For the Love of Health

The Next Era in Structural Heart Care with Dr. Neil Wimmer and Dr. Erin Fender

• ChristianaCare • Season 3 • Episode 10

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Structural heart disease is a condition that affects the heart’s structure, its valves, chambers and walls. Minimally invasive procedures are transforming treatment for these complex conditions.

Many diagnoses that once required open heart surgery can now be treated with minimally-invasive procedures, resulting in shorter hospital stays, fewer complications, and a faster return to the activities you love. Dr. Neil Wimmer, Medical Director of the ChristianaCare Structural Heart Program, and Interventional and Structural Cardiologist Dr. Erin Fender join us to unpack how transcatheter therapies work, why outcomes now rival open heart surgery, and what it's like to see patients go from breathless to walking the halls the next day. 

Along the way, we explore who qualifies, how to start with primary care or general cardiology, and what a comprehensive heart team brings to complex cases.

If you've wondered whether valve disease still means a big operation, or you're caring for someone slowing down with subtle symptoms, this deep dive offers clarity and hope.

Neil Wimmer, M.D., MS, is the Medical Director of the ChristianaCare Structural Heart Program and an expert in transcutaneous aortic valve replacement (TAVR), which enables patients who aren't good candidates for open heart surgery to receive a new heart valve inserted through a catheter. The procedure has increased in popularity in recent years.

Erin Fender, MD, is board-certified in interventional cardiology, cardiovascular disease and internal medicine by the American Board of Internal Medicine. A cardiology researcher and educator, Dr. Fender is engaged in educational programs and lecture series, and has presented nationally.

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Welcome And Today’s Focus

SPEAKER_00

At this point, we almost never have patients that we have to turn down because they are too high risk.

SPEAKER_02

You're listening to For the Love of Health, a podcast about delivering care and creating health, brought to you by Christiana Care. Hello everyone, I'm Jason Tekarski.

What Structural Heart Care Means

SPEAKER_01

And I'm Megan McGerman. Welcome to For the Love of Health, brought to you by Christiana Care.

SPEAKER_02

Today we're diving into one of the most transformative areas in cardiology, structural heart care.

SPEAKER_01

Over the past two decades, treatment for complex valve and chamber conditions has evolved from open heart surgery to minimally invasive procedures that restore health and quality of life faster than ever before.

SPEAKER_02

Joining us today to talk more about advancements in structural heart care are Dr. Neil Wimmer, Medical Director of the Christiana Care Structural Heart Program, and interventional and structural cardiologist, Dr. Aaron Fender.

SPEAKER_01

Aaron and Neil, thank you for being here today. It's a pleasure to be here. Thank you for having us.

SPEAKER_03

Yes, thanks for having us. We're excited.

SPEAKER_01

Christiana Care Center for Heart and Vascular Health is nationally recognized in a number of cardiovascular specialties. Before we dive into your work, let's lay the groundwork a little bit and talk about your specific work in the structural heart space.

SPEAKER_03

That's an interesting thing to think about. Cardiology has become really complicated over the last two decades. There's many different kinds of cardiologists. So Aaron and I both work doing some general cardiology care, but most of the time we spend doing procedures or evaluating patients for procedures, where we're doing what's called interventional cardiology or what we call structural heart interventions, which are procedures related to patients' valves or the how their heart is built. So doing things like closing holes in the people's hearts. It's a field that has evolved rapidly and didn't really exist 20 years ago. And so things have changed a lot. And we have developed a team here at Christianicare to address all of these needs and these new procedures that are now available.

From Surgery To Catheters

SPEAKER_02

Neil, you alluded to the fact that there's been a ton of evolution of what you do over the past two decades. Give us a little more detail about what that is like.

SPEAKER_00

So the field itself has evolved, as Neil said, pretty tremendously to the point where at this point, a large proportion of the patients we serve are able to be treated with far less invasive therapies than traditional open heart surgery, which previously was the only option available for most of our patients.

