57 – Understanding Heart Disease w/ Cardiac Surgery Dr. Seenu Reddy

Marcus: [00:00:00] If you enjoy this content, please take a moment to rate and review it. Your feedback will greatly impact our ability to reach more people. Thank you. Thanks for joining me on Sunday afternoon, Dr. Reddy. I appreciate it. So, I guess, um, I am wanting to learn more about heart disease, and so we’re gonna have a couple different, uh, guests in to Health Further to really help our audience understand it’s a leading killer in America.

Marcus: Still. After all these years. And you are a cardiac surgeon. You’ve been practicing in cardiac medicine for how long? Over 20 years now. Over 20 years. You’re only 25 years old. And so the hope on this, uh, kind of deep dive guest session with Health Further is Begin to dig into what is heart disease, how do we, uh, treat it, how does it, how does it build up in our body, what can we learn about it to help take care of ourselves and our loved ones, and then also a little bit of how medicine treats heart disease.

Marcus: Today and some [00:01:00] of the new advancements and where we’re headed maybe. Absolutely.

Marcus: Before we get started, just tell me a little bit about how you got interested in medicine and specifically cardiac care and uh, how did you decide to enter the business?

Seenu Reddy: Well, uh, I come from what I would say is a medical family. I’m very, um, fortunate to have, uh, a lot of, uh, My, uh, well, not just my parents, but so many aunts and uncles, I think we’ve counted up, last tally, over 26 physicians in my family.

Seenu Reddy: Yeah. My sister’s a pediatric cardiologist, uh, both my parents were physicians, my dad’s brother, my mother’s nephews, but anyway, we Yeah, so it’s, it’s in the, in the family. It’s definitely in the blood. Yeah. But, uh, you know, really, I did chart my own course, but I think one of the seminal moments I remember was as a young kid, and my dad was a pediatrician, um, And, uh, one time going to the ER and watching him sew up [00:02:00] a kid who had had a pretty big laceration and although I liked the medical stuff that he was doing in the office, to me that was really cool to see the immediate results that surgery could have, a surgical like procedure.

Seenu Reddy: So that sparked my interest and then certainly summers, uh, I was very fortunate to grow up in Alabama where, uh, Um, Ironically, one of the top heart centers in the world existed. In 19, uh, 66, uh, a surgeon by the name of John Kirkland left the Mayo Clinic and founded a heart surgery program in Alabama and put it on the map.

Seenu Reddy: And some of the world’s leading surgeons were trained there. And so as a high school student, I had a chance to do some work in the lab there and work in the cardiology department there. Wow, that’s pretty

Marcus: cool in high school. Yeah, and I saw the, I

Seenu Reddy: saw the development of echocardiography, cardiac MRI, So really, uh, it was fascinating, uh, to see all of that develop.

Seenu Reddy: I then, kind of during college time, did some other things, uh, was actually, actually did some work in the consulting world and investment banking, but always I had that tug back towards medicine. Um, when I went back towards medicine, I, I [00:03:00] was really, uh, attracted to the cardiovascular system because to me it seemed a lot of exciting developments going on there, innovation going on there.

Seenu Reddy: But then I also never, um, will forget the first time to see a beating heart and the fact that you could actually work on an organ that moved because most of the other organs in our body kind of sit still. But this was an organ that was in motion. And that was really fascinating that you could work on the beating heart or you could stop it, work on it, get it restarted.

Seenu Reddy: And then that began a very long journey. It took me, you know, after high school, 18 and a half years of training to become a heart

Marcus: surgeon. Um, it’s, it’s a long time. That’s incredible. So you graduate high school. Let’s say you know you want to be a heart surgeon. You have 18 years in front of you. So typically

Seenu Reddy: four years of

Marcus: college,

Seenu Reddy: right?

Seenu Reddy: Four years of medical school. Then I did seven years of residency, including two years in the laboratory, just studying general surgery and cardiovascular physiology. And then after that period, I spent another three years. Uh, of residency and fellowship training in cardiac surgery. Yeah. And then another six [00:04:00] months in some specialized areas that we’ll talk about a little later.

Marcus: Yeah. Wow. So, so after 18 years, then you are out and now you start practicing. Then you become a full fledged cardiac surgeon,

Seenu Reddy: but you never really stop learning. Yeah. Right. Uh, one of the, uh, Great, uh, challenges that, uh, one of my professors at Emory gave me, Robert Guyton, is learn a new procedure or technique or concept every year of your career.

Seenu Reddy: Hmm. Interesting. And we, we have certainly done that. Yeah. And, and you have to do that because the way medicine and science evolve.

Marcus: Yeah. I think that’s why they call it the practice of medicine, right? You’re never, it’s never going to be perfected. You’re always getting better and making improvements.

Marcus: Maybe making it a faster recovery for the patient or less risk for the patient.

Seenu Reddy: Yeah, that’s an area that I’ve really spent this last several years of my life focusing on in my career is what’s called enhanced recovery after surgery. We all recognize that surgery is a kind of trauma on the body, and so we’re trying to figure out, uh, better pathways of care and better techniques to enhance that

Marcus: recovery.

Marcus: Yeah, excellent. And then you’ve been practicing at HCA for, uh, A dozen years, [00:05:00] a little over a dozen years,

Seenu Reddy: yeah. Came back to Nashville after a period of time on faculty and doing things in an academic medical arena. Yeah. came back, uh, here to Nashville and joined a really premier cardiovascular institute at, at TriStar Centennial.

Seenu Reddy: And it’s been a great, uh, privilege to work with the many talented people there. Yeah.

Marcus: Great. I’m, I’m a patient of Dr. Riddick there. So I’m patient. One of my close colleagues. Yeah. Excellent. So I think, uh, how I want to start this is to really just lay the groundwork for, for what is heart disease? How does it progress?

