Cancer Patient Referred to Miami Cardiac & Vascular Institute Gets Rare Heart-Valve Procedure

A team of specialists from Miami Cardiac & Vascular Institute has performed a relatively new procedure on a 62-year-old breast cancer patient with metastatic disease who had to stop chemotherapy because of a critical heart valve condition.  

She was referred by her oncology/cardiology team at Memorial Healthcare System to Ramon Quesada, M.D., medical director of Structural Heart and Complex Percutaneous Coronary Intervention at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida. Dr. Quesada is a pioneer in complex, minimally invasive heart valve procedures, including TAVR (transcatheter aortic valve replacement).

The cancerpatient was diagnosed with critical “aortic stenosis” and high riskof left main coronary artery obstruction during TAVR. This occurs when theheart’s aortic valve narrows, preventing the valve from opening fully, whichreduces or blocks blood flow from your heart into the main artery to the body.

Dr. Quesadasaid the patient’s prognosis was very poor, “but the doctors taking careof her (at Memorial Health) said she is a very functional lady. And she wantsto live.” She has been fighting cancer for 4 years.  She was to have a TAVR at Memorial Health,but it was cancelled due to the complexity of the case and the risk of coronaryocclusion.

Joining Dr.Quesada on this case were Niberto Moreno, M.D., cardiothoracic surgeon and chiefemeritus of cardiovascular surgery at the Institute, and interventionalcardiologist Bernardo Lopez-Sanabria, M.D.

‘A VeryComplex Case’

“I hada meeting with some of my colleagues here,” says Dr. Quesada. “I saidthis is a very complex case with a high mortality. But we were willing to takeit because we thought we could help — and we’re here to help. So, we agreed togo ahead.”

The patientcould not continue to receive chemotherapy because of her heart valvecondition. “So, she came in and we developed a Plan A and a Plan B,”Dr. Quesada said. It’s very fortunate that Plan A worked, he said. That’s becausePlan B involved an extremely high-risk, so-called “chimney” stent procedureperformed in the left main coronary artery, with a high risk of stentthrombosis.

The issuewith her heart was diagnosed after she underwent an echocardiogram (echo), atest that uses ultrasound to show the functionality of the heart muscle and valves.During chemotherapy, she developed shortness of breath and heart failure (whenyour heart muscle doesn’t pump blood as well as it should), explains Dr.Quesada.  Moreover, the patient sufferedfrom anemia, a lack of red blood cells that reduces oxygen flow to the body’sorgans. She also was diagnosed with thrombocytopenia, or abnormally low levelsof platelets in the blood.

“Shehad this condition for a long time, but she became symptomatic (of the valve)while under chemotherapy,” explains Dr. Quesada. “They always performan echo because chemotherapy can be toxic. When they performed the echo, theyfound the critical aortic stenosis.”

Plan A:Rare Combination of Procedures

At MiamiCardiac & Vascular Institute, the patient underwent Plan A, a rare combinationof TAVR and a procedure known as BASILICA — Bioprosthetic Aortic ScallopIntentional Laceration — to prevent Coronary Occlusion, which is performedimmediately before TAVR to prevent obstruction of the coronary artery. BASILICAincreases treatment options for high-risk patients, including the 62-yearpatient treated at the Institute.

What madethis combination unique, and one of the first times it has been applied inFlorida, is that BASILICA is rarely used when the “left main”coronary artery is involved. The left main supplies blood to the left side ofthe heart muscle. Some patients who benefit from BASILICA have uncommonstructures in the heart, such as unusually large aortic valve leaflets, or thinflaps of tissue. The large leaflets block the flow of blood to the coronaryarteries as the new valve’s scaffolding opens.

As it turnedout, the breast cancer patient was born with a bicuspid aortic valve (BAV),which is an aortic valve that only has two leaflets, instead of three. Theaortic valve regulates blood flow from the heart into the aorta. The aorta isthe major blood vessel that brings oxygen-rich blood to the body.

Dr. Quesadarefers to the challenges in this case as “mechanical” — orstructural — that needed prompt attention by the Institute’s team ofspecialists. “This is a mechanical problem that requiresa mechanical solution,” he explains. “There are no pills that aregoing to get rid of this critical aortic stenosis. It’s deadly. It’s worse thancancer. After you have symptoms, the prognosis is usually six months. Therewere several factors that made this case complex, but this was a verysuccessful procedure and the patient now is ready to receive herchemotherapy.”