Rare Aortic Valve Surgery at UMMC Restores Health to Man Who Was Barely Alive
For immediate release: October 01, 2007
Aortic valve bypass successfully treats obstructed valve in very high-risk patients
Cardiac surgeons at the University of Maryland Medical Center have revived and modified a rare, aortic valve bypass procedure for older, high-risk patients whose blocked aortic valve has caused life-threatening symptoms of shortness of breath, fainting or chest pain. In a recent case, they successfully treated an 87-year-old man who had been told he had, at most, two weeks to live.
The aortic valve controls the flow of blood from the heart's main pumping chamber, the left ventricle, to the aorta, the artery that supplies blood to the rest of the body. In a condition known as aortic stenosis, calcium deposits narrow or block the valve and impair the heart's ability to pump blood. Aortic stenosis is the most common heart valve disease of the elderly in the United States. More than 50,000 patients in the United States require surgery for aortic stenosis each year.
Sylvan Naron had put off a recommended aortic valve operation in 2005 to care for his wife, who had had a series of mini strokes. On March 24, 2007, Doris, his wife of 62 years died. Two days later, Mr. Naron went to Baltimore to see his family physician and received devastating news””he had less than two weeks to live. By then, his faulty aortic valve caused fluid to accumulate in his lungs and legs. The reduced flow of oxygenated blood made him extremely tired. He had also lost weight and strength.
He was hospitalized with a month-long recuperation to stabilize his condition and build up his strength with the hope that he could undergo surgery. Even with this effort, surgeons at both the University of Maryland Medical Center and a Baltimore County hospital felt that he was not healthy enough to survive standard aortic valve replacement.
According to David Zimrin, M.D., director of cardiac catheterization at the University of Maryland Medical Center and assistant professor of medicine at the University of Maryland School of Medicine, “My first impression was he was not going to survive much longer. He was so thin. He had cardiac cachexia, a rapid weight loss and wasting away, associated with heart failure.”
Aortic valve replacement surgery is typically an open heart procedure that requires the patient to be on a heart-lung machine for up to two hours. The long recovery can pose a risk for a weakened, elderly patient, and the heart-lung machine has been linked to strokes and memory loss. The concern, says Dr. Zimrin, is that in a high-risk patient such as Mr. Naron, “You replace the valve successfully but the patient dies.”
To help Mr. Naron, yet avoid the risks of valve replacement surgery, Dr. Zimrin and Medical Center cardiac surgeon James S. Gammie, M.D., developed a staged treatment approach that proved successful: provide initial, temporary relief to the ailing aortic valve, build up Mr. Naron's strength, then perform an alternative to conventional aortic valve replacement surgery””aortic valve bypass surgery.
First, Dr. Zimrin and Peter A. Reyes, M.D., a cardiologist at the University of Maryland Medical Center and an assistant professor of medicine at the University of Maryland School of Medicine, performed a minimally invasive procedure called a valvuloplasty, during which a balloon attached to a thin, flexible tube or catheter opens the aortic valve, breaks through the calcium buildup and makes a larger space for blood to pass through.
Mr. Naron had no complications and almost immediately began to feel better. But in about three weeks, there was evidence that the valve was beginning to narrow once again, a common occurrence after valvuloplasty. However, those weeks of recovery enabled him to regain his strength so that he could be referred to Dr. Gammie for aortic valve bypass surgery at the University of Maryland Medical Center.
Dr. Gammie, who is also an associate professor of surgery at the University of Maryland School of Medicine, says his interest in the bypass procedure began about four years ago when he faced a similar very high-risk patient. Research indicates that the outcome for valve replacement in sicker, older people with a blocked aortic valve is not as good as in younger patients. According to Dr. Gammie, “It's been shown that in people over the age of 75, the death rate for aortic valve replacement is about 10 percent.”
Dr. Gammie investigated a bypass procedure, originally called an apicoaortic conduit, which had been developed in the 1970s by Dr. John Brown, the chief of surgery at Indiana University. The procedure was originally used in children. Dr. Gammie called the surgeon, learned more about it, and went forward with the first case.
Dr. Gammie performed that first case in 2003 with Bartley P. Griffith, M.D., chief of the Division of Cardiac Surgery at the University of Maryland Medical Center and a professor of surgery at the University of Maryland School of Medicine.
To perform the bypass procedure, surgeons place a tube, one inch in diameter, from the apex of the left ventricle, the pointed tip at the bottom of the heart, to the aorta, the main blood vessel at the back of the chest. Inside the tube is a standard replacement valve which will do the work of the patient's defective valve. Instead of replacing the patient's narrowed aortic valve, aortic valve bypass surgery opens a new pathway for blood to leave the heart. Nearly 30 patients have undergone the procedure at the University of Maryland Medical Center.
Dr. Gammie says that, in most cases, the surgery is now performed without stopping the heart and without the heart-lung machine, which decreases the risk of complications. Mr. Naron's procedure was performed with his heart still beating.
Dr. Gammie also avoids opening the entire chest. Instead, he works through an incision on the left side of the chest. “This is a great advantage for people who have had previous heart surgery where the chest was opened and scars have formed. We can avoid all the scar tissue and speed up the patient's recovery,” says Dr. Gammie.
Sylvan Naron, who continues to build up his strength with daily rehabilitation sessions, is well on the road to recovery and looks forward to returning to his golf game, his favorite lifelong pastime later this year. “It's terrific that I'm still around,” he says.
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