Physicians Perspective

Staying at the Forefront of Treating Structural Heart Disease

In the body, structures and tissues are interwoven to provide specific functions, contributing to a coordinated symphony of activity that supports life. In the cardiovascular system, this coordination is especially important, allowing for the synchronous and harmonious movement of blood among the heart’s chambers, through different doors (valves), and ultimately to the lungs and the rest of the body. Any abnormality in these organs or their tissues can result in a chain reaction of imbalances, altering the size, shape, functionality and pressures within the heart, contributing to a decline in function and quality of life. 

Structural heart disease encompasses a broad range of cardiovascular conditions that affect all components of the heart, including the tissues, valves and support structures. While some of these conditions are congenital (present from birth), many develop over time as the result of genetics, habits and lifestyle choices, and due to the general “wear and tear” that occurs with aging.

Most structural heart problems result from the process of aging and its effects on the heart. Generally, these conditions manifest in persons between the ages of 50 and 90, but for some individuals with known cardiovascular comorbidities such as diabetes, obesity, high blood pressure or high cholesterol, these problems can occur earlier in life. This type of issue is different from congenital heart defects, which arise during fetal development. While most severe congenital heart defects are detected in childhood, smaller and more subtle defects can lead to progressive symptoms and changes within the heart that go unnoticed for many years. Unfortunately, many of these changes ultimately reach a critical point at which they require timely attention and treatment. 

At Sentara RMH, our structural heart team is a distinct subspecialty within our Cardiology division and includes physicians, advanced care practitioners, nurses and support staff who are committed to providing expertise in the management of patients with structural heart disease. The team focuses on the multispecialty evaluation and treatment of patients with heart failure, advanced coronary artery disease, valvular heart disease and a variety of other conditions. As part of this evaluation, caregivers consider which patients may be candidates for minimally invasive, catheter-based procedures that have become available over the past decade, providing options to those patients deemed too high-risk for open-heart surgery. This “team approach” is crucial to the patient-centered care that is so important to our culture and environment at Sentara RMH. 

Correcting Valve Problems and Congenital Heart Defects

The most common structural heart conditions we treat are valve problems, mainly of the aortic and mitral valves. These conditions can include both stenotic (narrowed) and regurgitant (leaking) valves. Both conditions can lead to elevated pressures within the heart and symptoms of heart failure such as fatigue, shortness of breath, swelling in the legs and weight gain, but each condition requires its own unique evaluation and treatment approach. Typically, this evaluation seeks to determine why the valve has failed, the toll it has taken on the patient’s body, and the appropriate timing for intervention to avoid further complications or functional decline. 

The second-most common type of condition we treat includes select congenital defects, such atrial septal defects, patent foramen ovale (PFO) or ductus arteriosus, aortic coarctation, and pulmonic valve stenosis. Many of these defects are the result of the failure of certain fetal structures to close or develop at some point during early development, or shortly after birth. Given their delayed presentations into adulthood, these issues are typically not as severe, but over time they can result in significant derangements in the structure and function of the heart, requiring more rapid attention once detected. These conditions are classically managed with minimally invasive, catheter-based techniques but may require surgery, depending on the type and extent of the defect. 

Reducing Risk of Stroke

An individualized approach to reducing the risk of stroke for specific patients is another focus of the structural heart specialists at Sentara RMH. The two main strategies for reducing this risk are identifying individuals at risk with heart rhythm abnormalities (mainly atrial fibrillation), and identifying those with unique risk related to a PFO. Characterized by a small hole between the top chambers of the heart, PFO is a very common finding during an echocardiogram and is seen in approximately 25% of the population. However, certain individuals with this finding are at high risk for stroke and should be further evaluated for catheter-based closure in order to reduce the risk of stroke.

Atrial fibrillation, another common heart condition, is characterized by an irregular cardiac rhythm and has the potential to cause the formation of clots within certain structures of the heart. This condition significantly increases a patient’s stroke risk and typically requires “blood thinner” medications like warfarin. However, some patients are not candidates for these medications, due to prior bleeding or individual risk of falling. In those cases, a careful evaluation by our structural heart and electrophysiology teams is needed to identify potential candidates for certain procedures or implantable devices, in an effort to reduce the risk of stroke while avoiding long-term anticoagulation medications. 

Managing Heart Failure

Heart failure is a complex, challenging cardiac condition with a variety of causes. From a structural heart perspective, management of heart failure can be augmented though implantation of a small sensor known as CardioMEMS within the arteries of the lungs. This sensor provides daily readings to help a patient’s primary cardiologist understand and identify impending episodes weeks before the development of symptoms. 

Later this year, Sentara RMH will begin offering CardioMEMS to appropriate heart failure patients as an adjunct to medication, further engaging heart failure patients into a more collaborative and individualized care plan. 

Diagnosing Structural Heart Conditions

Many structural heart conditions present with symptoms similar to those of other heart problems, which can make diagnosis somewhat challenging and require a multidisciplinary approach centered on advanced imaging techniques. Symptoms vary depending on the patient, condition and severity of disease. They include, but are not limited to, the following: 

•Shortness of breath

•Chest pain or tightness

•Stroke or ministroke

•High blood pressure (hypertension)

•Leg swelling

•Fluid buildup in the lungs (pulmonary edema)

•Extreme tiredness or fatigue 

•Rapid weight gain

•Poor concentration or memory lapses

Many of these symptoms are also similar to those of pulmonary diseases like asthma or chronic obstructive pulmonary disease, which often makes it difficult to make a diagnosis based on symptoms or physical examination alone. Additional testing or procedures may be necessary to make a definitive diagnosis.

The diagnosis of all structural heart conditions requires some form of imaging, the most common being a screening echocardiogram. This imaging modality gives a real-time look at the chambers of the heart, as well as the structure and function of the valves. It also provides insight into the pressures within the heart that may be the cause of a patient’s symptoms. 

Basic screening tests are typically followed by more advanced imaging, which may be noninvasive (stress testing, CT scan or cardiac MRI) or invasive (transesophageal or intracardiac echocardiogram, heart catheterization), depending on the conditions suspected. All of this testing can be performed locally at Sentara RMH in collaboration with our teams, including the Advanced Cardiac Imaging and Radiology departments. The ultimate goal of this additional testing is to ensure the correct diagnosis for a patient’s symptoms and the development of an individualized treatment approach for the patient. 

Benefits of a Structural Heart Program 

Developing a structural heart program as a complement to our Cardiology and Cardiothoracic Surgery departments ensures that Sentara RMH patients receive the most up-to-date recommendations when it comes to managing a variety of different conditions. Our program runs parallel to the well-established, award-winning cardiology service line at our hospital, and helps ensure that our community has access to the most advanced technologies, procedures and medical devices. Investing in the structural heart program at Sentara RMH once again demonstrates our commitment to remain on the leading edge of advanced cardiac care and provide access to specialized care, close to home, for our community members.

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To learn more about Sentara RMH Cardiology and Cardiothoracic Surgery services, visit Sentara.com. 

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