Minimally Invasive Heart Valve Surgery

Intro: We're talking wellness at MemorialCare Health System. It's time for Weekly Dose of Wellness. Here's Deborah Howell.

Deborah Howell (Host): Welcome to the show. This is your Weekly Dose of Wellness. I'm Deborah Howell and today's guest is Dr. Erick Montero, medical director of cardiothoracic surgery at Saddleback Memorial Medical Center. Dr. Montero is here to talk to us about heart valve disease and the minimally invasive surgical options available to patients who need heart valve repair or replacement. Welcome, Dr. Montero.

Erick Montero, MD: Good morning. Thank you for having me.

Deborah Howell (Host): Lovely to have you here. Can you please describe for us the functions of the mitral heart valve and the aortic heart valve?

Erick Montero, MD: Sure. So these structures are very discrete structures within the heart and their purpose is really to allow blood to go throughout the different heart chambers and to move in a very forward direction so that all the blood that gets pumped out of the heart goes to the rest of the body. So that's what they really do. They are, in a way, exactly one-way valves.

Deborah Howell (Host): Got it. So what is the cause then of heart valve disease?

Erick Montero, MD: You know, there are various reasons, you know, we call them various etiologies. It could be that some of the valves are just very calcified over a period of time, or it could be that the valve tissue itself is very floppy and makes the valve incompetent. But there are many reasons, also it could be an infection that happened many years ago or an infection that just happened recently. So all that can make the valve, in a way, you know, function abnormally.

Deborah Howell (Host): I understand. So what are some of the signs and symptoms of heart valve disease?

Erick Montero, MD: You know, depending on the mechanism for the valve failure, it could be that you're short of breath, or patients sometimes experience just fatigue or they're very tired, or you know, if it's a worst case, maybe chest pain. And then in really bad cases, you know, the heart function actually starts to fail, so it does affect other organs.

Deborah Howell (Host): Ah, okay, that's not a good thing. So what are some of the ways that we can then treat heart valve disease?

Erick Montero, MD: You know, there's a spectrum of valve involvement if you will. And sometimes in the very mild cases, medical management with perhaps medications is enough, and of course close follow-up. But in some situations in which the valve tissue is just no longer competent or functioning properly, sometimes you have to either repair or replace the valve altogether.

Deborah Howell (Host): And why might someone need surgery to repair or replace a heart valve?

Erick Montero, MD: You know, there are certain what we call trigger points. And this is why a conversation with either a cardiologist or a cardiac surgeon is important because if there are certain clinical sort of events, for example, if you start having rhythm issues with your heart, if you start having more worsening symptoms, then something should be done. And most of the time when the valve itself is not working well, then surgery may be indicated.

Deborah Howell (Host): I got it, okay. So how do you determine whether a patient needs a repair or a replacement?

Erick Montero, MD: Yeah, so for example, if you have a valve that is just very calcified and very tight, if you will, so that blood has a hard time going through, as in, for example, aortic valve stenosis. Well, that valve traditionally in the United States is replaced. And of course, you know, you have the option to have a tissue valve or a mechanical valve. But then for example, in terms of the mitral valve, if you just have a valve that is floppy, that is leaking, sometimes you can do certain things to make the valve more competent. It could be that you're removing a little segment of the valve or you're plicating tissue to make the valve more competent. So it all depends on the etiology.

Deborah Howell (Host): And it used to be that heart surgery was a huge, huge deal for a patient. But now we have minimally invasive cardiac surgery. So can you tell us a little bit about that?

Erick Montero, MD: Yeah, so the best way to explain to a patient what minimally invasive heart surgery is is simply an alternative incision cardiac surgery. And what I mean by that is it is still heart surgery, we still have to use the heart-lung machine to be able to stop the heart and get inside the heart to do something to the valve. It's just that we're using smaller incisions. And while in the past traditionally we would just split the breastbone through what we call a median sternotomy, now we can make smaller incisions. It could be just the upper part of the breastbone or the lower part through a seven to eight centimeter incision, or on the side, something called a mini-thoracotomy. So there are various approaches depending on what the needs are.

Deborah Howell (Host): I see. And in your opinion, when is a minimally invasive approach an option?

Erick Montero, MD: You know, when patients come to me and they have an isolated, very discrete valve problem that needs to be surgically addressed, then, you know, if all else is optimal, including the anatomy of the chest, any previous operations or any perhaps previous radiation to the chest, if all that is not present and the patient has an isolated valve problem, those are actually addressed via minimally invasive approach. But I tell you, in cardiac surgery sometimes patients have multiple issues that have to be addressed. Let's say the patient needs two valves addressed and also bypass surgery. Well, the minimally invasive approach is not the right approach. You would have to use the traditional median sternotomy, which is by the way very safe as well.

Deborah Howell (Host): Understood. Now can both the mitral valve and the aortic valve be repaired and replaced with this minimally invasive approach?

Erick Montero, MD: Absolutely. You can do each of the valves individually or together. In fact, we've had some patients here at Saddleback that needed both their aortic valve replaced and their mitral valve repaired, and we were able to do those via a minimally invasive approach.

Deborah Howell (Host): That is an incredible advantage. Wow, love to hear that. So what are some of the biggest advantages for patients to have minimally invasive surgery versus traditional surgical methods?

Erick Montero, MD: You know, it seems to me that one of the biggest advantages for the patient is these small incisions. I think that that is a sort of psychological boost. But there are other advantages, for example, having less risk of bleeding, perhaps, or less pain. And in some cases, depending on the approach, you can have, you know, the ability to return to work faster or to resume your daily lives faster. So there are certain advantages, but again, it all depends on the issue at hand.

Deborah Howell (Host): Sure. When you say return to work faster and return to things like driving, how long are we talking about if everything goes well?

Erick Montero, MD: You know, if I were to do a traditional median sternotomy then I would recommend that the patient refrains from driving for six to eight weeks until the sternum heals, just like a fracture. But if you have a minimally invasive approach, you can go back sometimes and drive as long as you're off pain medication within two to four weeks. And some people have gone back to work within a week, depending on what you do, of course. But I think that there is overall a very real advantage of returning back to your normal life faster.

Deborah Howell (Host): It's just a fabulous day in medicine. Thank you so much for coming on the show today. What a pleasure.

Erick Montero, MD: You're very welcome. Thank you for having me.

Deborah Howell (Host): And to learn more or to listen to a podcast of the show, please visit memorialcare.org. I'm Deborah Howell. Join us again next time as we explore another Weekly Dose of Wellness. Have yourself a fantastic day.