Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) Welcome to Drivetime-Patient. I'm Rob Hungerford, a GP from Newcastle, New South Wales, and in this module, we're going to be talking about heart valve disease with a focus on aortic stenosis, a common type of valve condition. If you've been experiencing symptoms, referred for tests, or diagnosed with aortic stenosis, this series will help you understand what's going on and what to expect. We'll use plain language to break things down into simple, clear explanations so you can feel more informed and confident in managing your health. I'm joined by Dr Matias Yudi, an interventional cardiologist from Melbourne, who manages this condition every day. Welcome, Matias, and can you tell me a little bit about yourself and what you do in clinical practice every day? (Y) Thanks, Rob, for having me. It's such an honour to be here. As you said, I'm an interventional cardiologist and it's something that I'm very passionate about. And it's a great job because we actually intervene on different heart conditions, but we do this very minimally invasive. And my subspecialty is in intervening in different valves that are not functioning properly, usually through little tubes, either in the leg or in the arm. (H) Thanks so much, Matias. I'm looking forward to this conversation. Now, the audience can listen to all units or choose the topics most relevant to you. You can also come back and revisit sections at any time. Each unit is around 10 to 12 minutes and covers a different aspect of the condition. When you're ready, let's begin. (Voice Over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is Unit 1 of 10, covering heart valve disease. And in this unit, we're going to explain how your heart functions as a pump, the role of heart valves, why good heart valve function matters for blood flow, and what happens to your heart when flow is restricted. Dr. Yudi, to start us off, can you explain briefly what the heart does? (Y) Rob, I'm completely biased. So, the heart is the most beautiful organ in the body. And effectively, it really is a muscle that works as a pump. It really allows blood to move oxygen around the body and removes the waste products such as carbon dioxide. So, every time the heart beats, it contracts and pushes blood forward. It goes from different chambers. Some of them go and get oxygen to the lungs. The rest go and supply that oxygen to the rest of the body. And then we bring all the waste, the carbon dioxide, back. So, it really is a beautiful pump that moves blood in a very, very coordinated way, and it beats 60 to 100 times a minute for 80 to 100 years. So, it's an amazing organ. (H) Look, I think that's a really helpful analogy, the heart being a pump. It's something that we can understand. Can you explain to us where the heart valves fit in? (Y) Yeah, the pumping muscle has four chambers. There’s two atria and two ventricle. And the valves, they're like one-way doors in between all these chambers to allow flow to keep moving forward. And each valve has little leaflets which open and close within every beat. And each valve has its own very specific role, depending on where it's positioned. But very simply, you get the waist blood, the blue blood that has carbon dioxide, coming from the legs and other parts of the body into the right atrium, it goes through to the right ventricle and then up to the lungs to pick up the oxygen. Then it comes to the left side of the heart, to firstly the left atrium, and then to the big pumping chamber, the left ventricle, which pumps it all out and again supply the oxygen to the body so we can function. (H) Before we get on to what happens when heart valves go wrong, what do heart valves look like and what do they do when things are working well? What does it mean in terms of blood flow? (Y) Yeah, look, it's a beautifully functioning closed circuit. So, you're allowing blood to move through these different chambers into different parts of the body in a very, very coordinated way. So, when the heart's beating, you want valves to be opening, and so the blood can come out of that chamber. But equally, when the valves close, it's got time for it to fill as other valves open. So, it's very, very coordinated in the way that we're filling a chamber and then pumping the blood out. (H) And so, I guess we can see those valves as doors moving, as blood moves from one chamber to the next. What happens then if something goes wrong with these heart valves? What do you see? (Y) Very simplistically, you've got doors that may become stiff, so they're not opening properly, or they can become leaky. So, blood that gets pumped out also comes back into that chamber, so it's not as efficient as you like. So, you start to lose efficiency in the system. And as a result, the pumping chambers have to work harder to keep blood moving to the rest of the body. Over time, and as those valves either become more narrowed or more leaky, the heart works harder and harder, and at some point, it can no longer function efficiently enough. So, then you don't get enough oxygen to the body. And then you start to have some symptoms. And then your heart gets tired. And the heart function decreases. So, it's a big cycle that occurs when those valves are not working beautifully well. (H) So, we can see that there's this beautiful kind of system where blood moves through the body, the coordination between the different chambers and these doors or valves that allow blood to go from one into the next. When these valves go wrong, what types of heart valve disease do we see? What do we call those? (Y) Yeah, you can either get a narrowed valve, and that's called in medical terms; stenosis, or you have a leaky valve, which becomes a regurgitant valve, or you get regurgitation, which means leaking back. If you can imagine that a door is not opening properly, your heart pump is trying to push blood out, but not enough of that is going through that valve because it's not opening. So, it becomes inefficient and the muscle can get stiff and ultimately gets too tired to push against this closed door. The opposite is when you're getting regurgitation and you're getting leaking back. So, the valve doesn't close properly. So, you pump blood out well, but some of that keeps coming back. So, you're getting a larger amount of blood volume coming back in. And so, it's like a balloon that gradually gets bigger and bigger and bigger. And you can't effectively pump all that blood out in time. And then the heart gets very, very tired. And the whole circuit starts to break down. So, they're the two common ways that the valves can fail over time. And it’s usually because they get a little bit older, although in some conditions you can be born with abnormal valves that tend to degenerate a little bit younger. And I think the most common one of these is a bicuspid aortic valve. So, the aortic valve usually has three little leaflets that we're born with, but in a congenital abnormality, they only have two leaflets that open and close. So, because of that, they can both narrow, and get stenosis, or become leaky, become regurgitant at an earlier age. And they can present as young as in their 20s or usually later in life, but around 50s and 60s, where the normal aortic stenosis patient with a tri-leaflet valve tends to present more in their 70s and 80s. So just to be clear, when we talk about something that is congenital, it just means that you're born with it. (H) We can see that the heart is this elegant