{"id":27139,"date":"2019-10-22T09:43:01","date_gmt":"2019-10-22T15:43:01","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=27139"},"modified":"2023-10-06T17:01:35","modified_gmt":"2023-10-06T23:01:35","slug":"david-procedure-resolves-a-mystery-of-family-heart-history","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/david-procedure-resolves-a-mystery-of-family-heart-history\/","title":{"rendered":"‘David Procedure’ resolves a mystery of family heart history"},"content":{"rendered":"
<\/div>

Modern medicine sometimes can provide the comfort of clear-cut reasons for our illnesses and disease. Your genetics might explain your cancer. Your insistence on eating fatty, calorie-ridden foods and leading a sedentary lifestyle could tell the tale of clogged arteries that caused your heart attack. A stray particle from a blood clot might be the culprit that plugged a blood vessel, leading to your stroke.<\/p>\n

But the clues to puzzling medical problems can be far more elusive, even for skilled and experienced providers. Plain luck, both good and bad, that unexpectedly changes lives is hard to account for.<\/p>\n

\"Parents
Chris Lieu with wife Caitlyn and their kids, Landon and Ella. Daughter Laura later joined the family. Photo courtesy of Chris Lieu.<\/figcaption><\/figure>\n

Dr. Christopher Lieu<\/a> can speak to that. Lieu, an associate professor of Medicine-Medical Oncology with the University of Colorado School of Medicine<\/a>, was hardly a candidate for a serious heart problem back in 2014. He was just 36, in good health, and had a busy practice seeing patients at the UCHealth University of Colorado Cancer Center<\/a> on the Anschutz Medical Campus<\/a>. He stayed active on the basketball court and running trails and at home, where he and his wife cared for two kids, then ages 1 and 3.<\/p>\n

\u201cI\u2019d gone through life pushing myself in every way possible,\u201d Lieu said. Then some family news put a damper on that.<\/p>\n

Family heart history, medical mystery<\/strong><\/h3>\n

An uncle of Lieu\u2019s had died in Korea, seemingly of heart problems. At that time, the precise cause wasn\u2019t known, but Lieu\u2019s mother had survived an aortic dissection: a tear in the inner wall of the aorta, the artery responsible for transporting blood pumped from the heart to the rest of the body. His mother survived, but the death of her brother prodded Lieu to question whether family history made him vulnerable to aortic problems.<\/p>\n

Lieu posed the question to his primary care physician. The potential genetic link led to approval for an echocardiogram to obtain pictures of Lieu\u2019s heart. The resulting images revealed a bulge, or aneurysm, in the aortic root, the top portion of the artery, which is attached to the heart. The root includes the aortic valve and openings to the coronary arteries, which feed the heart blood. If an aneurysm ruptures in that area, the internal bleeding that results can be fatal.<\/p>\n

\"profile
UCHealth cardiologist Dr. Amber Khanna helped Lieu and wife Caitlyn decide on the risks and benefits of surgery to repair the aneurysm. Photo by UCHealth.<\/figcaption><\/figure>\n

The news was an unpleasant surprise, as Lieu felt no symptoms. That\u2019s not unusual, said his cardiologist, Dr. Amber Khanna<\/a>, an associate professor of Medicine-Cardiology with the CU School of Medicine<\/a> and a specialist in adult congenital heart disease at UCHealth University of Colorado Hospital<\/a> and the UCHealth Heart and Vascular Center<\/a>.<\/p>\n

\u201cSome people may have chest pain, but an aortic aneurysm is usually a silent killer,\u201d Khanna said. Lieu\u2019s aneurysm also remains a bit of a medical mystery and a testament to the role that chance can play in the course of a person\u2019s life.<\/p>\n

Khanna said that an aortic aneurysm at Lieu\u2019s age \u201cis almost always genetic, especially with his family history.\u201d Tests showed he had a pair of gene mutations not normally seen in otherwise healthy people, she said, but she and her colleagues aren\u2019t convinced the changes caused Lieu\u2019s aortic problem.<\/p>\n

