The so-called transcatheter aortic valve replacement uses a valve that got a Food and Drug Administration nod last year for people too sick for the standard open-heart version of the procedure. But it may hold great promise for other people with aortic stenosis, too, experts say. "Eventually, everybody would like to do this procedure on even ideal candidates for [open-heart] surgery, because it's much less invasive," says Makkar. But it's not without risk, and more data are needed on how well catheterization serves people who could undergo a full-fledged operation with only moderate risk, like Noonan, or with low risk.
Since Noonan has had surgery affecting his right femoral artery before, a vascular surgeon gets the ball rolling, to ensure the artery is hearty enough to stand up to an inserted catheter. It is. Within two hours, the surgical team, under Makkar's direction, has slipped the new valve into place, and expanded it to fit the opening of the aorta, pressing the leaves of Noonan's faulty valve to the vessel walls. The catheters come out, and Noonan is taken to intensive care. He is walking and cracking jokes within a day, and by Wednesday, he is well enough to go home. With open-heart surgery, his hospital stay would have lasted more than a week.
Tuesday's valve repair requires more working room than the sliver of space provided by a catheter. So surgeons turn to the da Vinci Surgical System, a robotic innovation whose slender tools and 360-degree action can outmaneuver even the most adept human hands. The da Vinci has found its way into more than 1,700 hospitals worldwide since 2000, when the FDA gave it a green light. Cedars-Sinai surgeons have been using the system since 2004, controlling the cutting and suturing from a console at one side of the OR while robotic arms follow their commands, without so much as a tremor, at the table.
Today's problem: Betty Trusel's mitral valve, whose job is to regulate the flow of oxygen-rich blood from the left atrium down to the left ventricle, where it is then pumped out to the rest of the body. Her valve doesn't close completely, allowing blood to leak back into the atrium. Trusel, 85, has known about her valve problem for years, but found it didn't interfere much with her life at home in Los Angeles, where she worked until March with individual clients as a hair and makeup artist after a long career at MGM Studios. But lately it has become increasingly difficult to breathe.
Again, a mitral valve repair usually would be an open-heart surgery. But Alfredo Trento, director of cardiothoracic surgery, has thought it best to avoid the trauma, given Trusel's age. In the OR, a 2-inch-long incision is cut into the right side of Trusel's chest, the opening stretched wide. Through her ribs, the doctors insert instruments and a camera aimed toward the heart. Trusel's heart must be completely still while it's worked on, so the surgical team plugs the heart-lung machine into the vessels coming and going, temporarily diverting the blood flow. They inject her with a potassium solution that stops her heart for 30 minutes at a time.
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Trento sits at the da Vinci console about 10 feet away, grabs the machine's controls, and looks into binocular eyepieces to access the inserted camera and see the heart in 3-D. He knows from Trusel's echocardiogram that her mitral valve is floppy, but when he sees it on the screen, he is troubled by its large size. "Let me see what I can do," he says, moving the controllers as robot-held scissors and clamps cut and remove the extra mitral valve tissue, snipping heart strings known as chordae tendineae that connect the valve to the heart ventricle wall.
Before he fixes the leaky valve by tightening the remaining tissue with permanent sutures, Trento addresses another problem, Trusel's irregular heartbeat. He applies a frosty wand containing liquid nitrous oxide at minus 75 degrees Celsius to her heart tissue. The extreme freeze kills off cardiac cells in a complex pattern, forcing beat-inducing electrical signals to move in an orderly fashion rather than the chaotic paths that cause the irregularity.