First-of-its-kind aortic root and valve surgery saves unique patient's heart
November 20, 2020
More than 99% of aortic root aneurysm and valve replacements are performed through traditional open-heart surgery. It requires making a 10-12 inch vertical incision and splitting the breastbone to access the heart, replace the patient’s own heart valve, and mend the aneurysm. The operation is typically followed by an ICU stay and eight to 12 weeks of recovery.
Though this is the standard of care at most medical centers, Shelley Lynne Tucker just kept thinking:
“There has got to be another way.”
In fact, she was contemplating that very notion as she lay in a hospital bed in Tyler, Texas.
“I had the gown on and IV hooked up, getting ready for surgery,” she said. “But I thought, with all the technology today, there had to be a better solution. So, I decided to put on my overalls and leave.”
The 56-year-old, who is just shy of 5 feet tall, admits she has an independent streak.
Every day, Shelley climbs ladders, hauls lumber, and walks her 75-pound Labrador, Daisy, around her rural homestead in rural East Texas. It’s just the two of them, so several months of recovery from open-heart surgery, during which she couldn’t drive, lift, push, or pull, just wasn’t feasible.
But left untreated, Shelley's aortic root aneurysm could rupture, causing internal bleeding, stroke, and even death. And her leaking valve could cause her heart to enlarge and possibly fail. So, she asked her cardiologist to help her find another option, one that suited her lifestyle, and he referred her to UT Southwestern.
When I first spoke to Shelley over a telehealth call and she described her unique circumstances, I thought she would be a good candidate for my team’s “mini-valve” procedure, which requires only a 2-inch horizontal incision with no broken bones, and provides a much faster recovery time and fewer restrictions.
We have performed more than 3,000 minimally invasive valve replacement or repair procedures with excellent results.
But to treat Shelley’s condition we had to adapt our mini-thoracotomy approach to perform an operation to treat both the aortic root aneurysm and the valve problem. We proposed doing this by using the world's first anatomically designed aortic root graft and tissue valve. This would mark the first time that implantation of this device had been attempted through a minimally invasive operation.
Because Shelley’s aneurysm was repaired through a small, 2-inch incision on the side of her chest, and because we did not have to split her sternum, Shelley’ recovery was remarkably quick: she spent one night in the ICU, went home within four days after surgery, and was able to resume her normal activities quickly with minimal restrictions.
Shelley believes her persistence paid off.
“We’re talking my heart, so I needed to feel confident,” Shelley said recently. “That’s why I was so stubborn. But after talking to Dr. Doolabh and his team, I knew they could do it. “When I was first referred to him, I had my list of questions ready. But he immediately asked about me, my situation, and he seemed really concerned. I knew right then he was my doctor.”
“Before the (procedure) with Dr. Doolabh, I wasn’t really living. I had to quit my exercise routine. Then COVID came along, and I had to quit my job. My life just came to a complete stop. Now I’m enjoying life again."
Aortic root aneurysm risks and diagnosis
The aorta is the largest blood vessel in the body, and the aortic root is the section that is closest to the heart. Aneurysms, or bulges, can develop there for various reasons, such as:
- Atherosclerosis (hardening of the arteries)
- High blood pressure
- Physical trauma to the chest
- Conditions that weaken the connective tissue, such as Marfan syndrome
- Certain autoimmune conditions, such as Kawasaki disease
Early symptoms can include chest pain during exercise and shortness of breath. If the aneurysm ruptures, it becomes a life-threatening emergency. Nearly 10,000 people died of aortic aneurysms in 2018, according to the Centers for Disease Control and Prevention (CDC).
Often, these aneurysms, which are also called thoracic aortic aneurysms, or TAAs, are diagnosed incidentally, when a patient is getting another imaging test. This is what happened to Shelley.
“My primary care doctor in Tyler probably saved my life,” she said. “When she listened to my heart, she heard a murmur and arranged for some tests. That got the ball rolling.”
Prior to visiting us, Shelley was referred to a cardiologist, who performed a heart catheterization and a root injection, which puts dye in her aorta to see what was going on inside the heart. The doctors found an aortic root aneurysm measuring 5cm, alarming in size for its location.
“I’m a small woman. So five centimeters seemed like a pretty big aneurysm,” Shelley said. “I was pretty nervous. But everyone at UT Southwestern was just so professional. They gave me a 24/7 phone number I could call with any questions, and everything went so smoothly.”
About the procedure
Using our “mini” approach, we opened the chest through an approximately 2-inch horizontal incision in the cartilage between the ribs. Cartilage heals much faster than a fractured bone and requires fewer movement restrictions during recovery.
Though the work area is smaller in this approach, we have excellent visualization of the cardiac structures, allowing us to perform this complex operation.
Once inside the aortic root, we detached the coronary arteries from the tissue weakened by the aneurysm. The entire aortic root and diseased valve are removed.
For Shelley's procedure, we used the newest Edwards KONECT RESILIA aortic valved conduit, which contains the latest generation bovine valve as well as a gel weave graft to replicate the human aorta. The valve is designed for enhanced durability, exceeding what is currently available on the market, and should the valve ever need to be replaced it can be done without another surgery.
Once the device was in place and everything was repaired, the heart resumed beating and we checked Shelley’s blood flow to ensure a perfect surgical result.
Faster, easier recovery
After a traditional open surgery, a patient spends several hours in the intensive care unit (ICU) on a breathing machine. But with our mini-valve approach, most patients are awakened in the operating room and no longer require a breathing machine. In Shelley's case, total operating time was 3 hours and 35 minutes – after which she was awake and talking to the entire team.
With our minimally invasive aortic root valve replacement procedure, patients can generally expect:
- Shorter hospital stay
- Less post-surgical pain due to a smaller incision, better chest wall stability, and no broken sternum
- Less blood loss during surgery
- Less downtime and restrictions – our patients can resume normal exercise, daily movement, driving, and work in a few weeks compared to several months with traditional open-heart surgery
Shelley was able to go home within four days after surgery. She was able to resume driving and began living independently almost immediately.
“Before the surgery, I wasn’t really living,” Shelley said. “I had to quit my exercise routine. Then COVID came along, and I had to quit my job. My life just came to a complete stop.
“Now I’m enjoying life again,” she said. “I’m going back to work. And I’m able to walk Daisy, which is something we both needed.”
Shelley’s follow-up care will be minimal. She will not need to take blood thinners like she would have with a mechanical valve, and after our initial post-surgery check-in, she will only have annual visits with her cardiologist to ensure ongoing heart health.
Second opinions matter
UT Southwestern is an academic medical center, which means we can take time to understand your personal needs and because of the broad spectrum of expertise here, we may be able to offer you an innovative approach to cardiac care that might not be available at other hospitals.
We often see patients for second opinions. Many of our heart surgery patients come to UT Southwestern when they're told they are out of options, and we ensure that they are offered access to the latest in surgical innovations.
In fact, the vast majority are candidates for our minimally invasive heart procedures.
“I knew that with all the amazing medical technology available today there had to be another way,” Shelley said. “But I’m still in awe of what the team at UT Southwestern was able to do. The surgery gave me my life back again.”
To request an appointment with Dr. Doolabh, call 214-74-VALVE. The phone is answered 24/7 by a registered nurse on his team who can assist you in setting up an appointment. We routinely offer visits within a week via telehealth to make it convenient for the patient.
The Magic of Minimally Invasive Aortic Valve Repair
Through a 2-inch incision, Dr. Neelan Doolabh routinely performs aortic valve replacement surgery. With the largest volumes for this surgical approach in the region, Dr. Doolabh has performed more than 3,000 minimally invasive valve repairs or replacements.