organ, which blood moves through and valves control the movement through this pump so the blood can get to the metabolising organs. The patients can visit the resources listed in this module to find out further information about the heart as a pump and valves, and next up we're going to be looking at when valves don't work, why it happens and who is at risk. (Voice Over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit number two of ten covering heart valve disease. In this unit we're going to explain what aortic stenosis is in simple terms, how common aortic stenosis is and who gets it, why heart valves can become stiff over time. We're also going to be looking about some common risk factors including aging and being born with a heart valve that wears out earlier, and also the role of family history and why many people are unaware they have heart valve disease. Dr. Yudi, aortic stenosis is a disease of the heart valves. Can you tell us more about it in simple terms? (Y) Let's break that down. So, you've got aortic and stenosis. Aortic refers to the aortic valve, and that is the valve between the left ventricle, which is the main pumping chamber, and the aorta. So, it opens and it allows all this oxygenated blood to get to the rest of the body. And stenosis means that the valve is getting narrowed. So aortic stenosis means that we're having problems, restriction in getting the blood to the rest of the body. When the valve becomes narrowed, and this happens usually over a long period of time, it gradually gets more narrowed, blood doesn't reach the organs, and it becomes inefficient, and you start to get symptoms such as shortness of breath when you're walking, you're getting some fatigue, some lethargy, chest pain, or you can feel dizzy and lightheaded. (H) Okay, so we can see aortic stenosis is a narrowing. How common is aortic stenosis in our population? (Y) Aortic stenosis is actually quite common, especially as we have an ageing population. It affects 2 to 3 people in every 100 of those who are over 75 years of age, and 1 in 10 who are in their 80s. So, in Australia right now, there's over 100,000 Australians who are living with aortic stenosis. And as you age, that aortic stenosis tends to get worse and you start to become symptomatic with that. (H) Yeah, and I'd like to dig into that a little bit. Is there any such thing as a typical patient and who would that be? (Y) The typical patient with aortic stenosis is someone who's a little bit older. So, we're talking about 60, 70, 80 and beyond. And because it is mainly a disease of age, imagine an 80-year-old house, some of the doors become a little bit stiff over time. So, it's the same sort of thing. There also are some risk factors that make you more likely to have aortic stenosis if you get it younger. And I think you kind of alluded to that there may be a congenital component. We've talked about aortic stenosis and this valve having three leaflets. If you're born with two leaflets, or some people are born with only one leaflet, so you can have a bicuspid valve or a unicuspid valve, they tend to present with aortic valve disease much younger. This is not the typical patient, but it is something that we need to think about if someone presents with symptoms, again, such as chest pain, shortness of breath on exertion, decreased exercise capacity, or feeling like you're going to faint at an earlier age. So, in summary, I guess you’ve got those two streams, the classic elderly and some of these younger patients that may have a congenital abnormal valve, when we talk about something that is congenital, it just means that you're born with it. (H) Okay, so we can see that some is congenital. Maybe in that first population you talked about, can you talk to us about what causes aortic stenosis or makes your heart valve stiffen? (Y) The main risk factor is age, and there are some associations with smoking, if you've had previous rheumatic fever, and also high cholesterol or a history of hypertension or high blood pressure. (H) Now, you mentioned before that some people may be born with a different structure. You talked about different numbers of leaflets maybe in the aortic valve. How do they find out that they have this type of birth difference? (Y) That is a very, very fascinating question. It's probably something that as a community, we don't do as well. And also, as doctors, we don't delve into a family history as well as we should. The most important thing is to talk to your family members, your parents, your grandparents, and find out what kind of history they've got. And if they themselves have had a bicuspid aortic valve, even though you may feel a million dollars, you should get screened for that. Even if you're younger and have those symptoms, it is really, really important that you get checked out to ensure that we're not missing a congenitally or an abnormal valve that could be causing you problems. And that is done very simply with an echocardiogram, which is an ultrasound of the heart. You have an ultrasound probe put on the left side of your chest so we can look at the heart in more detail, and we use ultrasound waves to see what that valve looks like and see how many leaflets they have. And if you've got a family history of bicuspid valve and you yourself have a bicuspid valve, you know that that valve will degenerate a little bit quicker than if you had three leaflets and you may need to have these ultrasounds done intermittently, usually in a period of three to five years, depending how your valve looks and whether it's already showing some signs of wear and tear. (H) Look thank you, Dr. Yudi. So, we can see that aortic stenosis is a disease of the aortic valve. We can see it's relatively common, maybe affects two to three in every hundred people. And it can either be congenital, so there from birth, or a process or part of the ageing process. And that causes the heart valve to stiffen. Look, I'd like to direct patients to resources listed in this module to find out more information if you want to read up about that more. And next we're going to be diving into symptoms and why you might feel fine despite having this diagnosis of aortic stenosis. (Voice Over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 3 of 10 on heart valve disease. In this unit, we're going to explain why you might not notice symptoms at all, subtle symptoms that are often mistaken for aging, looking at the more noticeable symptoms to look out for or to recognise as a patient, and when to speak to your GP and why it matters. Dr. Yudi, not everyone with aortic stenosis notices symptoms. Why is that? (Y) That is a fascinating question, and it is something that we see all the time in our cardiology practice. And the main reason is that aortic stenosis, as we've talked about, is common in patients that are elderly, and it usually develops very slowly over many, many years. So just imagine, as you're aging, you expect to be slowing down, not be able to walk as far. You can get more breathless going up the hills, and you can put it down just to aging. And I think that this is one of the key messages that we need to get out there, that if you do experience these symptoms, that you need to get investigated for diagnoses such as aortic stenosis, because the way that you're compensating for these symptoms could be because you have underlying aortic stenosis. (H) Okay. So, if symptoms are subtle, as you've mentioned, what kinds of changes, maybe changes in their body, might people notice but