Podcast Transcript

Introduction: Life is about the moments that make your heart tick, and we’re here to keep it ticking strong. I’m Dr. Barry Bertolet, and this is We're All Heart, where we dive into the latest cardiac care with the experts who live it every day.

From breakthrough procedures to the most cutting-edge treatments, we're putting heart health front and center. 

We're All Heart is brought to you by North Mississippi Health Services in partnership with Cardiology Associates of North Mississippi. Let's get to it. 

Dr. Barry Bertolet: Hi there. Welcome back to another episode of We're All Heart. This is a podcast talking about cardiovascular disease and some of the new therapies and procedures that address that. This is brought to you by North Mississippi Health Services in partnership with Cardiology Associates of North Mississippi. 

Today, my guest is Dr. David Talton. He's a cardiothoracic surgeon with North Mississippi Medical Center. Welcome, David. Thank you for being here.

Dr. Talton: Thank you. Thank you.

Dr. Bertolet: Tell me a little bit about your background, about your training.

Dr. Talton: Oh, I've been here so long now. So I started in North Carolina. I'm originally from North Carolina, trained at North Carolina State and went to Wake Forest Medical School. And then since 1990, I've been a Mississippian. So I trained in Jackson, did my general surgery and cardiac surgery there. And since 1997, I've been here. So I'm going on 28 years now. So it's been a while.

Dr. Bertolet: Yeah. So you've been here for a minute. 

Dr. Talton: Been here for a minute. 

Dr. Bertolet: Yeah.

Dr. Talton: Seen it change and grow and everything else.

Dr. Bertolet: Well, we're so happy that you're here.

We've told our listening audience and viewing audience that we have experts here that are in north Mississippi that are at North Mississippi Medical Center that are unique.

And we certainly are going to talk about something unique today that I don't think that anybody in our region is actually even doing that people may have to travel hundreds of miles to get this procedure. And that's minimally invasive valve intervention. Can you tell me in a nutshell, sort of what that is?

Dr. Talton: So basically, the heart has four different valves in it, but the ones we're most concerned about are the aortic valve and your mitral valves. That's where most of our open surgery is done and most of our minimally invasive stuff. We do have some stuff for tricuspid now, but mainly the aortic or mitral are the two main valves that we're dealing with.
(Continued)
 

Dr. Bertolet: And so with these valves you mentioned the aortic valve, what's the most common problem that you see, that you believe needs a surgical intervention on the aortic valve.

Dr. Talton: Aortic stenosis is by far the most common problem we have with aortic valves. And it's just where the valve just tightens up. I tell people, if you try to breathe through a water hose, you could do it because it has a big diameter. If you try to breathe through a coffee straw, you can't walk a foot before you pull it out. 

And so that's essentially what the heart is having. The blood gets so tight, it's going through such a small hole, it's literally choking the heart off. So that's the most common. 

We do see some from aortic insufficiency, but by far, in younger and older is aortic stenosis. Different causes, older is more degenerative valve. Younger people, more heart, congenital bicuspid type valves.

Dr. Bertolet: So when you say that degenerative valve, I assume by that is just wear and tear of the valve opening and closing. Over time, it just gets stiff.

Dr. Talton: Old age, it just starts. And why somebody has it and somebody else doesn’t, we don't know the answer for that.

Dr. Bertolet: Like arthritis in your knee, it gets stiff and it won't move. And then that's what happens to the valve.

Dr. Talton: It gets stiff in the calcium deposits and they won't move at all. A normal valve, if you laid it on a newspaper, you can read the newspaper through it. You know, a valve like that, you can't read anything. It is very, very thick and barely moves at all.

Dr. Bertolet: What would be a symptom that a patient would have if they had aortic stenosis? That really ought to drive them to get an evaluation.

Dr. Talton: You know, the most common thing is - see your physician every year, because a lot of times you hear a murmur. And unfortunately, older people say, well, I'm older now, I just can't do it. But you start giving out easier, you start fatiguing, you get short of breath, some people have swelling, you can have blackout spells. 

