Thursday, September 19, 2024 | New York Academy of Medicine (NYAM)
1216 5th Ave, New York, NY 10029
Dr. Samin K. Sharma, MD, emphasized the critical need for early detection and intervention in valvular heart disease, noting that many patients are diagnosed at advanced stages due to insufficient early treatment options. Traditionally, valve abnormalities are identified late and treated with cardiac surgery. However, he highlighted the benefits of transcatheter procedures, which are less invasive and safer for elderly patients, and reviewed recent data showing their effectiveness compared to traditional surgery. Dr. Sharma also noted the higher prevalence of valvular disease in women and stressed the need for better screening and follow-up to improve patient outcomes.
Watch Dr. Samin Sharma's Presentation Below:
See Dr. Samin Sharma's Slides Below:
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Transcript of Dr. Samin Sharma's Presentation:
[Samin Sharma] [0.24s] Good morning, all, and I'm happy that there's a split of all radiology, pulmonary, and cardiology in this audience.
[Samin Sharma] [10.08s] And the the topic, of the averting premature death from heart disease by early detection and getting the valvular disease and try to show some data.
[Samin Sharma] [18.86s] 1st, where we are and what we can do to, does it matter if we can detect the disease early?
[Samin Sharma] [24.79s] No financial disclosure.
[Samin Sharma] [26.99s] The basically, the valve or heart disease, there are 4 valves, aortic, mitral, tricuspid.
[Samin Sharma] [31.71s] Pulmonary is more for a congenital.
[Samin Sharma] [34.51s] So we we talk about the 3 valves.
[Samin Sharma] [36.99s] What has happened is, largely, most valve abnormalities are detected late as there is no prevention or treatment to halt the progress of the disease.
[Samin Sharma] [49.52s] So they are usually patient present at the final stage.
[Samin Sharma] [54.33s] And, traditionally, these have been treated by cardiac surgery.
[Samin Sharma] [57.65s] So that's what has been shown to improve life, mortality, survival, and the symptoms.
[Samin Sharma] [64.21s] But until last 10 to 12 years, this field had changed with the introduction of the transcatheter options and treatment, which can be less invasive and perhaps safer, which have been shown in various studies.
[Samin Sharma] [78.91s] The 4 valves, the aortic pulmonic and tricuspid, which I have put it here particularly from transcatheter point of view, We have a now approved by FDA.
[Samin Sharma] [88.61s] Only one has not been approved.
[Samin Sharma] [90.05s] It's still in trial in the, the mitral.
[Samin Sharma] [93.09s] Although the mitral one type, which is the clip, basically, decreasing the regurgitation, which is called tear.
[Samin Sharma] [99.01s] Transcatheter as to as repair is a has been approved, but the the true replacement transcatheter replacement of the mitral valve is under investigation still.
[Samin Sharma] [109.17s] But other valves can be done safely.
[Samin Sharma] [112.13s] So just to say, I think it may not be, yeah, play.
[Samin Sharma] [114.77s] So how simple it is?
[Samin Sharma] [116.71s] You puncture from the groin, patient is still, little sedation, you bring the valve in, you paste the ventricle at 180, inflate 10, 22nd, and deflate, take your balloon out, valve is there.
[Samin Sharma] [129.43s] You're done.
[Samin Sharma] [132.84s] Actual time, maybe 5 minutes.
[Samin Sharma] [134.28s] All the preparation, another one hour.
[Samin Sharma] [136.28s] But these are what has happened very safer or safe to the patient, particularly elderly patients where biggest region is their lung disease or CBA, the intubation, every surgical procedure required.
[Samin Sharma] [150.64s] Transcatheter procedure, mo majority of them, we do without intubation.
[Samin Sharma] [154.32s] So this really had changed the field, taking care of these patients.
[Samin Sharma] [159.79s] And this is very interesting slide.
[Samin Sharma] [161.31s] It's a little complex, but I'll just try to make it a point.
[Samin Sharma] [164.44s] This line is the tower in United States from 2012, and this is your surgical valve replacement for aortic stenosis.
[Samin Sharma] [172.76s] You see there, 1st 4 to 5 years when the tower was introduced, which is a replacing the aortic valve by the transcatheter, what had happened to the surgical valve?