\u201cHis genetic testing is indeterminate,\u201d Khanna said.<\/p>\n

There was a further twist. The cause of death for Lieu\u2019s uncle \u2013 a heavy smoker with emphysema<\/a> \u2013 was ultimately diagnosed as pneumonia. Lieu said that had he known there was no aortic connection to his uncle\u2019s death, he would never have mentioned it to his PCP and probably would never have gotten the echocardiogram that revealed the aneurysm.<\/p>\n

Caught in the middle<\/strong><\/h3>\n

The echocardiogram painted a clear picture of the problem in Lieu\u2019s aorta, but the questions it raised were murky. For one thing, the aneurysm at that point, 4.6 centimeters, wasn\u2019t big enough to demand surgery to repair it, Khanna said. It was on the borderline for surgery for someone with a confirmed genetic risk, which was uncertain in Lieu\u2019s case.<\/p>\n

In addition, unlike a person suffering typical signs of heart problems, like shortness of breath, chest tightness or jaw pain, Lieu wouldn\u2019t feel tangible benefits from a surgical repair, Khanna said.<\/p>\n

\u201cIt\u2019s fixing one of the pipes, but the pipe isn\u2019t causing the person any problems,\u201d she explained. In removing the aneurysm, \u201cwe don\u2019t make the heart stronger, we don\u2019t make the valves work better, we don\u2019t fix the electrical system. It\u2019s just preventing future problems.\u201d<\/p>\n

Khanna said, however, that Lieu\u2019s relative youth and otherwise good health pointed in favor of surgery.<\/p>\n

\u201cYounger patients have their whole life in front of them, and they are more likely to do well with surgery,\u201d she said. \u201cI was confident that Chris would do well with it.\u201d<\/p>\n

Waiting game<\/strong><\/h3>\n

That didn\u2019t make the decision a slam-dunk for Lieu. He was in the frustrating position of not having a definitive diagnosis \u2013 the aneurysm wasn\u2019t small enough to be confident that he could safely watch and wait or big enough to go to surgery immediately.<\/p>\n

\u201cIt\u2019s one thing if you are one edge or the other, where you have to get it done because it\u2019s life-threatening or you have some time to wait. I was right in the middle,\u201d Lieu said.<\/p>\n

And he felt fine, which complicated the prospect of an open-heart procedure and putting his practice on hold for at least six weeks of recovery.<\/p>\n

After consulting with Khanna, Lieu decided to wait while he had regular echocardiograms to see if the aneurysm grew. Late in 2015, the bulge had extended to 4.9 centimeters, a worrisome sign that increased the pressure for surgery.<\/p>\n

He and his wife, Caitlyn, spent October and November discussing the situation between themselves and with Khanna. They also met with Dr. Brett Reece<\/a>, professor of Cardiac Surgery and director of the Thoracic Aorta Program at CU, who would perform the aortic repair if Lieu approved it.<\/p>\n

The David Procedure<\/strong><\/h3>\n

\u201cWe\u2019re like primary care physicians for aortas that are larger than normal,\u201d Reece said. He added that the Thoracic Aorta Program sees patients of all ages, with the number of those in the 20- to 50-year range at least equaling the number of older patients.<\/p>\n

Both Khanna and Reece explained the benefits and risks of the procedure and answering as many questions as possible.<\/p>\n

Lieu finally decided that the risk of a rupture at his age and the resulting anxiety it would wreak on Caitlyn and their kids, were too great to bear. He chose surgery.<\/p>\n

\"profile
Dr. Brett Reece performed the David Procedure that repaired Lieu\u2019s aneurysm while sparing his aortic valve. Photo by UCHealth.<\/figcaption><\/figure>\n

In February 2016, Reece repaired Lieu\u2019s aorta with a technique called the David Procedure. In simplified terms, the open-heart surgery involves cutting the upper portion of the aorta, removing the section of tissue with the aneurysm, replacing the tissue with a graft, re-implanting the patient\u2019s own aortic valve in the graft (rather than putting in an artificial valve) and attaching the graft to the remaining aorta.<\/p>\n