You can start having heart failure from bad heart valves. So there's a combination of multiple things. People are seeing a physician regularly. A lot of times they'll just pick up a new murmur that they haven't heard before. And that's very, very common with aortic valve disease.

Dr. Bertolet: And so I know in the past that people would get a sternal incision, they get their chest cracked open, as it's commonly called. And, and then beyond people just not wanting to get their chest cracked open, why would we even consider minimally invasive surgery? Is there an advantage in certain patients?

Dr. Talton: Oh, there's a huge advantage in certain patients. I mean, I think the thing you just said is the most common problem. People just don't want to do it. And so you'll get a 70-year-old who says I'm just not having surgery. And when you can tell them, well, surgery is now overnight. You come in one day, you go home the next. It makes a big difference.

And I think the most important part, you know, in the older age group, these valves are great. Younger age group, they're not as good for. But the most important part, even for the older population is just having somebody to look at it and evaluate. We've done close to 900, actually just over 900 TAVR valves now. We were the seventh center in the U.S. outside of academic centers to do them. And so we've grown a lot over the years doing these procedures. And you have to be able to look at the valves. You need somebody to look at your valve, look at the echo, look at the calcium distributions.

We did a 65-year-old gentleman today who's a redo, third time redo, bad, complex issues, not good to go back in his chest.

But I've done an open valve on a 75-year-old in recent months. Not because I didn't want to do a TAVR, but when you evaluated his CT scan, his calcium was concentrating so much in one spot, there was a higher leak rate. So it's very important to look at all those patients and have a center that can look at all of them and look at all echoes and cath films and all of them put together.

Dr. Bertolet: So you mentioned TAVR - transaortic valve replacement and then that's. I'm assuming that that's the minimally invasive way to fix the aortic valve.

Dr. Talton: So we can come in most time we go through the femoral arteries down in your legs. We did five today. So last one we had to go through a neck incision and so we came through the neck.

Dr. Bertolet: Two o'. Clock. Yeah, you've done five already.

Dr. Talton: So we've done five today. And so they go actually very smoothly. You know, I'm a piece of the pie. We have a team. I'd like to say I'm more of the pie. I probably am more of the pie because I'm bigger than most, but I'm a piece of the pie. 

And it's my respiratory therapists who do a phenomenal job. It's my rehab people who get them out of bed. It's the Cath lab, people who get us in and out quickly. It's my team in the OR who I don't have to ask for anything for, it just shows up in my hand. So it's a combination of all those people. And my old boss used to say, pump time is dead time - OR time is dead time. And he doesn't really mean that, but what he means is you need to have a purpose and a goal. You need to keep cases moving, and in a lot of places, you know, they kind of spend a day with a case, and that's not best for a patient.

The longer you're in a cath lab, the longer you're in an OR, the more risk and potential complications you have. So we have a good team that works with us.

Dr. Bertolet: So I saw that you have some examples here, is that this is a TAVR valve. 

Dr. Talton: So this is a TAVR valve. And like I said, we come up through the groin. When I put it in your leg, it's about the size of a pen, you know, a writing pen. And we bring it up, we bring it all the way your aorta here and bring it across that.

And in layman's terms, this is a heart stent. And everybody's heard of a coronary stent that has a valve shoved in the middle of it. That's the best way to put it. It's very simple. It's a stent structure made out of nitinol, which is the same stuff that coronary stents made out of. Now, this is a little bit bigger, of course, but in the middle of it, it just has a heart valve which is sewn on the inside of it. So when we go in, we rapidly pace the heart, we blow that balloon up, and we let it down, and you have a new heart valve.

And once we get started, it's not a long procedure, as I said, because we have a good team working with us. But most patients come in the morning of surgery. They have surgery, they're on bed rest for about six hours afterwards, they're on the floor that evening. And by tomorrow morning, we check an echo at 7 in the morning. Usually by 9 or 10, they're ready to go home.

