October 21, 2020 by Peter B. Laird
Case Study: Backup Plan Helps Save A Weakened Heart
The situation appeared dire for a 67-year-old patient whose heart was so weak it could not pump enough blood to sustain his body. He was in cardiogenic shock. Suffering also from aortic stenosis, the poor functioning of his heart valve was impeding his circulation even further.
The patient arrived at the emergency department of South Miami Hospital complaining of chest pain and shortness of breath. “It looked like he was having a heart attack. But when we took him to the cath lab, it turned out he was not having a heart attack — but he had severe aortic stenosis,” explains cardiothoracic surgeon Lisardo Garcia-Covarrubias, M.D., of Miami Cardiac & Vascular Institute.
Aortic stenosis is the stiffening of the valve through which the heart pumps blood to the rest of the body. When it is no longer able to open and close properly due to calcium deposits, this valve presents the most common — and most serious — heart valve problem, affecting about 2.5 million people.
In many cases, the course of action would have been to surgically replace the aortic valve, but this particular patient, who also had blocked arteries, was too weak. “He was extremely sick to have anything done,” explains Dr. Garcia-Covarrubias, who also serves as chief of cardiothoracic surgery at Florida International University’s Herbert Wertheim College of Medicine.
Facing an extremely delicate and complicated case, Miami Cardiac & Vascular Institute physicians worked together to develop a successful treatment strategy. The case is an example of the collaborative, innovative thinking that has been the hallmark of the Institute since its inception. Known internationally for its approach to complex cardiac cases, the Institute has been at the forefront of more advanced care by leading the design, development and implementation of new techniques.
The man had previously experienced a near-fatal heart attack, which was treated elsewhere. The resulting scarring on his heart muscle affected his ejection fraction — a measurement of how much blood the left ventricle pumps out with each contraction. “With normal heart function, the ejection fraction should be about 55 to 60 percent, but his was 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 did not look good. Dr. Erwin arranged to meet them at Baptist Hospital, where he was on call. “I had given him my personal cell phone number because I was so worried about him. Thankfully, he was able to reach me on that Saturday morning,” Dr. Erwin says.
The patient’s wife rushed him to the hospital, where tests showed his ejection fraction was continuing to drop, now dipping to a dangerously low 10 percent. “At that point, we didn’t think he was going to make it, honestly,” Dr. Garcia-Covarrubias recalls.
Although the man was considered too weak for a traditional minimally invasive transcatheter aortic valve replacement (TAVR), the team opted for a hybrid procedure, hooking him up to a heart-lung machine as a backup. “We typically don’t put patients on cardiopulmonary bypass for a TAVR, but in this case we were very, very concerned,” Dr. Garcia-Covarrubias says.
Dr. Erwin compares the plan to having a hurricane supplies in case of a storm. “It was like having a stand-by generator. We had the tubing connected and the heart-lung machine was ready to go if it was needed,” he says. “This approach is a rare one.”
During the minimally invasive TAVR procedure, a new folded-up valve is inserted starting at an artery in the groin, using a catheter. Upon reaching the heart, the valve is deployed in place of the old, diseased valve without having to cut open the chest. Originally designed as an intervention of last resort for the sickest and most fragile patients, use of the procedure was expanded by the FDA last year to even low-risk patients because of the potential advantage of avoiding open-heart surgery. TAVR is offered is Baptist Hospital, Bethesda Hospital East, and Boca Raton Regional Hospital and South Miami Hospital.
Despite the patient’s weakened state, the TAVR procedure was a success, immediately doubling the man’s heart functionality. “When he came in we did not know if he could survive, and he walked out the front door of the hospital within a week of the final procedure,” says Dr. Erwin, who founded the Institute’s TAVR program at South Miami Hospital.
The Power of Teamwork
Building on past successes, Institute physicians tackle such cases by amplifying each other’s expertise. “This was a very collaborative effort,” Dr. Erwin says. “This patient would have been considered too sick for surgery in most institutions and in most hands, too sick for TAVR. But we didn’t want to let him go — we wanted to give him a fighting chance. We wanted to offer everything we could.”
Dr. Garcia-Covarrubias agrees. “This was truly a team approach.”