>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> More than five million Americans are diagnosed with heart-valve disease each year.

Advances in technology have made surgery easier and safer and recovery faster and less painful.

Joining us today, primary care physician from the University of Rochester Medical Center, Dr. Lou Papa.

>> Now we have this wonderful technology where they don't have to have damage done to their heart from the valvular disease.

So that close follow-up is important.

>> Interventional cardiologist Dr. Mustafa Ahmed from the University of Alabama at Birmingham.

>> We routinely take people in their 90s, take them back in, and put another valve through their leg, and those people can leave the hospital within a day.

>> And here to share his personal story, Bob Carson.

>> If you have some sort of a problem like this, it's a wonderful time to get it taken care of because there's brilliant people who are helping us to stay healthy.

>> I'm Joan Lunden, and it's all coming up here on "Second Opinion."

Thank you all for being here today.

Bob, I want to take you back to 2018 when you were sitting in your kitchen, I believe, and you felt a pain in your chest.

Can you describe to us what it felt like?

>> It actually wasn't a pain.

It was a discomfort.

It was a mild burning sensation across my chest.

Didn't penetrate through to my back.

Almost on the surface of my chest.

I questioned it because it was something I had never experienced before.

It was a very unusual sensation.

It wasn't a pain in my heart or the usual things associated with heart attack or a heart problem.

>> And did it go on for a while?

>> Yes, it did, yes.

In fact, I sat for a few minutes and had a glass of water, and it wasn't abating, and that's when we decided to take some action, calling the PCP and further.

>> And you went to a hospital.

>> Yes.

He suggested that we should go to emergency, yes.

>> Now, I do believe that they drove to the hospital.

If he had been your patient, Lou, and he had called you experiencing this feeling, what would you have told him to do?

>> So, first of all, it's not unusual for patients to say, "I didn't have a pain."

They'll say it's a sensation, a fullness, a pressure, because people associate pain with like a gut-wrenching-type thing.

>> How about that "burning sensation" we hear.

>> Burning is still a worrisome thing.

It's a chest symptom that wasn't abating even with rest, so I would have said exactly what his PCP said is, "You need to go to the emergency room" -- by 911.

And the reason why I say -- and I understand what you and your wife were trying to do.

You didn't want to use an emergency service.

But the emergency services are designed just for something like this because the problem is, if it's a cardiac event, they can start the necessary protocols that are there, because time is tissue, right?

If you're having a heart attack, you want to make sure you're doing something to try to preserve whatever tissue is at risk.

And sometimes bad things happen, you go into cardiac arrest.

They have all that equipment there.

That's what they train for.

That's what they are ready to do.

Always, you have anything where you have a cardiac issue or severe bleeding or stroke symptoms, neurologic -- that's what 911 is for.

>> Time is of the essence.

>> Right.

You're getting your emergency care starting right at your front door rather than in a 20-minute ride.

They can go through red lights.

You can't do that.

They can do all this stuff and they can get you there as quickly as possible, so it's really important that they do that.

>> So when you got to the hospital, Bob, what went on?

They ran tests?

>> Well, yes, they immediately checked me out to make sure -- to discover my condition, what was going on with me, as much as they could, as quickly as they could.

And then I was taken into the emergency department, where they began further extensive testing.

>> What was the diagnosis for you?

>> The diagnosis was that there was a buildup of calcium around the aortic valve, which prevented it from opening fully and supplying enough refreshed oxygenated blood to my body.

>> I want to turn to you, Dr. Ahmed.

Help us understand.

Educate us as to how the valves work in the heart.

Where are they, and what are they doing?

>> The valves in the heart are like any normal mechanical system has valves -- to keep blood flowing in one direction and to stop blood leaking back in the wrong direction.

So every time the heart pumps, it pumps into these vessels so it can supply the body, for example, on the left-hand side, or on the right-hand side, the lungs.

When the blood is pumped, in order that it stays forward and doesn't come back inside the heart, there's valves that basically stop, and it stops the leak.

So there's two valves on the left side of the heart, known as the mitral valve and the aortic valve.

On the right side of the heart, there's the tricuspid valve and the pulmonic valve.

