We breathe, love, hate, and feel tenderness or anger because our hearts beat. We are alive, as long as they beat. But sometimes our hearts fail – due to degenerative changes or calcium deposits on the edges of the aortic valve – and we feel the well-known symptoms: angina, dizziness, fainting, heartbeat, shortness of breath… pills are not enough, and drastic measures are called for.
For years, serious heart disorders were prompts for open heart surgery. This method of treatment was dangerous, but it was the only option. A few years ago, however, there was a revolution of sorts in this field of medicine: new, less radical, methods were introduced that allow for operations on vulnerable and elderly patients. The risk is lower and the outcome is better.
Prof. Dr. med. Franz Wolfgang Amann, Cardiovascular Center of Hirslanden Clinic im Park, the world-renowned specialist in the field of interventional cardiology, performs interventions almost every day to extend and improve the quality of human life. Several decades of practical experience and intuition have convinced him that in the next 10-20 years the distinction between cardiologists and cardiac surgeons will become obsolete: a doctor will have knowledge and skills in both fields.
– Professor Amann, Switzerland is the recognized leader in innovation. Local doctors’ approaches are based on the latest international breakthroughs, and also on their own breakthroughs. What can you offer to your patients today that could not have been offered even 10 years ago?
– The most important thing is that many issues can now be resolved in less radical ways. In the field of coronary heart disease, stenting is an alternative to open heart surgery. Aortic stenosis can be treated with TAVI (Transarterial Aortic Valve Implantation), a modern and minimally invasive method to replace the aortic valve.
This new direction in cardiology is developing quite rapidly. The advantage of the method is the fact that the surgery is performed under a local anesthetic and it takes about an hour to complete; the patient is discharged after 3-5 days. In addition, there is no need for extracorporal circulation.
Our team is a leader in performing aortic valve replacements. At our clinic, cardiologists and surgeons work together to offer a patient the best possible treatment. However, the final decision on which method to use is made only after a discussion with the patient.
Of course, there are many other common diseases for us to treat, such as coronary artery blockage and different forms of congenital heart disease using the catheter technique.
– Let’s focus on TAVI. How was this method invented? And what country can be called the leader in its use?
– It was invented in France, where the first such operation was performed in 2002. We started to use it in early 2008. In the United States, the process took much longer; it was only approved in 2011.
Today the method is primarily used in economically developed countries: in the USA, Western Europe, Australia, and Canada. The treatment is expensive: the valve alone costs approximately 30,000 CHF. There-fore, classic surgery remains more affordable. The valves required for classical surgery are much cheaper (3,000-4,000 CHF) and available in any country. But am convinced that with time the new method will spread across the world. Something new is always expensive at first, but the price falls once it becomes popular.
– TAVI is often used in the treatment of older patients, as it is a less invasive and less risky procedure. Is there any scientific basis for this?
– Yes, it is true. Two months ago a study was conducted in Denmark to compare it with classic surgery in elderly patients. The new method demonstrated greater efficiency, with decreased mortality and increased quality of life after the implant. The latter is particularly important: for people approaching 80 years of age, it is very important to remain independent. The populations of European countries are aging rapidly, and one of the consequences of this is an increase in valvular heart diseases. That is why TAVI is becoming more common. The method is truly minimally invasive, which is especially important for elderly patients.
To date, this method has been used on more than 500,0patients worldwide. Currently, 70-80 implants are performed in Switzerland each month. Each year one or two new valves are developed and introduced onto the market. The number of manufacturers is growing. For example, the newest type of valve has been developed and has started to be produced in Switzerland.
– I understand that each case is individual, but nevertheless are there any statistics on how TAVI can extend human lifespan?
– It is still too early to tell; not enough time has passed since we started to use this technique. I performed my first implant in 2008 and I can say that this valve has been functioning perfectly so far.
However, bio-prosthesis usually has a lifetime of 10-12 years. It doesn’t matter how they were implanted, by classical open heart surgery or by TAVI. When a bio-prosthesis fails, we replace the worn valve with a new one using the less invasive method of implantation (valve-in-valve procedure).
– What is a prosthetic valve?
– It is a tricuspid valve manufactured of bovine or porcine pericardial tissue, embedded in a metal frame (stent). the folded delivery system is inserted into the femoral artery using a catheter and delivered to the lumen of the affected aortic valve where it expands like an umbrella, pushing the old valve’s leaves out of the way. The principle is similar to Russian nesting dolls. The delivery system is removed, and the new valve begins to function.
