Restoring ageless zest
Dr. Stephen McIntyre, an interventional cardiologist, has been instrumental in developing the TAVR program at Martin Health System. MARTIN HEALTH SYSTEM PHOTO
Pioneering treatment saves lives, one heartbeat at a time
BY DONNA CRARY
When James Wigginton was diagnosed with severe aortic stenosis, he discovered that he needed a heart-valve replacement. Like many with this condition, he had few medical options. He was considered too high a risk to have traditional open-heart surgery, since he was 90 years old. Without the surgery, there was a good chance that he could develop advanced heart failure within one year. Timing is everything and fortunately for him, a revolutionary procedure for valve replacement called TAVR, or transcatheter aortic valve replacement, was about to be introduced on the Treasure Coast. Wigginton became the first patient to have the surgery at Lawnwood Regional Medical Center. It would not only save his life but open the door to saving many others throughout the region.
TAVR is a minimally invasive surgery used to treat patients with severe aortic stenosis who are considered intermediate risk or high risk for traditional surgical aortic valve replacement (SAVR). Severe aortic stenosis is a narrowing of the valve controlling blood leaving the heart on its way to the rest of the body. This narrowing reduces blood flow to vital organs, resulting in shortness of breath, chest pain, blackouts and heart failure.
For many patients, TAVR may be an option. Instead of opening up the chest, this innovative surgery involves threading a long, thin, flexible tube, or catheter, through the femoral artery in the groin to the heart. The new valve is crimped down to a diameter smaller than a pencil and guided through the catheter with the help of imaging, until it reaches the diseased aorta. Once it is precisely positioned, a balloon is expanded to press the replacement valve into place in the native aortic valve. The new valve then immediately starts working.
“So, what you effectively end up with is a valve replacement,” says Dr. Cary Stowe, a cardiovascular surgeon in Vero Beach. “It’s a valve placed inside your old valve, but we’re able to do it with a one-inch incision. It’s much less traumatic for the patient and allows us to perform aortic valve replacement in that group of patients who prior to TAVR were too high risk for traditional surgery.”
Patients experience a shorter recovery period with TAVR compared to traditional valve replacement. The recovery time from TAVR averages two to three days in a hospital. It’s an average five- to six-day stay for open-heart surgery. There’s no sternotomy, an incision through the sternum, with TAVR, which means an easier recovery.
“There’s much less injury to the person with a percutaneous procedure, so really they recover a lot quicker,” says Dr. Stephen McIntyre, an interventional cardiologist in Stuart. “They’re up and walking, feeling pretty good by the time they go home. Maybe a little soreness in the groin, but that resolves over the course of a week or so. There’s no recovery in the chest or heart area.”
But what’s even more remarkable is the impact TAVR has on patients’ lives. Dr. Prasad Chalasani, an interventional cardiologist in Fort Pierce, finds performing the surgery rewarding since it gives his patients a new lease on life.
“Patients who have the TAVR procedure … it’s a day and night difference, how you can switch a light off and a light on,” he says. “Their quality of life was so different before, because they were restricted on what they could do. When you’re getting one-half or one-third of blood flow to the rest of your body, you get fatigued and short of breath very easily. All of a sudden, you open the valve and you’ve got plenty of blood flow. You feel like, ‘Oh, I can swim now! I couldn’t do that for the last three years, Dr. Chalasani!’ That’s where you get the most gratifying results, that’s where you feel good.”
Randomized trials have pitted TAVR against traditional SAVR. In one trial, high-risk patients who had the SAVR procedure were compared with high-risk patients who had TAVR. The patients were followed for all-cause mortality and stroke. The findings showed that TAVR was safer and better tolerated than SAVR for high-risk surgical patients. Studies were later conducted on patients who were at intermediate risk for open heart surgery. Again, TAVR was shown to be as safe as traditional treatment, and fewer complications resulted from putting in the valve.
“Basically, it’s proven as good, if not better, in all populations studied at this point,” observes McIntyre.
TAVR is not yet approved for low-risk patients but is currently in clinical trial. The results of those studies should be available next year.
In April 2016, TAVR surgery became available to heart patients on the Treasure Coast. Lawnwood Regional Medical Center started the first program, headed up by Chalasani, who has performed 147 TAVR procedures so far. Indian River Medical Center began offering the new technology in February 2017. Led by Stowe, 74 TAVR surgeries have been performed at the hospital. Martin Health System began providing the procedure in May 2017. McIntyre has been instrumental in developing its program and has performed more than 150 of the procedures. Statistics regarding the outcomes of these programs can be found by accessing a TVT registry.
