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Robert Wood Johnson
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MEDICINE 39
W
hen Brenda Rossi told her primary
care doctor about the fatigue that had
been plaguing her for weeks, she never
expected her heart was the cause--or that the situation was
dire enough to put her in the emergency room.
"I kept feeling tired and was very weak. Everything was an
effort. I told my doctor about it during my annual physical,
and he said, `Brenda, you need to go to the hospital; your
pulse is 120!'" Rossi recalls.
That trip to the emergency department of her local hospi-
tal and subsequent testing revealed the toll her hypertension
and other cardiopulmonary issues had taken. Rossi was
experiencing congestive heart failure related to valvular
heart disease, her pacemaker was failing, and the aortic valve
replacement she had received approximately 15 years earlier
had degenerated, leading to significant aortic stenosis.
Her cardiologist recommended she seek the expertise of
the team at Robert Wood Johnson Medical School and
Robert Wood Johnson University Hospital (RWJUH),
which specializes in cases such as hers. Additional tests and
examinations confirmed that Rossi needed another aortic
valve replacement, and time was of the essence.
But while Rossi had originally had traditional open sur-
gery to replace her aortic valve in 2000, that option was no
longer viable, nor were some of the more traditional access
routes for transcatheter aortic valve replacement (TAVR),
one of the newest modalities for treating aortic stenosis,
says Leonard Y. Lee, MD '92, professor and interim chair,
Department of Surgery; James W. Mackenzie, MD,
Endowed Chair in Surgery; and chief, division of cardio-
thoracic surgery, Robert Wood Johnson Medical School.
Aortic stenosis is a condition whereby the valve at the top
of the heart, which controls blood flow being pumped to the
rest of the body, becomes extremely tight, forcing the heart
to pump harder and resulting in some blood going backward
through the heart, Dr. Lee explains. Without surgical treat-
ment, individuals who have aortic stenosis survive only
about two to five years after symptoms present, he says.
TAVR--a procedure that enables specialists to replace the
aortic valve using fluoroscopic-guided, catheter-based tech-
nology--is performed by making a small incision into an
artery, then feeding a catheter with a tiny balloon at the end
of the tip through the artery to the aortic valve. The balloon
is inflated to push the damaged valve open, then deflated and
removed. The new replacement valve is delivered the same
way, placed in position in the middle of the old
valve, and begins working immediately. Unlike some
surgical procedures that require cardiopulmonary
bypass and stopping the heart, the TAVR procedure is per-
formed while the heart is still beating and provides an option
for individuals who could not otherwise tolerate surgery.
Taking a Novel Approach
R
ossi's issues, not only because of the previous sur-
gery but also due to the inability to use some of the
traditional TAVR access points (such as the femoral
artery), put her in the unique position of being the first per-
son in the United States to undergo a transcarotid valve-in-
valve TAVR procedure--that is, the insertion of a new
replacement valve through an incision in the carotid artery
at the neck. The frame of the degenerated replacement valve
acts as the anchor for the TAVR valve, Dr. Lee explains.
TAVR procedures in general are not unusual, notes
Zoltan G. Turi, MD, MPH, MSCAI, FACC, professor of
medicine and associate director, division of cardiovascular
diseases and hypertension, Robert Wood Johnson Medical
School, and director of the Structural Heart Program at
RWJUH, who has been involved with the technique from
its earliest days. Since November 2011, when the U.S. Food
Identifying the Problem
T
he symptoms of aortic stenosis
often present very late in the disease
process, so individuals can be very
asymptomatic for years, says
Dr. Lee. Eventually, however,
the tightness will get to a
point where symptoms
begin to manifest. Those
symptoms include:
Chest pain/tightness
with exertion
Shortness of breath
with exertion
Lightheadedness or
syncope--nearly passing out
as a consequence of not enough
blood getting through to the brain
Fatigue, especially when particularly active
Rapid or irregular heartbeat, or heart palpitations
KIM
SOKOLOFF