Greg Gubler, 82, wasn't letting valvular disease sideline him. The retired Marine and professor of international relations recently completed the second of two procedures within six months to repair leaking mitral and tricuspid valves in his heart. Both were performed at Lankenau Medical Center, part of Main Line Health, using advanced, minimally invasive techniques.
Scott Goldman, MD, cardiac surgeon and director of the Structural Heart Program at Main Line Health, worked with William Gray, MD, interventional cardiologist and chief of cardiovascular diseases at Main Line Health and co-director of Lankenau Heart Institute, on both procedures — one of which was part of a research study.
A collaborative approach and high participation in clinical trials through the Lankenau Institute for Medical Research (LIMR) allow physicians like Dr. Goldman and Dr. Gray to provide state-of-the-art care on a routine basis to patients who wouldn't otherwise have access to these novel treatments.
An expanding heart
In 2017, Greg had a heart attack and underwent heart bypass surgery outside of Main Line Health. He recovered from that experience but later learned he had atrial fibrillation (AFib) — a common, but manageable heart rhythm disorder — and that his heart was expanding in size. After having a pacemaker implanted, he was referred by his doctor to the structural heart team at Main Line Health.
Dr. Goldman started the Structural Heart Program in 2012 to care for patients with mitral valve, tricuspid valve and aortic valve disease. He explained that what differentiates the program is its true collaborative approach to patient care.
"Our multidisciplinary teams include surgeons, interventional cardiologists and experts in imaging and heart failure. We work together to evaluate each patient's condition and disease process and determine the best way to manage them — whether that involves medical therapy, interventional treatments, minimally invasive surgery or one of our clinical trials."
In Greg's case, both his mitral valve (left side of the heart) and his tricuspid valve (right side of the heart) were leaking, a condition known as valve regurgitation. It's not uncommon for both sides to be affected, especially with older patients.
Dr. Goldman said that when treating valvular disease, they always move from the left side of the heart to the right, because many of the problems on the right are reflective of what's happening with the left. That's what was happening with Greg's heart. The leakage associated with his mitral valve added pressure to Greg's lungs, and that pressure got transmitted to the right chamber, worsening his tricuspid disease.
"Every time the heart beats, there's a leak back that shouldn't be there. Then the next beat has more (blood) volume than it needs, which stresses the heart over time, and it eventually dilates," Dr. Gray said. "That's the progression of a failing heart. Luckily, with correction of the valve leakages, the process and be halted."
Procedure 1: Mitral valve repair with MitraClip®
A mitral valve is structured like swinging doors. When the leaflets of the valve (the flaps that close) no longer touch, it creates a condition called mitral valve regurgitation, which allows blood to leak backward.
In November 2022, to fix Greg's mitral valve, Drs. Gray and Goldman performed a transcatheter edge-to-edge repair (TEER) using a device called MitraClip. This minimally invasive approach is much easier on patients than traditional surgery. The team at Lankenau Medical Center were among the first to offer MitraClip and have completed more than 300 procedures.
"The technology we use allows us to approach the valve through a catheter inserted in a vein in the leg. With our colleagues on the imaging side directing us, we clip the leaflets together and permanently repair the leak," Dr. Gray said.
Procedure 2: Tricuspid valve repair with CLASP II TR
In March 2023, Greg's doctors repaired the leak in his tricuspid valve, this time using a special device called CLASP II TR, which is only available through an FDA-approved clinical trial.
Although similar to mitral valve repair, tricuspid valve repair is more challenging from a cardiac imaging perspective because of its location. One advantage, however, is the structure of the tricuspid valve. When the valve is pulled together tight, it also acts to reduce the size of the heart, which generally continues to shrink over time.
"In the six to 12 months following tricuspid repair, we see the heart start to get smaller, an indication that it's probably not straining as much," Dr. Gray said.
Most other cardiovascular programs treat severe tricuspid disease with surgery or medical therapy — neither of which is optimal. Medication is not as effective as structural repair, and surgery can be risky, as it involves cutting through the patient's breastbone and stopping the heart with the use of a heart-lung machine.
Our team of surgeons and interventional cardiologists take the unusual approach of working in tandem for both catheter-based and surgical repairs. The majority of surgical valve repairs at Lankenau Medical Center are performed using a minimally invasive approach, without stopping the patient's heart. Transcatheter repair, which is what Greg had, is even less invasive, requiring only a small venous puncture and a day or two in the hospital.
"We take care of very high-risk patients, many of whom are elderly or have had previous heart surgery, and the minimally invasive approach is much safer," Dr. Goldman says.
Very few surgeons have the skills and training to offer "beating heart" options. Dr. Goldman and Dr. Gray are among the most experienced in the world — one of the reasons Lankenau Medical Center is recognized internationally for its expertise and outcomes in treating valvular disease.
Enjoying life again
Months after his second surgery, Greg is rebuilding his strength and endurance, spending time with his wife and family and enjoying the Japanese-style garden he created at his home in Montgomery County, Pennsylvania. He completed a one-month checkup and will have a follow-up evaluation at the six-month mark, then yearly.
Greg expressed his appreciation for his physicians and care team, for being a candidate for the clinical trial and for the care he received during and after both procedures.
"The nurses are really terrific, and I was very much impressed with the hospital itself," Greg said.