AREA’S FIRST TAVR
Talk to James Wigginton of Okeechobee and you quickly learn that he is a man with nine lives. As a World War II veteran who served in the Marines, he bravely fought in the battles of Saipan, Tinian and Iwo Jima. On February 19, 1945, he stormed the beaches of Iwo Jima and survived while over 2,000 Americans became casualties that day.
Later in life, he fell off the roof of a two-story home in Michigan while working on a chimney. As he fell, he hit a board, flew across the backyard and landed on his feet, unscathed.
“I’ve had a lot of close calls. The Lord looks after me, pretty good,” he says.
When Wigginton moved to Florida after retirement, he started remodeling homes. He does the work himself and resells them for a profit. While working on a home at the age of 90, he began experiencing occasional, minor chest pains. A bit concerned, he saw Chalasani, who conducted extensive tests on his heart. The results showed that his condition was serious, and he needed a valve replacement.
“They were trying to figure out what they were going to do with me,” he recalls. “I told the doctor, ‘Nobody is going to cut me open at 90 years old.’ That settled that, and they went with the new heart-valve procedure.”
As luck would have it, Lawnwood was just beginning their TAVR program. Wigginton was ready to have the new procedure and felt pretty confident that it would work.
“I don’t run from many things,” he says. “I’m not very scared. I’m an old Marine.”
SAVING VET’S LIFE
Chalasani performed the operation, the first such surgery on the Treasure Coast, and says he was excited, nervous and especially gratified after it was successfully done.
Looking back on that first TAVR surgery, the interventional cardiologist is not surprised by its success. He has personally seen numerous times how this technology has changed lives.
“I’ve seen the fact that when patients come back for their follow-up, they cope faster, their quality of life is better, and they’re much happier than some of these people who go through the whole process of open-heart surgery and bypass,” he says.
Chalasani also points out that selecting the right patients for the surgery is key in producing good outcomes.
“There are two things I have to improve — their quality of life and their quantity of life,” he says. “To me, they need to be able to sign a consent that means they are cognitively reasonable.”
Wigginton was released from Lawnwood within one day of his surgery. He says he felt good and had no pain when he returned home. It wasn’t too long afterwards that he resumed the activities that he enjoys.
“I do whatever I want to, when I want to,” he asserts. “My whole life has been that way.”
Today, at 93, he still fixes up homes — setting tile, installing cabinets and repairing electrical work. And his life would be incomplete without his wife, Elwanda, of 72 years. Wigginton still does the driving on family errands. He makes time to play the harmonica for audiences at nursing homes and at church. Mostly, he’s grateful to be living well and is enthusiastic about spreading the good news of TAVR.
“I’d do it again if I had to do it. I sure would,” he says. “There’s nothing to be afraid of because it sure beats being cut open. No pain, no strain. It works.”
FATIGUE SIGNALS HEART PROBLEMS
Carol Hales of Okeechobee is a healthy 83-year-old who stays active by spending time with her family and church congregation, solving crossword puzzles and working on the computer. As a two-time cancer survivor, she understands the importance of having annual physical exams. At a checkup in 2013, Dr. Maged Mehanni, a pulmonary specialist in Okeechobee, detected that Hales may have aortic stenosis. She then met with Dr. Joseph Gage, a cardiologist in Stuart, who confirmed the diagnosis.
“They did all the tests that were necessary,” Hales remembers. “Dr. Gage said, ‘I think it’s moderate, but we’re going to watch it.’”
Her condition progressed gradually for about five years. She initially ignored the symptoms of aortic stenosis, attributing fatigue to her age. But over time, she became increasingly tired to the point where she lacked energy to do simple tasks, like walking in a store.
“My daughter and I would go shopping and would park way out,” she recalls. “I would say, ‘Do we have to park this far?’ My daughter responded, ‘Mom, you need to walk.’ By the time I got into the store, I would be exhausted. I was getting to where everything was almost a drudgery. I also noticed I had become kind of pale.”
Hales’ aortic stenosis had become severe, so her cardiologist recommended a heart catheterization and other tests that determined she was a candidate for the TAVR procedure.
“Aortic stenosis is a relentlessly progressive disorder,” explains McIntyre. “What that means is the aortic valve starts with a murmur, but over time the orifice or the opening of the valve gets smaller and smaller and smaller. So, it gets to the point where the aortic valve is going to take that person’s life if it’s not replaced.”
A NEW LEASE ON LIFE
McIntyre performed TAVR on Hales at Martin Health System in March 2018. Her children saw instant results immediately following the surgery.
“When my children came into the ICU, they said, ‘Mom, your color is back! You look great, you look vibrant!’” she says. “It was amazing. That’s telling you how fast the blood began to circulate. Before, it wasn’t flowing like it should.”