dismiss? Maybe what happens in their life and with their capacity, but also what happens with their body? (Y) Humans are amazing at compensating, and the body's kind of listening. And so the body may slow down, and you may not be able to do things that you were doing six, 12 months ago. But you yourself may not be aware of this. It's important to listen to your body, but also, I think, and I find really, really interesting when my patients don't complain of any symptoms, but you sit them down with a spouse or a family member or a friend and they say, look, you can't do what you could do six months ago. You can't walk up those hills as quickly or you can't keep up with me. And they really are those subtle signs that something may not be right. And you, as a patient, can sometimes just downplay it and think that you're getting unfit or that you're just aging. So, it is really, really important if you notice something that's changed or if someone else in your family or your friends notice something that's changed, listen to what they're trying to say, because this is something that can be very easily treated and reversed. And if we keep ignoring it, unfortunately, the consequences can be quite significant. (H) So, you've talked about maybe less capacity for exercise or becoming breathless or fatigue. What are some symptoms that would really prompt patients to actually see their doctor. Some of what I'd call like red flag symptoms to be very conscious of and concerned about. (Y) The red flag symptoms, it means that we're really getting to a stage where you're no longer denying that something's not quite right. And the very, very common things that we see at this stage is someone getting very breathless on very minimal exertion. So, walking to the bathroom, they're getting chest pain. When they're doing any sort of activity, they're feeling dizzy and lightheaded. It gets to a point where their legs start to swell. And when they're having problems lying flat in bed, so all of a sudden, they're using three, four pillows to prop them up because they're so breathless, even lying flat. So, if you're getting these symptoms, you need to get checked out straight away. And if it gets to a point where you can't lie flat in bed, even going to the emergency department is a very good idea. So, you can expedite a diagnosis and potential treatment. But I guess it is important to note that these symptoms have not happened overnight. Very, very commonly, there's been that long lag of you slowly getting worse before you get to this point. So, I guess if we're going to take anything away from here is that if you get to this stage, clearly you need urgent appointment, but be aware of the preceding symptoms because that's when we're going to be able to ensure that you're not very high risk for any major interventions down the track. (H) What I'm hearing here is there's a spectrum of symptoms from very mild and subtle to more concerning symptoms. But it seems like you're saying even if these symptoms are subtle or easy to dismiss, we should be speaking to our GPs about these symptoms. Is that right? (Y) Without a doubt, it's amazing to have a great relationship with a GP. So, you're comfortable talking about subtle symptoms and they will also notice that there's been a deterioration in your overall function over a period of months, two years. So don't ignore those small changes. Talk to your GP. And as we age, it is very important to get a heart health check. And what that would involve would be your GP listening to your heart with a stethoscope. And then if they hear a murmur, which is just a noise from these leaky valves or narrowed valves so you hear turbulence and then it will lead to investigations down the track that should diagnose valvular heart disease. And then we can decide whether that is severe enough to cause those subtle symptoms or whether we just need to keep an eye on it because these conditions do get worse with age. And I guess I really want to emphasise that your relationship with a GP, is so very, very important. And if you're over 45, or if you're over 35 and have diabetes, or if you're over 30 and you're an Aboriginal or have Torres Strait Islander, you're eligible for a free heart health check. And obviously today we're focusing on valvular heart disease and aortic stenosis, but cardiovascular health is so very, very important to prevent major preventable conditions such as heart attack, stroke, renal disease, or kidney problems that if you pick up little things early such as blood pressure, cholesterol, diabetes, you'll do very, very well, long term. (H) Yeah, look, I 100% agree. I think your GP knows you better than anyone else and they see you over many, many years and they can often help you see and tease out these subtle changes and the impact this may be having on your life as well as doing those are first initial steps of investigations and looking into potential causes of some of these symptoms. Finally, though, Dr. Yudi, if heart disease goes undetected and untreated, we sweep it under the rug and ignore these symptoms, what are some of the possible consequences here? (Y) Great question because it is probably something that is underappreciated. And as we've talked about, aortic stenosis gets worse over a long period of time. But once you have severe aortic or that valve is not opening properly and it starts to cause you symptoms, breathlessness, can't lie flat, swelling of your ankles, chest pain. Once you get to that point, your outlook over the next few years is actually worse than having a cancer. So, once you've got severe aortic stenosis, 50% of people are not alive within two to three years. And that's been proven by multiple studies when we did not have technology to treat this. So, I think it is really, really important to recognise that if the valve is bad enough, and it is a mechanical problem, something needs to be done about it to ensure that you continue a normal quality of life, and most importantly, a normal life expectancy. (H) Look, thanks, Dr. Yudi. So, we can see that sometimes symptoms associated with aortic stenosis can be mild, you know, reduced exercise ability or getting breathless or some chest tightness. But it can manifest in a different way with significant shortness of breath or chest pain. And it's important for these symptoms to be brought to the GP's attention so they can do a formal assessment. Because if we don't identify it early it can lead to significant consequences. I'll direct the listeners to the resources attached to this module if they would like any further information and next we're going to be next up we're looking at tests to check the heart and who should be checked. (Voice Over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 4 of 10 covering heart valve disease. In this unit we're going to explain what an echocardiogram is and what the test involves, who should be tested, who sends you and what to expect when you get there, about the echocardiogram procedure, what doctors learn from the results and how long it takes to get your results, and when we need follow-up or what additional tests might be needed. Dr. Yudi, if someone has seen their GP about heart symptoms, what are the next steps and what tests might be organised? (Y) Rob, a great GP, of which there are many out there, will really always start with delving into those symptoms. It's taking a very good history and then that will lead on to actually listening to the heart. And I can't emphasise enough how important