– These surgeries seem to be a miracle: an hour in the operating room in the hands of experienced specialists can significantly extend a patient’s active life! Are all your patients eligible for the minimally invasive treatment or are there contraindications?
– If we talk about stenting, the suitability of the patient’s anatomy is important. In each patient you have to assess which method would be best. It should be discussed with the patient. In some cases, we immediately say that open surgery is not an option, and sometimes, on the contrary, we consider it to be the only option. So, everything is case-based. But in degenerative aortic stenosis, TAVI can be offered to the majority of patients.
If we are talking about TAVI, today we use it even with younger people.
– Can you please explain from your experience why heart vessels work just fine in some people, but cause a lot of problems in others?
– Naturally, genetics plays the crucial role. It determines the aging of heart vessels, and why they wear out so quickly. Other known factors are smoking, high blood pressure, diabetes, cholesterol, stress… atherosclerosis can start earlier in some people, and later in others. Sometimes the blood vessels can be in perfect working order even in a 90-year-old person, whereas familial high cholesterol can lead to myocardial infarction at the age of only 10.
– Can new treatments prevent an infarction?
– This is exactly what we do during the examination. For example, if a patient has high cholesterol, we try to optimize risk factors by medication. We conduct stress tests, stress ultrasound, and magnetic resonance imaging of the heart to detect possible scarring and circulation disorders. If a person can be treated by non-surgical methods, we provide advice on the normalization of blood pressure and motivate the patient to take up sports. Physical activity is a great way to prevent vascular disease. I can confidently say that the prognosis improves with the elimination of the cause of the disease. Therefore, it is important to have regular checkups and to manage the risk factors.
– You mentioned stress as a risk factor for the heart. What can you suggest to prevent the effects of stress on people working in business?
– A busy schedule does not mean that a patient is harming his health. A lot depends on how he or she copes with stressful situations. The stress in their line of work can be positive or negative, and can provoke different reactions. It is bad to eat and drink well into the night in smoke-filled rooms on a regular basis, but it is good to take a run for an hour between two business meetings.
Some people do not notice stress. Some can easily get rid of it, while others cannot. In any case, we provide advice and recommendations. For example, we recommend that those who are constantly on the road take time for jogging, swimming or fitness. Patients often come to me with this problem and I advise them to set aside more time to take care of their health. 30 to 60 minutes a day is enough. Beyond physical activities, proper nutrition and quitting smoking is also very important.
– What symptoms indicate that it is time to visit a doctor?
– In coronary artery disease, angina pectoris and shortness of breath are the leading symptoms. In aortic valve stenosis, the symptoms are very similar. In the physical examination, the main sign of aortic stenosis is a heart murmur. If a murmur is found, it is necessary to conduct an ultrasound examination to visualize the valve and to determine its function. If there is a significant valve dysfunction, an additional invasive examination (heart catheterization and coronary angiography) is performed before making a decision regarding the treatment: classic open heart valve replacement or TAVI.
– How long does this examination take?
– For symptomatic patients, as a rule it takes no more than 1-2 days. It is not necessary to spend all this time in the hospital; the examination can be performed on an outpatient basis. However, if we discover a problem, we offer the choice of starting the treatment immediately or scheduling it for the near future. My opinion is that you should not delay.
– What is your prognosis for the future of interventional cardiology and cardiac surgery?
– I believe that in 10-20 years, doctors will have two sets of skills, cardiac surgery and cardiology, and will be able to perform both kinds of treatment. The distinction will become obsolete.
In our team we have already noticed a change: surgeons are using non-invasive treatments that were previously used only by cardiologists, and cardiologists are involved in surgical interventions that have hitherto always been the realm of surgeons. Today, we talk with a patient together, make decisions together and stand at the operating table together.
Franz Wolfgang Amann
Prof. Dr. med., Cardiovascular Centre at Hirslanden Klinik Im Park. He graduated from the University of Innsbruck, Faculty of Medicine (now Innsbruck Medical University) in 1972. Until 1991, worked at leading medical institutions in Switzerland and the US, in departments of cardiology and general internal medicine. 19912002: Cardiologist at the University Hospital of Zurich. 2002 until present: Cardiovascular Centre Zurich at Klinik Im Park. The author of several scientific publications, he is a fellow of the Swiss Society of Cardiology (Schweizerische Gesellschaft fur Kardiologie; SGK), the European Society of Cardiology (ESC), and the International Society of Vascular Surgery (ISVS).