Over the last few weeks I have been summarising the biggest cardiac innovations of the last decade, having just reached that milestone as a consultant in Bournemouth.
When I was a registrar in London at the Heart Hospital, I recall in around 2012 they appointed a consultant in ‘structural intervention’. The Heart Hospital (University College London) was a big tertiary centre, with maybe 40 or so consultant cardiologists at the time. These included experts in stents, ablation, heart failure, cardiomyopathy, imaging…. But what was structural intervention?? At the time it seemed a bit of a dark art, I never really knew what went on in his catheter lab. It all seemed very complex, new and important.
That was the beginning of the era of structural intervention, which I think in lay terms is best described as keyhole surgery to treat anatomical issues of the heart, such as problems with the valves, or holes in the heart. All of a sudden, instead of having their chest carved open to fit a new valve, patients could opt to have a tube inserted via their leg, up to the heart, and have a new valve put in that way. Patients who were deemed too high risk for conventional surgery now became candidates for new valves to replace worn ones. Broadly speaking, the commonest interventions fall into a few categories:
Transcatheter Aortic Valve Replacement / Intervention (TAVR/TAVI)
Of valve treatments, this is by far the commonest procedure, and is mostly used to treat patients with aortic stenosis, or narrowing of the aortic valve. Aortic stenosis is the commonest valve issue, and you can read about it elsewhere in my members area if you like. TAVI is now mainstream: in its infancy it was used for patients otherwise too sick or high-risk to have conventional open-heart surgery, but has now expanded from inoperable to low-risk patients. Rather than a major London hospital having only a single consultant, most tertiary hospitals have several specialists in this. In countries such as Germany, it has arguably become standard of care.
Transcatheter Mitral/Tricuspid Repair
Rapid innovation in mitral and tricuspid valve repair now allows specialists to ‘clip’ parts of these valves together when they are too leaky, or ‘regurgitant’ as it is known. This can reduce the leak in selected patients. Again, this removes the need for open heart surgery, and can be performed as short day case procedures.
Hole-closure procedures
Holes in the heart are relatively common, and in many cases do not actually need treatment. However, when they do cause problems and require closure, this previously required open heart surgery. Now structural interventional cardiologists can close many of these holes with a keyhole procedure and far less risk.
Yes, we have much more to do, Yes, waiting lists in many areas are too long, but the pace with which things have accelerated goes some way to explaining this. Add to that the ageing population (these valve disorders get much commoner with age), and the struggles of the NHS to fund these expensive services (the replacement valves alone often run into tens of thousands of pounds), and it’s even more understandable. However, it’s only when I stop and think how different things were a decade ago that I appreciate how far we have come in structural intervention, and why I have picked it as one of the highlights of heart medicine over the last ten years.