And those four valves are the main four valves that we kind of know about and treat over time, and dysfunction in any of those valves, whether that's getting tight, in a process known as stenosis, or whether leaky, in a process known as regurgitation, those dysfunctions can lead to symptoms such as heart failure and shortness of breath and fatigue, and then it can have worse consequences if not treated and diagnosed appropriately.

>> So the two things that can go wrong is that -- you call it regurgitate or leaky, I guess -- and then the other one is like a buildup -- is it of calcium, or what we know as stenosis?

>> Yeah, so stenosis, the most common cause of stenosis and the most common reason for stenosis is aging.

And like with any joint or any other thing in the body where you get wear and tear over the years from buildup of calcium or other things, the valves in the heart can build up calcium, and that causes a tightening called stenosis, and almost it becomes like a door that becomes creaky and harder to open and harder to close and less soft, and that can result in an area going from like that big in the heart will go across, down to something like that when the stenosis becomes severe.

Now, there are are other causes of stenosis.

People can be born with conditions that are congenital, and that can predispose to stenosis.

In the aortic valve, for example, some people can be born with two instead of the three normal leaflets.

And that can predispose to wear and tear over time.

And then other conditions such as radiation, maybe certain medicines, or other unknown reasons why it could happen.

>> So, Lou, when someone comes into your office, what would be happening that would make you suspect that there was heart-valve disease?

>> So there's a couple of things.

The first thing is if they're having symptoms.

And the symptoms for heart-valve disease are very similar to what people think about with "heart attack" symptoms or blockages in their arteries, because you have the valve that's causing a problem with the arteries to the heart getting a blood supply because it's so stenotic.

So you can get chest pain, chest burning, shortness of breath.

But what also happens with them is they can become syncopal or presyncopal, which is a fancy term for they pass out, especially if they exert themselves, because that valve, as Dr. Ahmed said, it gets so tight that if you exert yourself, there's not enough coming out to get to your brain, and you can pass out.

So that exertional syncope, or passing out, is another symptom.

We also pick it up on the examination, where you listen to the heart and you can hear these murmurs.

Dr. Ahmed knows, you go through med school, you painstakingly learn about all these different types of murmurs and what they mean.

Those are helpful, but a lot of this disease you may not hear on an examination because we base a lot of our education about those type of murmurs on rheumatic fever, which we don't see a lot of.

A lot of it now is, just as Dr. Ahmed said, it's aging, and they don't sound quite the same.

Very often we pick it up by accident.

The patient has a stress echo or they have an echocardiogram done for another reason, and they find that they have aortic valve or other valvular disease in that way.

So symptoms, you hear it on exam, or you find it by accident.

>> What are the risk factors for this?

I assume age.

>> Right, age is a big one.

There are certain conditions that put you at higher risk.

As Dr. Ahmed said, the congenital issues.

But people that have kidney disease, they're at higher risk for this.

There's certain rheumatologic diseases that put you at higher risk for this.

Rarely there can be severe blood-borne infections that can destroy the valves and cause problems with them down the road.

Yes, and that can sometimes present very acutely.

Sometimes valvular disease can develop in some of the lower valves with a heart attack.

You have a heart attack, and it damages part of the heart that controls the valve, and the valve fails acutely.

And that's another emergent valvular issue.

But most of them are kind of slow, progressive processes over time.

>> So once you were in the hospital, you had -- what did they tell you your choices were, because there's several different kinds of surgery I know you can do for this.

>> The cardiac surgeon came in to talk to me, and he mentioned there were several options.

The two that were open to me were to have an animal valve inserted to replace the aortic valve or to have a mechanical valve.

The downside of the animal valve is that it lasts between 12 and 15 years.

So, at the time I was 74 years old.

Could I live to 86?

Maybe.

And that means I might have to have a second replacement done.

The other option is a mechanical valve.

The downside of that is you have to take Coumadin for the rest of your life.

I had already been taking Coumadin for over 20 years, so that wasn't a concern to me.

So I opted for the mechanical valve.

>> So, Dr. Ahmed, tell us the difference between why you would choose that or why you would choose the mechanical valve.

>> A couple of factors in this.

Often it can be a lifestyle decision, not necessarily a medical decision which can influence this.

