If cardiologists across the state were to all say what’s the most exciting aspect of their field today, the winning response might not easily roll off the tongue, but it’d be shouted in unison. …
Advances in tricuspid and mitral valve disease repair — that’s collectively inspiring leaders of local cardiac care centers in the Garden State.
It’s one of the features of the structural heart disease side of cardiology departments. And it’s in that segment of cardiac care, which looks at the valves, arteries and other structures that enable the heart to work, that experts expect to see the most benefits from recent innovations in minimally invasive heart procedures.
The bread and butter of these programs has been a minimally invasive replacement of the aortic valve, one of the heart’s four valves. That intervention, referred to as transcatheter aortic valve replacement, or TAVR, is part of a toolkit that now includes similar treatments for tricuspid and mitral valve disease, according to Hackensack Meridian Health‘s Dr. Ryan K. Kaple.
Kaple, director of the Structural and Congenital Heart Program at the Hackensack University Medical Center, said these new devices and surgical approaches — some of which have been approved by the FDA over the past few months, some of which are still under investigation — are expected to contribute an already flourishing area of cardiology.
“Over the next five years, most areas (of cardiac care) are going to stay flat in terms of growth,” he said. “But the projection for structural heart disease is 53% growth between years 2024 and 2029. So, along those lines, we want to position ourselves to be leaders in the area of structural heart disease.”
Hackensack Meridian Health’s programs were just this summer recognized by the American College of Cardiology after a vetting process of their treatment of patients receiving transcatheter valve repair and replacement procedures.
Kaple said that, in the coming years, institutions such as his will be doing more minimally invasive procedures involving mitral and tricuspid valve diseases, which he expects will further fuel the field’s growth.
The big news in regard to tricuspid treatment options was the April FDA approval of what’s called the TriClip device, which was introduced by medical device company Abbott as a way of treating damaged tricuspid valves without open-heart surgery.
Kaple, who was part of the Yale University team that investigated the device’s use prior to its approval, explained that this is the cousin of the MitraClip, a device that treats mitral valve regurgitation.
“And we’re proud to be part of the early adopters of this device (at Hackensack), which I anticipate is only the first one in a repair space that will continue to grow with new approaches,” he said.
There was also an approach to treating tricuspid regurgitation approved by the FDA this year called the Evoque Transcatheter Valve Replacement System that similarly helps avoid the need for open-heart surgery. Like TAVR, it involves doctors inserting replacement valves to fix diseased valves through a small puncture in the groin.
In participating in the current rollout of these techniques and tools, Hackensack is aiming to be a destination program in this specialty.
Dr. Matthew Saybolt, director of the Structural Heart Disease Program at Hackensack Meridian Health’s Jersey Shore University Medical Center, said part of that is also getting patients enrolled in trials for therapies that haven’t yet been made available to the public.
“We see a lot of value in these approaches,” he said. “The idea is that you’re making these repairs in an hour or less, and patients are walking around the next day.”
Paired with cardiac care centers’ excitement about treating structural heart disease in new ways is an emphasis on actually diagnosing these conditions in a timely fashion — sometimes also in new ways.
Dr. Partho P. Sengupta, chief of the division of cardiology at Rutgers Robert Wood Johnson Medical School, said detection makes a massive difference for patients who might require heart valve interventions.
“We want to diagnose these conditions early right now, well before they’re coming back to clinics with heart failure — and, perhaps, they’re at the end of the road by the time they actually reach a surgeon,” he said. “There’s an effort to shift that paradigm.”
Sengupta touts his institution’s role in developing research in this area over many years, as a multidisciplinary center that has physicians, technologists and artificial intelligence scientists working in concert to address heart health challenges.
To that end, he said there’s a lot of buzz around how screening tools can pick up on structural heart problems at an earlier stage than ever with the help of AI prediction. There’s also potential for digital tools to create “digital twins” of patients that map out a patient’s problems and model cardiologists’ options for interventions.
There’s also the question of when those interventions should happen, and if a wait-and-see approach is ever justified for a patient with a damaged valve.
Dr. Linda Gillam, medical director of the cardiovascular service line for Atlantic Health System, one of the leading centers nationally in volume and outcomes of TAVR procedures, said that, this fall, it’s releasing findings of research covering just that.
“Safe to say, whether positive or negative, (the findings) will change the guidelines,” she said. “It’s a landmark trial that’s looking to answer the question of whether or not the threshold at which we say it’s time to change a narrowed aortic valve has been too high.”
As Gillam explained, while people are waiting to manifest debilitating symptoms or to develop failure of chambers of the heart — basically, to get to a point that obviously warrants treatment — there’s a low level of cardiac damage.
“And some of that damage can be irreversible,” she said. “What’s being explored is whether patients would do better if they had their valve replacement earlier. And we’ve contributed a lot to the understanding as to what ‘earlier’ would translate to.”
There’s a lot that cardiologists are still learning about upkeep of the structural components of the vital organ they specialize in.
Maybe they’re biased. … But Gillam is happy to join the chorus of cardiologists expressing that it’s hard to find a more exciting and faster-moving area of medicine than structural heart health.
“You get the feeling that, collectively, there’s a very disruptive group of technologies entering the structural heart space,” she said. “It follows a several-decade shift in taking care that used to be provided through open-heart surgeries to catheters introduced to the heart. And, while there’s still reasons surgery might be the best choice for some patients, we have really good alternatives now.”
From child to adult
The past two decades represented perhaps the best time in history to be a pediatric patient with a complex heart issue. Advances in medicine and surgical approaches meant doctors have been able to treat and manage congenital issues in youth that might have once been a death sentence.
Thankfully, cardiologist Dr. Ryan K. Kaple said, that means many of those patients have lived into adulthood.
But, also, that means they have adult problems.
“Now, these folks have lived long enough to deal with more traditional cardiac problems, such as cholesterol issues and other problems they never had to worry about before,” he said.
Kaple is a specialist in assessing and treating individuals who have aged into adulthood after being born with heart defects. Two years ago, he brought that expertise to Hackensack University Medical Center, where he leads a program centered on adults with congenital heart problems.
“And it’s really one of very few (focused on that),” he said. “It’s a unique focus. It’s also underrepresented, because this is starting to be the fastest-growing population of patients in the area of heart disease.”
The reason there aren’t more cardiac care centers with this as a focal point is that, until more recently, there weren’t as many adults living with congenital heart conditions that needed care.
Kaple said that makes it so that, if a 20- or 30-year-old is told they’re not a surgical candidate because of an operation they had as a 5- or 6-year-old, Hackensack University Medical Center is often the first ones to get the call.
“These patients may have undergone at least one and sometimes multiple (open heart surgeries) at a young age,” he said. “To then subject them to another years later makes it higher risk.”
Kaple added that scar tissue buildup is one of the reasons for that.
That makes the recent advances in valve repair and replacement particularly beneficial for this population, as they sometimes require the mending of artificial valves put in many years ago.
“These catheter-based approaches not only don’t subject a patient to their third or fourth open heart surgery, they’re also able to be home for lunch for the next day,” Kaple said. “So, we’re excited about the innovation that’s happening across the board.”