it is to have a listen with a stethoscope. And I guess that's been pertinent because we had a post-COVID period when we had all these patients that were underdiagnosed because they couldn't see their GPs face to face. So, if we have symptoms and then an examination that is suggestive that there may be something wrong with the heart, then we go and do some, again, non-invasive tests that will lead to a confirmation of the diagnosis and be able to look at the heart muscle and the valves in great detail. And the most common test is an echocardiogram, which is an ultrasound of the heart. And it just uses a probe that sends sound waves to create images of the valves and also to measure the blood flow as we go through the different chambers. And this is a very common test, it is non-invasive. You don't have to fast. There is no contrast. There's no radiation associated with this. So, it is a great screening tool to let us know exactly what's happening inside of your heart. Other tests that can be done, depending on what we found on a history and clinical examination, would include an ECG, which is a heart tracing. So, it looks at the rhythm of the heart. And then we can do some more advanced tests if required, including CT scans and ultimately some invasive tests such as angiogram or stress test if that is required. (H) So, we see that maybe an echo is the next step in terms of testing or investigation. How does the referral process work and do patients need to do anything to prepare for that particular test? (Y) Once the GP has an index of suspicion, they'll be able to guide you to what is the next test. Echocardiogram is usually the best test, and it is so good because it is non-invasive. It is done in clinics and it's done by a sonographer where they put probes in different positions of the heart so we can look at all those valves very, very closely and measure the blood flow and try to work out exactly what it is that could be causing the symptoms. There is nothing that you have to do as a patient to prepare for this. You've got to eat and drink as normal. You take your usual medications. It does take about half an hour to 45 minutes. And that's important because you want to get really good images to ensure that you have the right diagnosis. And there's lots of measurements that get taken that the reporting cardiologist would look in great details and then give a nice summary of the situation back to your GP, where you can discuss in greater detail those findings. And if you found something significant, then we go on and potentially see a cardiologist about that. (H) Dr Yudi, I know some people might feel a bit unsure or uncomfortable about doing tests like this. Can you just walk through a bit of a visual and explain what happens? As a patient walks through the door in one of these heart centres, what actually happens with this test and what should they expect? (Y) As doctors, we sometimes forget this simple test for us can be quite intimidating for patients. And it is important as a patient to know that these tests are common and carry a lot of great information about your heart. But as you walk into a clinic, it is important to ensure that you're comfortable with what's going to happen. And there's also great resources about what these tests look like, and you can actually see some on the internet but as you go in there, I guess the most important thing is that you will have to expose your chest because you're going to have a probe and gel in different areas around your heart so we can look in there. There's a few little ECG or dots that get put into your chest and in your arm or leg so we can work out where the heartbeats are coming and be able to see when these valves are opening and closing. And then you do have to have some gel on your chest so we can visualise the heart structures properly with the ultrasound waves from the probe. And that can feel a little bit funny and a little bit sticky, but that all comes out very easily at the end of the test. You'll be in a few different positions, usually lying your left side, and also lying on your back. And you may be asked to take a few big breaths, to hold your breath, while we take different pictures in the different positions. Overall, as far as tests go, it is important to know these are very, very safe tests. The risks are incredibly low, and there is no radiation involved, and the sticky dots that we put in and the gel, that all comes off before you leave the clinic. The sonographers, in my experience, are usually quite chatty. So, they try to put you at ease while they're taking all these different pictures and pressing the different buttons to get the information that's required. But you are in a space with them close by for a period of about 30 minutes. (H) Okay, great. So, an ultrasound probe goes onto the chest. They get some images, no radiation involved. It sounds really safe. What do doctors learn from an echocardiogram? What can they gather from that? (Y) An echocardiogram, I remember learning about this for the first time, and I thought it was quite simple. And the more you know, the more you know how complex it is because you've got four chambers you've got velocities across different valves. So, there is a lot from a doctor perspective that we learn and it's great that we can get that information from such a simple non-invasive test. But really what we do is we're just generating pictures of the heart, of the chambers, of the valves, and seeing how the blood goes from the different areas and seeing if there's any restriction, seeing if there's any leaking, seeing if there's any abnormal structures that you may have been born with, such as a congenital aortic valve. And then we try to put it all together to fit into the symptoms that the patient may be having. And then we give recommendations about what may be required and that is quite a broad spectrum. You could be very well reassured that the heart is structurally normal or you could pick up something that's very early in the disease process like aortic stenosis, but it could be in the mild range, which means that there's nothing that needs to be done at this point in time and it is not bad enough to cause symptoms but it is something that you need to monitor as you age because inevitably that valve gets worse with age. And once we know about this, it's essential because we'll be able to ensure that we don't miss little symptoms of ageing, such as slowing down that could be as a result of aortic stenosis. There's many, many documents that us doctors look into when we're grading aortic stenosis. And I think if you ever get a hold of your report and you're trying to work out what it all means, the key terms that you want to know about would be your aortic mean gradient. So that is the difference in the pressures across that aortic valve between the left ventricle and the aorta. And in basic terms, the magic number is 40. So usually if you get to a gradient greater than 40, that tends to be severe aortic stenosis. And another important number that's often quoted would be the ejection fraction, which in very simple terms is how much blood in your left ventricle or the main pumping chamber, what percentage of blood you're pumping out every heartbeat. And roughly if you're pumping out more than 60% of blood, that is quite normal. But if with every heartbeat, you're only pumping out 30% of blood, it means that the heart is getting tired and there could be many reasons for that, but one of those could be that you're