Marcus: in the human body. I think often it can start fairly young, uh, with osteoarthrosis, probably saying that wrong. Yeah, no, that’s, um, and so I have a couple images I want to get you to comment on for us here. As you’re pulling that up, let’s

Seenu Reddy: just remind everyone in the audience, as Vic pointed out, you know, heart disease is the number one killer of, of Americans and really of, of, uh, Humanity worldwide, but the other points are that there are three [00:06:00] broad buckets of heart disease, maybe four.

Seenu Reddy: One is you have can ailments of the electrical system, and we, you know, there’s the whole world of atrial fibrillation and other ailments of the electrical system. There’s problems with valve disease that we can talk a little bit about, but as you point out, what we’re looking at here is the most common heart disease.

Seenu Reddy: ailment, and it does begin many times, uh, early in life. We’ve seen it begin as early as adolescence.

Marcus: Yeah. Yeah. So, um, due to, uh, maybe somewhat poor diet, or any, lots of just living, You could have inflammation and, um, slight issues with your, um, with your veins, arteries, all your cardiovascular system.

Seenu Reddy: Yeah, the vasculature, really.

Seenu Reddy: So,

Marcus: what are we looking at here?

Seenu Reddy: This is, this is an artery. So, I think the first thing to understand is, is let’s talk about what are the modifiable and non modifiable risk factors, right? Certain things just affect your risk of [00:07:00] developing what Vic is showing you here, which is atherosclerosis. And atherosclerosis is the disease of blood vessels.

Seenu Reddy: Uh, the non modifiable ones are the ones that unfortunately, we’re all given when we’re born, right? It’s the gene. It’s the genetic imprint. It’s kind of what I call the circuit board. And then the modifiable risk factors are the things that are the breakers that you flip on that circuit boards and then activate You What you see here is that inflammatory cascade and that what I would, uh, tell you is that in our modern day of living that inflammation abounds and it can be triggered by many things.

Seenu Reddy: One thing that we often focus on is diet, but it can also be caused from stress. It can be caused from hypertension, you know, elevated pressure in the vessels, uh, and, and many other secondary causes. But as you point out, once the inflammation starts. It’s causing injury, damage, uh, to the lining of the vessel.

Seenu Reddy: All blood vessels, as this picture shows here, are made up of three basic layers. There’s the intima, which is the inner layer, the media, which is the muscular [00:08:00] middle layer, and then there’s the adventitia, kind of the outer layer. Uh, layer. So, of course, we’re talking about the most inner layer. Once that gets damaged by the inflammatory cascade, then it starts a series of Yeah, so the blood, of

Marcus: course, is flowing through the middle part and it’s right next to the inner layer.

Marcus: What was the name of the inner layer? It’s the lining, the intima. Intima. And that one and then the middle one is where the inflammation can grow into plaques, I think. That’s right. Okay. So

Seenu Reddy: I think in this next picture, we’ll see that over time, and like I said, we have picked this up in, in studies in vessels of even, uh, older adolescents, the very beginning of the layering of these plaques, and the plaques are typically comprised of, uh, cholesterol, calcium, and magnesium.

Seenu Reddy: And white blood cells, these all come together and there are many other compounds and reactions going on here. But that’s the biggest thing that happens is the, there’s some damage done to that intimal layer. The damage then [00:09:00] results in the laying down of, as you pointed out, some plaque, uh,

Marcus: in the wall.

Marcus: And my understanding is it’s, it’s um, like a lot of things in healthcare, it is a reaction to the inflammation, to the slight damage. The plaque actually repairs the The strength and sort of make sure that the structure is okay, but if you have too many of them, then it can become really problematic or too thick or too thick of one.

Marcus: So,

Seenu Reddy: yeah, just like when you break your bone, you have a formation of a callus. It’s a kind of a thicker bone around the fracture site. As Vic’s pointing out, if you have some small damage to the inner layer, the intima. You may have some plaque laid down so the damage doesn’t go through the entire wall of the vessel, but if that plaque now, the inflammation continues and becomes thicker and thicker, or you have things like high blood pressure or other things that are affecting that plaque, the plaque will start into hypertrophy or grow larger.

Marcus: Yeah.

Seenu Reddy: And that’s when the trouble starts, right? Because you can see there’s a reduction in the lumen or the [00:10:00] size of that blood vessel. Yeah,

Marcus: you can’t, I mean, from, not everyone will be watching the video, but It’s significantly, maybe it’s half as wide where those two plaques have, have grown up. And so it’s a lot less blood can get through that one little area.

Seenu Reddy: And we’ll see it in the next slide with the cross section, but what’s amazing in our bodies is we can live with 50 percent reductions many times. It’s really when it gets to a 70 percent reduction across sectional area is when people start developing symptoms. So we can almost compensate for blockages of up to 50%.

Seenu Reddy: And in fact, the general teaching has been, whether myself as a surgeon, um, or a cardiologist, whether they’re putting stents in these blockages, or I’m doing bypass, we found that bypassing or stenting arteries less than 50 percent really doesn’t have any impact on outcome. With the

Marcus: risk, it’s not worth it.

Marcus: Yeah, the risk outweighs the benefits. You’re exactly right. Okay, so here we’re looking at, I think, the thrombus, which is [00:11:00] a break off of the little piece of the plaque kind of breaks off, and then it’s floating down through the blood stream. And can be a real dangerous for stroke, heart attack, lots of other issues.

Marcus: That’s right.

Seenu Reddy: So if the little piece goes floating and goes into a small end artery, it’ll block the entire artery and can result in some real disastrous outcomes for the area of that vessel is supplying. The other thing is, stable plaque, you might produce stable symptoms. Meaning, you got a 60 70 percent blockage.