Very limited. You know, if you're driving today, I let you start driving next Monday. And I don't care what you do in two weeks. So it's very limited. As opposed to old surgery, you know, full sternotomy is three weeks at home with no driving, and then it's eight weeks before you're really back to full duty.

Dr. Bertolet: So backing up a little bit. So the access on this. So we're not going through the chest. You mentioned that we're going through the leg.
Is there a big incision with that? Or is this a needle stick? Or how do you get access?

Dr. Talton: It's a little bit bigger than a needle stick just because the catheter's a little bit bigger. But we put a piece of tape over it when we're done. You can't tell it the next day. And like I said, in the neck, it's about, you know, 3-4 centimeter incision in the neck if we have to go through the neck. And the reason we would go through the neck, if our legs are, you know, we're the world leader in peripheral vascular disease in north Mississippi. And so it sometimes we have so much calcium and occlusions in the legs, we physically can't get up.

Dr. Bertolet: So how fast would that procedure be? So if we get access in the leg, we go up to the heart, we place the stent crimped onto the balloon into the position, we pace the heart, we inflate the balloon, we deploy the valve, we pull that out.

How long does that take?

Dr. Talton: Don't go get coffee. There's literally not enough time.

Myself and one of my partners and one of the cardiologists are in every case, we all have a goal and point to get the cases done. Again the faster you are in the OR - we're very precise when it comes to deploying the valve. We're very precise on where we put our needles and our catheters. But it's very important that you keep the cases moving and you don't want to have to be guessing around something. We have a game plan when we walk in the door.
So literally we've done five today and we were done by 1:30.

And I've got a great team. Team is the key to making these things successful.

Dr. Bertolet: So you're looking at a 35-minute procedure time?

Dr. Talton: And half of that's anesthesia. Just going to sleep and waking up. You know, I would say from the time we stick needles in, it's probably not 15 minutes.

Dr. Bertolet: So. And they spend the night and they go home the next day.
Wow, that has changed a lot. Do you put the TAVR valve anywhere else or can it be used for other purposes at all?

Dr. Talton: And that's good you bring that up, Barry, because there are a lot. So over the years, we've put thousands and thousands. I think I've done almost 900, close to a thousand open aortic valves. I've done a lot of open aortic valves. And every valve that I've put in that's a tissue valve before, you know, the same thing that has occurred to the native valve can happen again. It can become stenotic over time.

And so these valves can go inside of a tissue valve that we've placed in before.
We also, here on the mitral side, which is on the left side of the heart, we can actually, if you've had prosthetic valves placed there, we can put one of these valves in that too. We can come across the top part of your heart, make a little hole, and track that valve through the valve and deploy a valve there. We've put one tricuspid valve in, and a person who's had a previous tissue valve, and, you know, it was the lights came on. She'd already had four operations before we got to her. And, you know, she could barely walk. And now she's running circles everywhere she wants to go. And so it's a big, big difference.

Dr. Bertolet: So just to reiterate is that you're saying if somebody had a previous surgical valve, you could take this, if that valve narrowed, degenerated, and you could put it inside a valve, inside of a valve, and then open it back up and then end up with a functional valve.

Dr. Talton: Exactly. And you can actually do it more than one time.
And that's the one thing about the TAVRs. You do have to watch your age group, because if you start going younger and younger, younger people tend to tear up valves a lot quicker. And so you don't want to get three and four of these inside. So you do want to, you do want to - the more 70 plus range, more of a low risk, even intermediate and high risk, or where you're looking. But again, I think the key to determine who's the best candidate is having somebody who does them to look at the scans. 

You've got to look at the scans, you got to look at the echo. It's not a one shot fits all. And when I see patients, you know, we have a long discussion when they come and say, hey, I'm getting a TAVR. And I say, no, we're not getting a TAVR. That's a tough discussion to have with some patients. But, you know, come open. I'd love to put a TAVR in you, but it needs to be the right person. And if I would do it for my mother, if I do it for my brother or my sister, man, I'll do it for anybody. But if I wouldn't do it for them, I'm not going to do the operation. So it's very important. I'm not trying to punish anybody, but you've got to have the right patient selected for it, and it's an awesome operation for those.

