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Minimally Invasive Cardiovascular Procedures: New Options Extend Quality of Life

Peter Tadros, MD, Medical Director, Heart Valve Center
Trip Zorn, MD, Surgical Director, Heart Valve Center

Interventional cardiology, electrophysiology and cardiothoracic surgery offer new alternatives for patients who otherwise face diminished quality of life.

"Ultimately, when evaluating a surgical program, you need to know the outcomes. The University of Kansas Hospital has a .58 observed to expected ratio for coronary bypass surgery. This is critical to us. Our interventional cardiology program is built on that foundation of excellent outcomes.”

- Peter Tadros, MD, medical director, heart valve center

These innovations rely on fresh ways to use established technologies and an unprecedented level of cooperation among medical and surgical disciplines. At The University of Kansas Hospital’s Center for Advanced Heart Care, we offer interventional procedures and access to clinical trials, including:

  • Bioabsorbable cardiac stenting
  • Minimally invasive valve repair and replacement
  • New treatment options for hypertrophic cardiomyopathy
  • Surgical treatment of atrial fibrillation
  • Other new applications of interventional cardiology techniques

New generation of absorbable stents

One of the first truly new advancements in years the treatment of coronary artery disease is the bioabsorbable stent. Like a traditional stent, it aids in restoring blood flow to the heart. But a traditional metallic stent can affect vasomotion. In addition, traditional metallic stents increase risk of stent thrombosis and restenosis.

By contrast, the bioabsorbable stent provides excellent scaffolding and drug delivery for six months and then begins to be absorbed. The stent is completely absorbed in two years. Early studies show vasomotion returns to normal after absorption, as well. Eventually, the new stent may lower the risk of stent thrombosis and reduce the need for prolonged dual antiplatelet drugs.

The Absorb™ Bioresorbable Vascular Scaffold stent is nearly ready for randomized clinical trials and The University of Kansas Hospital is the only hospital in the region to participate.

Catheter-based valve repair and replacement therapy

About 60,000 valve replacements are performed in the United States every year. And as many as 400,000 people with valve disease go without treatment due to their surgical risks. Transcatheter valve replacement therapy offers a new option, especially for those who have high surgical risk for morbidity to mortality. The University of Kansas Hospital is one of the only hospitals in the nation, and the only one in the region, to offer all three transcatheter options, two for aortic and one for pulmonic valve replacement.

Aortic valve replacement

The Center for Advanced Heart Care is one of only a few offering transaortic valve replacement or implantation (TAVR or TAVI) that use the FDA-approved SAPIEN valve and offer clinical trials using CoreValve®.

The CoreValve procedure is most appropriate for patients who are symptomatic with severe aortic stenosis and at moderate or high risk for surgical aortic valve replacement and patients deemed inoperable. For most patients, TAVR involves accessing the femoral artery via the groin to advance a strong stent, which holds the replacement valve. If the femoral vessel is not large enough, due to disease, we also can access the valve through the subclavian artery or directly through the aorta. The new valve anchors onto the existing valve and essentially displaces it.

The SAPIEN valve procedure is fluoroscopically guided and generally takes one or two hours. Patients are walking again on the day of the procedure, and hospital stays are typically three to seven days.

TAVR does include risk of stroke at approximately 3 to 5 percent. Other complications can include vascular injury and a high degree of conductive block. The risk associated with TAVR is at least equivalent to the risk of open surgery.

Pulmonic valve replacement

We also offer catheter-based pulmonic valve replacement using the Melody® valve to address pulmonic regurgitation and stenosis. It is typically used in children or young adults with congenital heart disease. Surgically replaced valves have a lifespan of only about 10 years, so these patients often face multiple sternotomies. We do not yet know the long-term durability of the Melody valve, but it may be as durable in the short term as a traditional surgical replacement. This much less invasive technique offers fewer complications, a quicker recovery and less scarring. Because the condition is so rare, the FDA has approved the Melody valve under its humanitarian device exemption. It is offered in only a few centers nationwide.

Valve clinic streamlines therapy

Through The University of Kansas Hospital’s Valve Clinic, we coordinate consultation with the cardiothoracic surgeon and cardiologist in a single patient visit. We also can often perform necessary imaging and other tests in the same appointment. Ultimately, we are able to streamline the process and reduce the number of visits. Patients – especially those traveling some distance to the hospital – appreciate this coordinated approach.

Mitral valve repair

We will participate in the new COAPT clinical trial using the investigational MitraClip® System. This trial is available for patients with severe mitral valve regurgitation who are showing significant symptoms of severe mitral insufficiency and are not good candidates for conventional surgery. Earlier trials comparing the technique to surgery found the clip was safe and successfully reduced regurgitation but that surgery was superior. The COAPT trial, by contrast, will test the MitraClip only on those who are not good surgical candidates and face near-term heart failure with medical therapy alone.