Seenu Reddy: You notice when you’re, Exerting yourself, you just don’t have the same get up and go and oomph that you used to have. That, a lot of people live with. They live with these 50, 60, 70 percent blockages. However, as you said, when there’s a plaque rupture, that’s a sudden event. And now you can go from a 60 percent blockage to a 100 percent blockage because that piece of plaque could go downstream and block off this narrowed part of the artery.

Seenu Reddy: Or it can cause a certain [00:12:00] inflammatory cascade to occur and you get thrombus forming, and you have a blood clot now inside the middle of an already narrowed artery. Yeah. And now you have zero blood flow going to the far side of that artery, and that’s your heart attack. I mean, it’s literally like a,

Marcus: uh, in a stream, if a big log breaks off from a pack of other wood and flows down, it might get, Lodged in somewhere that is a really fast part of the stream.

Marcus: Completely disrupts the water flow. You’re right. And so the same thing’s happening, but it’s inside your body with your, with the blood. So then obviously oxygen can’t get to that part of the body, whatever it’s being blocked off. Yeah, that’s right. Because

Seenu Reddy: blood’s main purpose is to deliver oxygen and remove carbon dioxide.

Seenu Reddy: And that whole process comes to a screeching halt. And that is literally what a myocardial infarction is, or MI, or heart attack.

Marcus: Yeah.

Seenu Reddy: That’s, that’s the acute event, is the heart attack.

Marcus: Yeah, and so, the, a heart attack would be, there is a thrombus or, or piece of the plaque broken off and then it goes into the heart and causes trouble in the heart, for the heart itself to get [00:13:00] blood to flow.

Marcus: Yeah,

Seenu Reddy: or the plaque could just, it could be a little cap sitting here and that plaque ruptures, nothing has to really break off, but it exposes a raw area. And then suddenly platelets and thrombus and it just clogs the entire whole thing.

Marcus: Yeah,

Seenu Reddy: that’s right. That’s the number three that you have there called plaque rupture resulting in thrombus.

Seenu Reddy: Right. Remember in the stable situation, when you have the blockage, just the narrowing, you get angina. And angina or angina is that sensation of chest pressure, chest tightness, arm, neck, and jaw pain. that you may have with exertion and activities. That’s the chronic, relatively stable condition. The sudden onset of jaw, neck, arm pain or sudden onset of chest pain is typically the acute plaque rupture event that you see here at number three.

Marcus: Okay. Okay. So then the cross section here Yeah, this really shows

Seenu Reddy: you what a normal artery should look like. A nice big tube with no disease in it. Over time, you get progression of that. You get development of some plaque formation. You might get a cholesterol cap. Okay. They can have a little rupture, [00:14:00] these little loose pieces can then attract platelets, and then you get the blood clot now either narrowing the artery to 90 percent or 100%.

Marcus: Yeah, that’s when you, so the body can withstand 20, 30, 40, even 50 percent blockage. Pretty well. But as you build it up, you’re now getting risk for these other larger events more and more around your body. Right. The more stable plaques you have, the more risk there is that something will

Seenu Reddy: happen.

Seenu Reddy: Eventually happen. In most cases, they progress. There are very few Studies that have been shown to be able to regress plaques, there are, there’s some very, you know, uh, advanced diets. There’s been one diet that’s been shown, but it’s very difficult, plant based diet that most people can’t adhere to.

Seenu Reddy: There’ve been some medications that over time may stabilize plaques like your typical statins and even reverse some of this, uh, coronary disease. But in general, it’s a progressive problem. Um, and that’s why it’s insidious, because as you build up plaque, a lot of people may choose to, you know, just to do [00:15:00] less activity so as not to get the sensation of that angina.

Seenu Reddy: So they’re living with it and they have advanced disease, but they say, oh, do you have any problems, doc? They go, no.

Marcus: Yeah, but they, they’re not able to exercise like they were previously. That’s right. So their whole cardiovascular system gets weaker and weaker over time.

Seenu Reddy: And that’s the, that’s the insidious thing when you ask people, that’s why I always ask the question, are you as active as you were six months a year ago?

Seenu Reddy: Well, no, doc, I figured I was getting older. Well, you get older over like five year periods, right? You know, I can’t do what I did in my 30s and my 20s or my 40s when I did my 30s. But if something’s changed where you can’t mow your yard this summer and you were mowing it last summer, you gotta start thinking really about something else.

Marcus: As we have this, um, chronic disease progressing, there’s several, uh, negative things that could happen. For sure. So I just threw up this picture to, to, to prompt you on some different ideas of where, what, like, how would this manifest in a patient for you or in centennial with a cardiologist or something else?

Seenu Reddy: [00:16:00] Yeah, I think an important concept to remember is atherosclerotic disease or that whole process in these arteries, although we see it most commonly in the heart, right? Yeah. can certainly affect any of the vasculature in our body. So let’s say it affects the arteries in your legs, going down to your legs.

Seenu Reddy: You might find what’s called claudication. That’s when you walk and you get cramps in your legs and your thighs. And that should give you an alert that, wait, I may have blockages in my leg arteries. You may have it where you get, this is much more infrequent, but if you get a lot of abdominal pain after eating, you may actually have blockages in some of the arteries that feed your intestines.

Seenu Reddy: Uh, if you, uh, have problems with, uh, angina, we talked about that, especially cardiovascular, but if you’re getting small mini strokes, Or you’re, you’ve had a stroke, well, by definition, you must have blockages either in the carotid arteries in your neck or in those smaller arteries that go into the brain.

Seenu Reddy: Yeah. So really, this process can occur to any of the arterial systems.

Marcus: Yeah. Really, anywhere that is A critical part of the body that doesn’t get blood is going to have a [00:17:00] problem. That’s right.

Seenu Reddy: In fact, one cause of high blood pressure is when you develop narrowing of the arteries that go to the kidneys.

