Cardiovascular disease (CVD) remains one of the leading causes of fatality in the Middle East. Faulty heart valves are a common cause of CVD and can be a result of age-related changes to the heart. In the UK, experts at Royal Brompton and Harefield Hospitals Specialist Care have led the way in recent years to develop new lifesaving alternatives for patients with faulty valves. These innovative options are suited to patients who are at increased risk from conventional open-heart surgery, or who might benefit from a minimally invasive approach.
The transcatheter valve service was established in 2007, which means it is now 12 years since the first transcatheter aortic valve implantation (TAVI) at Royal Brompton and Harefield Hospitals. The service brings together a multi-disciplinary team, including surgeons, cardiologists, anaesthetists, imaging experts and specialist nurses to ensure patients of all ages have access to innovative treatments for the two most common heart valve conditions, aortic stenosis and mitral regurgitation, which between them account for well over 75 per cent of all patients with valve disease.
The transcatheter programme is led by consultant interventional cardiologists’ Dr. Simon Davies and Dr. Robert Smith and is unique in the UK in terms of volume of TAVI activity, the complexity of cases treated, for the range of catheter-based procedures used to treat the mitral valve, pulmonary valve, and tricuspid valve.
Dr. Davies explains: “For many high-risk patients’ conventional open-heart surgery is not an option, however, the expertise available at Royal Brompton and Harefield Hospitals ensures that patients have access to the most suitable alternative procedure.”
Which patients benefit most?
Due to an ageing population and the ever-increasing number of patients requiring heart valve repair or replacement later in life, the minimally invasive procedures available at Royal Brompton and Harefield Hospitals are particularly beneficial to older patients, who often have co-morbidities and are at high-risk for conventional surgery.
Some of the techniques being used by Royal Brompton & Harefield Hospital experts were pioneered at our hospitals, with the very first patients in the country – or sometimes even the world – benefitting from new revolutionary procedures.
Patients from across the globe are benefiting from greater choice than ever before and have access to world-class specialist treatments that are not widely available elsewhere. Whilst each patient is individually assessed to ensure the best treatment path and procedure. Here we describe some of the novel techniques our team has undertaken.
The aortic valve is the outlet valve from the main pumping chamber, and it controls the blood flowing out of the heart and to the body. Aortic stenosis is the most common and serious form of valve disease. With advancing age, the valve can become progressively stiff and narrow as a result of calcium deposits, making it more difficult for blood to leave the heart. As blood flow through the valve becomes significantly restricted, symptoms can include breathlessness, chest pain, fainting and palpitations.
Royal Brompton and Harefield Hospitals specialists run the largest programme in the UK for transcatheter aortic valve implantation (TAVI). The only effective long-term treatment for aortic stenosis is to replace the aortic valve, therefore, TAVI is a lifesaving non-surgical alternative for many patients.
For those suffering from aortic stenosis, one of the only options in the past for treatment was open heart surgery to replace the valves that are failing. The TAVI procedure is a less invasive form of aortic valve replacement that can be offered, whereby a new aortic valve can be implanted either via the arteries in the groin, the arm, directly into the aorta or via a small cut in the chest.
During the procedure, which can be performed under general or local anaesthetic, a catheter is guided through an artery to the patient’s heart using special scanning equipment. The new valve is then placed within the narrowed aortic valve and expanded to relieve the obstruction.
Since none of these methods require the breastbone to be cut or open-heart surgery to be performed, they are less traumatic than conventional surgical aortic valve replacement. This procedure should cure aortic stenosis, so reducing the risk of heart failure and any shortness of breath, chest pain or fainting.
The Royal Brompton & Harefield Hospital team has expertise with many of the different TAVI devices currently available. They have considerable experience in using TAVI to treat previously implanted surgical aortic valves that are showing signs of degeneration.
The mitral valve is the inlet valve to the main pumping chamber. It separates the upper left heart chamber from the lower left chamber and helps control blood flow through the heart.
Mitral regurgitation (MR) occurs when the valve becomes damaged and fails to close properly. This results in blood flowing backwards or leaking, through the valve when the heart contracts.
There are several conditions that can lead to MR, but most commonly it is the valve becoming weaker over the years from ‘wear and tear’ or persistent high blood pressure. Symptoms can include shortness of breath, tiredness, dizziness and chest pain.
As every patient is different it is important to have a variety of treatment options. These include MitraClip, mitral valve-in-valve and valve-in-ring implants with different devices, transcatheter mitral valve implantation with the Tendyne system, and transventricular mitral neochordal implantation utilising the Neochord system. The Royal Brompton & Harefield Hospital team has an international reputation in these fields.
In late 2014, a 68-year-old patient with mitral regurgitation became the first person in the world to have the ‘Tendyne Transcatheter Mitral Valve (TMVR)’ system, which was implanted at Royal Brompton Hospital.
The tissue valve replacement is placed into a patient’s beating heart without the use of cardiopulmonary bypass, commonly known as a heart-lung machine. It is implanted via a catheter through a small incision between the ribs. During the procedure, the novel Tendyne device can be repositioned as necessary, allowing the surgeon to precisely place the device during implantation, which improves patient outcomes.
Royal Brompton and Harefield Hospitals is one of the most experienced centres in the UK for this minimally invasive procedure to treat MR, having undertaken more than 250 cases to date, more than double any other UK hospital. MitraClip is a relatively new ‘keyhole’ technique that offers a less invasive approach to conventional surgery.
A catheter is inserted through the top of the patient’s leg and via the femoral vein, and a small hole is made to enable the catheter to cross from the right to the left side of the heart.
The MitraClip device is a small clip that is attached to the mitral valve. It treats MR by allowing the mitral valve to close more completely, helping to restore normal blood flow through the heart. The MitraClip procedure is guided by both x-ray and transoesophageal echocardiogram (TOE) to ensure the best possible outcome. The MitraClip device is then steered into the left atrium and can literally ‘clip’ the leaking portions of the valve leaflets together. The procedure immediately reduces MR.
The NeoChord procedure is an innovative approach used for beating heart mitral valve repair. Using a minimally invasive technique, implantation of transventricular neochordae (artificial chordae) under live echo guidance enables treatment of severely regurgitant mitral valves. The procedure provides real-time confirmation of mitral valve repair without the need for an incision through the breastbone or temporarily stopping the heart.
Royal Brompton Hospital is one of the only centres in Great Britain with expertise in beating heart mitral valve repair with NeoChord. High-risk patients with MR who have been declined treatment at other UK centres have been offered successful treatment at the hospital with this procedure.
Expert team approach
The multi-disciplinary approach adopted by the transcatheter valve team has led to Royal Brompton and Harefield Hospitals experts pushing boundaries and routinely carrying out increasingly complex operations with excellent outcomes.
Dr. Davies comments: “For most patients with heart valve disease, conventional surgery is still the standard treatment. However, for many patients this is not an option because of their advanced age, frailty, or other medical problems.
Over the last three decades the average life-expectancy in the Middle East has steadily increased, the international expertise of the Royal Brompton and Harefield Hospitals multi-disciplinary team can be invaluable in ensuring that patients have access to an alternative life-saving procedure. The Royal Brompton and Harefield Hospitals team carefully review each individual patient and advise which of the above procedures may be suitable.”