Hales stayed in the hospital for only two days after her surgery, and she says she felt absolutely wonderful.
“Most of the patients with TAVR are transfemoral assessed — they’re up and walking at the end of the day,” says McIntyre. “No chest incisions, and they’re home about 48 hours after the procedure. There’s not really much in the way of discomfort because there’s no sternotomy.”
Now that her heart is pumping better, Hales feels more energetic and walks about 30 minutes every day. She was denying herself sugar until Gage explained at a follow-up visit that she could occasionally indulge in some sweet pleasures.
“He asked, ‘What do you eat?’” she recalls. “I said, ‘I try to maintain a healthy diet, like oatmeal with flaxseed. But it’s been hard because I haven’t had any sweets since the surgery.’ The doctor said, ‘Carol, he fixed you so you can enjoy life — so enjoy life!’”
Right after that visit, Hales treated herself to a scrumptious ice-cream dessert at a local restaurant.
Feeling stronger and fortunate today with her improved health, Hales credits the medical team at Martin Health System for her quick recovery.
“I feel very blessed,” she says. “I cannot say enough about my care and treatment with Dr. McIntyre and the whole TAVR team. Even the personnel in the hospital. They were just wonderful, very caring. You hear about angels of mercy. I think that depicts them.”
TURNING BACK PAIN TO HEART HEALTH
Judy Richman owns and runs her own real estate business, selling commercial, residential, and oceanfront properties in Cocoa Beach. To unwind from her busy schedule, the 81-year-old likes to walk on the beach, swim, dine with friends and sail on monthly cruises to the Caribbean.
“I keep active. To me, life is going to be short and you want to enjoy what you can of it,” she says.
Declining health began to impact her activities about three years ago. She progressively experienced back pain, shortness of breath and exhaustion when she engaged in simple physical activity.
“A lot of things changed,” she says. “Walking was difficult. Climbing stairs was difficult. I couldn’t walk the beach anymore. I was tired, so I just took it easy. I got myself a walker. I attributed it all to my back, not even thinking I had problems with my heart.”
She had an electrocardiogram (EKG) in January 2018 as part of preoperative tests to have cataract surgery. Dr. Egerton Van Den Berg, her cardiologist in Orlando, noticed a drastic change from her previous EKG test a year before. To be sure, he arranged for Richman to have a heart catheterization. The results revealed the source of her health problems.
“I had 91-percent blockage on one side; on the other side, I had three blockages between 50 and 70 percent that needed to be taken care of right away,” Richman says. “Then he told me that I had stenosis of the aortic valve and I needed a valve replacement.”
IT TAKES A TEAM
Like other TAVR programs on the Treasure Coast and throughout the country, Indian River Medical Center offers a heart team of trained, medical specialists who conduct a comprehensive evaluation to see if a patient is a candidate for TAVR. If approved, the team further collaborates and discusses the best way to handle the patient’s treatment.
Richman arranged for Stowe to replace her heart valve.
“Every patient that’s selected for TAVR at IRMC is seen by two cardiac surgeons and an interventional cardiologist,” says the Vero Beach cardiovascular surgeon. “This careful analysis of each patient’s case by a group of specialists with different skill sets and clinical perspectives allows us to develop and implement the best care plan for the individual patient. Prior to the planned aortic valve replacement, the TAVR team meets and reviews all of the patient’s clinical history and data including cardiac catherization results, echocardiogram and CT angiogram to make a joint decision on how best to treat that individual patient. I feel that this team approach to individual patient care has been the key to the success of the TAVR program, not only here at IRMC but also nationally.”
In early 2018, Richman had stent surgery in Orlando to repair the blockages in her heart, and then had TAVR at IRMC the following June. She was impressed with Stowe’s work and how she felt after the TAVR procedure.
“He’s a wonderful doctor!” she says. “I can’t tell you enough how pleased I am with him. I had a fast recovery and very little pain. I thought it would be more painful than it was. I don’t think I took more than a Tylenol and that was it. I felt pretty good.”
On the road to recovery, Richman was able to resume her normal schedule of working in her real estate office just a few days after having the surgery. She also said that her walking improved and she has higher levels of energy, so she sings the praises of TAVR.
“I found it fairly easy — the surgery and the whole process. I called this a piece of cake,” she says. “It was wonderful the way they could do it. I didn’t have to have the chest cut open. I was very pleased with the surgery, that it took care of the problem. To go into a hospital and have a valve replacement, be out in two days, and home just resting for one day. The following day you’re able to get up, get dressed, and go out to drive a car. What can be better than that?”