Seenu Reddy: It fools the kidneys into thinking that your blood pressure is low because the blood getting to the kidney is going to that narrowed artery. So that’s called renal vascular hypertension. So the kidney secretes more and more of this enzyme to raise your blood pressure. Yeah. Thinking the blood pressure it’s seeing is low.

Seenu Reddy: So you run into this cascade of high blood pressure due to the kidney, uh, trying to raise your body’s pressure. Yeah.

Marcus: Okay. Um, now let’s talk about what the different roles in the healthcare system. So you’re a cardiac surgeon. Right. And there’s another role called a cardiologist. There might be other ones too, but what, what, how should the audience think?

Marcus: How should I think about the differences between those? those roles. And often they work together, I think.

Seenu Reddy: Absolutely. I think more and more in the modern era, we’re working very close together, more closely than ever. I think the way you should think about it is a little bit of how you navigate the health system.

Seenu Reddy: All of us should have some kind of primary [00:18:00] care physician who’s taking care of all of our systems. But if the problem or the complexity of the needs of one organ system get to be more demanding, in this case you’re talking about the cardiovascular system, then you would seek out the care of a specialist.

Seenu Reddy: As we talked about, if it’s a rhythm problem, there may be a specialized cardiologist, an electrophysiologist.

Marcus: Yeah, so

Seenu Reddy: the rhythm

Marcus: would be the, the electrical signals keeping the heart Uh, beating in the right, um, in the right rhythm. Yeah,

Seenu Reddy: absolutely. So problems like atrial fibrillation or supraventricular tachycardia or any sort of like what people would call, I’m having palpitations or arrhythmias, may be sorted out and best treated by an EP, electrophysiological cardiologist.

Seenu Reddy: The other problem, maybe we’ll talk a little bit about this a little later, is heart failure. There are cardiologists that specialize in heart failure. And then there are good general cardiologists that may be specialists in treating the high blood pressure or low blood pressure. And then you have what are called structural cardiologists and interventional cardiologists that now use, you know, [00:19:00] advanced devices and tools and techniques to treat those blockages and heart arteries and heart valves and In some cases when they can’t be treated by those more minimally invasive or less invasive techniques Then you have the role of the heart surgeon We typically are trained and have expertise in the open or surgical repair of many of the heart ailments So the typical procedures I would perform would be bypass surgery to bypass those blockages, heart valve repair replacement to fix the heart system, and in some cases, even ablation procedures to fix, uh, rhythm problems, and then certainly the repair of holes and other defects in the heart that one may be born with or have developed over time.

Marcus: Okay, so just to recap, the, the cardiologists, and there are a couple of different types, EP structural, but the cardiologist is the ones that

Seenu Reddy: specialize in

Marcus: making pictures

Seenu Reddy: of the

Marcus: heart that class of Doctors they are treating patients with with medicines or they’re treating [00:20:00] Intervenously is through their veins and arteries and arteries as opposed to a cardiac surgeon Where now you’re putting the patient under there in the operating room, right?

Marcus: And often you’re putting the patient on the heart lung machine, stopping the heart, and actually opening them up, like we would imagine a classical surgical procedure. That’s right. Cardiologist does not do that, typically. No. They would be working through the vein or artery. Correct. And they have a, uh, I think it was like a wire, like a guiding wire and the catheters and they go and they can do a lot of work because they’re working balloons on the cardiovascular system, you can, you can get a lot of access through the veins and arteries.

Marcus: Exactly. And that’s where they’re working. They’re putting a stent in or. Whatever is required. That’s right.

Seenu Reddy: And they’ve been very successful in treating many, many aspects of heart disease through those techniques. Yeah. Um, but what we’ve learned through the years is there are some cardiac conditions that are better treated [00:21:00] initially with those techniques, but there’s a whole host of other things that are treated better initially with surgery.

Seenu Reddy: Mm hmm. And then there are even those procedures we’re now developing that are treated with a combination of both. Yeah. And those are called hybrid procedures.

Marcus: Yeah. And so, um, let’s talk about why the valve system. So I guess the, there’s several valves in the heart. Yes. And the heart has four chambers.

Marcus: There’s a valve. Four valves. Four for, between each one. Mm hmm. And it, the valves have to open and close exactly at the right time and seamlessly so that the blood can go through, but then it, they stop the blood from backflowing. That’s right. And it allows the chamber then to fill up for the next, the next cycle, the next cycle.

Marcus: And so if the valves are not functioning, not opening correctly, not closing correctly, that can be a significant problem. So there’s, there’s, I think you said there are three major classes of problems. That’s the [00:22:00] The electronic wave, like, is the heart beating correctly? There’s the valve, some of the valves, one or more of the valves are not working correctly.

Marcus: Right. And then there’s the arthrosclerosis, the, uh, thing we started with. Yeah. With the veins deteriorating. The arteries, the blocked arteries, yeah. Yeah, yeah. And so, let’s talk about the valve, uh, replacement. And I want to talk about the traditional one first. I have this little video here. Oh,

Seenu Reddy: great. So I think what this video is really trying to depict is here you see a rib cage, you see the beating heart.

Seenu Reddy: And you see kind of a line in the middle through the sternum. This is the sternum here.

Marcus: Yeah.

Seenu Reddy: And really, what we do as a heart surgeon is, you know, we, you hear this terrible term called, we’re gonna crack the chest open. We don’t crack anything open. The ribs are left intact. We make a surgical incision through the sternum.

Seenu Reddy: But you do, uh, cut through the sternum. The sternum. Yeah. We make a surgical incision through the sternum. And that gives us full exposure to the heart and keep letting it play through. What, what a misconception a lot of people have is that when you do get into the heart, the heart’s sitting right there.

Seenu Reddy: No, [00:23:00] it’s sitting in a sack that they showed just a second ago. We open the heart sack. Then we use a series of catheters or tubes or what we call cannulas to connect to the heart. arteries and veins. And this lets us put the heart on the heart lung machine. So now we have connected the heart in this picture to the heart lung machine.