fighting against a very narrowed valve. (H) Okay. Look, Dr. Yudii, I understand some people might need further tests. Can you give an example of when these tests are recommended and what they are? (Y) Let's focus on aortic stenosis because that's what we're talking about predominantly today. But your GP and your cardiologist will be able to guide that specific test depending on what pathology or abnormality they may have found in your echocardiogram. But if you have a severely narrowed aortic valve and you have severe aortic stenosis, and we've learned that if we don't do anything about it, you don't do very well over the next couple of years, we need to work out predominantly how that may be fixed. So, we often do a CAT scan or a CT scan where we inject contrast to have a look at the valve in more detail and we do lots of measurements to work out how big the valve is, how calcified it is or how it's become hardened over the years and then how we may be able to fix it. Other tests involve an x-ray which looks both at the heart size but also at the lungs to see if you've got some fluid in the lungs as a result of your valve disease. And when you've got narrowed aortic valve, there are some other conditions that can also cause very similar symptoms, such as chest discomfort and shortness of breath, that coexist or can occur in a high proportion of patients with severe aortic stenosis, such as coronary artery disease. So, we do tend to do an angiogram to look at the coronary arteries, either with a CT, or invasively through a little tube in your wrist to ensure that there is no other pathology or other abnormalities from a heart perspective that are causing those symptoms. We do routine blood tests to check kidney function, make sure you're not anaemic, or it means you don't have a low haemoglobin reserves or oxygen reserves in the blood that can also cause some of these symptoms. And we look for specific cardiac markers in the blood as well. And this is quite comprehensive because we want to get a picture of you as a person and your pathology, which is the abnormality that we find on your ultrasound, which in this case is severe aortic stenosis, because we want to work out how we're going to be able to fix this and what the specific risks may be for you as the patient. (H) Thank you, Dr. Yudi. So, look, we can see that if a GP has concerns about your heart symptoms, they might order an echo or echocardiogram. And that's a non-invasive way of having a look at the chambers in the heart and the valves. Sometimes there might be some additional tests, but all of this is really important to understand what's happening with the heart on a second-by-second minute by minute basis. If listeners have any other questions, they can visit the resources listed in this module to find out further information and next we're going to be thinking about if you're diagnosed what happens next. (Voice over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 5 of 10 on heart valve disease and in this unit, we're going to explain why many people are monitored rather than treated straight away, what monitoring looks like in practice with regular follow-up, what changes clinicians are watching for over time, can medicines reverse valve narrowing, that's a question that we're going to dive into, and why timing of treatment matters. Dr. Yudi, if someone is diagnosed with heart valve disease such as aortic stenosis, is treatment always recommended straight away? (Y) Rob, this is a great question because as we've talked about, aortic stenosis develops slowly and over a long period of time. So, if your heart valve is functioning well and the aortic stenosis is not causing any symptoms and your heart is not getting tired as a result of this, no active treatment is needed. But in saying this, it's important to realise that if there's any degree of stenosis or narrowing, we know that this condition gets worse with age. So, you will need to have regular check-ups and you need to have in the back of your mind these symptoms of chest pain, shortness of breath, decrease in exercise capacity as you progress over the years because it could be a sign that things are getting worse. If you're not severe enough to cause symptoms or need any intervention, then you will have ongoing tests and that all depends on how bad your valve is at that particular time. For example, if you only have mild aortic stenosis, your next ultrasound may be in three to five years. Whereas if you have moderate to severe aortic stenosis, that would be done within 6 to 12 months. And that is something that the cardiologist or your GP will determine just based on some of those numbers that we've talked about and how close you're getting to that threshold of severe aortic stenosis, and also most importantly, what your symptoms are. So, if your symptoms are getting worse and the ultrasound is not matching your symptoms, there may be other tests that we need to look at to ensure that this test is not missing your severe aortic stenosis. And even though echocardiogram is a wonderful test, there is also an operator dependency. So you may not be able to have the most beautiful pictures between your ribs, so they could miss some of the narrowing, so that’s whys it is important to keep a close eye on your symptoms and your aortic valve with your cardiologist and your GP, especially if your symptoms are progressing. (H) Sounds like if you've got mild disease, maybe you expect to get retested every two or three years, moderate to severe, maybe every one to two years. In this waiting period, are there particular red flags or signs of progressing disease or worsening disease that patients should be looking out for? and, when do we intervene? (Y) It's great that they've got a diagnosis of aortic stenosis and that they're invested in their own health and they are aware of what symptoms to look out for. I think that's really, really important. And know that this gets worse over a period of time. And we need to pick the right time to intervene because any intervention carries some risk. So, if you do it too early, the patient will have some risk with the procedure without really any of the benefits. And if you leave it too late, then the risks are incremental. So, you've got to find that sweet spot when the valve is bad enough to cause problems and then the benefit will be greatly in the patient's favour without a lot of risk. And when we're talking about what are the signs that it's time to intervene, it really comes down to the patient feeling the valve being too narrow, so they're getting breathless, doing things that they could previously do. They get chest discomfort. Their blood pressure can actually drop, and they start to feel dizzy or lightheaded because there's not enough oxygen getting through that valve. So, if you're getting those symptoms and your valve is severe or there are signs that the heart is getting too tired along with your severe valve, then that is the perfect time to intervene. (H) And when the cardiologist, the technician who does the echocardiogram is repeating these tests, what specifically are they looking out for that might be a sign of the disease getting worse? (Y) We take a lot of parameters during an echocardiogram. And with aortic stenosis, we're looking at the pressure difference between the left ventricle and the aorta. And we're trying to find what that pressure difference is. And that does get worse, usually a couple of millimetres of mercury every year. And the threshold, the