Clara Freeman anticipated attending her oldest granddaughter's wedding. Liz and her fiancé, Denis, had picked a date for their beach nuptials, and Freeman could hardly wait.
With sparkling eyes and glowing cheeks, Freeman’s smile charms those she meets. Mother of nine, grandmother of 12 and great-grandmother of four, she prizes her family above all else.
Active at age 85, Freeman lived on her own, enjoyed long walks around her Poplar Bluff, Mo., hometown, shopping at local clothing and antique stores. Last winter, however, her family noticed changes.
"Mom seemed out of energy," says her daughter, Susan. Freeman had no interest in her hand embroidery, a favorite pastime she learned from her grandmother as a young girl.
Freeman also napped more frequently and had very little appetite, Susan noticed. She grew concerned and asked her physician to see Freeman. After an exam, the doctor suspected Freeman had a serious heart condition known as aortic stenosis.
What is aortic stenosis?
The aorta is the main artery that carries blood out of the heart to the rest of the body. Blood flowing out of the heart and into the aorta passes through the aortic valve. In aortic stenosis, the aortic valve doesn’t open fully, decreasing blood flow from the heart. As the aortic valve narrows, the left ventricle must work harder to pump blood out through the valve. This extra work causes the muscles in the ventricle walls to thicken, often causing chest pain. Over time, aortic stenosis can lead to numerous heart conditions, including heart failure or pulmonary hypertension.
The heart team
At her first appointment at Missouri Baptist Medical Center, Freeman and her family observed the cardiologists and cardiac surgeons collaborating to guide diagnostic testing and decisions about her case.
Freeman met with Arun Thukkani, MD, PhD, interventional cardiologist, who referred her for tests to determine if she was a candidate for a trans-aortic valve replacement (TAVR) procedure. TAVR is a less invasive technique used to replace an aortic valve using a catheter. Michael Klein, MD, cardiologist and BJC Medical Group physician, performed a transesophageal echocardiogram, an imaging test, and a cardiac catheterization that showed Freeman’s aortic valve and mitral valve were diseased.
"We discovered Clara actually had two problems, a tight aortic valve that wasn’t opening properly, as well as a leaky mitral valve. These two valve problems made her overall treatment strategy more complex," says Dr. Thukkani.
James Scharff, MD, cardiovascular surgeon, also reviewed her results. Drs. Scharff, Klein and Thukkani are specially trained in a new mitral clip catheter procedure to repair the mitral valve. Cardiovascular surgeons Joshua Baker, MD, and Michael Mauney, MD, also consulted on Freeman’s case, and all six heart specialists discussed the best option with her.
A more complex solution
The doctors could have treated Freeman’s aortic valve with the TAVR procedure; however, tests showed that her mitral valve was extremely small, making the chance of a successful mitral valve repair more difficult. “If we hadn’t done our homework and just corrected the aortic valve with the TAVR procedure, I doubt Clara would have felt all that much better," says Dr. Thukkani.
"Any time we consider a patient for the TAVR procedure, two surgeons and an interventional cardiologist are involved," says Dr. Mauney. "A third surgeon was included because of the mitral valve disease. We can often do both non-surgical procedures for a patient, but for Clara, we had to face the reality that neither one, nor the combination of the two, would fix her condition."
Freeman, however, expressed her worries about missing her granddaughter's wedding.
"I had been looking forward to seeing my granddaughter get married on the beach for quite some time,” she says. “I needed to get better so I could be part of her big day."
The MBMC cardiology team recommended open-heart surgery for Freeman, leaving the decision to her and her family.
"I explained to Clara and her family that it was a 90 percent likelihood we could get her through surgery without any life-threatening complications,” Dr. Mauny says. “I also explained that recovery would take longer, but assured everyone that she could remain at MBMC for her rehabilitation. She’s is a delightful grandmother who only cared about getting to the wedding in Florida."
Dr. Thukkani talked individually with each member of Freeman’s family before and after the cardiac catheterization.
"He took his time, even repeated details, until everyone understood the information,” Freeman’s daughter, Susan, says. “Before her surgery, the anesthesiologist held Mom's hand and looked into her eyes while he told us what to expect. It was amazing to see how everyone worked together to save Mom's life."
The circle of caregivers grows
Following a successful surgery and a brief stay in recovery, Freeman soon headed to the inpatient rehabilitation program. There, patients receive intensive, comprehensive therapy, including physical, occupational and speech therapy. It offers patients a very structured, but compassionate, environment. The program's goal is to get patients home and as independent as possible, says Lizette Alvarez, MD.
"Our patients receive three hours of therapy a day, five times a week. Since our unit is located in the hospital, primary care physicians and specialists can see a patient several times a day," says Dr. Alvarez, who serves as medical director for both the inpatient and outpatient rehabilitation programs at MBMC.
"For patients like Clara, whose doctors visited almost daily, the continuity of care with a structured schedule is important for recovery,” she says. “Our team meets weekly to discuss each patient's progress."
The program maintains an 80 percent discharge-to-home rate with an average patient stay of just two to three weeks.
Freeman's family decorated her hospital room in a beach theme to motivate her toward her goal of being on the beach at her granddaughter's wedding. Freeman's hard work and the expert care of her MBMC cardiology and rehab teams combined to help her meet that goal.
When Liz and Denis were married on June 4, 2016, Freeman was seated in the front row. That evening, she even performed a brief jitterbug on the dance floor and took a long walk on the beach.
"I wanted the surgery because I have more weddings to attend and trips to take," says Freeman. "Everyone at Missouri Baptist took such good care of me, and I can't thank them enough for getting me to the beach on time."
Heart care terminology
MitraClip: The MitraClip is a small device used to repair the mitral valve. The clip is mounted on the end of a cardiac catheter used to deliver it to the malfunctioning valve. Physicians then deploy the valve, helping the damaged mitral valve close more completely and restoring normal blood flow through the heart.
TAVR: The transcatheter aortic valve replacement (TAVR) is a non-surgical procedure to treat aortic valve issues. TAVR allows a team of specialists to insert a new valve using a catheter. In 2012, Missouri Baptist Medical Center was approved to perform the technique.
Cardiac catheterization is the insertion of a small catheter into a large blood vessel artery or vein to image or repair the heart and cardiac blood vessels.
Transesophageal echocardiogram is a test that uses sound wave technology to take pictures of the heart via the esophagus (the tube that connects the mouth with the stomach).
Surgeons at MBMC perform about 350 valve procedures a year; one out of two open-heart surgeries conducted at the hospital is a valve procedure.