Marcus: Yeah. So that’s a machine in the operating room. Correct. But it is going to perform the action of moving the blood through the body. So the heart can Two

Seenu Reddy: things it’s going to do, right? It’s going to pump blood through the body and keep the pressure and the perfusion, the kidneys, the brain, the liver, All of that’s still going to have blood flowing to it.

Seenu Reddy: The only organ that will not have blood flowing to it would be the heart. The second thing it allows us to do is also stop the heart. Because now we will give a special solution to the heart to rest the heart. So you want to continue. It shows it going from a beating state, uh, right here. But we’ve got to work on either these [00:24:00] arteries or the heart.

Seenu Reddy: Yeah, so now they’ve stopped it, right. So we’ve stopped it by giving a special solution. That allows us now to access the structures inside the heart, like this diseased heart valve, by making incisions into the blood vessels. So let’s talk about this valve

Marcus: right here. It looks to me like it’s not fully closed.

Marcus: That’s right. So this valve is mis malfunctioning. Yeah, right, yeah. And so it doesn’t, in this case, maybe it doesn’t close all the way.

Seenu Reddy: And it’s probably not going to open all the way, so it’s become very stiff and dysfunctional. And I think you have another video that probably shows a lot more on that heart valve.

Seenu Reddy: Yeah. But this allows me to access the heart valve. The still heart also allows me to access the arteries on the surface of the heart. Yeah. You saw at the end of that video, they were about to implant a surgical heart valve. And we would take a series of sutures, uh, as you see here. Yeah. And now we’re putting in a brand new heart valve and replacing the one you pointed out was diseased.

Seenu Reddy: Okay. So,

Marcus: Let’s talk about this image. The valve is being placed in there. Mm hmm. And is [00:25:00] it, how big is it? Is it the size of a quarter? Is it nine? Between a quarter and a half dollar. Between a

Seenu Reddy: quarter and a half dollar size. It’s typically a valve that’s mounted on a fabric and metal or plastic stent. And the leaflets are comprised of either Cow or pig tissue.

Seenu Reddy: So most commonly we’re bringing in The leaflets are the part

Marcus: inside the valve that are opening and closing. Yeah. Right.

Seenu Reddy: Now, in some cases, we could replace in a young person, if we want to avoid any future operations, what we call a mechanical heart valve. And these are leaflets made out of pyrolyte carbon that are harder than steel, and open kind of like a flapper valve.

Seenu Reddy: Now, the advantage of those valves is they never wear out, whereas a cow or a pig valve eventually will wear out. Okay. Yeah. But the advantage of those flapper valves, they never wear out. The disadvantage is you got to keep them lubricated just like your valves in your car. So like you put oil in your car, you’ve got to take a special medication or blood thinner called Coumadin or Warfarin.

Seenu Reddy: So now the rest of your life, you have to take a blood thinner or an oil to lubricate that valve. And a lot of patients don’t find that, [00:26:00] that want to do that.

Marcus: Okay, and then the valve, does the valve come with the sutures already queued up like that?

Seenu Reddy: No, we, we, that’s the Did you do that ahead of time? We do it right after we cut out the valve.

Seenu Reddy: So we cut out the old valve, we put in the sutures into the patient’s body, and then we pass those same sutures through the new valve. Okay. And then we, we call, we call seat the valve.

Marcus: Yeah. So like here And then secure it. The sutures have been put into the body first. Then they’ve been put in through the valve.

Marcus: And then you sort of like push it down along the sutures. And then tie it in. Yeah. Lock

Seenu Reddy: it in place.

Marcus: Yeah, interesting. So, so your technique is to put all those sutures in the right spaces around the The annulus it’s called. The annulus. And then, um, then you can do the valve a little bit away and then push it into the exact right place.

Marcus: That’s right. Yeah. Okay. So that is a valve replacement done through an open procedure. Yes. Just like we talked about in the beginning. And that’s been [00:27:00] done for Over 55 years. Yeah, for a long time. But you, you and Others started working on trying to do this minimally invasively. And I want you to talk through that so I don’t, uh, say it incorrectly, but the TAVR procedure, T

Seenu Reddy: A V R.

Seenu Reddy: Yeah, which stands for transcatheter aortic valve replacement, as opposed to SAVR, surgical aortic valve replacement. What was really the genius of Dr. Cribillet and others in France sometime in the late 2008 to 2010 period was the concept of my understanding, just like we put stents in arteries to open them and push that plaque to the side.

Seenu Reddy: Yeah. Could we come up with a technique to mount a valve on a stent and using a balloon, crush the old disease valve to the side and now put in a functioning heart valve? And this was really a revolutionary breakthrough, and I have to say the speed of it moving from, from first in human to then commercial availability around 2011 [00:28:00] and 12, and our adoption of it in Nashville in 2012.

Seenu Reddy: Uh, at one time, we being the only city in, in, in Tennessee doing these procedures at the three centers here in town to then now in 2024. You know, 12 years or so later, it’s almost every major city in, in, yeah. So in 10 years,

Marcus: it’s gone from

Seenu Reddy: highly specialized centers, specialized trials. Yeah. To any everywhere.

Seenu Reddy: Yeah.

Marcus: So instead of opening the chest, putting the patient on a heart and lung We can do all of this. You can do all of

Seenu Reddy: that. With the patient not even fully asleep, just with what’s called conscious sedation. Yeah. Meaning they’re in a very light sleep. Okay. So

Marcus: I

Seenu Reddy: think this video will show a lot of the concepts we’re talking about.

Seenu Reddy: You know, the first concept is understanding what is aortic valve stenosis? And Vic, you were kind of commenting on, what do you notice about this valve right there? There’s the normal valve. So you can see how it’s opening.