traditional threshold for this is 40 millimetres of mercury. And that's what they're looking for there. They calculate the valve area. So how big is the little valve opening? And a number less than one centimetre squared, again, is suggesting that the valve is severe. So, we look at the valve in great detail and looking for those signs that it is severe. But we also look and see if the muscle or the left ventricle is getting tired as a result of having to push blood through this severe narrowing so that the muscle can get very thick because it's got to work extra hard. And then at one point, it starts to get too tired. So, the thickening leads to increasing enlargement, and then very much inefficiency. So instead of being able to pump out 60% of blood every heartbeat, you may only pump out 30%. So, the heart is really getting fatigued from pushing against this resistance. So, they’re all these little markers that we look for on the echocardiogram, and then we try to put that together with the patient's symptoms to work out when is the right time for them to undergo some sort of intervention to treat the aortic valve. (H) And I think that's what I want to dive into next, so are there any medicines that can slow the progress of heart valve disease? (Y) I think it is important to note that there's no medications at this point in time that slows down aortic stenosis progression, or they can treat it. This is a mechanical problem, and we've talked and we've given an analogy of the valve being like a door that's not opening. So, if the door's not opening, we have to get a new door or repair that door, so it works properly. Tablets, unfortunately, can't do anything to fix that. (H) As a cardiologist, what questions do you think are helpful for someone to ask after the diagnosis? (Y) As a patient, it is very, very important to ask as many questions as you can. And there's lots of great literature out there for patients, like the National Heart Foundation, that talk about this in great detail. But the important things to really ask about is about the severity of your aortic stenosis. Also, to discuss what the treatment options are now or will be in the future. How are you going to choose the right time to intervene? And what that intervention will look like. So, they're really key questions. You need to look after your overall cardiovascular health really well because it can also cause problems as we age, such as high blood pressure or high cholesterol, diabetes and obesity. All of these things can also lead to symptoms and other forms of heart disease. It is really, really important that we look at holistically, as you age, all the cardiovascular risk factors as well as valvular heart disease. And then the most important thing, as a patient, you want to make sure that when it's time to get it fixed, to go to a place that fixes these things all the time and have that expertise on how to fix it and what's going to be the best treatment option for you, not only now, but also for the rest of your life. (H) Look thank you, Dr. Yudi. So, we can see that once aortic stenosis is diagnosed, we don't necessarily need treatment straight away, but monitoring is critical. And that may depend on the severity of disease, requiring an echo every, say, two to three years if it's mild, or maybe every year if it's moderate or severe. And there's particular changes in the structure of the heart that the cardiologist that will be looking for in order to determine when the time is right to intervene. So, it's important to be aware of the process that's happening but also to ask these questions like how severe is my disease, and how often will I need follow-up as Dr. Yudi mentioned. Look listeners can visit the resources listed in this module to find out further information about this section and next up we're going to be looking at what you can do day by day. (Voice Over) The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit six of ten on heart valve disease. In this unit we're going to explain what lifestyle and daily habits we can use to support cardiac health, how to exercise and stay active safely, managing other health conditions that can affect symptoms and aortic stenosis, the importance of noticing any changes to your condition and who to report changes to. Welcome back, Dr. Yudi. How important is it for people living with heart valve disease, such as aortic stenosis, to think about their lifestyle and daily habits? (Y) Let's take a step back, Rob. And cardiovascular health in general is so important, particularly as we age. And I think this is something that we should be doing, irrespective of whether you've got valvular heart disease or aortic stenosis in particular. Because factors such as high blood pressure, high cholesterol, being overweight, they all carry risks of developing other cardiac conditions, such as putting you at risk of having heart attacks and strokes, which can be very devastating. So, it is really important to get these numbers checked and appropriately treated and without a doubt, the best intervention are lifestyle measures of changing diet and being based on the Mediterranean diet with lean meats and vegetables, exercising minimum of 30 minutes a day. But we know that the more you exercise and keep active, the better you do long term, not just from a cardiovascular perspective, but in general. We know that smoking is a very, very poor prognostic marker from a cardiovascular health, but multiple other cancers as well. And minimizing alcohol intake has been, again, associated with many cardiovascular conditions, such as atrial fibrillation and weakening of the heart or cardiomyopathy. So, these general lifestyle measures are invaluable for you to live a long and healthy life. We know a lot about sleep and we're learning a lot more about this and that is essential. And trying to get seven to nine hours of sleep a night is associated again with better long-term cardiovascular outcomes. And when you're putting all this together and with a great relationship with your general practitioner, you will be able to both manage these risk factors, which will decrease your risk of having cardiac concerns. And then if required, you'll be able to pick up any abnormalities early and with greater technology that we have available, you can be treated early and do very, very well with minimal symptoms and a normal life expectancy. So, heart health is without a doubt something that can be prevented and treated appropriately early to lead to a very good outcome. (H) I think that's great advice. Now, let's talk about exercise for a second. People may have a fear of symptoms during exercise. How much physical activity is safe when someone has aortic stenosis? (Y) When you're talking about aortic stenosis again we need to see where you're at on the spectrum. So, you have had a great GP that's listened to you. You've had an echocardiogram that has confirmed the diagnosis. And then you're going to see where you are on the spectrum. Are you mild aortic stenosis, moderate, or are you severe? If you have severe aortic stenosis and you're getting symptomatic, this is not a good time to start running up hills or doing extraneous exercise because oxygen can't get through that valve. So, you would carry just normal activities of daily living and stop when you have symptoms because you need to get appropriately treated. But if you have mild aortic stenosis, or moderate aortic stenosis and you're doing well, there shouldn't be any fears of