[Samin Sharma] [181.96s] Nothing.
[Samin Sharma] [183.40s] So what happened here?
[Samin Sharma] [185.00s] What happened to the CS patients?
[Samin Sharma] [187.31s] Where were they?
[Samin Sharma] [188.19s] They were right here.
[Samin Sharma] [189.71s] They were not being treated.
[Samin Sharma] [192.03s] Many of them were left to making inoperative or palliative, left to die.
[Samin Sharma] [196.59s] What transcatheter option has done in these patients who are high risk for surgery, when most most common region for high risk is elderly age.
[Samin Sharma] [206.70s] 85, 90, 95, but their function and COPD.
[Samin Sharma] [210.86s] Those are the 2 most important, region to decline surgery and just to say that how the transcatheter option has really changed a treatment of these patients.
[Samin Sharma] [220.79s] There was no option.
[Samin Sharma] [222.72s] And good thing is if you compare with surgery, which is the traditional gold standard, that transcatheter valve with multiple strategies of the risk, low risk, high risk, intermediate risk, all of them has come as good as surgery.
[Samin Sharma] [239.53s] This is the 10 year data or even slightly better in many of the studies and the valve deterioration is equal.
[Samin Sharma] [247.10s] So now we have the transcriptor option, safer to the patient, worse as good as surgery, and we know that these patients would remain less in the ICU and can be extended to more patient.
[Samin Sharma] [258.86s] So whole paradigm of treating and diagnosing the disease will change.
[Samin Sharma] [264.14s] Now just like I've been showed quite a bit, various risk factor for the coronary artery disease, we have the same for the valor heart disease.
[Samin Sharma] [273.06s] The there are stages.
[Samin Sharma] [274.65s] A, b, c, d is at risk patient at the risk of development.
[Samin Sharma] [278.50s] Valor heart disease, elderly, calcium, rheumatic heart disease, and so.
[Samin Sharma] [282.25s] Then progressive is b, the patient with progressive disease, mild to moderate severity, but asymptomatic.
[Samin Sharma] [288.98s] Then the 3rd group is asymptomatic, but now they are severe.
[Samin Sharma] [292.98s] And there we actually divide in c 1 and c 2 based on their chamber dysfunction, whether it's a mitral or aortic or tricuspid.
[Samin Sharma] [301.46s] So in the the chamber dysfunction.
[Samin Sharma] [303.30s] And then lastly is the symptomatic severe patients who have developed symptoms as a result of, valve or heart disease.
[Samin Sharma] [309.46s] What we have done so far in the past, that surgical procedure is done in class d.
[Samin Sharma] [316.25s] But what if the thing which I showed you that we go to the asymptomatic or severe?
[Samin Sharma] [323.93s] Why?
[Samin Sharma] [324.57s] Because wait and watch.
[Samin Sharma] [326.17s] I'll show you some data.
[Samin Sharma] [327.45s] That itself has a problem once you become severe.
[Samin Sharma] [330.82s] Or we can go even one step further, and that is what if we go to even moderate disease, be asymptomatic.
[Samin Sharma] [339.46s] And this is what I would say the transcatheter options will provide.
[Samin Sharma] [343.56s] So what is the re logic behind to go early in this disease process of the vast wild or heart disease?
[Samin Sharma] [350.28s] So this this is kind of a nicer description in our graphic form that before going to the top, if you can do intervene early, clearly that your gain and improvement and the the overall survival and more importantly, durable benefit of the patient will happen more.
[Samin Sharma] [368.74s] And this actually, we have shown, this will be learned almost, half a century ago.
[Samin Sharma] [375.87s] And this actually even true now.
[Samin Sharma] [378.11s] The patient with aortic stenosis, they continue at one point at mid age.
[Samin Sharma] [384.12s] The one symptoms or any of the symptoms, angiography or heart failure develop rapidly decline.
[Samin Sharma] [390.19s] The mortality 50% in 1 year, 80% in 2 years.
[Samin Sharma] [393.63s] Even at present, about 10 years ago, we did the trial, tower versus medical management, and mortality was 50% in 1 year in the medical management group and 80% in 2 years.