SPEAKER_03

Yeah, and things have changed a lot. Even in our careers, uh, we have gone from being able to do procedures on one kind of heart valve, the aortic heart valve. That's a procedure that became available starting in about 2012. And in the last 12 or 13 years, things have evolved where we now can offer patients procedures to avoid open heart surgery for really all of the other heart valves. It's been an exciting ride, and we are really proud of the expert team that we've built.

TAVR Becomes The New Standard

SPEAKER_00

In the last decade or so, doing these non-surgical procedures for the aortic valve, in fact, has evolved so much that it's gone from being a procedure that was limited to people who were too sick to have traditional open heart surgery, which at the time was the standard of care, to now these less invasive procedures are the new standard of care. And in fact, the vast majority of patients are treated this way because not only does it provide comparable long-term outcomes to patients, but it does so at a safer profile with much more rapid recovery rates.

SPEAKER_03

A little bit more than a decade ago, the treatment for patients who had aortic valve disease, which is disease of the valve that separates the heart from the rest of the body, was it was generally treated at that point all with open heart surgery. And there was the development of a procedure which we call TAVER, which is just an acronym, which stands for transcatheter aortic valve replacement, where we can replace a patient's aortic valve without having to open their chest. We do it all through catheter-based procedures with tubes that go in through the blood vessels, usually in the groin area, and we can advance those tubes through the blood vessels and replace the patient's aortic valve. That became available to a subset of patients in about 2012. And in the last 13 years, that kind of technology, although it's a little bit different for each specific valve, has evolved. So now we can offer procedures that can address people's mitral valve problems, where we can do procedures where we can reduce the leakiness of the mitral valve without having to do open heart surgery. And just recently, in the last year or so, we have developed and had access to technology where we can do similar kinds of procedures, either reduce people's leakiness of people's tricuspid valve or actually replace the tricuspid valve also with procedures that don't involve open heart surgery. And so it's been a huge change for patients. Most of the time in the past, we were discussing with elderly patients whether or not they wanted to have surgery or say, I'm willing to live and take my chances without having this problem addressed, knowing that it's a problem that can end people's lives. And now we have so many more options for how to treat patients.

SPEAKER_00

At this point, we almost never have patients that we have to turn down because they are too high risk. For most patients, we can find some way somehow to get them the therapy that they need safely.

Expanding To Mitral And Tricuspid

SPEAKER_03

And it's interesting how, as the field has evolved, we as cardiologists kind of wake up to the idea that some of these problems are probably more serious than we as a field have appreciated. And so the development of a valve replacement procedure for the tricuspid valve just recently has kind of woken the field of cardiology up to the fact that people don't have to suffer with this disease, that now we have an option that's a good option for patients. And we actually are a little bit overwhelmed by the interest in this by other cardiologists in our department, in our community, um, and really across the country, who have said, wow, we've really identified these patients who we were kind of ignoring on some level and realize that they have a big problem and we can really make their lives a lot better.

SPEAKER_01

Talk about these conversations you are having with patients. Do you think back to patients maybe you had a decade ago and say that person's life would have been fundamentally changed had that happened in 2024?

SPEAKER_00

We see patients regularly that had open heart surgery for problems such as uh the aortic valve that nowadays would 100% have been treated with a TAVER procedure. And when you speak to those patients and they recall what it was like to recover from those surgeries, it's often a scary time in their life that they went through that involved a lot of pain, discomfort, and disability. And these patients now are occasionally confronted with that surgical valve that was placed a decade or so ago, now failing. When we see these patients, we are now able to actually offer them the Taver procedure as a way to treat the failing surgical valve so that these folks are spared having to go through a second to open heart surgery.

SPEAKER_03

It's really eye-opening for us how you can take a patient who has had to struggle to make it into our office from the front door of the building, and then you see them even seven days later, and they say, Can I go back and play pickleball? Like it's totally it can be totally life-changing for patients in a way that's really gratifying on the doctoring side.

