HerzTeam: Experience is decisive

The experience of the heart team is crucial

Stenosis and leakage of the heart valve are among the most common structural heart diseases. Depending on the heart valve affected and the type of defect, patients have a variety of treatment options from cardiac interventions to cardiac surgery. Two heart specialists provide information:

What is meant by structural heart disease?

Prof. Dr. med. Peter M. Wenaweser - Interventional Cardiology - HerzKlinik Hirslanden

Prof. Dr. med. Peter Martin Wenaweser: Structural heart diseases are diseases of the heart that predominantly affect one of the four heart valves, i.e. the aortic, mitral, tricuspid and pulmonary valves. The left-sided heart valves in particular, such as the aortic valve as the outlet valve and the mitral valve as the inlet valve, can show signs of wear over time.

What is the difference between a stenosis and an insufficiency?

PD Dr. med. Pascal André Berdat: In functional terms, heart valves are nothing more than a one-way valve. They regulate the blood flow in the heart in the right direction. The heart, as a blood pump, can only direct the blood flow correctly if the valves function normally. A heart valve can become narrowed and obstruct blood flow for a variety of reasons. This is called valve stenosis. A heart valve can also leak, causing blood to be pumped back through it. This is called an insufficiency. There are also mixed forms in which a heart valve has both a stenosis and an insufficiency with different degrees of severity.

What are the typical symptoms of patients with structural heart disease?

Prof. Dr. med. Peter Martin Wenaweser : Many valve diseases can be endured for a very long time without symptoms. If symptoms are present, this is usually a sign of advanced disease. Certain valve diseases can cause symptoms similar to those of coronary heart disease, including chest tightness and pain. A slow onset of shortness of breath, which leads to a decrease in the ability to perform daily activities, can be another consequence. Patients with a severe narrowing of the aortic valve, known as aortic stenosis, often suffer a typical circulatory collapse, known as syncope. This is a brief loss of consciousness due to impaired blood flow to the brain. In the advanced stages of mitral regurgitation, symptoms may include shortness of breath, fatigue, fluid accumulation in the lungs, swollen legs and cardiac arrhythmias with atrial fibrillation.

How is structural heart disease diagnosed and which doctors are involved?

PD Dr. med. Pascal André Berdat: The disease is often detected by chance when the patient visits the doctor because of another problem, because it usually runs for a long time without symptoms. The general practitioner then detects a heart murmur with the stethoscope. If structural heart disease is suspected, further examinations are carried out by a cardiologist. For example, the cardiologist will perform a heart ultrasound, an exercise ECG and, if necessary, a cardiac catheter examination. In special cases, cardiologists also perform magnetic resonance examinations or a computer tomography of the heart in the clinic.

What cardiac interventions are available to patients today and why are they increasing?

Prof. Dr. med. Peter Martin Wenaweser : In the past, structural heart diseases were primarily treated either surgically or with medication. In the last ten years, new treatment options have emerged for certain diseases without opening the chest or using a heart-lung machine. Today, we can effectively treat most structural heart diseases via a catheter. We use the TAVI procedure to replace an aortic valve. In this procedure, we replace the defective valve by implanting a new biological valve prosthesis, which can be inserted in a folded state via the inguinal artery. Initially, TAVI was only performed in high-risk patients, but recent study results show that it can also be used in lower-risk patients and can achieve comparable or even better results than conventional surgery. A detailed preliminary clarification including team discussion is important.

What other cardiac intervention options are available for structural heart disease?

Prof. Dr. med. Peter Martin Wenaweser : Furthermore, we have the possibility to treat severe mitral valve insufficiency in certain inoperable patients by means of catheter procedures. A catheter with a clip at the tip(MitraClip) is inserted via the inguinal vein. After positioning using three-dimensional ultrasound technology, the clip is attached to both leaflets of the mitral valve, reducing leakage. Catheter interventions are on the rise overall because heart valve diseases usually occur at an older age and catheter interventions are gentler than surgical procedures.

What surgical methods are used today?

PD Pascal André Berdat: Valve surgery has been routine in cardiac surgery since the late 1970s. In most areas, surgery is still the treatment of choice, i.e. the gold standard. We can replace any valve, be it with a biological or a mechanical prosthesis. For mitral valve regurgitation, however, surgical repair of the mitral valve is the method of choice. In recent years, procedures have also evolved that allow the cardiac surgeon to perform surgery through smaller approaches, known as minimally invasive methods. Especially in mitral valve surgery, we use keyhole surgery on the heart. In this procedure, we gain access to the heart through several small skin incisions and operate with the help of imaging through a video camera. During the operation, the patient's circulation is diverted and maintained by a heart-lung machine.

How does the decision-making process for the respective therapy work?

Prof. Dr. med. Peter Martin Wenaweser : All physicians involved in the patient's evaluation form the heart team and are important. In addition to the general practitioner and the resident cardiologist, various specialists are involved in the decision-making process: Imaging specialist, interventional cardiologist, cardiac surgeon, anesthesiologist and possibly other specialists meet in a board and subsequently recommend the individual treatment to the patient. The experience and expertise of the team are crucial to the success of a therapy.

When is which therapy appropriate - for which cases is surgery suitable and for which is cardiological intervention?

PD Dr. med. Pascal André Berdat: The heart team makes a recommendation to the patient and explains the advantages and disadvantages of the options. A recommendation is always made on an individual basis, taking into account the underlying medical conditions, the patient's age and concomitant diseases. A recommendation also depends on whether alternative treatment options exist. We base each individual recommendation on international professional guidelines.

PD Dr. med. Pascal André Berdat (cardiac surgery) and Prof. Dr. med. Peter Martin Wenaweser (interventional cardiologist), have specialised, among other things, in the treatment of structural heart diseases.

Source: Heart Supplement Daily Gazette 2020, Athena Tsatsamba Welsch (interview).