Science ‘catching up’ for patients with heart conditions

Cardiology has experienced some of the greatest advancements in technologies and techniques of any field of medicine in recent years. Local health care providers are able to perform advanced procedures to repair heart valves without the need for open-heart surgery, and are investing in new facilities to provide world-class heart care.

Jill Jack, 65, is one example of how advancements in heart care are changing lives. Growing up, she thought she simply couldn't run, despite being otherwise athletic. She would gasp for air running to first base during softball games and get winded after climbing a flight of stairs.

A caring grade-school teacher encouraged her to get a health exam.

“When I graduated eighth grade, she said, ‘If you don’t get a medical exam I’m going to follow you into high school,’” Jack said.

Her teacher’s encouragement may have saved her life. After a health exam the early 1970s, at age 14, Jack was diagnosed with aortic valve regurgitation, meaning that her aortic valve did not close properly: some of the blood being pumped out of her heart leaked backward into her heart’s left ventricle. It was a life-threatening condition.

Doctors said that in order to repair the valve, Jack would need open-heart surgery, a procedure that was uncommon at the time. Her surgeon said that even if the procedure was a success, her outlook wasn’t good.

“He said, ‘There’s a 96-percent chance you die on the table,’” Jack said. “‘You’ll have another in five to 10 years and hopefully medicine will catch up with you.’”

Fortunately, that turned out to be true.

After two more open-heart surgeries, both 10 years apart, Jack’s options for care were narrowing. Her body wasn’t as resilient as it used to be, and she needed an alternative. In 2015, her search for care led her to the University of Iowa Heart and Vascular Center in Iowa City.

There, UIHC cardiologist Dr. Ramzi El Accaoui discovered that the stress of Jack’s condition had caused additional damage to her heart: her tricuspid valve, which helps blood flow from the right atrium to the right ventricle, was now leaking. She was beginning to show signs of congestive heart failure, but the risks of another open-heart surgery were greater than the potential benefits. She was treated with medication until 2021, when El Accaoui told Jack about a new clinical trial, the first of its kind in Iowa, for a minimally invasive procedure to repair the tricuspid valve. She was the first patient in the state to undergo the procedure.

“One of the advantages of having your care established here is the access to newer treatment options,” said El Accaoui. “Jill got early access because we’ve been following her for years.”

Today, catheter-based procedures are a less invasive alternative to open-heart surgery for patients like Jack who have heart valve problems.

Patients ‘bounce back immediately’

In December 2021 Jack became the first Iowa patient in a clinical trial to test a new device, referred to as a clip, which is meant to treat tricuspid regurgitation, or a leaky tricuspid valve. This is caused by the leaflet of the valve not closing properly.

Edwards Lifesciences, a medical technology company, developed the CLASP II TR, which is designed to repair the tricuspid valve without open heart surgery. It is delivered through transcatheter edge-to-edge repair, which has been used to perform a similar repair to the mitral valve.

El Accaoui, who was part of the team that performed Jack’s procedure, was also part of the team that did the first MitraClip procedure in Iowa. That team has largely been together for almost a decade.

“We practically don’t have to talk during the case,” he said. “We read each other’s minds.”

The delivery of Jack’s clip was through the groin with a small incision. El Accaoui described the benefits for the patient, not only in undergoing an effective operation, but in their ability to heal afterward.

“So you fix the problem with open heart surgery but the patient is struggling to heal,” he said. “Because there’s not the injury that comes with doing an open heart surgery, these people just bounce back immediately.”

Heart surgery becomes less invasive

Many aspects of heart care have advanced in recent decades, including treating irregular heartbeats, opening blockages and replacing valves.

“We can do many things we couldn’t do just a few years ago,” said Dr. Richard Kettelkamp, an interventional cardiologist and medical director of cardiovascular services at UnityPoint Health – St. Luke’s Heart Care. “Heart conditions that may have needed major surgery may now be done as an outpatient procedure.”

Care for complex irregular heart rhythms, for example, can be treated with medication or a minimally invasive procedure known as an ablation.

Interventional cardiology focuses on diagnosing and treating the heart and blood vessels non-surgically using a catheter. These advanced procedures are less invasive than an open surgery. Cardiologists are able to access the heart with a catheter through a small incision in the groin or wrist. These minimally invasive procedures allow patients to go home either the same day or the day after their procedure and typically experience faster recoveries.