Marcus: Right, it’s [00:29:00] opening quite wide, letting blood go through. Yeah,

Seenu Reddy: leaving the left ventricle.

Seenu Reddy: This is the main pumping chamber of the heart. But then what’s happened here? Yeah, it’s narrowed, it’s not, it doesn’t open as much. And typically that happens because the disease state here is calcification. Rather than plaque, it’s the deposition of calcium. So the valve, instead of opening nice and widely It’s not as flexible as That’s right, it becomes very stiff.

Seenu Reddy: So now what you have is reduced blood flow getting to the body. And you also cause a thickening or a hypertrophy of that left ventricle.

Marcus: Yeah, it has to almost work harder continuously. And look at the

Seenu Reddy: symptoms that occur. You get people short of breath, you get You get them really fatigued. They could even, they stand up very quickly.

Seenu Reddy: They could get lightheaded or just from that

Marcus: valve, not being able to fully work.

Seenu Reddy: And then in the really late stages of that condition, you can get swelling and even fluid building up in the lungs. So again, a normal valve opening large, a diseased valve opening very narrowly. Causing it. So how do you diagnose it?

Seenu Reddy: How do you figure all this out?

Marcus: Yeah, like if a patient comes in, how do you know [00:30:00] without being able to see them? So here’s the well the first step

Seenu Reddy: They kind of skipped in this video, but of course a doctor we still do use those antiquated things called a stethoscope So I might listen and hear what’s called a murmur now if I hear the murmur We then go and get this test done, which is an ultrasound Okay, so you can hear a suspicious murmur like in the beat and the murmur is actually that abnormal blood flow going across When you see this kind of turbulent blood flow, yeah That produces the murmur.

Seenu Reddy: So now, we can take that echocardiogram or, uh, that probe, put it on the surface of the heart, and we can see the chambers of the heart, we can see a diseased heart valve, and we can see if valves are leaking, or if they’re too tight or stenotic. So this ultrasound probe can shoot those, uh, Ultrasound. You can do that

Marcus: right in the, in your office.

Marcus: To be done

Seenu Reddy: in the office. It’s an outpatient procedure. It doesn’t, uh, take it. So now what you’re seeing here is the end result of a TAVR procedure. Again, we have a narrowed heart valve. It’s not opening. But here, instead of now making that open chest incision that we heard about and [00:31:00] talked about, we have this other technique to try to treat this abnormally function valve.

Seenu Reddy: So we want to restore this. This nice picture in this situation without

Marcus: opening up the chest and going through all of that. So how

Seenu Reddy: do we do that? It’s done through this transcatheter technique that was developed. And that technique involves ultrasound. It involves fluoroscopy. So a patient first undergoes a CT scan.

Seenu Reddy: to see if we have adequate vasculature to access the heart valve.

Marcus: Yeah, and really find where all the, the veins and arteries could go through. So

Seenu Reddy: then you, you take a needle and you put a wire and you thread that wire through the diseased heart valve. What we had here was the groin. That picture before was the groin.

Seenu Reddy: You went

Marcus: through the patient’s groin, And then, up through their, their chest, the aorta, and then almost down. Yep, back over the arch, and down through the diseased valve. Yeah, over the arch and down into the valve. And there’s a wire. [00:32:00] Might be hard to see for people listening, but there’s a wire that starts it you kind of Feed up through the artery.

Marcus: That’s right all the way up to the order That’s a pretty true, right? Right? Cuz that’s narrowed

Seenu Reddy: the valve is now Mission

Marcus: it’s

Seenu Reddy: yeah. Yeah, it’s very tricky to get that wired across that valve in the backwards Uh, way, but that allows us and that acts as a monorail. So now you’ve got a way to access that valve with many other catheters.

Seenu Reddy: Yeah, so that you

Marcus: can bring other things along

Seenu Reddy: that

Marcus: wire,

Seenu Reddy: along that monorail. So that wire becomes your main, uh, kind of monorail, your, your guide to doing everything else. Yeah. So that’s a very important step in the procedure. The other step you’ll see here is there’s a catheter being put into the other side of the heart that allows that.

Seenu Reddy: Remember in the open heart situation, what did I do to work on the heart? Yeah, you had to stop it, right? That’s right. But here, we’re not going to be able to completely stop the heart, but we can make the heart quiver with that pacing wire. So it’s effectively a brief period where the heart is not pumping and squeezing because you [00:33:00] can’t put a valve in there while it’s still squeezing blood out.

Seenu Reddy: Yeah,

Marcus: right. Yeah, so you um, you don’t turn, It’s off totally, but you fibrillate it so it’s not beating very aggressively. It’s not beating at all, it’s really just quivering. Yeah.

Seenu Reddy: So then, as this picture shows, we’ve now, over that wire, threaded a valve inside a sheet or a catheter. It’s like all folded up and then you’ll balloon it

Marcus: out in a minute.

Marcus: Yeah. Yeah.

Seenu Reddy: So then, we’re in this particular valve type. We’re able to unsheathe the valve, and now here’s the pacing. So now the heart is quivering rather than beating. During that brief period of quivering, we unsheathe the valve and it pops open. It’s made out of a special metal called nickel titanium.

Seenu Reddy: The other technique is one you mentioned where they balloon it. And those are two techniques we use, and we do both, uh, to put the new heart plates. Then we stop the pacing, heart starts beating again, we take out the wire, and now look, we’ve restored that nice open thing, uh, structure of the valve. So we went from this, now we’re back to this.

Seenu Reddy: [00:34:00] From a narrowed valve to an open valve. But, you know, even with this technique, there are risks, and we’re really trying to reduce these risks. One of them is, Some of those pieces of calcium could break loose and cause a stroke. So we’ve now developed a technique through the arm. We can put filters in the arteries that go to the neck and brain.

