Heart valve surgeon providing patients with innovative options

Facing major heart surgery, the worst-case scenarios kept bubbling up.

Chris Pagano faced surgery to fix a leaking aortic valve in early January. The New Whiteland resident had blood pumping back into his heart, putting him at risk for heart failure. Though he had confidence in his surgical team, he couldn’t help but consider what would happen to his wife Kari and 8-year-old daughter, Kinley, if the procedure went poorly.

But as the day of the surgery approached, the anxiety seemed to melt away.

"Walking in the morning of, it was a little nerve-wracking, but I had the comfort that I had one of the best doctors not only in the country, but probably the world to repair my valve. I’d wake up from this and focus on recovery," he said.

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Pagano was the patient of Dr. Marc Gerdisch, chief of cardiovascular and thoracic surgery and co-director of the Heart Valve Center at Franciscan Health Indianapolis. Through Gerdisch’s leadership, the heart center has become one of the most innovative in the world, proving to be on the forefront of new ways to repair damaged heart valves to ensure patients have longer and healthier lives.

For Gerdisch, the ability to help patients using new medical discoveries is incredibly rewarding.

"I feel like I’m providing patients a genuinely new opportunity that didn’t exist before," he said. "They get to choose from all of the options we talk about, and I love being able to expand out that conversation. I really enjoy having them engaged in the decision-making, so they feel like they’re empowered to have access to the most advanced techniques."

The list of innovations that Gerdisch has introduced at Franciscan Health Indianapolis is lengthy.

During the last 21 years, he has performed more than 5,000 innovative surgical procedures, of which 3,750 involved heart valve operations. He has worked on procedures that would allow him to rebuild the entirety of the valve’s leaflets to help patients with extremely damaged valves.

He led enrollment in a study demonstrating that a newly designed mechanical valve replacement could be managed with a lower dose of blood thinner. In 2018, he and his team was the first in the world to use a robotic arm that would more precisely position the device used to expose the heart valve in surgery.

Most recently, Gerdisch was chosen to be part of a national clinical trial, becoming the first surgeon to regrow damaged tricuspid valves, which prevents the backflow of blood from different chambers of the heart. The device uses extracellular matrix as a support, which enables patients’ own cells to infiltrate the structure of the tricuspid valve. Over time, naturally growing cells remodel to become a fully functioning valve.

The trial and tests of the early-stage clinical study are ongoing, but the initial results have been promising, Gerdisch said.

But one of the most exciting innovations has been in aortic valve repair. He has been able to implant a fabric-covered frame — about the diameter of your index finger — that strengthens the internal structure of the aortic heart valve.

The aortic valve regulates blood from the left ventricle, the primary pumping chamber of the heart, and the body’s main artery called the aorta. The valves have tiny leaflets, which when working properly, keep the blood moving correctly in and out of the heart.

In some patients whose valves have become weakened and don’t line up the right way and have blood rushing backwards into the heart, which can lead to heart failure and other potentially deadly conditions.

"Leaking aortic valves are the ones we can repair. The reason for that is we need to be able to reorient the leaflets of the valve with respect to their geometry, to get them in position to start working again," Gerdisch said. "The changes those valves go through and the ulceration of the leaflets those go through makes it very difficult to do free-hand."

In the past, aortic heart valve repair was rarely done, Gerdisch said. The procedures had been done, but the circumstances had to line up perfectly for it to be a benefit to the patient.

"If you look at it nationally, even in centers that are identified as the hubs of aortic valve repair, the likelihood of having your heart valve repair was low," Gerdisch said.

Creation of the valve repair device was spearheaded by Dr. Scott Rankin, an accomplished cardiothoracic surgeon specializing in the heart valve. His vision was to develop a better option for patients with aortic valve disease than what was previously available. The device is a geometric ring that is located around the damaged valve to help those leaflets again reach the proper orientation.

By strengthening the internal structure of the valve, giving it the correct shape so that the surgeon can make tiny repairs to the valve so it opens and closes correctly.

Rankin helped train Gerdisch, and the two have worked together closely on training surgeons to be able to complete the procedure.

"He is the guy who trained me, and who came to my operating room and spent time with me doing these. When I first started, he came and we did five valve repairs in three days. That was a great run there," Gerdisch said.

Heart valve repair and reconstruction is preferred to biological and mechanical valve replacement, because patients have better recovery and fewer complications. They don’t have to take blood thinners for the rest of their lives, as they would with a mechanical valve. Valve replacements improve the patient’s heart function, but it carries with it the risk of stroke that they didn’t have before, Gerdisch said.

"(The replacement) is a foreign body. It doesn’t matter what kind of valve we put in, it doesn’t matter if it’s a tissue valve or a mechanical valve. It gives them a long-term risk of stroke that is related to the valve itself," he said. "The longer I can keep a person from needing to replace their valve, the shorter time they’re exposed to that risk."

That was a choice that Pagano, 47, had to make.

In 2007, he was diagnosed with atrial fibrillation, a quivering or irregular heartbeat. Doctors found that his aortic valve was leaking blood back into the heart slightly. His cardiologist at the time suggested monitoring the heart using echocardiograms, making sure the valve wasn’t deteriorating or dilating.

Once it reached a certain point, they could explore surgery to repair or replace it.

For about a decade Pagano’s heart function remained stable. But early last year, the gap in the valve structure had grown larger. His cardiologist, Dr. Carl Rouch, suggested that he speak with Gerdisch to see if he’d be a candidate for this new type of valve repair.

"Instead of getting (the valve) replaced, we could get it repaired. From everything I had read and been told, that’s the best case scenario to keep your own valve," he said. "I didn’t want to be on blood thinners or get a mechanical valve if I didn’t have to."

Gerdisch met with Pagano, outlined his options, explaining that he thought he could repair the valve, but if not, it could be replaced with mechanical. He gave Pagano the choice of what he wanted to do.

After consideration, he decided to try the repair procedure. Surgery was scheduled for January, and went perfectly. Pagano has been slowly recovering since, starting cardiovascular rehabilitation and gradually implementing light exercise into his routine.

As of this week, he had progressed enough that he was finished with rehab.

"Usually you do 36 sessions, but after my 20th one, the nurse said I was doing so well it wasn’t necessary for me to do any more, as long as I continue exercising at home," he said. "I feel like I have more energy, I feel so much better than I did. I’m so thankful I’m still here."

Gerdisch has been pleased that not only has the surgery been so successful, but that patients such as Pagano are empowered with another option to improve their health.

"It’s really kind of a beautiful thing, because now we can provide on a regular basis some of these options that carry considerably less risk for them, no matter how it fits into their long-term outcomes, and redefines the way we manage those valves, especially in young people," Gerdisch said.