Dr. Bertolet: And I know that it's, you know, for surgeons, it's all about the numbers. You know, you hear that old adage, practice makes perfect. So how many of these have you actually done?

Dr. Talton: So TAVRs, I think we just crossed 900. So we'll be at 1,000 this year. We do 10 to 15 a month.

So we try to schedule them on certain days because we, like I said, we have a big team for those. And we want to be sure that everybody is on the right page. I think when you try to stick one in here or stick one in there, you're missing part of your key team makers. And, you know, so we try to make sure everything's exact same every time we're doing them.

Dr. Bertolet: Well, that's absolutely amazing. And we talked earlier about the mitral valve, and I see that you got something here that's something for the mitral valve. What do you have here?

Dr. Talton: So the mitral valve. And again, the audience knows this.
We're the center of the U.S. for vascular disease. This is it. North Mississippi is a black dot of the U.S. and it's just our eating habits, our smoking, our exercise, all those things.

So our part of the country, we see a lot of ischemic mitral valve disease. And when you get heart disease, Barry puts stents in, sometimes the muscle never recovers. And this is the mitral valve here, and it will leak.

Now we can do open surgery on them. There's reasons for open surgeries. There's reasons for minimally invasive stuff. 

But this is what we call a mitral clip. And we've been doing these now, I want to say, three or four years. That's an open clip. And this right here is what they look like when they close completely off. And basically what it does, it's a clothes pin. It looks like a clothes pin. You go outside, fold the clothes over line, just stick clothes pin. That's what it looks like when you put it on.

It's for people who have severely leaky mitral valve disease. And basically we come up through the leg on these. You come in one day, we take you to the cath lab, our hybrid operating room. And we basically create a hole in the top part of your heart. And I have a catheter that guides this little clip and we reach down and grab that clip and basically a normal mitral valve looks like a big old shotgun barrel. 

It's wide open and you put a clip on it and I tell people it looks like a double barrel shotgun. Then you have two separate holes, one on each side of the clip. And it literally just pulls the leaflets together to decrease the amount of regurgitation. A lot of times people with ischemic heart disease, it's more the valve is just dilated. If you can just pull the leaflets back together, you decrease the amount of flow going backwards.

Dr. Bertolet: And I've read the clinical trials on these clips and see that the repeat hospitalization rates for these people that have MitraClip from shortness of breath symptoms is markedly reduced as well as their sense of well-being, how well they feel is markedly better as well. So there is some great scientific evidence to support this device.

Dr. Talton: There's some studies that show there may be a slight increase improvement in survival. I'm not 100% sure of that, but every one of the studies shows, you know, when we started these, the whole goal is improving your quality of life. You know, if you cannot walk to the bathroom without gasping for air, can we do something to help you get that? 

You know, if, you know, you have a year or two years, even three years left to live, would you not like to be able to walk around during those three years? Or would you like to be, you know, stuck in a chair or bed because of symptoms? 
So this really does help. And as you said, it markedly decreases our rehospitalization and nobody wants to be up there with us. 

Dr. Bertolet: And you were mentioning the TAVR valve. They spend the night, they go home the next day. What about the MitraClip? 

Dr. Talton: We do the same thing.

Dr. Bertolet: So basically overnight. 

Dr. Talton: Basically overnight, you come in one day, you get it done, you go home the next morning.

Again, we'll repeat your echo at 7 in the morning. Usually by 9 or 10, we have you ready to go home.

Dr. Bertolet: And what's the access site for the MitraClip?

Dr. Talton: So we just come up a vein. We go through the femoral vein down in the leg and we go up on the right side of the heart. Instead of the arterial side, it's the venous side.

And we come up that way and when that's done, we just put a purse string around that and we have you come back a week later, take that out, and you can pretty much drive by the next week.

Dr. Bertolet: So a needle stick in the leg, overnight stay and you're done.