Patient Outcomes And Recovery

SPEAKER_00

I've had patients before where the following day I go to check on them after their procedure and they're walking in the hallways at the nurses' station, chatting up the nurses, and already are feeling remarkably better. It's like a light switch for some patients. Now, that's not true for every person. It's important to remember that the symptoms of aortic stenosis are often fairly subtle, things like shortness of breath, decreased exercise tolerance. And in many of our patients who are elderly, they may have multiple reasons for those symptoms. But to the extent that the valve was the problem, the Taver procedure is almost like flipping a light switch and it alleviates all of the obstruction to blood flow and people can feel remarkably improved. And because the whole procedure is done through a half-inch incision over the hip bone, there's minimal discomfort afterwards. People are going upstairs, walking around, even just eight hours after the procedure.

SPEAKER_03

Yeah. If we go back to your original question, I remember very clearly, as Taver was being developed, and when we first had access to this technology, the device was not as small as it is now. And so there were patients who we knew needed something done, but the technology had not progressed to the point where this particular person was a candidate. And we had to say, you can't have this done safely. And that is now very rarely true. We have figured out ways to be able to do this in many more patients who need it, which gives people the opportunity to feel better much more commonly.

SPEAKER_00

The equipment at this point is about five millimeters across. And so if the patient has blood vessels about the size of my pinky finger, then we're able to successfully deliver the equipment. It has been a transformative technology that's undergone a tremendous evolution in a very short period of time and fundamentally changed how we care for 95% of elderly patients with this particular valve problem.

SPEAKER_02

Literally life-changing here in every possible way you could possibly mean that. What is setting Christiana Care's structural heart program apart from these other programs that are available out there?

Who Qualifies And Access Routes

SPEAKER_00

There are other programs in the state of Delaware who offer these procedures. However, the expertise and the integration of a multidisciplinary heart team at Christiana has allowed us to care for the sickest of the sick patients. So while smaller programs may feel comfortable with treating only the most straightforward of patients, we are able to offer patients these procedures, as Neil alluded to, through a variety of different access techniques. So patients who perhaps have blood vessel disease, peripheral arterial disease, which is relatively common in this population. We have the ability to do this procedure by using the blood vessels in the neck, the carotid arteries, the blood vessels under the collarbone, the subclavian, and even sometimes going directly through the aorta by making a tiny incision in the chest. These are just not options at smaller programs.

SPEAKER_03

Yeah, we are very committed to continuing to have the expertise to be able to treat all of these patients here at home. Our program has grown extensively over the last decade. We have recruited people like my colleague, Dr. Fender, sitting next to me, to bring world-class training to our community to be able to treat people at home. And so we're really committed to being able to do that in an expert way.

SPEAKER_00

And of course, folks who have these problems, they never occur in isolation, right? It's not that one valve is affected and every other piece of their heart is just fine. We often find that these patients have complex and multiple aspects of heart disease that could involve arterial blockages. It may include either reduced flow across the mitral valve or a leaking mitral valve or tricuspid valve problems in a way that other programs in our community are not. We offer a 360-degree comprehensive heart program that's able to address each aspect of their heart disease.

SPEAKER_01

Erin, you mentioned a number of different valves that I think most people listening aren't necessarily familiar with. If someone thinks they're having heart issues of any kind, where do they start? How do they get in the door at the heart and vascular center?

What Sets Christiana Care Apart

SPEAKER_00

We hope that many of our patients have established relationships with their primary care doctors. And so the symptoms of heart disease are often indistinguishable from other problems because they may present with issues like decreased exercise tolerance, feeling short of breath with exercise, or having chest pain or pressure, dizziness, lightheadedness. And there's a long list of other non-cardiac problems that could create those symptoms. So beginning with your primary care doctor is a good idea. However, many folks in their 50s, 60s, and 70s also prefer to regularly see a cardiologist, a general cardiologist, to ensure that their blood pressure, their cholesterol, these sort of issues are well managed. When I see a patient in the general cardiology clinic who describes to me these symptoms that are often difficult to pin down, we'll do basic testing like echocardiograms, EKGs, or a stress test. And those can help point us into the right direction. If a patient's been identified on one of those tests as having a heart valve as being responsible for the symptoms that they're complaining about, at that point they come and see Dr. Wimmer and myself, or one of our colleagues in the structural heart clinic to talk about what non-surgical options may be a good fit for them.

