Doc Talk

Patient couldn't bear thought of heart surgery again

Severely breathless because of leaky heart valve, he opted for less invasive procedure

Mr R was referred to me in June as he had heart failure because of a leaky heart valve.

The 66-year-old came into my office in a wheelchair. He was too breathless to walk 30m from the lift to my clinic.

He had open-heart surgery nine years ago where his mitral valve was replaced with a heart valve made with artificial tissue.

He led an active lifestyle until two months ago, when he started to feel breathless while walking.

Despite seeking medical advice and taking medicine, the breathlessness continued, and reached a point where he would get severely breathless even with minimal exertion.

An echocardiogram or heart ultrasound showed that there was severe leakage along the perimeter of his artificial heart valve prosthesis.

The leak was due to a breakdown of the sutures holding the artificial heart valve to his own tissue.

Studies show  that mild valve leakages are well-tolerated and usually do not have deleterious effects on the heart. The hope is that, with time, the leakage will continue to decrease as scarring takes place around tissues adjacent to the plug.

This created a gap between the artificial heart valve and Mr R's tissue.

This type of suture breakdown may occur in up to 15 per cent of patients with an artificial heart valve.

The conventional treatment option would be to offer a repeat open-heart operation to repair the gap or hole between the artificial heart valve and the patient's tissue. However, this would entail significant risks and a lengthy post-surgery recovery period.

Since 2010, an alternative option has been made available - a minimally invasive or percutaneous "sealing" or "plugging" of the leak.

This leak repair is performed through a small puncture in the groin. There is no need to cut open the chest, and the heart remains beating throughout the procedure.

A small catheter (plastic tube) is fed through the artery or vein in the groin to the heart.

With the help of a guiding wire and advanced X-ray imaging, a plug-like device - a small round- or oblong-shaped device made from a metallic mesh - is then deployed into the leak to close the gap.

Overall, the risk of serious complications from the procedure is less than 5 per cent.

A possible complication is that the plug only partially seals the gap, causing residual leakage. In this case, further procedures may be needed to fix the problem.

In rare cases, the plug can obstruct the normal function of the artificial heart valve and may have to be removed, either by a minimally invasive approach or open-heart surgery. The risk of this particular complication, however, is probably between 1 per cent and 2 per cent.

There are also the usual risks that come with any cardiac procedure, such as bleeding, stroke and heart attack.

After a thorough discussion, Mr R and his family decided on the percutaneous option, as he could not bear the thought of undergoing another open-heart operation.

He was under general anaesthesia during the procedure, which requires a scope-like device to be placed in the oesophagus. It emits ultrasound waves to help guide the plug to the correct position.

For Mr R, an appropriately sized plug was successfully implanted into the "hole". The technically complex procedure took several hours to perform.

The next morning, he looked cheerful and told me that he was already feeling better.

He went home later that day, after a one-night hospital stay.

About one month later, he returned for a review.

This time, he walked into my clinic. His symptoms had improved tremendously and he happily reminded me that when he last saw me, he was in a wheelchair.

Today, he regularly goes for walks with his family and can walk a fair distance without feeling out of breath.

A repeat echocardiogram showed that the severe valve leakage has been reduced to a mild one.

Studies show that mild valve leakages are well-tolerated and usually do not have deleterious effects on the heart.

The hope is that, with time, the leakage will continue to decrease as scarring takes place around tissues adjacent to the plug.

As he walked out of my clinic, I thought to myself how modern techniques and technology can make a big difference to patients' lives.

And the quick pace of medical advancements today means that something better is always around the corner.

The procedure that was performed on Mr R already seemed dated. It will, inevitably, be overtaken by other newer techniques soon.

  • Dr Chiam is an interventional cardiologist at the Mount Elizabeth Hospital. In 2009, he performed the first minimally invasive aortic valve replacement in Asia - a procedure where a diseased aortic valve is replaced via a small puncture in the groin, on a beating heart.
A version of this article appeared in the print edition of The Straits Times on October 20, 2015, with the headline 'Patient couldn't bear thought of heart surgery again'. Print Edition | Subscribe