Don and Amy Lovell, recipients of his-and-hers minimally invasive aortic valve replacements, sat side-by-side in a UCHealth University of Colorado Hospital exam room. Eight days earlier, Don, 89, had received his new valve, an Edwards Lifesciences Sapien 3. Amy, 85, had gotten hers, a Medtronic CoreValve Evolut, about nine months before, in July 2016.
As tends to be the case for couples married 68 years, they had developed their own, rather simpler names for the artificial valves that had returned color to their faces and energy to their bodies.
“She’s a ‘moo,’” Don quipped, “and I’m an ‘oink.’”
Not long ago, Don Lovell wouldn’t have enjoyed the good fortune of having his aortic valve replaced, much less have been out watering his garden a week after the procedure. Aortic valve replacements were big, open heart surgeries that carried serious risk for elderly patients with a combination of aortic stenosis and other health concerns.
Aortic stenosis typically happens when the aortic valve calcifies with age and, because of that stiffening, fails to fully open for blood to flow to the body. While it also can be a rare congenital condition, aortic stenosis is most often a health issue with those 75 and older – 12.4 percent of those in that age group have some form of it, and in 3.4 percent of them it’s severe.
Severe aortic stenosis’s combination of stressing the heart itself and starving other organs of blood used to mean that, left untreated, roughly half of patients die within a year or two of the symptoms appearing, according to John Carroll, MD, director of Interventional Cardiology at UCHealth University of Colorado Hospital. Carroll was part of a multidisciplinary team of cardiologists, surgeons, anesthesiologists, radiologists, nurses and others involved in preparing for and performing the procedures, known as transcatheter aortic valve replacements, or TAVR, on both Amy and Don Lovell.
For both Lovells, TAVR was the culmination of both deliberation and late-breaking urgency. Amy had a cardiac stent inserted in 2010, open-heart double-bypass surgery in early 2015 and another stent inserted in late 2015. Echocardiograms had shown the aortic valve to have stiffened. A March 2016 auto accident – a drunk driver clipped the Lovells and spun them into a bus and a pickup – sent her to the hospital with bruises. A workup found something more serious: an adrenal tumor. Before treating the tumor, doctors told her, TAVR had to happen first. And so in late July, the Medtronic “moo” went in and, six weeks later, the tumor (benign), went out.
For Amy, in addition to having more energy, the TAVR procedure stopped her angina. Her skin color improved “tremendously,” too, added Donna Killman, the Lovells’ daughter, who accompanied them to Don’s follow-up exam. She and Amy credited TAVR as well as ongoing treatment by the UCH Pulmonology team.
“They were always telling me, ‘Your lips are blue,’” Amy said.
As was the case with his wife, Don’s aortic valve had been on his doctors’ radar. That Amy had done so well after TAVR had motivated him to prepare for a similar procedure. He was already on the schedule when cardiorenal syndrome took hold, and failing kidneys lent enough urgency to move the procedure date up, to April 5.
Don got the Edwards Lifesciences’ “oink” much the same way as Amy had received her “moo”: via a percutaneous needle stick in the groin to access the femoral artery. Carroll snaked the compressed Sapien 3 (less than a half-centimeter in diameter) up into the heart, positioned it inside Don’s failing aortic valve and then expanded the Sapien 3 to take the old valve’s place. The decision to go with the Sapien 3 versus the CoreValve Evolut rested on the shapes of Amy’s and Don’s aortic valve and surrounding arteries, Carroll said.
“Both of these valves come in a spectrum of sizes, such that it’s not the major deciding factor,” Carroll said. “It’s more the nuances of different anatomical conditions.”
Carroll has a lot of experience with such nuances. He and colleagues at UCHealth were the first in Colorado to perform the procedure and have been doing them since March 2012, just months after the U.S. Food and Drug Administration approved the first TAVR device – in November 2011. UCH, UCHealth Medical Center of the Rockies in Loveland and UCHealth Memorial Hospital Central in Colorado Springs are all clinical trial sites for TAVR. Those approvals were initially for patients at very high risk of complications or death from traditional open aortic valve replacement surgery; with time, the FDA has greenlighted the procedure for patients at intermediate risk (high-risk patients have an 8 percent or greater risk of dying from open surgery within 30 days; for intermediate-risk patients, that risk is from 3 percent to 8 percent). UCHealth is now participating in clinical trials on low-risk patients, too, Carroll says. All told, UCHealth has done nearly 900 TAVRs.
The positives of the surgery are easy to see – Don and Amy Lovell being good examples of the good it can do. But as both a clinical researcher, Carroll sees TAVR is entering a phase of maturity that opens the door to new questions. Durability is one: five to seven years out, there are no red flags, he said, “but to really make decisions about the optimal way to get an aortic valve replaced for someone at low risk, we really need 10-year data to make sure the valve is durable – or even longer-term data to make comparisons with surgically implanted aortic valves.”
A second question has to do with patients who are much more high-risk than the Lovells. The accompanying health issues that contribute to patients being sick enough that surgery might be too much for them – such as severe kidney disease or lung disease – contribute to roughly 25 percent one-year mortality even with TAVR, Carroll said. These compounding conditions diminish the quality of lives of some who survive to the point that it’s fair to call into question to the utility of doing TAVR, Carroll said. With such ultra-high risk patients, there must be a frank discussion of whether TAVR or more of a palliative care approach is appropriate, he added.
“We’re trying to understand this better – to have a crystal ball, if you will, as much as that’s possible in medicine – to see which patients could benefit,” he said.
Tending to life
During the office visit, Kristy Gama, NP, checked out Don’s heart. “It sounds so much better! You barely even hear a murmur,” she said. She also spent a lot of time listening – not only to health status updates and questions, but also to stories about the Lovells’ lives.
Don produced his smartphone to show Gama a photo from their wedding, taken in 1949. Gama learned that he was a motor pool driver during World War II and a machinist and later superintendent of the fabrication shop at Gates Rubber. Amy had been a photo tinter – airbrushing and hand-colorizing photos in a studio decades before Photoshop. She learned that he and Amy built houses together and then sold them as a side gig, as if one needs a side gig when raising six kids. Then they moved to Fairplay after retirement and didn’t particularly slow down, building their own geodesic-dome home, running the South Park Museum, launching a volunteer ambulance service (he drove; she got trained and served as the emergency medical technician). They rode dirt bikes on mountain trails and Harleys across the country. As Don put it, “I can’t get past my wife of 68 years without giving her a hug and a kiss.”
“I think we still have some life left and can have some good times,” Don added.
Carroll, still in scrubs from a procedure, knocked lightly and entered the exam room. He seemed pleased with how well Don was doing.
“This morning I filled the birdbath and watered the flowers,” Don told the doctor.
“Sounds like a great morning,” Carroll said.
Carroll headed off to the next procedure; the Lovells headed off to lunch.
“We are ready to rumble,” Don said.
Amy took a moment to reflect on the care she and her husband had received at UCHealth.
“We have complete trust,” she said. “And they always have time to talk to you. These are specialists who have high demands on their time. We never feel rushed in our conversations. They’re just fine people.”
For more information on TAVR at UCHealth, visit our TAVR Program page.