Case Study: Backup Plan Helps Save A Weakened Heart

The situationappeared dire for a 67-year-old patient whose heart was so weak it could notpump enough blood to sustain his body. He was in cardiogenic shock. Suffering alsofrom aortic stenosis, the poor functioning of his heart valve was impeding hiscirculation even further.

The patientarrived at the emergency department of SouthMiami Hospital complaining of chest pain and shortness of breath. “Itlooked like he was having a heart attack. But when we took him to the cathlab, it turned out he was not having a heart attack — but he had severeaortic stenosis,” explains cardiothoracic surgeon Lisardo Garcia-Covarrubias,M.D., of Miami Cardiac & VascularInstitute.

Aortic stenosis is thestiffening of the valve through which the heart pumps blood to the rest of thebody. When it is no longer able to open and close properly due to calciumdeposits, this valve presents the most common — and most serious — heart valveproblem, affecting about 2.5 million people.

In many cases, the course ofaction would have been to surgically replace the aortic valve, but thisparticular patient, who also had blocked arteries, was too weak. “He wasextremely sick to have anything done,” explains Dr. Garcia-Covarrubias, whoalso serves as chief ofcardiothoracic surgery at Florida InternationalUniversity’s Herbert Wertheim College of Medicine.

Facing anextremely delicate and complicated case, Miami Cardiac & Vascular Institutephysicians worked together to develop a successful treatment strategy. The caseis an example of the collaborative, innovative thinking that has been thehallmark of the Institute since its inception. Known internationally for its approach to complex cardiaccases, the Institute has been at the forefront of more advanced care by leadingthe design, development and implementation of newtechniques.

StrategicPlanning

The man had previouslyexperienced a near-fatal heart attack, which was treated elsewhere. Theresulting scarring on his heart muscle affected his ejection fraction — a measurement ofhow much blood the left ventricle pumps out with each contraction. “With normalheart function, the ejection fraction should be about 55 to 60 percent, but hiswas about 20 percent. So really, his heart was not in very good shape,” Dr.Garcia-Covarrubias says.

The first step was for interventional cardiologist Phillip Erwin, M.D., PhD., the director of Complex Coronary and Structural Interventions at South Miami Hospital, to perform an angioplasty. Using this minimally invasive procedure, Dr. Erwin threaded a balloon through a catheter to the patient’s right artery, where it was inflated to push obstructing plaque outward. Dr. Erwin, then placed a stent to support the artery and keep the blood flowing. Dr. Erwin also performed balloon aortic valvuloplasty to stretch out the patient’s stiffened aortic valve and relieve the obstruction to improve cardiac output. The goal was to buy the man some time and send him home so that his heart could get strong enough for his valve problem to be addressed.

About a week later,Dr. Erwin got a phone call from the man’s wife, who was worried her husband didnot look good. Dr. Erwin arranged to meet them at Baptist Hospital, where hewas on call. “I had given him my personal cell phone number because I was soworried about him. Thankfully, he was able to reach me on that Saturdaymorning,” Dr. Erwin says.

The patient’s wiferushed him to the hospital, where tests showed his ejection fraction was continuingto drop, now dipping to a dangerously low 10 percent. “At that point, we didn’tthink he was going to make it, honestly,” Dr. Garcia-Covarrubias recalls.

Proactive Thinking

Although the manwas considered too weak for a traditional minimally invasive transcatheteraortic valve replacement (TAVR), the team opted for a hybrid procedure,hooking him up to a heart-lungmachine as a backup. “We typically don’t put patients on cardiopulmonarybypass for a TAVR, but in this case we were very, very concerned,” Dr. Garcia-Covarrubiassays.

Dr. Erwin comparesthe plan to having a hurricane supplies in case of a storm. “It was like havinga stand-by generator. We had the tubing connected and the heart-lung machinewas ready to go if it was needed,” he says. “This approach is a rare one.”

During theminimally invasive TAVR procedure, a new folded-up valve is inserted startingat an artery in the groin, using a catheter. Upon reaching the heart, the valveis deployed in place of the old, diseased valve without having to cut open thechest. Originally designed as an intervention of last resort for the sickestand most fragile patients, use of the procedure was expanded by the FDA lastyear to even low-risk patients because of the potential advantage of avoidingopen-heart surgery. TAVR is offered is BaptistHospital, BethesdaHospital East, and Boca Raton RegionalHospital and South Miami Hospital.

Despite thepatient’s weakened state, the TAVR procedure was a success, immediatelydoubling the man’s heart functionality. “When he came in we did not know if hecould survive, and he walked out the front door of the hospital within a weekof the final procedure,” says Dr. Erwin, who founded the Institute’s TAVR program at South Miami Hospital.

The Power of Teamwork

Building on pastsuccesses, Institute physicians tackle such cases by amplifying each other’sexpertise. “This was a very collaborative effort,” Dr. Erwin says. “Thispatient would have been considered too sick for surgery in most institutionsand in most hands, too sick for TAVR. But we didn’t want to let him go — wewanted to give him a fighting chance. We wanted to offer everything we could.”

Dr.Garcia-Covarrubias agrees. “This was truly a team approach.”