Advancing Minimally Invasive and Transcatheter Valve Therapies

The history of surgery for valvular heart disease at Brigham and Women’s Hospital (BWH) dates to May 1923 when Elliott Carr Cutler, MD, performed the first ever valve operation in the world. Since then, BWH has been at the forefront of the clinical practice and innovation in the management of valve disease.

Lawrence H. Cohn, MD, performed the first minimally invasive heart valve surgery at BWH in 1996 and the surgeons and interventionalists in the Heart & Vascular Center (HVC) ushered in the world of minimally invasive and transcatheter valve procedures which has been progressing at a rapid pace ever since.

“We owe an enormous debt of gratitude to the late Dr. Cohn for his vision and pioneering work in minimally invasive valve surgery that is now becoming commonplace,” says Prem S. Shekar, MD, chief of the Division of Cardiac Surgery and surgical director of the Heart & Vascular Center, who performs and continues to develop and foster the vision of minimally invasive valve surgery.

BWH is one of few cardiac centers in the nation to offer a comprehensive minimally invasive aortic and mitral valve practice that includes a minimally invasive upper hemisternotomy approach to aortic valve surgery and minimally invasive lower hemisternotomy and right thoracotomy approaches to mitral and tricuspid valve surgeries. The hemisternotomy approaches are done through small 4- to 5-inch incisions in the midline and the right mini-thoracotomy approach allows for patients to have their mitral or tricuspid valves repaired or replaced with a small three-inch incision between their ribs, allowing for more rapid recovery. Cardiac surgeons in the HVC were among the first to use minimally invasive approaches for elderly patients, providing lower risk than traditional open procedures.

To date, they have performed more than 2,600 minimally invasive valve surgeries and have published several papers describing the advantages of these techniques.

The HVC offers one of the largest transcatheter aortic valve replacement (TAVR) programs in New England, having performed nearly 1,000 cases, including nearly 300 cases in 2017. The  team routinely performs TAVR procedures with only mild sedation and, more recently, has been performing alternate access trans-subclavian TAVRs without general anesthesia using a percutaneous approach. “This permits patients to recover quickly, with most being discharged within 36 hours,” says Marc P. Pelletier, MD, surgical director of the TAVR program.

In addition to Dr. Pelletier, the program’s multidisciplinary team includes cardiac surgeon Tsuyoshi Kaneko, MD, interventional cardiologists Pinak Shah, MD, medical director of the TAVR program, Piotr Sobieszczyk, MD, and Natalia C. Berry, MD, cardiologists Patrick T. O’Gara, MD, Alice Y. Kim, MD, and Yee-Ping Sun, MD, and anesthesiologists Douglas C. Shook, MD, and Charles B. Nyman, MBBCh.

Favorable experience thus far with transcatheter valve surgeries has generated great interest in making these less-invasive procedures available to a broader array of patients, including low-risk patients and those with mitral valve disease. The HVC at BWH has most recently participated in the PARTNER 3 trial evaluating the safety and effectiveness of a transcatheter heart valve in low-risk patients with severe aortic stenosis. The BWH specialists have participated in all the previous PARTNER trials that have sequentially examined the efficacy of the TAVR procedure in inoperable, high and intermediate risk patients which have then led to FDA approval of the device in these patients.

Many patients with existing valves that require re-replacement are now being treated with this technology: valve-in-valve procedure. In addition, the team currently utilizes transcatheter technology to repair and replace the mitral valve using a variety of innovative techniques.

Additionally, specialists in the HVC are participating in studies to better understand important issues regarding the expanded use of transcatheter valve therapies for mitral valve disease, comparison of transcatheter versus surgical mitral valve repair/replacement, durability of transcatheter valves relative to surgical valves, given the shorter experience with transcatheter valves, and valve-in-valve procedures where transcatheter valves are implanted within an existing bioprosthesis that has degraded.

“Using less invasive methods enables us to repair the mitral valve in patients traditionally considered too high risk for open valve repair surgery,” adds Dr. Pelletier, who also performs minimally invasive procedures. “I think repairing or replacing the mitral valve with minimally invasive surgery will become the gold standard in the next five to 10 years.”

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