Through transesophageal echo guidance, we deliver the detachable clip via the femoral vein and a transseptal puncture. The clip approximates the two leaflets of the mitral valve and provides better coaptation resulting in significant reduction in mitral regurgitation.

Alcohol septal ablation for HCM

The University of Kansas Hospital is one of the only facilities in the region offering an approach to obstructive hypertrophic cardiomyopathy that is much less invasive than the standard myectomy, delivers excellent results and may be an option for patients as an alternative to surgery. Patients can be evaluated at the multispecialty Hypertrophic Cardiomyopathy Clinic to discuss complex management options, indications for an implantable cardiodefibrillator, genetic screening and septal reduction options. Alcohol septal ablation has offered many patients significant improvement in symptoms via a catheter-based approach resulting in much shorter hospital stays and lower procedural risk.

The traditional approach – surgical resection of the intraventricular septum through a medial sternectomy – has an 85 percent success rate. In patients with symptoms secondary to a high outflow tract gradient, alcohol septal ablation can be just as successful at eliminating HCM symptoms while imposing a much lower surgical risk.

This procedure involves delivering an alcohol drip percutaneously that will essentially infarct the portion of the interventricular septum that involves the left ventricular outflow tract, easing blood flow between the left ventricle and the aorta.

New approaches for atrial fibrillation

More than three million people in the U.S. suffer from atrial fibrillation, at a cost of nearly $9,000 per person, per year. Medical management is costly, requires frequent testing and dramatically increases the risk of hemorrhage. While catheter-based techniques have shown promise, they are often lengthy, require retreatment and include complications. Surgery – primarily the maze procedure – has great potential, but many physicians are reluctant to take this step when the condition is medically manageable. Hybrid ablation and structural correction are two new approaches that show great promise.

Structural: Amplatzer™ cardiac plug and LARIAT® device

More than 90 percent of clots that cause strokes in patients with nonvalvular atrial fibrillation arise in the left atrial appendage, or LAA, a ubiquitous embryologic remnant. Blood thinners are the mainstay of therapy for stroke prophylaxis. However, a significant portion of patients who might benefit from blood thinners have contraindications due to systemic bleeding, frequent falls and other potential problems. Some patients without contraindications may experience stroke despite the use of blood thinners. Patients need treatment strategies that can potentially eliminate the LAA from systemic circulation. The Amplatzer Cardiac Plug, or ACP, and the LARIAT are devices used to occlude the LAA.

The University of Kansas Hospital is one of 70 sites participating in a clinical trial for stroke prevention with the ACP, and the only location in the region. This is a two-to-one randomized trial of the ACP vs. anticoagulation studying overall success, safety and efficacy. It involves inserting a catheter through the femoral vein, performing a transseptal puncture and placing the device within the LAA. This seals off the LAA to blood flow and prevents clot formation. Scar tissue then forms to permanently seal off the LAA where most AF-related embolic strokes originate.

The LARIAT suture delivery device is a catheter-based system that uses a snare to close off the LAA. It has been shown to safely and reliably suture the LAA shut using combined endocardial and epicardial access. Like the ACP, the LARIAT involves inserting a catheter through the femoral vein, performing a transseptal puncture and placing a wire with a magnetic tip into the LAA. A catheter is also placed into the pericardium and another magnet-tipped wire is then placed through the catheter on the outside of the heart. The magnets find each other. A lasso or LARIAT is then placed over the wire ensnaring the LAA. An embedded suture then is cinched down over the LAA, closing it off.

In both of these procedures, the aim is to prevent strokes, and eliminate the need for long-term anticoagulant drugs in patients with atrial fibrillation.

Hybrid ablation

For patients with persistent or longstanding AF, ablation therapy doesn’t yield similar results as it does in those with paroxysmal AF. A new hybrid technique, combining a percutaneous electrophysiological approach with a mini-maze procedure, holds great potential for bringing the best of all these treatments together. With this approach, the surgeon performs anatomically guided epicardial ablation using continuous lines and creates a left atrial box lesion through minimally invasive right chest access. The electrophysiologist employs electrically guided mapping to perform endocardial ablation, to identify gaps in the epicardial ablation lesion sets and to abate triggers and re-entry arrhythmias.

The benefits of hybrid ablation include

  • Shorter time for each procedure
  • Complete lesion set: epicardial + endocardial
  • Epicardial occlusion of LAA, if desired
  • Fewer complications
  • Improved outcomes

This approach is currently under study for a clinical trial later this year.

To consult with a physician at the Center for Advanced Heart Care, call 913-588-5862 or toll free 877-588-5862. Read more about minimally invasive procedures offered at the Center for Advanced Heart Care.

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