demonstrated the disadvantages of extracorporeal circulation in patients with the following: compromised renal function preoperatively, calcified ascending aortas, depressed pulmonary function and significant cerebrovascular disease. These patients definitively would see benefit from an off-pump CABG approach.
The off-pump technique also has been demonstrated to decrease both blood product transfusions and the incidence and severity of postoperative stroke. At Cleveland Clinic Indian River Hospital, the off-pump CABG technique is utilized routinely due to our particularly elderly population with complex coronary disease and multiple co-morbidities. We have had a 0 percent mortality rate in the last year and hold a 3-star rating by the Society of Thoracic Surgeons for isolated CABG procedures.
Soft stabilizer facilitates construction of coronary bypass anastomosis during beating heart surgery.
Dr. Brizzio began practicing at Cleveland Clinic Indian River Hospital about a year ago. Since then, he has performed more than 100 CABG procedures, most of which were off-pump. Dr. Brizzio’s experience over the past 14 years includes more than 900 CABG procedure, with the majority being off-pump.
Dr. Brizzio brizzim@ccf.org
Enhanced Operating Rooms Accommodate Multispecialty Use While Improving the Patient Experience
By Philip Bongiorno, MD
New surgical techniques and advanced technology require the modern operating suite to easily accommodate multiple specialists working alongside each other. Cleveland Clinic Florida Weston Hospital’s five-story, 221,000-square-foot expansion wing has allowed the space for three enhanced operating rooms to fill this need -- giving our surgeons access to the additional room along with the necessary technology including robotic surgical platforms, angiography and an array of mechanical circulatory support options. The evolved ORs are in close proximity to the intensive care units and create an efficiency in patient transport and enhanced patient safety. Each features almost 1,000 square feet of open floor space created by overhead booms that lift lights, monitors and equipment off the floor. The additional space is welcomed by the OR staff, surgical residents and medical students, and is key for moveable equipment such as the surgical robots and mechanical circulatory support machines.
Our surgeons are enthusiastic about the enhanced facilities and how they will allow us to continue to provide the highest quality care for our patients. Ultimately, the new ORs will optimize surgical scheduling and provide the ability to care for more patients at Weston Hospital. They also may help with shorter patient transport and anesthesia times and, possibly, shorter hospital stays for patients.
Dr. Bongiorno bongiop@ccf.org
Enhanced Recovery After Cardiac Surgery Provides Many Perioperative Benefits and Favorable Long-Term Outcomes
Two years ago, the Cleveland Clinic Florida Heart, Vascular and Thoracic Institute (HVTI) cardiac team at Weston Hospital was among the first in the nation to adopt a revolutionary approach to all open-heart procedures – enhanced recovery after cardiac surgery (ERACS).
Colorectal surgeons began using the enhanced recovery after surgery (ERAS) approach about a decade ago. Since then, many other specialties, such as orthopaedics, have begun to use it and adapt it to their needs. Cardiac surgery has recently joined the ERAS Society with cardiac surgeons’ own guidelines proposed by the Cardiothoracic Surgery Task Force.
The goal of ERACS is to promote healing and optimize recovery by enhancing the ability for patients to get back to their baseline levels faster postoperatively.
While Cleveland Clinic Florida Weston Hospital cardiac anesthesiologists have been using components of the ERACS during their practice for some time now, ERACS requires the participation of many other types of practitioners in the pre- and postoperative period to maximize its effect.
“It is important to take a multimodal, multidisciplinary approach to ERACS for perioperative care because 80 percent of preventable perioperative morbidity occurs outside of the operating room,” says Tatiana Jamroz, MD, Section Head Cardiothoracic anesthesiologist at Weston Hospital.
Cleveland Clinic Florida HVTI anesthesiologists’ experience in ERACS is the foundation for ERAS protocol development across several surgical specialties within the Anesthesia Institute at Cleveland Clinic Florida.