exercising, and actually, the more you do, the better you're going to do overall. Exercise is not going to slow down your progression of aortic stenosis, but it will increase your cardiovascular health in general and decrease the risk of other conditions, such as coronary artery disease or narrowing in your arteries, that can coexist with aortic stenosis. It is always important to get a cardiac check before you start a new exercise regime. But if you have the diagnosis of aortic stenosis and you're not in that severe range, I would encourage you to continue doing as much as possible while you're listening to your body. (H) Now often conditions like aortic stenosis, they don't exist in isolation. There's often other health conditions that patients might have at the same time. What are some of these conditions and some of the symptoms that they might be looking out for? (Y) It's funny because cardiology can be quite simple because the symptoms that as cardiologists, we look out for, I normally just put them down to chest pain, shortness of breath, palpitations or feeling your heart racing or feeling dizzy and lightheaded. They're really the main symptoms. And then you've got consequently other symptoms such as fatigue and lethargy and not be able to do as much. But it's usually because one of those first four symptoms. So, they're the symptoms that we really always knuckle down on. And that can be symptoms of aortic stenosis like we've talked about. But it can also be symptoms of other conditions, other valves getting narrowed or leaky. It can be symptoms of coronary artery disease, which is narrowing in the arteries. And it is really, really important that we look at the overall cardiovascular health because everything is very much intertwined. The biggest fear is not so much symptoms because when people have symptoms, they usually ask for help. It's about picking up things before they have symptoms. So that's why, again, getting your heart health checked with your GP is so important., so they can check your blood pressure. They can check your cholesterol levels. They can make sure that you're not getting diabetes or you're having insulin resistance, so, this pre-diabetic phase. They can talk about your weight and potential ways that you can decrease that while you're increasing your exercise capacity and improving your diet. Because if you're doing all those right things, you know, and you're getting screened we're very lucky to live in a country like Australia where you will do very, very well and you should be able to live well into your 80s and 90s and living well. (H) I've talked in a previous section about monitoring for some of these symptoms and keeping an eye on where we're at in terms of aortic stenosis. Is that correct? Can we monitor ourselves and what are some of the things that our GPs, our cardiologists, and even our family can be looking out for to monitor this condition over time? (Y) The first thing is if you've got aortic stenosis, you need to have ongoing surveillance, ideally for the rest of your life because we know that valve will get worse. And that depends on where you're at on that spectrum, how routinely you may have those echocardiograms that we've talked about. But you want your family and friends to be aware of any changes that they see in you. Because if they're noticing that you can no longer walk around the golf course and you're taking a buggy, that could be a sign that your aortic stenosis has gotten worse because you're not getting enough oxygen to be able to do those little things. So that's why having family and friends involved in your care and noticing the little things is very, very important. We briefly talked about congenital aortic stenosis. If you have a family history of a bicuspid aortic valve, it is recommended that all family members get screened at some point. We tend to do this once people are out of high school, and what it does is going to be able to dictate if you need ongoing clinical surveillance or whether you're going to need ongoing ultrasounds, usually over a period of three to five years for the rest of your life, or whether you don't need to do that at all, unless you get symptoms or unless you get to the age of 60 and beyond and have a murmur on a clinical examination. (H) Now, we've touched on this again in previous sections, but who should people speak to if they notice any changes in their symptoms? Who's the point person in a patient's life, in a patient's journey? (Y) Look, having a great general practitioner is the key to your overall health. And if they have been managing your aortic stenosis, that would be the first port of call. If you have got aortic stenosis, the first person to talk to is your GP, who you have known for a very long time. If you have seen a cardiologist about your aortic stenosis in the past, they will have a plan on how to treat that when you got to that severe range and you're starting to have symptoms or signs that the heart's getting fatigued as a result of that aortic stenosis. So, I'm sure that I speak on behalf of cardiologists that if you have a cardiologist and you have aortic stenosis and you're feeling worse, they'll be more than happy to see you because they know how important it is to treat that urgently at that time. (H) Thank you, Dr. Yudi. Look, listeners can visit the resources listed in this module to find out any additional information. Next up, we're going to be talking about your care team, what the heart team means. Voice Over The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 7 of 10 on heart valve disease. In this unit, we're going to explain what is a heart team, including what an interventional cardiologist is, who may be involved with your care, who will see you in follow-up, how treatment decisions are made, shared and reviewed, and what the heart team approach means for patients. Specifically, what's your role as a patient within this heart team? Dr. Yudi, when our diagnosis of aortic stenosis is made, who can the patient expect the GP to refer them to? Do they have any control over who they'll be referred to? So, what does that first step look like? (Y) If you've got severe aortic stenosis, it is paramount to be referred early. That's the most important thing. And ideally, you get referred to a heart valve team. GPs are very well versed now on aortic stenosis. And I guess the key is that you want to be referred to people that are involved in this procedure and have the whole infrastructure, so they know what's best for the patient. In saying that, the current landscape in Australia is that you refer to either hospitals or individuals. But the key is that they should be part of that heart team. And there are heart teams all around Australia, which are very, very good. As a patient, you have the choice to go to whoever you like. And I think that that's really, really important. And you can do your research online, talk to friends, I guess you want to know who does the most of these procedures. And it's important to remember that it is not just individuals. You're talking about teams, right? And that is important when we talk about the different treatments that are available. In summary, in a severe aortic stenosis, you need to be referred quickly, and you need to be seen quickly. And then you want to be part of a team that can offer all spectrums of treatments from minimally invasive aortic valve replacement to open heart surgery, depending on your condition. (H) Dr. Yudi, so people are diagnosed with a heart