Sometimes things just make sense.

And so let's imagine we had someone that was 30 years old.

We're expecting another need for 50, 60, maybe even more years for that valve to function.

The thing about a mechanical valve is the chance of it degenerating over time is tiny.

So that valve will usually last what we call lifelong.

So in younger patients where it makes more sense or patients kind of in the middle age where they're already taking blood thinner and so it makes sense to continue blood thinner, you can put a valve in without the concern that it's going to degenerate in 10 or 15 years' time.

Now, the downside to taking a mechanical valve is the need for lifelong blood thinner.

People typically take a drug called Coumadin, or warfarin, and there are lifestyle issues associated with that.

You would need to get that checked periodically, even though now that can be checked at home fairly routinely.

It needs to be assessed.

It can't go too high or too low.

And sometimes there needs to be some consistence in diet to make sure the things that people eat aren't making that go too high or low.

But let's imagine you have a valve when you're 30, but then when you're 60 or 70 you may have some bleeding issues.

If you have a mechanical valve and you're predisposed to bleeding issues, that's not going to work because then the blood thinner required to keep the valve going also ends up causing problems.

Now, if we look at a bioprosthetic valve made of animal tissue such as a cow or a pig, the advantage to that would be the fact you don't need blood thinner.

The disadvantage is, over time, those will wear or tear.

Now, if someone is 80, 90 years old, we'll say, "You know what?

It's going to be a great problem to have if at the age of 95 we need to worry about the next valve."

But when someone is 60 years old and we are expecting them to do okay to the age of 75, we are then faced with a decision -- "Well, this valve is going to either become tight or leaky, and we're going to have to address this down the road."

And sometimes you might have a patient, for example -- I have patients who do high-risk sports or things where taking blood thinner is not an option, and even though they're young, they say, "Well, I don't want to take a blood thinner.

I'm gonna have the animal valve and in 10 or 15 years' time, we'll get together and make a decision on reoperation or so."

But I will tell you, the way that the technology has advanced just in the last few years has led to this problem becoming even more complex because now when people are at the age of 74, the typical valve we would put in is now a valve through the leg -- and we can go into more detail on this -- but that valve, even if that degenerates in 10 or 15 years' time, we routinely take people in their 90s, take them back in, and put another valve through their leg, and those people can leave the hospital within a day.

And that's just how much technology has advanced in the last few years.

>> Absolutely, I mean, it's just these are amazing advancements.

What about any other health conditions that a person has.

Does that come into play?

>> For choosing a valve type?

Yes.

Mainly it comes into play with if you have -- say you have a kidney disease and you are more likely -- and on dialysis -- and your valve may be more likely to degenerate, when you put a biologic valve in those patients it's going to wear and tear quicker.

If someone's a little younger and they've got kidney disease, it almost would make very little sense to be putting a biologic valve in when you would want to put a metallic valve in.

And then there's bleeding conditions.

There's people that have bleeding conditions or young people who may want to have pregnancy without taking the risk of taking blood thinner.

Those people will say, "Well, you know what?

I'm 30 years old and plan to have children in the next few years.

I'm gonna take my chances with a biologic valve, get that out of the way, and then when I'm 40, 45, we'll do a reoperation, and at that time we may put a mechanical valve in."

So there is a lot goes into it -- patient factors, medical factors, and then it's an informed choice.

You get together with the patient, their wishes, what makes sense medically, and come up with the best decision.

>> So, Bob, you ended up having the surgery.

And now that we've talked about valves, we'll talk about the kinds of surgery.

You had the one where they went in through your chest.

Tell us what it was.

>> No, the options are the radical surgery -- >> Sternotomy, where they cut the chest open.

>> That's where they go in through the chest, they make an incision, and they pull the rib cage kind of apart.

>> Right.

>> Okay.

>> But the cardiac surgeon also mentioned that there is a new procedure, and it's called a mini AVR -- a mini aortic valve replacement.

They make a tiny incision here and spread your rib cage, and they're able to gain access to the heart from this tiny incision over here.

>> So, sir, how old were you when you had your valve surgery.

>> I was 74.

>> 74.

And how old are you now?