Reduced narcotic use improves recovery process. Traditionally, cardiac anesthesia was opioid-based and patients generally stayed in bed for two to three days postoperatively. ERACS intraoperative protocols limit opioid use and its side effects.
Excellent analgesia can be obtained with a combination of non-opioid medications (e.g., ketamine, lidocaine, dexmedetomidine) and regional anesthesia of the chest wall under ultrasound guidance. Around-the-clock acetaminophen is used pre- and postoperatively unless contraindicated.
Williams JB, McConnell G, Allender JE, Woltz P, Kane K, Smith PK, Engelman DT, Bradford WT. One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program. J Thorac Cardiovasc Surg. 2019 May;157(5):1881-1888. doi: 10.1016/j.jtcvs.2018.10.164. Epub 2018 Dec 8. PMID: 30665758.
The specifics of multimodal analgesia may vary among patients, depending on different procedures, patient comorbidities and local resources.
The ERACS approach allows for earlier extubation and earlier mobilization of the patient after surgery, thereby also reducing the risk for blood clots and pulmonary complications. Average length of stay is shortened and complications are reduced, according to the ERAS Cardiac Society.
Active participation from patient and loved ones is important before and after surgery.
“Patients’ families and their caretakers must be active supporters and participants in the ERACS protocols in the pre- and postoperative periods to achieve optimal recovery for the patient,” according to Dr. Jamroz. When patients are actively involved in pre-procedure optimization rather than waiting fearfully and anxiously for the operation itself, better postoperative outcomes result.
Future goals of ERACS at Weston Hospital will include optimizing patients’ nutrition, blood glucose and hemoglobin levels before surgery to achieve the best outcome. In addition, identifying patients who may be at highest risk of postoperative complications (e.g., frail patients and patients on a cognitive decline trajectory) will allow proper diagnosis and early intervention if necessary postoperatively.
The postoperative course is also important for faster recovery after cardiac surgery. Close coordination of care, with the ICU team focusing on proper hand-off to highly skilled nursing staff, makes a substantial difference in the patient’s recovery. Our ERACS patients are identified during hand-off and generally are extubated within four to six hours after surgery.
Proper selection and identification of patients for ERACS protocol prior to surgery is important to allow time for health optimization. The involvement of patients, families, surgeons, anesthesiologists, intensivists and nursing staff is the only way toward a successful implementation of ERACS protocol.
Dr. Jamroz jamrozt@ccf.org
- Tatiana Jamroz, MD
Cardiac anesthesiologists provide highly specialized care
Due to an expansion in the number of cardiac procedures we offer (including growth in the heart transplant program, and heart failure therapy, and the many transfers from hospitals in the region), as well as advances in the field of cardiac surgery and structural interventional procedures, we felt it was important for Cleveland Clinic Florida Weston Hospital to have a dedicated team of cardiac anesthesiologists. From about 20 anesthesiologists we selected seven with formal cardiac fellowship training to create our team. Weston Hospital’s cardiac anesthesiologists focus on technical excellence and fast clinical judgement in critical scenarios and have experience and clinical knowledge of mechanical circulatory support for the treatment of heart failure. They are board-certified in perioperative echocardiography to allow for a highly specialized monitoring method. Their expertise in perioperative echocardiography also is used for diagnosis to aid in surgeon decision-making. The cardiac anesthesia team works together to reduce variability in outcomes by:
• concentrating a higher volume of specialized surgeries to a dedicated group of fellowship-trained professionals
• allowing for a focused interest on research and advances in the specialized care of cardiac surgical patients
• standardizing easily achievable perioperative practices across small teams
• building operating room teams consisting of surgeons, nurses, perfusionists, anesthesiologists, assistants, technologists and technicians because operating room performance depends on a team’s expertise and experience, as well as communication and teamwork
• collaborating closely with critical care specialistsintensivists to provide for a smooth transition in care in the postoperative period
• establishing a specialized team to ensure that highly trained cardiac anesthesiologists are available year round on weeknights, weekends, holidays and every day.
