Michael Jessen, M.D. Answers Questions On: Heart Disease and Treatments

Most heart disease involves structural changes to the heart or a component of the heart.

A good example is coronary artery disease, in which narrowing or blockages in the coronary arteries occur over time. If the blood supply is suddenly denied to parts of the heart muscle, it cannot function properly and a heart attack may result.

Or, it could be a more gradual and incomplete narrowing. When the patient tries to exert himself or herself more, the heart beats faster and stronger to increase the blood supply. If the supply is insufficient, they may experience symptoms like chest pain.

Another example would be valve disease. There are four valves in the heart, and the most common ones that need attention are the aortic valve and the mitral valve, both of which can narrow over time, making the heart strain to pump blood through a smaller opening. In some cases the valve allows blood to leak backward when it relaxes, again making the heart work harder to deliver adequate blood supply throughout the body. Some of those patients can be managed medically, but when the valve disease gets more severe, often surgery is the best option.

Some diseases manifest in problems with the heart rhythm itself, some are congenital, some are caused by lipid disorders, and there are aneurysms, most commonly of the aorta. We treat all of these serious conditions and continually work to discover new ways to reduce the patient’s pain, use the least invasive treatment, minimize hospital stays and recovery time, and return the person to a high quality of life, extending that quality as long as we can.

We want patients to understand that the treatment of diseases has progressed to very, very complex levels. And, the best way to manage a disease nowadays often doesn’t mean picking a single doctor to manage everything. A lot of times the best disease management for patients is through teams.

One example would be our heart transplant program. You could have the best surgeon in the world, but if the other parts of the team, which are very, very important, were not as good, the result would not be great. So, you need to have excellent, experienced heart failure specialists. You need extremely good heart surgeons to do the actual operation. And you need top notch anesthesiologists, radiologists, surgical nurses, and other highly trained, experienced heart team members.

Another example would be the treatment of patients with thoracic aortic disease. These are aneurysms of the aorta and they are now treated in a number of different ways. In the past, open surgery was the main treatment: When the aorta expanded to a certain size there was risk that it would rupture, so it was replaced in an open operation. That is still done today, but there are new options to treat it less invasively using special devices called endografts that fit within the aorta.

Endografts are performed in specialized hybrid operating rooms on surgical beds that have special imaging or X-ray machines built into them. A very fine catheter is inserted through a small incision, usually in the groin, and moved through an artery to the location of the aneurysm.

The aneurysms can be treated very effectively, and the patient often goes through less stress and spends less time in the hospital.

An LVAD (left ventricular assist device) is a battery-operated device used to help the left ventricle pump blood through the body. It’s implanted during an open procedure.

We are seeing more and more advances in LVADs, and in recent years they have gotten smaller and more reliable. We are now seeing patients who can be offered LVADs, and instead of the device lasting two years it is lasting six or seven years. And yes, in some cases, the patient with very serious heart disease can return to a high quality of life without transplantation.

Since the donor pool for heart transplant is very limited, developing an LVAD that will be the final treatment for more and more patients’ heart failure is a major focus of research and clinical trials. This so-called “destination therapy” will be pursued for many years down the line, and certainly new generations of left ventricular assist devices are in the offing.

Our surgical team has the most experience in North Texas with the LVAD. In fact, we were part of an exclusive group of 20 of the nation’s leading medical centers chosen to take part in the REMATCH trial (Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure). This landmark trial was sponsored in part by the National Institutes of Health.

Physicians here don’t compete with each other. So, if I see a patient and Dr. Richard Wu from Electrophysiology also sees the patient, we sit down together and try to figure out what the best treatment option is for that patient. In the academic medicine environment, we don’t compete for treatment dollars; we collaborate to find the best possible outcomes for each patient.

That "multidisciplinary approach" works best for our patients. Teams of people in different disciplines best treat even common diseases like coronary artery disease. I think this multidisciplinary approach – working together to decide what is the best treatment for an individual patient – is what patients want.

We worked on the team that developed national guidelines for best practices in cardiovascular and thoracic surgery. The guidelines were published by the American College of Cardiology and the American Heart Association in November 2011.

The heart team concept actually emerged from the process of developing the guidelines. This is, I think, where most practices need to evolve, but we are already there at UT Southwestern, working together, where a patient comes in and is thoroughly evaluated and collaboratively diagnosed.

Then, working with interventional cardiologists and surgeons, we make a recommendation for the patient of what we think the best therapy would be. It may be an interventional cardiology procedure like a stent, or it may be a bypass surgery, or it may be medical therapy.

And the patient is a member of the heart team, too. Importantly, the patient is a big part of the decision process. I think this is what patients really want nowadays. They want to know what is wrong – to hear all the facts – and to have a voice in the decision-making process.