Torrance Memorial’s Lundquist Lurie Cardiovascular Institute is ranked
one of Southern California’s top heart programs. People come from
all over the southland for the innovative treatments its Structural Heart
and Valve Program has been building for years. Many of these treatments
are taking the place of more invasive heart surgeries, some of which cannot
be performed on patients who are very ill, have other medical conditions
or are simply too advanced in age.
One of the newest and most exciting treatments is for a condition called
mitral regurgitation (MR), which is when the heart’s mitral valve—one
of four valves that control the flow of blood through your heart—doesn’t
close tightly enough. The condition allows blood to flow back, or “regurgitate,”
into your heart’s chambers instead of out to the ventricle. When
this happens, your heart has to work harder to push blood through your
body. As a result, people with MR have shortness of breath, difficulty
breathing when lying down, irregular heartbeat, fatigue, leg swelling
and worsening heart failure.
“Currently the gold standard for treating MR is open heart surgery
to repair the valve,” says Torrance Memorial cardiologist Salman
Azam, MD. “But for a certain population, open heart surgery is not
an option, and in the past these patients’ only choice was to take
The new treatment is called MitraClip, a minimally invasive procedure that
repairs the mitral valve using a catheter that is guided from the groin
to the heart. The damaged mitral valve is in essence clipped together
with what Dr. Azam likens to “a butterfly clip. It clamps onto both
doors of the mitral valve, pulling them closer together and reducing the
gap causing the leakage.”
There are two types of mitral regurgitation, according to Dr. Azam: “Functional
MR is caused when the valve itself is normal but the muscle at the bottom
of the left chamber of the heart is not working well and will not close
completely. And degenerative MR means there is a problem with the valve
itself—sometimes a tear in one of the valve’s leaflets.”
Functional MR is the most common and is often caused by heart disease.
But viral infections can weaken the muscle, as can alcohol overconsumption.
Since smoking can increase the risk of heart attack, it also can be a factor.
The procedure has been in clinical trials for a long time (more than 40,000
procedures have been performed worldwide) and has been used at Torrance
Memorial for more than three years, with great success in treating some
of the most vulnerable patients. “Our oldest has been 97,”
says Dr. Azam, “and she went home the next day.”
Typically patients do go home within a day or two. Since they might be
pretty weak, “it will take time,” he explains, “but
they are usually well enough to start cardiac rehab soon after the procedure.”
Dr. Azam says the benefits include a reduction in both kinds of MR—functional
and degenerative—with much less trauma and quicker recovery for
the patient, and a reduction in mortality. “Initial landmark studies
showed that patients with degenerative MR who underwent a MitraClip procedure
lived longer than those just treated with medication. And the recent COAPT
[Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy]
study for patients with functional MR showed a similarly significant improvement
in mortality at two years.”
Dr. Azam says he’s excited about these findings “because the
number of patients affected who aren’t suitable for open heart surgery
is significant, and if they are not treated they might have a recurrence
of congestive heart failure and repeated hospitalizations. This is a meaningful
intervention that will keep them at home—out of the hospital—and
improve their quality of life.”
Further good news is that the MitraClip procedure has been approved by
the FDA for degenerative MR. Because of the success of the COAAP study,
it will soon be approved for functional MR as well, Dr. Azam predicts.
And the clips seem to last indefinitely, he says: “A patient might
have to come back for an additional clip, but once placed, they seem to
last.” So far, recurrence rates at Torrance Memorial are about five percent.
Dr. Azam does stress that this is not heart valve surgery, which has been
shown to be the gold standard in randomized studies. “This is an
adjunct option for those who are not strong enough for open heart surgery.
Each patient is evaluated by the Torrance Memorial Heart Team and offered
the best treatment for their case.”
Another procedure Dr. Azam is excited about at Torrance Memorial is Transcatheter
Aortic Valve Replacement, or TAVR. TAVR is indicated for aortic stenosis,
a fairly typical complication of aging that is the stiffening of the aortic
valve in the heart. Because blood flow is compromised through the stiffened
valve, it can cause extreme fatigue, chest pain, dizziness and high risk
of a heart attack—even sudden death.
“In the past,” says Dr. Azam, “our only option was open
heart surgery, which some patients are just not strong enough for. Now
we have the option of passing a catheter through the groin and inserting
a replacement valve into a patient’s own valve, and it works instantly.”
TAVR is done under light anesthesia and requires a minimal hospital stay—usually
one to five days.
Also in the past, TAVR has been approved only for inoperable, high-risk
patients, but studies have been conducted that are expanding the indication
to intermediate-risk and, with luck, low-risk patients as well. “This
will be important for patients whose aortic valve is not yet at the point
of morbidity. We can offer the technique prior to failure.”
Dr. Salman Azam can be reached at 310- 257-0508.