At age 58, Laura Hosking was unusually young to need a new aortic heart valve. But her situation was not typical. As a teenager, she had received treatment for late-stage Hodgkin’s lymphoma. After surgery to remove her spleen and part of her lung, Laura underwent three cycles of chemotherapy, followed by 12 weeks of full-body radiation from the back of her skull to her groin, and three more cycles of chemotherapy. By Christmas of her sophomore year in college, she was cured. But the barrage of treatments necessary to save her life left a legacy on her internal organs.
Laura began to feel the late-term effects of her radiation treatment when she was in her 40s. A finance professional and mother of three, she began to tire easily. Walking and carrying groceries made her short of breath. She could no longer play golf, or spend her days volunteering with the sick and the poor. One by one, Laura had to stop the activities that gave her life meaning.
As her condition worsened, Laura sought the help of Stanford Medicine cardiologist Randall Vagelos, MD. She was suffering from aortic stenosis, a narrowing of the aortic valve opening that resulted in restricted blood flow. Her health was further compromised by the discovery in 2013 of lung cancer, which was brought under control with a combination of CyberKnife radiotherapy and localized surgery.
Facing progressive valve disease and a cancer diagnosis, Laura searched for a primary care physician to help navigate her care. Megan Mahoney, MD, was her choice.
“I think Laura came to see me because she knew she needed a captain for her care,” said Mahoney, chief of general primary care for Stanford Health Care. Mahoney works collaboratively with all of Laura’s specialists to monitor and coordinate her care. “At Stanford, we provide world-renowned care,” said Mahoney. “But we also need to hold the patient’s hand and walk them through their medical journey.”
A complex medical history
As Vagelos watched his once vibrant patient became more and more limited in what she could do, he knew it was time to intervene. Given her complex medical history, Vagelos was concerned she might not tolerate open-heart surgery to repair her valve. He conferred with colleagues William Fearon, MD, an interventional cardiologist and Michael Fischbein, MD, PhD, a cardiothoracic surgeon. All were in agreement that a non-surgical approach to her valve repair would be her best option. They suggested Laura undergo a relatively new, minimally invasive heart-valve procedure known as transcatheter aortic valve replacement, or TAVR.
“An open surgical approach to valve replacement in a patient so young is still the gold standard because a mechanical prosthetic valve can last a lifetime,” said Vagelos, professor of cardiovascular medicine. “But the global damage to her chest from childhood radiation made a non-open surgical approach to her aortic valve disease more attractive.”
In a traditional aortic valve procedure, surgeons open the chest and use a heart-lung bypass machine to temporarily stop the heart, then remove the damaged valve and replace it with a new one. With TAVR, the new valve is compressed inside a thin catheter, which is inserted into a blood vessel in the leg, then threaded up through the aorta and into the heart. The new valve then is released from the catheter and expanded with a balloon. Once in place, it begins working immediately.
The TAVR procedure is considered by many in the field to be a game changer. It was approved by the Food and Drug Administration in 2012 for use in patients who, like Laura, are considered at high risk of complications or death from open-heart surgery.
“The main advantage of TAVR is the fact that it’s less invasive,” said Fischbein, associate professor of cardiothoracic surgery. “We avoid opening the patient’s chest and placing them on cardiopulmonary bypass, which allows for a quicker recovery.”
Patients usually recover after two or three days in the hospital, compared with five to seven days for open-heart surgery. Laura, who was younger than a typical TAVR patient, recovered even more quickly. She was walking and talking the day after her procedure, which took place in January 2017, and was back home within two days.
‘TAVR gave me back my life’
“TAVR gave me back my life in an immediate and profound way,” Laura said. Today, she is able to play golf, clock 10,000 steps a day and volunteer again. She continues to see her team at Stanford Health Care to monitor her heart valve and her lungs, and checks in regularly with her “captain” Dr. Mahoney.
“She can live life again,” said her husband Doug, who said he was most appreciative of how the Stanford medical team cared for his wife. “They would look at her as a person,” he said. “They all had different specialties, and different things they were focused on, but at the top of their list was caring about her.”
Stanford Medicine doctors have performed more than 1,000 transcatheter aortic valve replacements. The Stanford TAVR program was the first in Northern California, and Stanford remains one of only three hospitals in the region to perform the procedure. Stanford Medicine physicians were involved in the development of the procedure, and continue to study its use in different patient populations.
“We now perform approximately six TAVR cases per week,” said Fearon, a professor of cardiovascular medicine who performed Laura’s TAVR procedure. “We are treating intermediate and high-risk patients and have an ongoing trial randomizing low-risk patients to TAVR or open surgical aortic valve replacement.” The Stanford team is also studying the use of TAVR for aortic stenosis patients at all risk levels who have no symptoms.
“If it wasn’t for Stanford, I don’t think I’d have the confidence in my own future. Stanford gives me such hope,” said Laura. “I don’t know what’s going to happen with my health, but I know where I’ll go for help.”