[Samin Sharma] [403.37s] So whole question is, why don't we go early, in this scheme?
[Samin Sharma] [409.05s] The one of the region which I mentioned earlier that, many of these patients don't go, the type of, valve disease that happens, whether it's aortic, mitral, almost 20 to 50% do not go for surgery despite a class one indication.
[Samin Sharma] [425.50s] And as I said, this is these viral diseases predominantly Purdue America and other places, not the rheumatic.
[Samin Sharma] [432.22s] It's all the disease of the elderly, and many of them don't don't get treated.
[Samin Sharma] [436.62s] But at the same time, once you have a severe stenosis, this is a classical example from the aortic stenosis that patient has, the trials have done that you have a severe aortic stenosis.
[Samin Sharma] [448.88s] And now with the class of the c, there is c group, asymptomatic, severe.
[Samin Sharma] [453.36s] Should you wait and watch, or should you replace it?
[Samin Sharma] [456.08s] And the answer is replace it because wait and watch is creating a trouble.
[Samin Sharma] [460.64s] Every trial has shown the surgery will be better.
[Samin Sharma] [463.76s] Whether it will be with a transcatheter, we'll know the trial will be presented next month in the TCT with the early tower.
[Samin Sharma] [470.06s] And this goes back to the point that more the higher the stage of the patient because you start developing the ventricular dysfunction and, irreversible damage, even you replace by the time you are to the stage 3 and 4, there's still some fibrosis.
[Samin Sharma] [484.79s] And, of course, all the data of the noninvasive MRI and showed that that damage persist.
[Samin Sharma] [491.11s] Whether it's a mitral or aortic and patients continue to have some death, all the improvement.
[Samin Sharma] [495.52s] And this is actually have shown that not every patient, your severe aortic stenosis, one percentage in the stage one group where there's no myocardial damage.
[Samin Sharma] [504.81s] Other one is in the stage 4 group.
[Samin Sharma] [506.40s] There's a myocardial damage.
[Samin Sharma] [507.93s] Survival is dependent on what the myocardial damage is.
[Samin Sharma] [510.73s] Irrespective, we improve the outflow.
[Samin Sharma] [513.50s] We replace the valve by the transcatheter option, and not everybody gets improvement as you can see, and so.
[Samin Sharma] [519.58s] So, therefore, the burden of valve heart disease valve heart disease, a population based study, just to emphasize who develops, valve heart disease, and that is what our goal is.
[Samin Sharma] [529.68s] The many studies have shown that whether you go with the all valve disease, the mitral or aortic, it's a disease of elderly.
[Samin Sharma] [537.70s] Some factors comes in.
[Samin Sharma] [539.14s] They have high cholesterol, inflammation, and all, but prevention for those using the drugs statin.
[Samin Sharma] [544.26s] Nothing has really made any difference, but it's the disease of age.
[Samin Sharma] [548.42s] And more importantly, it's very interesting.
[Samin Sharma] [550.66s] Women are less diagnosed than men despite higher disease.
[Samin Sharma] [555.30s] So any you take aortic stenosis at 90 years of age.
[Samin Sharma] [557.87s] There'll be more women than men.
[Samin Sharma] [559.63s] At 50 years, and a coronary artery disease, they are way more men than women.
[Samin Sharma] [564.75s] But aortic or mitral, all these diseases more in women than men.
[Samin Sharma] [569.20s] One, likely, because the older age.
[Samin Sharma] [571.60s] 2nd, women lives longer than men.
[Samin Sharma] [574.56s] So they will chances to having a valvular heart disease is much higher, and, therefore, this is very important public health problem.
[Samin Sharma] [582.86s] But question is, what to do?
[Samin Sharma] [584.86s] And this is where the whole, things happen, in the sense that you have to follow these patients with the various criteria.
[Samin Sharma] [591.65s] And just emphasizing once again, the increasing age, giving rise to increasing regurgitation, stenosis, or so.
[Samin Sharma] [600.53s] So just to emphasize on the, part of the aortic, or mitral disease process.
[Samin Sharma] [605.97s] Now is it does it matter?
[Samin Sharma] [607.88s] Yeah.
[Samin Sharma] [608.13s] Even you have mild, moderate, or severe, well, disease, mortality is higher.
