Todd:
Hi, and thank you for joining us at EmpowHer – women’s health online. My name is Todd Hartley and I am here right now with Dr. Lishan Aklog - he is the Chairman of EmpowHer’s Medical Advisory Board. He is also the Director and Chief of Cardiovascular Surgery at the Heart and Lung Institute of St. Joseph’s Hospital and Medical Center and that’s in Phoenix, Arizona. Hi Dr. Aklog.
Dr. Aklog:
Hi Todd.
Todd:
Dr. Aklog, there’s a lot of conversation going on about the different types of valve replacements that are going on inside of hearts and I know that Barbara Bush had one done in her 80s, Robin Williams in his 50s. What’s the difference between the different types of valves that we keep hearing about?
Dr. Aklog: That’s a great question. So, so, both those patients, as described, had a condition involving their aortic valve, and the aortic valve is the main valve that the heart has to pump against to pump the blood out of the body and when that valve becomes defective, it can put a strain on the heart and if it’s severely defective it requires replacement. It’s not one of the valves in the body that we commonly can repair. We have to replace it with another valve.
The problem is that as humans we have not been able to create a valve that’s as good as the one god gave us. So, all of the options that we have as surgeons when we replace a defective valve all have their pros and cons.
The two broad categories of valve replacements are valve that are made out of animal tissue or animal valves, we can talk about those in more detail, and the other category are valves that are purely mechanical. Some times I referred to those as metal valves, that’s a little bit of a misnomer because they are really made out of a high-tech carbon material, but they are purely mechanical. They are not made out of any animal parts, and both have their pros and cons.
Todd:
So Dr. Aklog, what kind of animals, what type of animals are used for valves?
Dr. Aklog:
Well that’s always, patients is always very, very interested in that. They always want to know what type of valve am I going to get. Am I going to get a pig valve or a cow valve? Really at the end of the day it’s important to understand that these valves are made out of animal tissue. They are typically, the tissue is taken and actually mounted on a scaffolding artificial material, but the portion that’s actually the valve, the part that actually opens and closes is made out of animal tissue.
So the two big categories are pig valves where the valve, the tissue comes actually from the valve, heart valve of a pig, and then the other category are cow valves where it’s not the actual cow’s valve, but tissue surrounding the valve called the, surrounding the heart, excuse me, called the pericardium. That tissue is processed and cut and then mounted in a way to form a valve.
The most, the most important thing with animal valves or animal tissue valves is that typically they don’t require you to be on blood thinners. That’s the huge advantage. So you don’t need to be on a blood thinner for life and typically, a patient will just take an aspirin a day to keep the blood just a little bit thin.
The downside to animal valves, animal tissue valves, is that they do have some wear and tear. Now people ask this all the time about rejection, you know, “Isn’t it, won’t I have rejection of this tissue because it’s animal tissue?” And the fact is that you won’t because the tissue is treated so that it’s been neutralized of all of those effects that can occur from rejection. So you don’t reject them, but what can happen over time is that there is wear and tear in the valve. So they don’t last forever. We hope that we usually will get 12 to 15 years out of an animal tissue valve. Occasionally it’s short of that. Occasionally it’s longer than that and that’s the most important thing and that really relates to the age group that patients that will get tissue valves.
Todd:
Is the mechanical valve, on the other end of the spectrum, designed to really outlive the patient?
Dr. Aklog:
That’s correct. So, the mechanical valves, the mechanical valves have become very sophisticated from an engineering point of view. So, at this point, the problem of the valve actually structurally failing, the mechanics of it has been eliminated. So that just doesn’t happen anymore. So the goal is, when you put in a mechanical valve, is in fact to give a patient a valve for life. Now that’s a little bit, we can’t say that with a 100% certainty because there are about between three to five percent of patients who ultimately will have to have their mechanical valves replaced for a variety of issues that can occur, blood clots on them or infections or other complications, but the vast majority of people who get a mechanical valve will keep that valve for life.
But the converse, the opposite is true in mechanical valves. The big downside to mechanical valves are in fact that you have to take a blood thinner for life and that carries a lot of issues for patients. There’s a bit of hassle to take blood thinners, you have to have your blood checked every two weeks, and if your blood is too thick, you can have complications of clotting. If your blood is too thin, you can have complications of bleeding, and so, a lot of patients are very reluctant to be on blood thinners for life.
So that’s, so that’s why the decision and the choice of valve can be quite tricky depending on the age of the patient and I think the two examples that you raised…
Todd:
With Robin Williams and Barbara Bush.
Dr. Aklog:
Yes, so Barbara Bush is pretty straightforward because in a patient in her age the tissue valve really can be considered a valve for life. It would be extremely surprising and I tell my 90-year-old patients, “Look, if you come back, you know, and you are 105 or 107 and you’ve worn out this valve, I will be happy to put another one in you,” but practically speaking, it would be extremely unlikely for a patient in that age group to outlive their valve.
Todd:
I think she is one of those thousand points of life, you never know.
Dr. Aklog:
That’s fine, and as I said I have told my patients that I would be ecstatic to have the opportunity to do that because that means they have lived an incredibly long life.
Now, Mr. Williams, on the other hand, is a much more, a much trickier case because in the past, the cut off had typically been about 70s. If you are below 70, generally you would get a mechanical valve. But that has changed as the tissue valves have gotten better and patients have understood the downsides of being on blood thinners and really, at the end of the day, in someone who is 57, we would give that patient the choice. We would let them find out what’s really important to them. Is it more important that they avoid blood thinners or is it more important that they avoid the potential for another operation, and I would say, most of our patients in his age group are actually going against the historical grain and choosing a tissue valve because they would rather have a possibility of having another operation in, you know, 12, 15 or 20 years down the road than be on blood thinners for that period of time.
