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A New Home for Structural Heart Disease

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LOUISVILLE They say, “Home is where the heart is.” Well, now the heart has a new home – at the Structural Heart Center at Jewish Hospital.

The Structural Heart Program at the University of Louisville and Jewish Hospital, part of KentuckyOne Health, was begun in 2011 by interventional cardiologists Michael Flaherty, MD, PhD, and Naresh Solankhi, MD, with cardiothoracic surgeon Matthew Williams, MD, who was director of clinical cardiac operations at the time. While other cardiac programs address coronary arteries and electrophysiology, the scope of the Structural Heart Program is defined as abnormalities of the walls, muscle, and valves of the heart.

Since its inception, the Structural Heart Program operated within the hospital but did not have a dedicated space. Now, the Structural Heart Center at Jewish Hospital will provide a central home to further distinguish the program’s services for patients.

By bringing all the services of the Structural Heart Center together into a new singular clinical space at Jewish Hospital, a prospective patient can see a multidisciplinary team of practitioners in one location, on the same day. All relevant testing such as CT scans, echocardiograms, and EKGs will be immediately available. As Flaherty points out, “The greatest value for the patient and the providers is that in one visit there will be no unanswered questions.”

While traditional open heart surgery is and always will be an important part of a structural heart program, minimally invasive techniques are gaining ground for appropriate patients. The Structural Heart Center takes a team approach to therapies such as transcatheter aortic valve replacement (TAVR) and MitraClip® for mitral regurgitation. “Our multidisciplinary team is setting a new bar for patient care and continuing to establish Jewish Hospital as a valve and structural heart Center of Excellence. We are a regional training site for these minimally invasive technologies,” says Kendra Grubb, MD, MPH, cardiovascular surgeon and surgical director of the Structural Heart Program.

Building the Foundation

Before 2011 there was no center in Kentucky offering the TAVR procedure. Flaherty, an interventional cardiologist with U of L Physicians, was already certified and working at U of L when he decided to go to Baltimore to pursue a fellowship in minimally invasive techniques in 2009. “The main reason I went to Johns Hopkins was to learn transcatheter aortic valve and mitral valve therapies because we didn’t have that in Louisville at the time,” he says. Flaherty is board certified in internal medicine, cardiology, and interventional cardiology and is now director of adult structural heart disease and research interventional cardiology at U of L and medical director of the Structural Heart Program at Jewish Hospital.

As Flaherty was starting the TAVR program in Louisville in 2011, 200 miles away, Grubb, a fellowship-trained cardiovascular surgeon was completing an additional fellowship year in interventional cardiology and transcatheter therapies at Columbia University in New York. In 2013, she was recruited to join U of L Physicians and the faculty at U of L in the Cardiothoracic Surgery Division and help expand the TAVR program at Jewish Hospital. Grubb has since become surgical director of the Structural Heart Program.

TAVR for Lower Risk Patients

Grubb’s enthusiasm is shared by the whole team when she says, “Transcatheter therapies such as TAVR are an absolute paradigm shift in the way healthcare professionals view the evaluation and treatment of patients with cardiac valvular disease.” Prior to FDA approval for TAVR clinical trials, patients with aortic stenosis who were too sick to have open heart surgery had no other alternative. These patients, the very sick and high risk, were the first to be entered into an FDA trial of TAVR at U of L. The first trial, which randomized patients to TAVR or standard cardiac treatment, was so successful that a trial of intermediate risk patients was immediately planned and carried out. The second study randomized patients to TAVR or conventional open heart surgery. The intermediate patient trial showed TAVR was at least as good as open heart aortic valve replacement and was minimally invasive to the patients. Patient comfort and rapid return to normal life compared to the trauma of open heart surgery cannot be over emphasized. Due to the success of the previous trials, a current study is underway on low risk patients with aortic stenosis.

The Jewish Hospital Structural Heart Team performs the entire TAVR procedure under twilight anesthesia. There is no intubation, and the patient can speak and be spoken to throughout. According to Jiapeng Huang, MD, PhD, cardiac anesthesiologist who is board certified in anesthesiology and cardiac anesthesia, “Easy anesthesia for the patient means that this is the most demanding form of cardiac anesthesia for the physician. There is no down time for the anesthesiologist.”

Minimally Invasive = Maximum Team Effort

The intraoperative team consists of an interventional cardiologist, a cardiothoracic surgeon, a cardiac anesthesiologist, and an experienced team of nurses and surgical technicians.

Taking on clinical trials, such as the early TAVR trials, requires many well-trained and dedicated personnel in addition to the physicians. For the research studies, Anne Marie Webb, RN, BSN, and Sharon Vincent, MSN, RN, serve as clinical research coordinators with the assistance of Genny Sanders, MSN, APRN, FNP-BC, the nurse navigator, and Erika Keithley, BSN, RN, CCRN, the nurse/valve coordinator. Grubb states emphatically that, “The Structural Heart Program could not exist without these nurses and coordinators.”

Both Flaherty and Grubb see great advances coming and coming soon. TAVR and MitraClip will continue to improve at the design and the implementation level. Beyond MitraClip, which only addresses mitral regurgitation, there are already devices being evaluated for transcatheter mitral valve replacement. Research is also developing devices for the right side of the heart, specifically the pulmonic valve. Grubb describes the tricuspid valve as the next target for minimally invasive therapies.

The program recently celebrated its 450th TAVR and now is performing more than 150 transcatheter valve therapies a year. Huang believes strongly that performing a large number of carefully monitored procedures per year is key to operative efficiency and a low complication rate.

Clearly this group of healthcare providers already functions at an exemplary level, but the opening of the Structural Heart Center at Jewish Hospital means that patients that once had no options can see a multidisciplinary team of providers in a single visit and potentially be treated with minimally invasive life-saving technology. It also means these providers are training the next set of physicians across the region and setting the stage for the next generation of leading-edge technology.