>> I'll be 77 in a couple of months.

>> Great.

So, firstly, you look incredible, and this is important because, you know, it shows that when you're in your 70s and even sometimes in your 80s, if heart surgery is the right option for you, you can get through it, get on back with your normal quality of life, and do very well.

This is a great example of technology has advanced so much in the last few years that now -- and this has changed from maybe even three or four years ago due to many trials and studies that have come out.

But if we take a normal 74-year-old that comes in with just a tight aortic valve now, as things stand, the typical approach for that valve will be to go in through the leg, and we've learned this through studies, whereas for decades it was going through the chest, and sometimes surgeons will go through these tiny incisions that may often just be here, sometimes here.

Now the typical way in someone in their 70s is to come in, go through the leg.

And I will tell you a bit about this procedure because it's been such a -- I would use the word "mind-blowing" advance in the treatment of valve disease that it's normal now.

And I've done a couple of these today, and let me tell you what a patient would typically happen to them.

So you'll have a patient, they'll come in, they'll have a workup and they'll lay on the table, and they'll be completely awake.

This is someone often in their 70s.

And through a small incision in the groin, we'll go up, we'll place a valve while the patient is awake but having some sedation to keep them very comfortable, and then under the X-ray, just like doing a stent in the heart, we'll go and place a valve in the heart.

The procedure could last about 20 to 30 minutes.

And that patient will have their valve replaced and be sitting up within a few hours' time, walking the same day.

And I will tell you, we have sent patients home the same day, routinely the next day.

And this is so incredible.

If you had told me -- and I'm a valve specialist, but if you had told me 10 years ago, "Hey, you're gonna send someone home," I'd say, "I don't even know what you're talking about."

[ Laughter ] And now it is routine, an expectation for someone that comes in, valve through the leg, home the same or the next day, sometimes the day after.

And this can be done with excellent longevity rates.

These valves are lasting longer and longer.

And it's basically seen as an equivalence to the surgery.

And so that field has night-and-day flipped around even in the last two or three years.

I would think if you were to -- and you obviously had a wonderful surgery.

And don't get me wrong -- There's times in people's 70s where they need to have their chest cracked open and the heart team -- which is the surgeons, the interventionalists, the structural heart specialists, we say, someone like myself -- will get together and say, "This is what we think is best for you."

But now those teams are moving more and more, in the right scenario, to say, "The right valve for you is to go through your leg, replace that valve," and we're just seeing amazing results from this and patients just doing so well.

>> That's just so ama-- what is this surgery called?

>> It's called the TAVR.

It's the TAVR -- T-A-V-R. Now, I tell you, I'm in the South, and every now and then I hear somebody call it the "Tayver," but I'm gonna call it "Tavver," which is transcatheter aortic valve replacement.

And this is a surgery -- to put it in context that people would understand, a famous musician, Mick Jagger, he had this surgery, and he had his aortic valve done and was up and, honestly, back living normal life and going on tour shortly afterwards like nothing happened.

>> I mean, it's just amazing where we've come in medicine.

Let me ask you a question, Lou.

Considering what Bob, what kind of surgery he had, what kind of aftercare should he expect or would you want him to have with a primary care physician?

>> So the team that Dr. Ahmed's talking about extends beyond the surgery with the primary care doctor.

There has to be good coordination between the cardiologist and the primary care doctor to continue to monitor that valve.

So these patients very often have serial echocardiograms to make sure the valve's functioning and staying healthy.

We watch for any signs -- sometimes people can get these valves replaced a little bit too late, and they may develop heart failure.

They could still develop coronary artery disease as time goes on.

And you want to manage their risks.

You want to make sure if they have risk for coronary disease, that blood pressure control becomes even more important now.

Actually, a good point also is, even before the valve is placed, like I told you, very often we can pick this up by exam or by echocardiogram.

When I was in medical school, we were taught, you pretty much don't replace the valve until they're symptomatic, right?

That's giving my age away.

We don't think that way anymore.

These patients have to be very carefully monitored depending on the degree of heart valve disease they have, and they may need echocardiograms every couple years, sometimes every year, because you're watching not only for symptoms but we're watching the way the heart's pumping, how strong it's pumping, because very often that's an indication to get them to the surgeon, someone like Dr. Ahmed, sooner than later.