Todd:
Okay, so that’s a really nice overview. You explained the difference between tissue and mechanical valves, who can benefit from one over the other, but what about the surgical procedure? Is there a difference or is it pretty similar?
Dr. Aklog:
No, the procedure is actually the same. So, it’s really, the procedure can be essentially done in exactly the same way. If the patient is a candidate for minimally invasive operation, they can have it done minimally invasively whether it’s a tissue valve or a mechanical valve.
Todd:
So then I guess… go on.
Dr. Aklog:
I just wanted to make sure to add two things because as with most things in medicine, these things are often a moving target, right? So there are advances in the horizon that can change some of these dynamics and they are really too interesting things that may enter into this decision making that may change things quite a bit in the next, let’s say, 3 to 10 years.
One of them is that there’s significant progress in catheter-based valve replacement. So, instead of having to do an actual open-heart surgery like we do, there are now valves that are being mounted on catheters that can be deployed through a poke, literally, in the groin where the catheter and the valve are advanced and deployed in the heart without having to make an incision at all. That technology is advancing. It’s not quite ready for prime time for most patients, but it is advancing and will be factor in our decision making in a not too distant future.
The other interesting development, which definitely, or has already had an impact on our patients is that there’s one mechanical valve out there, it’s called the On-x valve, which is now under trials. There are clinical trials going on right now to see whether this mechanical valve will be safe to use without blood thinner. So that would be a huge advance if that’s a case. We don’t have any answer to that yet. The results of the trial won’t be available for a few years, but we have been putting this valve in many patients because the study does show that you can come off Coumadin, that will be a huge advantage to these patients to able to come off blood thinners and it will definitely shift the balance, the patient will back more towards mechanical valves.
Todd:
Dr. Aklog, for a woman who is listening right now and needs to have valve replacement, regardless of what type of valve she has, what is the hospital stay and recovery time like?
Dr. Aklog:
That’s really dominated by other things that might be going on. So, if the patient is generally healthy and the operation is being done in a timely fashion so the heart is still strong and there are no other permanent damage or other issues that have gone on then, it’s generally, you are looking at probably a 5 to 7 day hospital stay.
If it can be done minimally invasively through a partial incision, sort of the full incision in the chest, you can improve that a little bit and then after that 5 to 7 day period, it depends a little bit on the patient, but I would say most of our patients who come back for their three week follow up visit are feeling pretty good by that point. They are up and about. They are quite active. They, you know, are maybe not 100%, but may be 80% and then, it’s usually a few more weeks after that, four or five weeks after that, before they are back to full activity.
Todd:
A moment ago you hinted at the minimally invasive approach and I am hearing that there’s minimally invasive spine surgery and all these different types of minimally invasive surgeries popping up so, how does this fit in with aortic valve replacement?
Dr. Aklog:
Well this has become, this has been around for a while, and what it really boils down to is that, if you, if you just need your aortic valve fixed, so you don’t need other additional procedures done at the same time and the only problem is related to your aortic valve, then we can do that operation through a much less invasive approach. Now, you have to be careful because at the end of the day it’s still open-heart surgery. We still have to stop the heart. We still have to open the aorta and replace the valve, but we can do it through a much smaller incision without having to open the entire breastplate.
So standard heart surgery involves opening the entire breastplate, the entire sternum. If you need just some isolated aortic valve replacement and we can do it minimally invasively then that can be done through, instead of a, you know, a 15 inch incision, it can be done through about a two to three, three and a half inch incision in the upper part of the chest and a lot more important than the size of the incision, it can be done without having to open the entire breastplate though. So it only opens partially, so that really facilitates the ability for that part of the bone to heal back up and to get people back to their regular activity.
Todd:
What should women know about the scarring issue that takes place? I mean, it’s going to differ, but depending on what type of procedure they have, but is there a way for them to minimize the scarring so they could go on to wearing…?
Dr. Aklog:
I think, I mean obviously again, if their surgeon is able and has experience in doing it minimally invasively that having a shorter scar obviously is more cosmetic. I would say, you know, sometimes on these patients who have, especially women who have, you know, at least medium-sized breasts, that incision we make is really hidden in the cleavage. I mean, you can’t see it at all and that’s very gratifying to the patient and to us.
One important thing about any incision actually in the body is to understand that the healing process at the level of the skin happens over many weeks and it’s, one of the very important things is obviously to keep, to take care of it, to keep it clean, to watch out for signs of infections and so forth, and to avoid direct sunlight because that can actually, the healing incision is actually very, more susceptible to sunlight than normal skin and so we encourage patients to keep that covered for, you know, a period of at least four to six weeks and that will minimize the healing.
Other than that, unfortunately some people heal wounds better than others, from a cosmetic point of view. So, there’s some patients who can develop, you know, thicker wounds, so called cheloids, and there are other people who just, you know, heal wounds very nicely, so that, some of that depends a little bit on the patient.
Todd:
Well he is Dr. Lishan Aklog. He is the Chairman of EmpowHer’s Medical Advisory Board and Dr. Aklog will be checking in regularly, responding to questions and Dr. Aklog, thank you so much for helping us empower women.
Dr. Aklog:
Thank you Todd.