Dr. Talton: Yeah. 

Dr. Bertolet: It's amazing. How many of the MitraClips have you done?

Dr. Talton: I think we're at about 180 to 200 right now. So we've done a good number of them. We're doing about two to four of those a month now.

Dr. Bertolet: And the MitraClip is for the mitral valve. What about the tricuspid valve?

Dr. Talton: It's new and coming. You know, the hardest thing about starting something like those is we're in the process of training on those. And so we're looking for patients right now for them, you know, just got FDA approved.
And the tricuspid valve does not give most patients as much problem as the mitral or the aortic does. 

And so there's a lot of swelling, it can fatigue you. So there are some significant symptoms with it. So we're looking now to get a few patients on board, and then we'll start those hopefully in the next month or so.

Dr. Bertolet: And if patients knew that they had aortic valve disease or if they knew they had mitral disease and they have been told that they're going to need surgery, what would be the best way for them to reach out to you or your group?

Dr. Talton: Well, probably if somebody knows. So we have to have this live documentation we have to have from patients and stuff. And I'll say probably 95% of all my patients come from cardiology, either come from you; I see a good number of patients from Columbus. I still see a good number of patients from Oxford, and I've had a bunch of patients come see me from the coast. So we've had people come from all over the state to see us.

Usually a cardiologist will reach out to us and say, hey, I have somebody with significant. I've had several internal medicine. We'll have a patient say, hey, I've got somebody would want you to look at. We'll take those on and look at those. But we usually need some kind of documentation of an echo or something that is abnormal. But we will take them from, you know, internal medicine, cardiologists.

And I've taken some, like I said, from a patient's family before that I've known, you know, on the Gulf coast, they've come up to see me. So we try to make it easy wherever we get them from.

Dr. Bertolet: So I got one last question to ask you.

We know that the slogan for North Mississippi Is you are our true north. I want to ask you, what is your true north? What brought you to Tupelo? What's your drive? To develop programs like a minimally invasive valve program and develop that here.

Dr. Talton: Ah, so that's tough. You know, when I finished training, I was always going back to North Carolina. My dad was the chairman of the hospital there, and they started hearts at my local hospital, and I was always going back, and I trained here in general surgery. 

So I kind of liked it. And I said, it's okay. It's a good town. You know, Tupelo is a good town. But I think what has driven me and has driven my partners, too, is I don't want to leave Tupelo, you know? You know, I want anything that can be done on hearts to be done here.

And anything that's done for hearts here, if we do it, it needs to be the best or we don't need to do it. And so I think we've kind of. Dr. Sachdev's been here, you know, 25 years now, myself 28. And I think our drive has been the whole time is to make the program - I think at this point, we're by far the best program in the state. I don't think anybody can come close to that. And the only thing we're not doing is heart transplants. And that we will probably never do, I hope, at least not while I'm here, because they always occur in the middle of the night. 

But I think our main goal is to make sure that the people in north Mississippi do not have to travel anywhere to get the best care in the country for heart disease and coronary disease. I don't think you have to go anywhere to get those kind of things. And I think I've always driven to be hopefully one ahead of the next person. So I think we've driven a lot of stuff. 

When TAVRs came out and they got FDA approved in 2010, and we did our first one in 2011, and it took a year of just wearing people out to get the hybrid room ready, to get our training up and going as you well remember, we went to California to present to the company, because why would anybody send it to Tupelo as a first site? 

But we were. Because they saw what we offered and our quality and what we offered to our patients. So I think at the end of the day, that'll be what I say I’m leaving.

Dr. Bertolet: All right, well, thank you very much. You're an amazing surgeon, and thank you for coming to Tupelo and sticking around here and developing these programs. And as Dr. Talton said, if you want to hear from more experts, just like Dr. Talton, we'd like for you to join our next podcast when we bring back We're All Heart. I thank you again for listening today. I'm Dr. Barry Bertolet. Signing out.

We're All Heart is brought to you by North Mississippi Health Services in partnership with Cardiology Associates of North Mississippi.