Cardiologists, take heart! (Pun intended.) The newest and best technologies for the correction of cardiac disorders are standard fare at the University of Maryland Heart Center. The top-notch cardiac surgeons there are pushing the limits of restoring, repairing and, when necessary, replacing the heart. The University of Maryland Heart Center is a nationally known leader in medical and surgical techniques, while serving the region as a highly respected referral center for the most difficult cardiac cases.
All of the Center physicians are University of Maryland School of Medicine faculty members. "The Heart Center is different because at its core is the largest education and research enterprise influencing the physicians of Maryland," says Bartley P. Griffith, M.D., Professor of Surgery and Chief of the Division of Cardiac Surgery. "As a university medical center, we can call upon deep resources to plan and execute new therapies and provide the region with an incredible ability to attempt to do what others will not. Like Shock Trauma, we hope to be on the minds of regional physicians and the public we serve as a 'go to' place for the 'sick at heart.'"
Under Dr. Griffith's leadership, each of the surgeons at the Heart Center is focused on a specific area of expertise. James S. Gammie, M.D. specializes in mitral valve repair and trained at the University of Pittsburgh Medical Center with Dr. Griffith.
Dr. Gammie explains that two primary problems can occur with the mitral valve. The first is mitral stenosis, in which the valve fails to open completely and prevents blood flow from the lungs into the ventricle. The second and more common malfunction is mitral regurgitation or mitral valve prolapse ('leaky' valve), which causes some blood to leak back into the lungs instead of being directed out to the body as it should. Patients with this condition typically experience shortness of breath.
In the early era of heart surgery, beginning in the 1960's, the standard approach to valve disease was replacement. "We still do that occasionally," says Dr. Gammie, "[but] no valve is as good as the one God gives us when we are born." Today, most of the mitral valve surgeries at the University of Maryland are performed as valve repairs, rather than replacements. The faulty valve can be replaced with a mechanical, metal valve or with a tissue valve, most commonly a cow valve. Both types have their pros and cons. Placement of a metal valve requires the patient to take a blood thinner indefinitely; the tissue valve is lacking in longevity, lasting a projected 10-15 years. Both types are associated with a risk for stroke.
The key innovation in the treatment of mitral valve disease came in the early 1980’s when world-renowned French cardiac surgeon Alain Carpentier introduced techniques of fixing a diseased mitral valve rather than replacing it. "His original paper was called the 'French Correction,'" says Dr. Gammie. "His techniques have slowly been adopted. Now, we always prefer to fix rather than replace the valve because the repair is durable and rarely requires a repeat operation." Currently, only 40% of mitral valve surgery patients nationwide have the repair. At the University of Maryland Heart Center, the repair versus replacement rate is 85%. "We can never fix 100% of the valves," says Dr. Gammie. "Some are beyond fixing. ... It is important that the patient have mitral valve surgery at a center which is dedicated to that specialty."
Previously, when replacement was the norm, cardiologists were understandably reluctant to refer patients for surgery until they were experiencing severe symptoms and significant weakness of the heart muscle," Dr. Gammie says. "Recently, because of our expertise in mitral valve repair, we have seen patients referred earlier to surgery, before the weakness is irreversible, and they are doing better in the long term."
Donald Thomas, a 44 year old, small business owner in Pasadena, Maryland had been a runner off and on and began having difficulty keeping a steady pace, finding it necessary to stop and rest after about a half mile. Other than that, he was asymptomatic and discovered his severe mitral valve prolapse as a result of a routine physical examination. Thomas's cardiologist referred him to Dr. Gammie, who performed a videoscopic minimally invasive mitral valve repair via a two-inch incision on the right side of the chest. Thomas, who went into the surgery in excellent health overall, was pleased that, about three weeks after surgery, he was released to resume normal activities with no restrictions. He gave the entire experience a stellar rating. "Dr. Gammie comes across as confident and that is what you want," he says. "I felt perfectly at ease with him. My cardiologist said we should pick a doctor, not a facility; but the fact that it was done at the University of Maryland was definitely another plus."
Jamie M. Brown, M.D., a cardiac surgeon at the University of Maryland Heart Center and an associate professor of Surgery at the University of Maryland School of Medicine, focuses on aortic valve surgery, which, unlike mitral valve surgery, usually involves replacement rather than repair. Some aortic valves, however, can be repaired by reshaping the aorta. Problems of the aortic valve include aortic stenosis, aortic regurgitation and aortic valve disease associated with aortic aneurysms and aortic valve infections.
"We see and treat all of these disorders at the University of Maryland Heart Center," says Dr. Brown. "This is an exciting time for treatment of aortic valve diseases. For years, treatment options were limited to mechanical valves that required high-dose anticoagulation associated with documentable risks to the patient or early generation, stented tissue valves with limited hemodynamic profiles and a risk of structural valve degeneration. Up to 30% required re-operation by 10 years after aortic valve replacement."
Newer generation tissue valves, Dr. Brown explains, have proven excellent freedom from structural valve degeneration at 15-year follow up. Furthermore, tissue valves without a stent, after implant, offer hemodynamics that parallel normal physiology in addition to long-term durability. "We continue to offer procedures involving cryo-preserved homografts, the Ross procedure and repair of the aortic valve in situations where the aortic valve leaflets are normal or nearly so," says Dr. Brown. "Although this particular group of patients is the minority, we believe that offering the repair of an aortic valve is important, much as it is in the situation of the mitral valve, because the patients retain their own tissue and avoid the use of anticoagulation."
Dr. Brown thinks that surgeons are not only technicians. In fact the bond with the patient which occurs over the course of their care is the most rewarding aspect to the practice of medicine in a surgical subspecialty. Surgeons do technical things to people. They mainly heal, however. Patients understand this. It is a great relationship and a great feeling for the surgeon.
The specialty of heart valve surgery in the future will see strong movement toward minimally invasive approaches, according to Dr. Gammie. "Ultimately, I envision that we will be able to fix heart valve disease without using the heart/lung machine and that we'll be able to fix a person's heart valve and have them go home the next day. Heart valve disease is becoming more common because it is a disease of older individuals and the population is aging."
Dr. Brown anticipates that tissue preservation techniques, valve regeneration techniques and tissue engineering techniques will advance and create yet another generation of valves that are easier to implant and longer lasting, while providing near-normal hemodynamics.
The Heart Center's exceptional team, advanced procedures and comprehensive care offer encouragement for patients facing very scary surgery. "We understand that no one wants to have open heart surgery," says Dr. Gammie; "but if needed, this is the place to have it. We think the fact that volumes have doubled in the last year is a sure sign that we are doing something right!"
For consults, referrals and assistance, physicians can contact the University of Maryland Heart Center at 410-328-6622 or 1-800-318-1019.
by Martie Callaghan
Reprinted from the January, 2004 issue of M.D. News, Baltimore-Annapolis edition. Reprinted with permission of Sunshine Media/Lund Media Associates (elund@lundmedia.com)
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