We don't really want to wait until they get very symptomatic because now we have this wonderful technology where they don't have to have damage done to their heart from the valvular disease.

So that close follow-up is important.

>> And of course I'm sure that your doctor, your primary care physician, said, "Be careful how you eat."

You've been great.

Tell us how you've felt since then.

I know you've lost weight.

>> Well, I took the advice of the people in the classroom telling me how to care for this marvelous event that happened in my life, and, actually, out of a sense of obligation to them.

There are so many brilliant people.

I just said that to Dr. Lou.

So many brilliant people walking around the planet, and a lot of them were there taking care of me, and I feel I owe them a debt of gratitude, so I really have made an effort to lose weight, and as of right now I've lost about 50 pounds using something they told me in the cardiac wing when I was there, to make my progress in baby steps.

>> Yeah.

>> And I've adapted that to weight loss.

And I take baby steps.

I change little things and try to continue to lose weight and stay healthy.

My PCP manages my blood pressure very well and manages the Coumadin very well, so I'm well taken care of, and I'm very grateful for that.

>> The little baby steps, they become a way of life and habits as opposed to a "diet."

>> Yes.

>> So, what advice would you have for anybody watching today that hears that they have to have this done, what your advice be?

>> Well, I think, just listening to Dr. Ahmed, I mean, he is obviously a brilliant man, and he's excited about all these new technologies, and I think it's a wonderful time -- if you have some sort of a problem like this -- it's a wonderful time to get it taken care of because there's brilliant people who are helping us to stay healthy and patch us up, as I say.

>> Don't be afraid of the surgery.

>> No, I certainly wouldn't be afraid of the surgery.

>> And I'll give one more call-out, one more shout-out here to the primary care physician.

Stay in a real close relationship with your PCP, correct?

>> Absolutely.

This is mind-boggling technology.

And Dr. Ahmed, this technology is expanding to other valves in the heart too, correct?

>> I mean, it's incredible.

It's one of those areas which is growing so fast, the technology's almost moved faster than when we know how to apply it.

Firstly, listening to you, I wish you were my primary care doctor, my gosh.

I mean, you have such a good insight into -- that was a brilliant insight, what you were saying before, which is following this stuff up.

When people do badly from valvular heart disease, it is because they are lost to follow-up.

And if you don't have symptoms now, the subtle signs, the subtle things that can be picked up by the doctor -- there's worsening of murmurs, there's enlargement of the heart, there's slowing down a little bit.

And that being picked up and being sent at the right time, as we learn year on year.

10 years ago, we would have said wait till someone's really symptomatic.

Now we say wait till someone's hardly symptomatic.

And with the mitral valve, we say don't even wait till you're symptomatic.

We have surgeons that can repair this and get this repaired before any permanent damage is done.

The science has advanced, and the great thing is the technology and the teams have advanced in parallel.

Now you can provide great options, and everything is about all of this science should be based about, how can we get the very best long-term outcome?

We don't want to do anything too early, but we really don't want to do anything too late.

And now the options are just wonderful for valve patients.

>> It has been so exciting to listen to you, Dr. Ahmed, really exciting, about all these advances.

Thank you.

And thank you, Dr. Papa, and as well thank you for sharing your story with us today, Bob.

I also want to thank all of our medical advisors who are with us every step of the way to ensure that we bring you evidence-based, up-to-date, accurate medical information.

And, of course, for all of you at home, we thank you for watching.

From all of us here at "Second Opinion," we encourage you to take charge of your health care.

I'm Joan Lunden.

Be well.

♪ ♪ ♪ ♪ ♪ >> Find more information about this series at SecondOpinion-TV.org.

You can also follow us on Facebook and YouTube.

>> From coast to coast, Blue Cross and Blue Shield companies stand side by side with our neighbors, investing in local non-profits during the most challenging times, using data to drive solutions and support healthier living and turning ideas into action, remaining true in our commitment to achieve health equity for the health of America.

>> "Second Opinion" with Joan Lunden is produced in conjunction with UR Medicine, part of the University of Rochester Medical Center, Rochester, New York.