Reece said the David Procedure is an option for patients like Lieu whose aortic valves are \u201crelatively normal\u201d or even those that don\u2019t close completely. It\u2019s not used in patients whose valves have become stenotic, or stiffened. He said the Thoracic Aorta Program is now doing nearly 50 such procedures a year for patients of Lieu\u2019s age or younger.<\/p>\n

With his own aortic valve still in place, Lieu does not have to take blood thinners for the rest of his life, as do those who receive artificial valves.<\/p>\n

\u201cHis valve is now perfect and I hope it serves him for the rest of his life,\u201d Reece said.<\/p>\n

Surgical slowdown<\/strong><\/h3>\n

The operation was successful. After a roughly week-long stay at UCH, Lieu went home for six weeks of recovery, during which he didn\u2019t work or drive. He couldn\u2019t lift anything for four weeks. He returned to work at the six-week mark and two weeks later flew to New York City to give a presentation. That went well, he said, but the physical challenges were severe enough that he labeled it \u201cnot the brightest decision I have ever made.\u201d<\/p>\n

Khanna was aware of the trip, stressing that she treats adults. They make their own choices about their recovery. In general, she added, she talks to all her patients about the risks of activity after surgery and ways to minimize it.<\/p>\n

\u201cI try to put it into a context of the degree of risk but that\u2019s very difficult,\u201d she said. Lieu was no exception.<\/p>\n

\u201cHe knew he couldn\u2019t put his own suitcase in the overhead bin,\u201d she said of Lieu\u2019s decision, adding she was not surprised by his struggles with the trip.<\/p>\n

\u201cIt takes so much energy to recover, even if you are young and healthy,\u201d she said. \u201cI tell patients, \u2018Give yourself time.\u2019 They learn that if they push themselves too hard one day, they are going to pay for it the next couple of days.\u201d In fact, she added, full recovery generally takes at least six months and often a year.<\/p>\n

\"Parents
Surgery, called the David Procedure, to repair a dangerous aortic aneurysm helps to ensure that Lieu will spend many more moments with his family. Photo courtesy of Chris Lieu.<\/figcaption><\/figure>\n

New perspective<\/strong><\/h3>\n

The experience in New York was one of several lessons Lieu said he learned from switching roles, from provider to patient. For example, many of his patients go through aggressive surgeries to treat their cancer. Many lose their desire to eat and face debilitating fatigue. He found himself encountering the same challenges after his heart surgery and gaining a new appreciation for his patients\u2019 battles.<\/p>\n

\u201cAny time you put yourself in your patients\u2019 shoes, it has a benefit because you have a better sense of what a good day and a bad day really feels like,\u201d Lieu said.<\/p>\n

As he approaches the three-year surgical mark, Lieu said he feels no ill effects. He gets periodic imaging tests and takes a blood pressure medication to protect the aorta. He\u2019s returned to life as it was \u2013 with the addition of a third child \u2013 but remnants of the unexpected ordeal stay with him.<\/p>\n

\u201cYou have the scar to help you remember,\u201d he said. He still hits the basketball court but sometimes a nagging thought accompanies him and slows the fast break a step or two.<\/p>\n

\u201cThere is always something in the back of my mind that something could happen in the future,\u201d Lieu said.<\/p>\n

Chris Lieu serves as a different kind of reminder for Brett Reece.<\/p>\n

\u201cI love seeing him around campus now because I know we gave him the best care possible,\u201d Reece said.<\/p>\n","protected":false},"excerpt":{"rendered":"

Modern medicine sometimes can provide the comfort of clear-cut reasons for our illnesses and disease. Your genetics might explain your cancer. Your insistence on eating fatty, calorie-ridden foods and leading a sedentary lifestyle could tell the tale of clogged arteries that caused your heart attack. A stray particle from a blood clot might be the 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