[MUSIC PLAYING]
We're going to talk just briefly.
They told me to talk quickly, which
I have no problem doing, about just three or four things
that we do in structural heart.
And I was asked to say, pretend people don't
know what we do at all, people that might not
be in cardiology, and show them a little bit
behind the curtain about what we actually do.
So let me show you a little bit here
about some of the things we do.
So transcatheter aortic valve replacement
is a procedure in which we treat patients that
have a diseased aortic valve.
And usually, that valve is very calcified
and very stiff and stenotic.
And the valve just does not open very well.
And treatment of choice for these particular patients
has to be some sort of replacement.
There's not very many medications we can use
to try and stop the process.
Some of our patients are born with a congenital abnormality.
It may be a two leaflet or a bicuspid valve.
Some people have had rheumatic heart disease
from rheumatic fever.
And the most common of which are age-related
calcified degenerative AS, where we
get all these calcified nodules and things
that form on the valve, and the valve won't open.
And eventually, this will lead to symptoms.
Our population is living longer partially
from the therapies that are brought
about through cardiovascular and cancer therapies.
And the longer we have patients live,
the more disease processes we'll run into, and a lot of them
are related to heart-related diseases, some of which
we'll show you today.
So we know from even in the 1960s,
when Eugene Braunwald and his team
followed patients that had rheumatic aortic valve
disease, that patients can do well for a very long time.
But at the point where they start to do poorly,
the mortality increases substantially.
So once you start to have symptoms of chest pain,
shortness of breath, or something related to your valve
disease, your chance of dying in five years is almost certain.
So you need to do something about it.
So traditionally, open heart surgery was done,
and it still remains the standard
of care for many patients that have valvular heart disease,
including aortic valve disease.
But what we found, that there's a lot of patients initially
that were too sick and just were not great candidates
for surgical valve replacement.
So we needed options.
Rather than patients dying of their disease,
we need to have other options.
And the first company out on the market,
I won't show you the original valves,
was Edwards Lifesciences.
Medtronic has a valve out as well.
Abbott has a valve out as well.
And I'll show you some of these valves here today.
These are valves that we can place
without surgical intervention.
Most of the time now, we're going
through one of the blood vessels in the legs,
the femoral artery, making our way up to the valve
and placing a valve inside.
Here's what this looks like.
On the left-hand side, you can see us just taking
a picture inside the aorta.
And on the right-hand side, you can
see a valve that's been crimped down on a balloon.
We pace the heart quickly so the blood pressure goes down
a little bit.
And then we can inflate that balloon,
and we put the valve in place.
So we move the old aortic valve out of the way.
This new valve starts to function right away
underneath it.
And we've taken a patient from a critical disease
to now a new aortic valve without having to undergo
surgical valve replacement.
Here's what the self-expanding valve looks like.
I'll show you again the aortic shot.
We try and line everything up, make
sure we're in the right plane.
Sometimes we stretch the valve with a little balloon
to create some space.
And then we can bring in the valve
and slowly deploy these valves.
This is what we call a self-expanding valve
by Medtronic.
And we can set this valve in there
slowly, slowly, make sure the valve's in the right place.
Again, moving the old valve out of the way
and having the new valve start to function right away.
So once we stop the pacing process,
the next beat that the patient has,
they're pushing blood through a normal valve again.
So these are things that now can really be done in about 55,
60 minutes or so.
Most of the time, it can be done in a cath lab.
We have a hybrid OR, which allows us to do them there.
But they can be done in the cath lab
with really low complication rates and great success.
This past year was the first year in the US
where transcatheter valves were done more than surgical valves
for patients with severe aortic valve stenosis.
And as long as the durability is there, the trend will continue.
We have ways that we can put up little filters
to try and protect the brain during the procedure as well.
And then there are devices in clinical research right now
being placed for patients with aortic insufficiency or leaks
that would allow us to treat patients
with any type of aortic valve disease.
And the clinical trials for these are recently finished,
and we'll have some data on them soon.
So what about closing off left atrial appendages?
We spent this last few minutes talking
about opening up a blockage.
Now, what about closing an opening that's already there?
So these are patients that have irregular heartbeats,
atrial fibrillation.
And in certain patient populations,
that atrial fibrillation increases
your risk of a blood clot.
And the majority of these blood clots
can form in the heart in what we call the left atrial appendage.
The treatment of choice for any patient with AFib
who has risk factors would be anticoagulation of some variety
taken by oral medications.
But some patients can't do that due to bleeding, recent cancer,
recurrent falls, really, a lot of falls,
and we need some way to try and help these patients as well.
If you're going for some sort of other heart
surgery, a lot of times, our surgical colleagues
will now remove that left atrial appendage.
And what is this, this little outpouching
that sticks off the left atrium?
And blood does not flow through that appendage very quickly.
And when there's not great flow in the top chambers
of the heart or the atrium, blood can become stagnant,
and we can form blood clots in that left atrial appendage.
And this is an ultrasound.
You can just see these clots that hang out there.
And if they just stayed there, that'd be great,
but they don't.
They then embolize to the brain, giving patients strokes.
So if this appendage didn't exist,
if there was a way to block it off, that would be fantastic.
So we have ways that we can go through the femoral vein again,
go across from the right atrium to the left atrium.
And now we're looking right at that left atrial appendage.
We can get inside that left atrial appendage
and then place devices that help close it off.
And then over time, here's what we call a tug test.
You can see Dr. Singh and colleagues,
they want to make sure that thing's not coming out.
So they put in there, and they try and pull
on that thing to make sure that the little barbs that
are holding it in there are going to hold
this little device in there.
And then we have ways to just close it off,
and it'll seal up over time.
And patients can come off of anticoagulation.
