Imagine being faced with two difficult choices: let your malfunctioning heart continue to deteriorate or face high-risk surgery. That has long been the reality for many people with valve disorders. But advances in valve replacement technology and novel thinking by Sunnybrook health-care experts are providing patients with new ways to get their lives back.
Photography by Kevin Van Paassen
Marilyn Ostrander feels like she’s been given a third chance at life.
In 2010, doctors operated to give her a replacement heart valve. But eight years later, it was failing her. She was on the brink of palliative care.
“Surviving day-to-day was the biggest challenge of my life,” the 86-year-old recalls.
Marilyn’s daughters remember talking her through bouts of severe shortness of breath – a sensation so intense it felt like suffocating. Leg cramps at night made her restless, and she suffered extreme fatigue during the day. Her diet was so strictly regimented that she had to weigh and measure all her food and didn’t dream of ever eating out.
Because of Marilyn’s age and fragile condition, another open-heart surgery – like the one she’d had in 2010 for her first replacement valve – was out of the question. The risks were too great.
In June 2018, Marilyn got that third chance in the form of a replacement valve delivered to the heart through a tube inserted into her leg vein. The procedure was lower-risk and took around 60 minutes.
Describing Marilyn’s post-procedure improvement as dramatic is an understatement.
“When I first saw her in the clinic, she was essentially bed-bound. She couldn’t move, she couldn’t do anything,” recalls Dr. Andrew Czarnecki, a cardiologist at Sunnybrook and a member of Marilyn’s care team. “And then when I saw her again, she was out shopping with her daughters.” She’s now back to living independently at her home in Prince Edward County, Ont., where she cooks for herself, gardens, eats out and travels with her daughters.
Marilyn’s success story is thanks to monumental advances in heart valve repair and replacement technology. It’s also due to the innovative thinking of Sunnybrook health-care experts who have joined forces to apply the technology in creative ways – often funded by donors. In the past, she and 900,000 other Canadians with her condition typically faced a choice between inaction and high-risk surgery. Today, they have a range of options and more chances to get their lives back.
A revolutionary approach
Valve disorders affect the thin, strong flaps of tissue that separate the chambers of the heart. The flaps open to let blood flow forward through the heart when it beats and close again to stop blood flowing backwards. When the valves aren’t functioning properly, sometimes due to an infection or because calcium buildup makes the valve stiff, they begin to leak. Blood flows in the wrong direction and the heart has to work harder to provide enough oxygen-carrying blood to the body. A person can feel tired, breathless, have swollen ankles or find it hard to breathe when lying down in bed at night.
As recently as 10 years ago, the only options for patients were to do nothing, take medication or have open-heart surgery. Surgery to repair or replace the valve requires a 15-to-20-centimetre incision in the chest, stopping the heart and placing the person on a heart-lung machine.
“The challenge was not so much that the surgical treatment didn’t work. People would often have good results,” says Dr. Eric Cohen, deputy head of the cardiology division of the Schulich Heart Program at Sunnybrook. “The challenge was that it was uncertain whether a patient who was sick or elderly would get through the surgery.”
Now those replacements and repairs can be performed by feeding a catheter up an artery or vein through a small incision in the patient’s leg. These procedures are called percutaneous implantations, or implantations through the skin. The heart remains beating and the patient can be sitting up within a few hours and go home in a few days. (One of the more well-known percutaneous implantations is TAVI, or transcatheter aortic valve implantation, which is used to treat aortic valve problems.)
“When that happened, it revolutionized our approach to valve pathology in that it opened up the realm of treatment possibilities for patients who we previously deemed inoperable,” says Dr. Gideon Cohen, division head of cardiac surgery at Sunnybrook and medical director of the Schulich Heart Program. “It’s rare now that we turn down a patient.”
Marilyn’s recent procedure was a tricuspid valve-in-valve replacement, meaning she had a new artificial valve implanted on top of her existing failing one. The old valve acts as an anchor for the new one.
New techniques like this do more than broaden the types of patients who can receive treatment. They’ve prompted the creation of a new specialty in cardiac medicine – structural heart intervention – where surgeons and cardiologists join forces to treat disease. That team approach makes Sunnybrook one of the largest and most successful intervention groups in Canada.
“We are the gold standard in this approach. Nobody really matches the collaborative program that we have between surgeons and cardiologists,” says Dr. Gideon Cohen.