Seenu Reddy: Oh, interesting. To catch any of that debris. So we’re doing that routinely. We’ve also found that sometimes these catheters can puncture the heart. So we’ve done things to reduce that risk.

Marcus: So talk about the impact to the patient outcomes? Oh, it’s

Seenu Reddy: expanded the patients that we can help. For example, if you were 80 years old, none of those patients were looking forward to any open surgery.

Seenu Reddy: Yeah, and they’d really be given a terrible, you know, sentence of they may be fine in every other organ, but now you’re just going to develop heart failure and have a miserable existence. But we 75 to 85 year old, our oldest as we did one on a hundred year old, you can go through the groin and put these valves in and take care of very straightforward problems.

Seenu Reddy: That’s not going to make them Superman. But all those symptoms we talk about are going to be [00:35:00] alleviated, the heart failure, the swelling, the breathing problems. You can restore this without them having to spend more than a day or two in the hospital.

Marcus: Yeah, and so because it’s minimally invasive, but really not even very invasive because you’re going intravenously, it’s a really fast recovery time.

Seenu Reddy: Yeah, because you’re going through the vessels. The biggest thing they got to heal from is that puncture site in the groin.

Marcus: Yeah, right.

Seenu Reddy: It’s a much different healing process than trying to heal the bone of your chest. Okay, and

Marcus: you typically partner with a cardiologist in this? Oh, absolutely. This is a,

Seenu Reddy: uh, what I would call a heart team procedure.

Seenu Reddy: Okay. This is a procedure that, uh, we come together as a heart team. Cardiologists of very, uh, multiple specialties. Imaging cardiologists, invasive cardiologists, and occasionally we call in our EP specialist as well. Yeah. Uh, because some of these patients sometimes need pacemakers before or after the procedure.

Seenu Reddy: And then the cardiac surgeon, we make very precise measurements. We make a, a really, uh, uh, healthy determination whether the patient’s better served with a surgical strategy or this catheter [00:36:00] strategy. And it’s not based solely on age. There are many other factors that go into it. And then we work together to give the solution for them.

Marcus: So there are some times when the open procedure is still better. Absolutely. Yeah. Absolutely. Yeah. It has to be the right situation for, maybe there’s a particular valve that works in this way. Right. But not as many option, options for it. Well, the

Seenu Reddy: optionality, one of the things you might notice is when you put this valve in, you don’t cut the old valve out.

Seenu Reddy: Yeah. So you have a little bit of the Russian doll phenomenon. So if we have to come back in the future, because this is made out of tissue, and in 6, 8, 10 years when it wears out, We’re now talking about the lifetime management of aortic stenosis and valve disease. So what, what that fancy term means is, well, if we do this this time, what are we going to do in six to eight years?

Seenu Reddy: What are we going to do that six to eight years after that? That’s why when a 45 or 50 year old comes to and says, Oh, I just want the TAVR valve. We’re saying, but wait a minute, you’re only 50. Yeah. When you’re 60, are you taking a lot of other options away from yourself? Because it only will last eight, ten years.

Seenu Reddy: Either valve may not [00:37:00] last as long. So we really want to give them the most optionality not only at this interval, but what in the ten years and the twenty years after that.

Marcus: Yeah, because you are doing it through the veins, it crushes the old, Valves to the side. Tissues to the side. That’s what you meant with the Russian doll.

Marcus: You can’t do that too many more times. Too many times. Yeah. Yeah, right.

Seenu Reddy: So what we’ve really shifted to is in the younger, healthier patient, get the surgery now. Just go ahead and do this, where you can tolerate

Marcus: it. Yeah, and recover from it.

Seenu Reddy: Save the TAVR procedure when you’re 70, 80, 90 years old.

Marcus: Yeah.

Seenu Reddy: It’s the ideal procedure in the, in the octogenarian.

Seenu Reddy: Yeah. These, I mean, it’s been transformative for what we can do for aortic stenosis in, in 80 year olds. You know, 70 year olds, we, we, I’d still say the majority get the TAVR valve. Mm hmm. 60 year olds, I’d say we’ve shifted back to majority getting the surgical valve. Mm

Marcus: hmm. Because then, um, they’ll come back in ten years or If they go with the tissue valve choice.

Marcus: Remember,

Seenu Reddy: you still have the choice of the mechanical valve [00:38:00] and never need another forever. Yeah, but then

Marcus: you’re taking daily, uh Blood thinners. Yeah. Okay. And then, there is, people talk about robotic surgery.

Seenu Reddy: Yeah. These guys I think this is the part

Seenu Reddy: that gets very, a lot of people excited, right? So the first thing we want to point out in this picture, Vic, is what you had mentioned early in our is the heart lung machine, and that’s there to the right.

Marcus: Yeah,

Seenu Reddy: right. And so you still have the heart lung machine, you still have the red and white, uh, red and blue tubes connecting to the patient to stop their heart. What’s different, you see in this picture, however, is the surgeon is sitting at a console to the left rather than at the patient, but you still have to have surgical assistants now dock the robot to the patient.

Seenu Reddy: And really what robotic surgery brings, uh, does is another tool. It’s a tool that improves visualization and allows us to do work on the heart through smaller incisions. That’s really the advance of the robotics. It’s still what I would have to say not Investigational or experimental what I would say is that it’s still in its early days and we’re still trying to figure out who best Benefits from this procedure.

Marcus: Yeah, and when do you [00:39:00] need that? It’s almost like a virtual reality Significant magnification for the surgeon but the the difference is now you’re at a distance. That’s right. You’re not

Seenu Reddy: Right at the patient. Directly hands on. Yeah, we’re finding that for certain valve ailments, such as mitral valve disease, this may be a real advancement because it allows us to visualize that valve so much better when we want to effect a repair.

