Dr. Xavier Ruyra Baliarda is a specialist in cardiac surgery. Head of Service at the Germans Trias i Pujol University Hospital in Barcelona and Head of the VidaalCor Cardiac Surgery Unit at C.M Teknon. His healthcare activity has focused especially on reparative heart valve surgery, transfusion-free surgery, minimally invasive surgery and new alternatives for the treatment of the aortic valve in high-risk patients.
How does the aortic valve function under normal conditions?
The heart is a highly specialized muscle that has a pump function to facilitate the circulation of blood to all parts of our body. The cardiac valves act in a coordinated manner by opening and closing according to the cardiac cycle and ensure that the blood circulates in the correct direction. The normal functioning of the aortic valve is essential so that the heart can empty its contents with each heartbeat without exerting resistance to the flow, and can close at the right moment so that the propelled blood does not return to the heart.
What happens if we have a narrowed aortic valve (stenosis)?
The obstruction to the flow that conditions this narrowed valve determines an overload on the heart, because in each heartbeat it is difficult to push the blood forward. The heart will thicken its walls over the years to be able to beat with more force and overcome the obstruction, but there will come a time when it will begin to dilate and lose its contractile force. At that time, the patient experiences symptoms such as increased fatigue, shortness of breath, chest pain on exertion or dizziness and loss of consciousness.
Is aortic valve involvement very common?
It is very frequent and appears fundamentally in two groups of patients; young patients who have had an abnormal aortic valve since birth (bicuspid aortic valve), and elderly patients in whom the valve has been degenerating and calcifying until it has narrowed significantly. In fact, we could say that if we lived long enough, we would all end up having some degree of aortic valve involvement.
What is the treatment for severe aortic valve stenosis?
The treatment is always replacement of the narrowed valve with a new valve that opens and closes properly. Actually, we do not have drugs that work well with this pathology and can improve the patient, because basically the problem is a “plug” or difficulty in the ejection of blood that requires the removal of this obstruction. It is very important to treat all these patients, because apart from the symptomatology that prevents them from leading a normal life, the vital prognosis will not be good in the short or medium term.
What type of interventions can be performed in these cases?
Surgeons have been replacing these diseased aortic valves with different types of valve prostheses (mechanical or biological) for more than 60 years, with very good results. However, with the progressive aging of the population, we increasingly have to operate on older patients and with greater surgical risk. In view of this situation, new types of prostheses and new treatment alternatives have appeared that allow us to solve aortic valve problems with better results.
Is it possible to treat that diseased aortic valve by means of a catheter procedure, avoiding surgery…?
At present, we can implant a new heart valve through a catheter that we introduce through an artery in the patient’s groin area. These techniques are known as TAVI (Transcatheter Aortic Valve Implantation), however, these procedures should be reserved for inoperable and very high-risk patients, since they still present serious problems that have not yet been fully resolved. In the case of TAVI, we do not replace the patient’s diseased valve, but insert a new valve inside the pathological valve itself. As these valves are very thickened and calcified, these procedures can have serious complications (cerebral embolisms due to calcium, residual leaks and the need for implantation of a definitive pacemaker) in a significant number of patients. In addition, vascular problems may appear in the artery entry zone.
What other alternatives do we have in these patients?
Aortic valve replacement can be performed today with modern sutureless valves. These new valves are especially indicated in patients of advanced age or at high risk for conventional surgery and allow a much shorter intervention with less aggression for the patient. In this case, the narrowed and calcified aortic valve is removed and in its place we implant a new biological valve mounted on a spring or “stent” very quickly and without sutures. The advantages are very significant: it is a large-opening valve that offers no resistance to flow, it can be placed in a very short time, the possibility of calcific embolism is very low and the presence of residual leaks around the valve is very rare. In addition, these new valves can be placed through very small incisions (as little as 7 or 8 cm) using minimally invasive surgical techniques. With sutureless valves we have all the advantages of conventional surgery but with much less surgical aggression and fewer complications.
What is the current experience with these new valves?
The new sutureless valves are initiating a small revolution in the treatment of severe aortic stenosis. More than 5,000 have already been placed worldwide with excellent results in the short, medium and long term and they could become the valve of choice in a very short time. At C.M. Teknon we have been pioneers in the use of these valves in the private sector and it has allowed us to operate on very elderly and high risk patients with very good results.