[Samin Sharma] [613.32s] So we understood.
[Samin Sharma] [614.52s] We need to diagnose early and intervene.
[Samin Sharma] [617.49s] Whether intervene by surgery or by transcatheter, but key is the diagnosis first.
[Samin Sharma] [621.96s] So this is the one important point.
[Samin Sharma] [623.63s] Then there and then the what we can do?
[Samin Sharma] [627.07s] Same emphasizing another that was the earlier publication.
[Samin Sharma] [630.75s] This is a more recent publication, emphasizing all 3 validity.
[Samin Sharma] [634.67s] Calcific aortic, degenerative mitral, tricuspid regurgitation, male in blue, and female in red.
[Samin Sharma] [641.88s] And you see more women than men, the increasing incidence of disease process with increasing age as shown below.
[Samin Sharma] [651.21s] So, therefore, the point basically is that we need to diagnose at early stage all the valve.
[Samin Sharma] [657.13s] So there is a third valve, which is talk we in the community is less spoken, but now it is really emerging, which is the last one is the tricuspid valve, which is actually maybe more common than any of these two valve disease.
[Samin Sharma] [669.88s] But then we call it a forgotten valve.
[Samin Sharma] [671.73s] But now since we have the treatment option, we have more and more being spoken about.
[Samin Sharma] [676.37s] So this basically is puts it together some concluding slide that what we can do about it, the gaps which we have, and more importantly, solution.
[Samin Sharma] [685.04s] The screening, the patient, and how would you start the whole process, and follow-up of these patients before getting to the more advanced treatment.
[Samin Sharma] [692.96s] And I would say this will start with simple symptoms, and examination.
[Samin Sharma] [698.76s] I know the stethoscope is almost like a for many people obsolete, don't use it, but that's probably the first thing.
[Samin Sharma] [705.73s] Patient comes to the office, you start seeing murmur.
[Samin Sharma] [708.23s] Everyone has a murmur.
[Samin Sharma] [709.35s] So when we you know, our fellows present the cases, nobody has sculpted the patient.
[Samin Sharma] [713.03s] I say, murmur was detected on echocardiography.
[Samin Sharma] [716.55s] Nobody listened to the heart.
[Samin Sharma] [718.39s] But that could be the just first screening because at how can you do at the mass level?
[Samin Sharma] [722.80s] But once you found that, the murmur, then you go to the next level.
[Samin Sharma] [727.68s] And that's where you go in as a primary care or the general office, then you go to the next test.
[Samin Sharma] [732.96s] And that is echocardiography.
[Samin Sharma] [734.56s] That's kind of the gold standard to determine how bad what is the situation of the valve disease.
[Samin Sharma] [741.81s] And then, of course, you go to the more expert cardiologist with expertise in valvular heart disease.
[Samin Sharma] [746.45s] There are separate clinics, which we have also.
[Samin Sharma] [749.09s] And, of course, the there's more complex.
[Samin Sharma] [751.90s] You go to the valve center of excellence and try to follow-up those patients.
[Samin Sharma] [755.99s] Not every patient which comes referred to us goes for the procedure because in cases if if they are, when patients in a if they're a moderate level, we say come back for follow-up and so.
[Samin Sharma] [769.27s] So, basically, this will be the I I would say the scheme of early detection, getting to the treatment after the full, show.
[Samin Sharma] [777.99s] And then, of course, is virtual ward clinic, and I'll just sum it up.
[Samin Sharma] [781.61s] They're basically that in absence of symptoms, there might be a benefit of surgical or transcatheter intervention to prevent deleterious long term effect on the left ventricle.
[Samin Sharma] [792.18s] So even if, they mentioned that sometimes you can change the valve, but patient may still have bad outcome.
[Samin Sharma] [797.54s] These are issue because current most of the guidelines is still class 1 for the symptoms, but guidelines are changing.
[Samin Sharma] [804.58s] And, the patient need to have more close follow-up to detect the severity or the symptoms and intervene.
[Samin Sharma] [813.75s] And that overall in the population point of view will make a big difference.
[Samin Sharma] [816.96s] Thank you very much.
The presentations were hosted by I-ELCAP – The International Early Lung Cancer Action Program.
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