This is the WATCHMAN implant.
There are other implants, and the WATCHMAN
has gone through certain iterations.
And the iteration which is out now and approved in 2020
is even more effective and easier
to use for certain patients.
So there's an Amplatzer occluder as well
that we can put in the left atrial appendage.
So lots of ways to help people out.
I'll end with telling you briefly
about the mitral and tricuspid work, which is ongoing here.
The mitral valve is extremely complex,
and the tricuspid valve is even more complex than that.
So the aortic valve turns out to be probably the easiest
valve that we work on.
The mitral valve itself has got, between the two leaflets,
supporting structures, muscles, chordae.
There's lots of stuff that help the mitral valve function well
and not allow it to leak.
But if it does leak, lots of times,
patients would go for surgical mitral valve repair, which
Dr. Kia, and Dr. Catrip, Evans, Wozniak, et cetera
here can work on patients with mitral valve disease.
And our surgeons have many ways to try and repair
that mitral valve.
In patients who are too sick, sometimes,
as a bailout procedure, they'll sew the middle of the two
leaflets together, allowing the patient
to have two separate orifice or two separate holes for blood
to get through, but it decreases the leak down the middle.
This brought on a way to--
trying to find ways that we could do this for patients who
were not surgical candidates who could get clips placed
through a transcatheter means.
And this is how MitraClip began.
You can see, on the upper left, any of that color
that's going backwards to the upper top part of the screen is
mitral regurgitation.
Patients, we can go in, put these clips in,
and then the amount of color flow on the upper right
has been markedly diminished.
I would say it rarely goes to 0.
But if you could take a patient with severe mitral
regurgitation and take them down somewhere into a mild range,
the patients will do much better.
And again, initially designed for patients that
were not surgical candidates.
And even today, they need optimal medical therapy
to treat heart failure before a clip should even be considered.
These are ways, once again, that patients
don't have to undergo traditional open heart surgery.
You saw, and I'll show you the team, that here, just did
the first transcatheter valve replacements
for the mitral valve, some going through the interatrial septum,
some going through the apex of the heart.
And both of these techniques and strategies
are under clinical research and ongoing
here right now to actually replace these valves,
not just put clips or try and repair them,
but replace these valves without traditional heart surgery.
And the techniques are getting easier
and will be more defined in the future.
There's the team there, the first transfemoral transseptal
mitral valve procedure on the West Coast.
You can see Dr. Kia and colleagues,
Dr. Singh, Dr. Rogers.
Dr. Smith's in the back, hanging out, and the team there.
Dr. Rogers's got his arms folded.
He's ready to have lunch maybe.
It was a long day for him.
That case took a lot out of him.
He's getting older.
So one brief thing about that tricuspid, initially
thought to be the forgotten valve.
We weren't going to be able to do much for it.
That tricuspid valve is extremely
complicated in trying to deal with it surgically
and through transcatheter means.
There are a myriad of companies that
are trying to treat tricuspid regurgitation mainly
because if you look at patients with severe tricuspid
regurgitation or a leaky valve, patients that have high blood
pressure in their lungs or pulmonary hypertension,
patients with severe leaky valves do not last very long.
So if we can get to these patients early on
and try and either get them medically treated
or do something to help out the tricuspid valve,
we can extend the life of these particular patients.
So not everyone can have surgery,
and trying to find ways to fix these leaky heart
valves through transcatheter means are being done.
The first ways that they're being done,
again, are with clip procedures to try and clip
these valves tight and closed to prevent their leak.
Patients can go from significant leaks to less leaks.
And there are multiple strategies right now
ongoing and ongoing clinical trials
with multiple different companies
to try and either repair or replace these valves
and a lot of trials we have ongoing here at UC Davis
as well.
So again, if one or two clips is good,
what if we could replace these valves?
So there are ways now that I'll show you
that we can try and replace the tricuspid valve as well.
And again, Edwards leads the innovation
in this field, along with other companies.
I'll show you a video here of going up
through the femoral vein, up through the inferior vena
cava towards the right atrium.
We'll make our way across the tricuspid valve.
And I'll show you how this one particular valve works.
Again, there's a lot that goes on when
you watch this video that makes it look pretty easy to do,
but there are many things that go on
to try and make sure you make it through the center
of the valve, you don't get caught on the cords,
you don't catch a papillary muscle,
you don't injure the right ventricle, which is quite thin.
You could perforate it with your wires.
And then you have to be able to gather
all the leaflets of the tricuspid valve
and gather and grab them with your device
before you deploy this valve.
So as you'll see, it becomes a little complex.
But there's ways in which you can
get a hold of all these leaflets,
make sure that you have a good grasp,
and then you'll deploy this valve in its position,
getting rid of tricuspid regurgitation.
I'll show you as this valve is deployed
in a slow and steady way.
And the tricuspid valves are clearly
much bigger than closing the left atrial appendage
or putting in a transcatheter valve.
So you'll see, after this valve is released, it's in place.
There's no suture.
Everything has to be properly fit with proper ways
to grasp the anatomy that's there.
There's no way to go back with bubble gum and duct tape
once you let go of it.
And then the valve can start working right away.
So I'll tell you that this is in clinical trials.
It has been done in humans already.
And some of these are from Dr. [INAUDIBLE] et cetera.
So the future, I would tell you, is bright for structural heart
disease.
I think the burden of proof is on us
to make sure that we can do a job as well
as our surgical colleagues.
If not, we should not be doing it.
And if the durability of what we do is not the same as surgery,
then we should not be doing it as well.
So even though we can do things, I
think the burden is to make sure that we can do it in a way that
helps the patient as well as the techniques
that they have available to them right now.
[MUSIC PLAYING]