SPEAKER_03

Yeah. There's a lot of overlap in what people can experience and feel as patients with their own bodies. And it usually makes sense to see a general cardiologist first and then have the appropriate sort of expert level testing that a cardiologist would be able to perform to be able to point a particular patient in the direction of our program versus it could be a heart rhythm problem that you just have not identified yet. That is something that should be evaluated and treated by a different specialized program.

SPEAKER_00

And you'd asked earlier what sets Christiana apart from other programs. And I think one of the many things that sets us apart is that we offer every different subspecialty discipline within a single practice. So whether you have a problem with a weak heart muscle squeezing issue like ingestive heart failure, we have a team that is dedicated to treating those patients exclusively. We also have a team dedicated to heart rhythm problems, to interventional cardiology, which could be the treatment of blocked arteries, or as Neil in my case, the treatment of bad heart valves.

Getting In The Door For Care

SPEAKER_02

The progression of what you're working on at this point really sounds exponential, how quickly things have changed for you. And I doubt that's going to change anytime soon. So what are some of the trends and innovations that you're seeing coming down the pike that really have you the most excited for what you do?

SPEAKER_03

There has been a huge amount of change already. And one of the things that I think makes the two of us so excited is that there's still a huge amount of investment, both from physicians, from institutions that offer these treatments and from our partners in industry who develop some of the technologies alongside us. So we participate in some of that work. We have participated and are offering uh new technologies that aren't necessarily available for patients as part of research studies. And that is very exciting to us. We are sort of on the cutting edge of where the field is. But I think there's likely going to be much more change here in the next few years. We're very excited about the development of a mitral valve that can be put in through a similar kind of approach to what we're doing in the tricuspid valve or the aortic valve. I think we both think that that is likely right around the corner and will offer a lot more patients the opportunity to be treated without having to have more invasive procedures. And so that's the space I think that I'm most excited about.

The Next Wave Of Innovations

SPEAKER_00

As we're entering this sort of new era where we're treating now the tricuspid valve and soon to be the mitral valve, those are the two valves that separate the top heart chambers from the bottom heart chambers. The tricuspid valve separates the top chambers on the right side, and the mitral valve separates the top from the bottom on the left side. Historically, those were two of the valves that were the most challenging to treat surgically. Patients had a rocky postoperative course and sometimes clinically didn't respond as well to those interventions. So they were really tricky diseases to manage for us. And as a result, a lot of times patients, especially elderly patients, we tried to kind of temporize them with medications to the extent that we could, but we would delay or defer surgery because it was so difficult for the patients. Now we're on the verge of having an option to treat the mitral valve, having only just introduced therapies for the tricuspid valve within the last several months. So this is about to be another inflection point in the field of structural cardiology where the type of patient and the therapies that we can offer are going to completely disrupt the field the same way that Taver did over the last decade, where a decade ago, 5% of people got a Taver. Nowadays, 5% of people get an open surgical aortic valve replacement. I think that we're going to see a similar change in the next decade for both the mitral and tricuspid valve.

SPEAKER_03

Yeah, it's hard for patients to be on top of what's happening technologically and what we can offer. And so the best thing for patients to do is to maintain the relationship with their doctors so that as things develop, we can offer them what comes around. It's a different kind of thing as compared to say having patients like seek us out saying, I want to have X or Y. I think patients need to see their doctors and tell their doctors what they're experiencing. And it's otherwise impossible for people to stay on top of this themselves. The field is really changing very rapidly.

SPEAKER_01

Neil and Aaron, thank you so much for all of your information today. We hope to have you back as things progress to talk about your incredible work.

SPEAKER_03

Our pleasure. Thank you.

SPEAKER_01

Check out the show notes for this episode for more information on Christiana Care's structural heart program and the Center for Heart and Vascular Health.

SPEAKER_02

You can also keep up with For the Love of Health on social media. Just search Christiana Care on your favorite platform.

SPEAKER_01

We'll be back in two weeks with another great conversation.

SPEAKER_02

Until then, thanks for joining us for the love of health.

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Megan McGuriman

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