Stents are used to open narrowed or blocked blood vessels to the heart. These tools have been in use for more than 30 years but they are more reliable than ever today.

Kettelkamp said a decade ago stents would fail about 20 percent of the time and patients would have to return for another procedure in six months to a year. This is no longer the case as stents rarely fail anymore.

Another minimally invasive heart procedure introduced in recent years is called transcatheter aortic valve replacement, or TAVR. Initially approved for patients who were too high-risk or sick for open-heart surgery, this minimally invasive procedure places a new valve into the old aortic valve. A catheter is inserted through a tiny incision in the groin into the femoral artery. It typically involves an overnight stay.

UI Hospitals and Clinics was the first hospital in Iowa to perform the TAVR procedure in 2011. St Luke’s became the first provider in the Cedar Rapids area to offer TAVR in 2016.

Local hospitals invest in heart care

In Cedar Rapids, Mercy Medical Center and St. Luke’s are investing in their respective heart care programs.

In 2021 Mercy announced it was building the Jewel & Jim Plumb Heart Center, a 72,000 square-foot facility under construction at the corner of 9th Street and 8th Avenue SE that is on schedule to open in May 2023.

“By consolidating the providers and ancillary services in a one-stop shop location we will be able to truly deliver holistic care,” said Jim Atty, the center’s executive director.

Cardiologist Dr. Ryan Hollenbeck is the co-medical director of the center. He views the addition of the center not just as an investment in the future, but as one that is necessary now. In the last 10 years, Mercy’s heart care patient volume has nearly doubled. Due to that high demand, he said Mercy has outgrown its current facilities. To deliver the best care, it was time to think bigger.

“Cardiology, surgery and all the different services in the same clinical space allows for real-time collaborative care,” Hollenbeck said. “That is the most important thing as we are seeing more complex patients.”

The center was designed with input from the clinicians and with patients at the forefront of planning. Hollenbeck said the Heart Center planning team focused on the smallest details to make patients as comfortable as possible. From easy navigation to clinics, to proximity and availability of imaging equipment and spaces to promote collaboration among care teams, patients will benefit from the thoughtfully designed new facility, he said.

Enhanced patient education and awareness are additional goals of the new heart center. Hollenbeck said the layout of the center intentionally placed cardiac rehab at the corner of the facility so passersby could see people engaging in healthy activities like exercise.

Atty said education is a crucial part of the continuum of care.

“If we can educate an individual about their case, about the care they are receiving, that's one thing,” Atty said. “Are there things we can be doing on the front end to hopefully prevent individuals from needing interventions? That should be the goal of health care.”

The Jewel & Jim Plumb Heart Center was designed with future expansion in mind so that two more stories can be added when needed, which Atty expects will be sooner rather than later.

Last spring St. Luke’s announced it was investing $25 million to expand its heart and vascular services within its 98,000 square-foot Nassif Heart Center. The expansion will consolidate and enhance St. Luke’s heart and vascular capabilities into one comprehensive center. Construction is underway, and the investment is focusing on several areas, which include adding a second electrophysiology lab, relocating and expanding vascular and interventional radiology labs and building a dedicated cardiovascular hybrid operating room.

“St. Luke’s is a longtime leader and innovator in offering complex, specialized cardiovascular care,” said Kettelkamp. “Our heart team is proud of this reputation, takes pride in this distinction and considers it our responsibility to continue to offer advanced cardiac care.”

A new lease on life

Jill Jack’s first heart surgery took 16 hours. There was no surgical way of closing her ribs at the time so her chest was left open and forced to heal naturally. She remained in intensive care for a month.

Her second and third surgeries each took about eight hours, with the third being in 1992 when she received an artificial metal valve.

The transcatheter operation at UIHC took just four hours.

Within two days, Jack was released from the hospital and could already feel a difference.

“Every aspect of my life has improved,” she said. “I can do normal things which I couldn't do before. My quality of life has been increased 100 percent.”

Jack said she never would have thought about riding her bike or taking out her kayak before. She does both without hesitation, improving not only her quality of life, but her son’s as well. They have gone on vacation since she received the tricuspid clip and done many things she was unable to do a year ago.

“I lived with heart conditions most of my life,” Jack said. “When I can do something that might have been a challenge at different points in my life, I'm always grateful for it.”