Seenu Reddy: Yeah. So this is when you’re repairing the valve and not replacing it, you may have to do a lot more things to try to fix that, that I think, um, the robot may offer a significant advance. Yeah. We have seen the robot bring big advancements to other types of surgery. For example, surgery deep in the pelvis.

Seenu Reddy: Yeah. Prostate surgery, GYN surgery, because it can reach that hard to get to place a little bit better than, uh, even than laparoscopic or traditional surgeon hands.

Marcus: Tell me where you think this is going, like, you’ve been practicing for 20, 25 years. Uh, I think we’re seeing decent amount of changes in the treatment of heart disease over [00:40:00] that time.

Marcus: And where do you see it going? What’s, um, what are you hopeful about and what’s, uh, maybe makes you a little concerned going forward?

Seenu Reddy: Well, I guess one area of concern is I don’t see it going away. Yeah. I think heart disease is with us. Yeah. The good news is that the arsenal of tools that we have are growing and getting better and more advanced.

Seenu Reddy: One thing that’s come out of kind of left field that’s had a huge impact on the cardiovascular side are the GLP class of drugs. Yeah, all of these drugs that were originally thought to be for diabetes and then had this big wave of adoption excitement regarding obesity. are turning out to have maybe some real salatory effects for cardiovascular disease.

Seenu Reddy: So I’m excited about that. We’ve also had, so I’m still very excited about the drug therapy, the medical therapy of heart disease. We’ve been a whole nother class of medications that have come out that have been shown very effective at combating heart failure. Both heart failure where the ventricle is starting [00:41:00] to peter out, and even in heart failure where the ventricle is just not working well and relaxing well.

Seenu Reddy: That’s been exciting. Then on the interventional side, I think the stents, the catheters, the tools to treat all of the stuff we’ve been talking about today continue to evolve and get better. So we have better stents, better heart valves, better techniques to treat atrial fibrillation through catheter based therapies.

Seenu Reddy: And then finally on the surgical front, I think you’re seeing adoption and development of more minimally invasive techniques. The concept of the enhanced recovery after surgery I mentioned where we’re, uh, understanding the surgical journey, is one that does, uh, inflict trauma on the body, but that we may be able to reduce it by preparing people better for surgery, performing better surgery, and then helping them recover after surgery in a, in a more, uh, uh, I would say, uh, protocolized way.

Marcus: Yeah. Yeah, it’s exciting. I, I’m gonna do, uh, probably three or four sessions like this with different, different experts in healthcare. Wonderful,

Seenu Reddy: yeah.

Marcus: I think we’ll, um, maybe talk about, [00:42:00] Disease, uh, prevention, disease prevention, and diet, and exercise, and you know, how can you prevent or maybe, uh, forestall the progression of cardiac disease?

Marcus: We’ll try to get, um, someone, maybe a cardiologist, different experts in that can bring different points of view to things. But, it’s such a, um, big issue in our society today. And it’s been, I have heart disease, not, not, you know, late stage, but I have heart disease. And it’s it’s hard to get easy to access information.

Marcus: There’s a lot of very scientific information for doctors. And then there’s very high level information, um, like on the American Heart Association website and things, but not that middle ground where you dive in a little bit deeper.

Seenu Reddy: I agree. I think that’s important about things like this podcast. I mean, part of what we as doctors, the term doctor in Latin, of course, means to teach.

Seenu Reddy: And I really do think one of the important roles of a physician and a surgeon is to teach patients and inform patients and educate [00:43:00] patients. I always tell my patients when they come to my office, I’m not here to talk you into anything. I’m not here to sell you surgery. I’m here to explain to you your disease state and some options that you have.

Seenu Reddy: Yeah, and then you can make the decision. You make the decision if you feel like surgery is the right option. Um, having said that, I also think what’s exciting is the world of, of health information technology. I think, uh, just, uh, innovation in healthcare in terms of everything from the way we get that information to the patient.

Seenu Reddy: Uh, the way that apps and other things like these watches you and I wear can monitor the patient. Um, and the way that we can affect the patient’s health journey. Whether it’s little, uh, uh, teasers to tell them, Hey, don’t forget to walk today. Or did you take your medicine today? Or, uh, teaching them to do the right amount and quantity of exercise in a day.

Seenu Reddy: Or monitoring what foods they’re putting into their, their body. And, and what class of foods those are. Yeah, it’s

Marcus: all interrelated. So as we learn more, how, what I eat. this afternoon is going to affect my health tomorrow, I can now make a better informed decision. I still may want to eat it, but at least I [00:44:00] know what I’m doing.

Seenu Reddy: I’m really seeing that in the area of diabetes and blood glucose management. It’s been remarkable how patients can get real time feedback on, hey, when I eat this kind of bread versus that kind of bread, this is the jump and bump I see in my blood sugar. Wow, when I exercise or I don’t, you may see like this is your VO2 max for your cardiovascular fitness.

Seenu Reddy: So I think even these little step counters and all that. The main thing I think for our audience and others remember who are combating heart disease is, don’t get disheartened and think that it takes a lot. It’s, it’s just a little bit can make a big difference. We’re finding that you don’t have to hit the gym for an hour every day, but 30 minutes of walking can have 80 to 90 percent of the benefit.

Marcus: Yeah. Yeah, it’s just getting up and doing something is, makes a big difference. Same

Seenu Reddy: thing, no one has to go out and you’re eating just spinach leaves all day long. I think it’s the understanding if you make just better, safer, uh, more educated choices of what you purchase in the grocery store and what you purchase when you eat out, uh, can make big differences.

Marcus: Yeah. Great. Well, Senior, thanks for doing this. Really fun. I may have you back at another time to talk through [00:45:00] things, but we have a lot to learn. And cardiac disease learned a lot today.

Seenu Reddy: for having me and it’s a great privilege to be able to help people out there.

Marcus: Yeah.