Marilyn felt supported by her team throughout her treatment. “Their confidence made me confident,” she says.
Her daughter, Kim Bouma, says her mother was looked after with dignity and respect not just by the physicians but by the entire health-care team. “The environment there was so supportive,” she says. “It truly was patient-centred care.”
Changing the storyline
Now that Sunnybrook doctors have performed many valve repairs with percutaneous implantations, tackling more than 200 each year, they’re developing exciting ways to expand the use of the technology they have at their disposal.
One option for repairing the mitral valve, which separates the left heart chambers, is to secure its two leaflets together using a staple-like device called the MitraClip. This device has been in use at Sunnybrook since 2011, but Dr. Gideon Cohen and Dr. Eric Cohen recently pioneered its use as an emergency procedure, stabilizing patients until they’re well enough for surgery.
In one case, a patient came in with a burst mitral valve after a heart attack. He was close to death, but his heart couldn’t tolerate the stress of an operation. The risks were extremely high, with an 80 per cent chance that he wouldn’t make it.
“We used to operate because there was no other option. A 20-per-cent chance of living was better than nothing,” says Dr. Gideon Cohen. “With the clip procedure, we’ve changed the storyline here.”
The patient underwent the minimally invasive and far less risky MitraClip procedure. A few months later, after recovering from his heart attack, he received a repair operation. In a different case, a patient avoided surgery altogether because the clip worked well enough on its own.
Because the MitraClip is being utilized in ways not originally intended, its usage isn’t funded by OHIP, but rather through donations to Sunnybrook Foundation.
Dramatic change on the way
While the ingenuity of Sunnybrook surgeons and cardiologists continue to move the field forward, Dr. Gideon Cohen explains that some challenges still remain. Mitral valve replacement (not repair) through a catheter in the leg, rather than open heart, is still in its infancy.
“The mitral space is a lot more complex,” he says. In comparison to other valves, the mitral is more difficult to anchor to and also bigger, making delivery of a new valve through a tiny catheter difficult.
Sunnybrook is testing a new technology called the Caisson device, which has been successful in two patients already. What sets the Caisson apart from the many others under development is that it can be fed up through a vein along the same path as the MitraClip. Other devices require making an incision in the chest and piercing the tip of the heart to deliver the replacement valve. While this procedure is not quite as invasive as open-heart surgery, Dr. Gideon Cohen explains, it’s still a surgery with significant risks. In contrast, the Caisson valve is a lot more delicate, he says. The Caisson is currently undergoing a redesign to make it even more effective in the long term before a new clinical trial begins.
Another challenge is replacing a tricuspid valve non-surgically in first-time patients, says Dr. Czarnecki. The valve-in-valve replacement that Marilyn had works well because the existing valve acts as an anchor. Clinical trials are underway at Sunnybrook investigating whether a form of the MitraClip can be used to repair the tricuspid valve. Elsewhere, trials of new replacement devices are ongoing.
“There’s no doubt that over the next five to 10 years, this is going to be a huge area of growth because of a very clear recognition that this is the most under-serviced population in the valve space,” says Dr. Czarnecki.
The team is optimistic that the technology in the valve space will improve even further in the next decade. When Dr. Gideon Cohen first replaced Marilyn’s tricuspid valve through open heart surgery 10 years ago, he knew there was a possibility that it would need replacing again.
But he never dreamed of the options that would be available when that time came.
“It just goes to show you how things change dramatically in a short period of time and can really change people’s lives,” he says.
Marilyn’s three daughters are still overwhelmed by the improvement they’ve seen in their mother, thanks to the procedure.
“We’re still pinching ourselves….Did this really happen?” says Kathryn Ostrander, Marilyn’s oldest daughter. They’ve gone from being caregivers to spending quality time with their mom. The four plan on many more adventures in the future, including a trip to the Okanagan
“I’m just so overjoyed to be home and [to be] able to do things,” says Marilyn. “It’s worth a million dollars.”
How a tricuspid valve-in-valve replacement works
Marilyn Ostrander is the recipient of a novel procedure in which an artificial heart valve is implanted inside an existing artificial heart valve, all while the heart is still beating. Here’s how:
- A catheter is inserted into the groin.
- The compressed artificial valve is transported by catheter into the heart. It is placed inside the failing artificial tricuspid valve.
- The new artificial valve is expanded and anchored to the old valve.
- The new valve opens and closes as the heart pumps, allowing blood to flow properly.