September 18, 2020 by Adrienne Sylver
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 cancer patient was diagnosed with critical “aortic stenosis” and high risk of left main coronary artery obstruction during TAVR. This occurs when the heart’s aortic valve narrows, preventing the valve from opening fully, which reduces or blocks blood flow from your heart into the main artery to the body.
Dr. Quesada said the patient’s prognosis was very poor, “but the doctors taking care of her (at Memorial Health) said she is a very functional lady. And she wants to 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 coronary occlusion.
Joining Dr. Quesada on this case were Niberto Moreno, M.D., cardiothoracic surgeon and chief emeritus of cardiovascular surgery at the Institute, and interventional cardiologist Bernardo Lopez-Sanabria, M.D.
‘A Very Complex Case’
“I had a meeting with some of my colleagues here,” says Dr. Quesada. “I said this is a very complex case with a high mortality. But we were willing to take it because we thought we could help — and we’re here to help. So, we agreed to go ahead.”
The patient could not continue to receive chemotherapy because of her heart valve condition. “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 because Plan B involved an extremely high-risk, so-called “chimney” stent procedure performed in the left main coronary artery, with a high risk of stent thrombosis.
The issue with her heart was diagnosed after she underwent an echocardiogram (echo), a test that uses ultrasound to show the functionality of the heart muscle and valves. During chemotherapy, she developed shortness of breath and heart failure (when your heart muscle doesn’t pump blood as well as it should), explains Dr. Quesada. Moreover, the patient suffered from anemia, a lack of red blood cells that reduces oxygen flow to the body’s organs. She also was diagnosed with thrombocytopenia, or abnormally low levels of platelets in the blood.
“She had this condition for a long time, but she became symptomatic (of the valve) while under chemotherapy,” explains Dr. Quesada. “They always perform an echo because chemotherapy can be toxic. When they performed the echo, they found the critical aortic stenosis.”
Plan A: Rare Combination of Procedures
At Miami Cardiac & Vascular Institute, the patient underwent Plan A, a rare combination of TAVR and a procedure known as BASILICA — Bioprosthetic Aortic Scallop Intentional Laceration — to prevent Coronary Occlusion, which is performed immediately before TAVR to prevent obstruction of the coronary artery. BASILICA increases treatment options for high-risk patients, including the 62-year patient treated at the Institute.
What made this combination unique, and one of the first times it has been applied in Florida, is that BASILICA is rarely used when the “left main” coronary artery is involved. The left main supplies blood to the left side of the heart muscle. Some patients who benefit from BASILICA have uncommon structures in the heart, such as unusually large aortic valve leaflets, or thin flaps of tissue. The large leaflets block the flow of blood to the coronary arteries as the new valve’s scaffolding opens.
As it turned out, 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. The aortic valve regulates blood flow from the heart into the aorta. The aorta is the major blood vessel that brings oxygen-rich blood to the body.
Dr. Quesada refers to the challenges in this case as “mechanical” — or structural — that needed prompt attention by the Institute’s team of specialists. “This is a mechanical problem that requires a mechanical solution,” he explains. “There are no pills that are going to get rid of this critical aortic stenosis. It’s deadly. It’s worse than cancer. After you have symptoms, the prognosis is usually six months. There were several factors that made this case complex, but this was a very successful procedure and the patient now is ready to receive her chemotherapy.”