valve disease, they may need to see various health professionals along their journey. Can you tell the audience who typically is involved in caring for someone with aortic stenosis? (Y) Rob, this is an area that's evolved so much over the last decade because we have now specialised heart valve teams. As the patient, I think the most important thing is to get the diagnosis and have surveillance as required until symptoms develop until you have severe aortic stenosis. At that point in time, the most important thing is to be assessed by a heart valve team, which includes general cardiologists, interventional cardiologists, cardiac surgeons. And then you've got the broad team, and probably the most important person is the valve team coordinator, who coordinates all your tests and your care, and there’s anaesthetists and other allied health teams that are involved. And it is really, really important to get the concept of a heart valve team, because everyone's got different sub-sub-specialties and we need to come up what's the best treatment decision for you and when is the best time to intervene for you. So, we've talked about the symptoms, we've talked about the workup. We've talked about all the investigations that need to get done. When all of that is done, what we do is we actually sit down in a room, all of us, and we go through the patient's clinical information, all their other medical conditions, their age. We review the ultrasound. We review the CT. We review the angiogram. And then we discuss what are the least risky option for treatment, and what's likely going to happen to that patient over their lifetime. So if you've got severe aortic stenosis and you're 80, we're looking at the next 10 years, which will be a very good outcome for them, which will be completely different to someone who may be 50 and has got bicuspid aortic stenosis, who's going to be around for another 40 years. So, this really influences how we are going to treat that person and how to come up with the best treatment option for them at the particular time, but also to ensure that we do the best for them for the rest of their lives. (H) So, we can see there's a number of players in the heart team and they're heavily involved with decision making and ultimately outcomes. Let's just slow it right down for a second. In order, what is the kind of sequential order of people that patients will meet in this heart team as their journey evolves from diagnosis of heart valve disease? (Y) Once you get a diagnosis of heart valve disease, if it's not at a stage where it needs treatment, it needs surveillance, that can be done by general practitioners and cardiologists or general physicians. So, there's very clear guidelines on how often people need to have an echocardiogram and examine clinically until we get to a stage where you need intervention. When you need intervention, usually the best way as a patient, would be to get assessed by a heart valve team. And you may be seen by a primary interventional cardiologist or a primary cardiac surgeon, or a primary echocardiographer who's got expertise in aortic valve disease. So that will be the clinical point of contact. And then we usually, after the workup, we all sit down together. We usually have enough information on that patient to be able to come up with a conclusion of what that treatment option is going to be. They usually have met the person who will be involved in the particular intervention, whether it be the interventional cardiologist or whether it will be the cardiac surgeon. (H) So, it sounds like in Australia, it's part of the management of aortic stenosis that the team makes these decisions and is heavily involved. Is this something that happens face to face in a room? Is this something that happens online or through correspondence? And who ultimately makes the decision about care and about what particular treatment is appropriate? (Y) Rob, this is one of the greatest things for patients is that you don't have one person making a decision. And everyone becomes accountable for the best treatment option for that patient. So, the heart team, they don't all have to meet the patient, but there are intricate people that are usually with the patient all the time, particularly the heart valve coordinators who coordinate all the care, who follow up the tests and arrange the appropriate appointments. But the heart team in itself when we're all there we sit down and review everything we actually look at the pictures we look we scan through the whole body from the legs to the heart and work out what are the potential risks what's potentially feasible and how we can potentially treat that patient, that meeting about the patient that gets done without the patient because it's a very technical meeting where we calculate risks where we discuss how we're going to best treat it and what are the potential issues, both during the intervention and also down the track. So, we come with a team consensus. So, after every patient gets discussed, there is a recommendation. And then that gets portrayed to the patient. And usually our valve coordinator gets in touch with them all after that meeting's done. The patients already know what the potential options are. And they've been given enough information, and they've talked to our coordinators in great detail. But only once we've reviewed all their tests and their anatomy, then we can come up with firm recommendations for them. If you're a rural patient, I urge you to come to the big centres that assess these patients and do these procedures because it'll mean that you'll have the best long-term outcome. It doesn't mean that you have to come all the time. You just come in potentially just for your workup and potentially for your intervention and then you can have everything else done rurally where you're from. I think the key is to have big centres that are specialised in these conditions, and its usually once-in-a-lifetime intervention. So, it is a small price to pay to come to these big centres, but I think it is worth it, so you have the best short and long-term outcomes. Unfortunately, there are no rural centres that can provide this high-level technology, both in the public system and in the private. (H) So, it sounds like there's lots of people involved in a heart team. They all have different specialties or maybe a different vision on what's happening and ultimately, they are there to give the best advice personalised advice for that particular patient and then once all of those individual specialists have got together, they can communicate that one plan. My question next question is what is the role of a patient in the heart team? (Y) The role of the patient is they are the centre of the heart team. So, we are working with the patient to try to give them the best treatment options for them, depending on obviously all the medical history, their age, and also their wishes. But we want to educate them to ensure that they're also on board to work out what is the best medical recommendation for them and whether that fits into what they want done. I guess most importantly is that we know that if we don't treat aortic stenosis, people do very badly if we don't treat it over the next few years. But once we treat the aortic stenosis, they do really, really well and they go back to living a normal life. So, the key message we get across to those patients, and then we work more on the individualised recommendations for them once we've had all their imaging. (H) So, we can see there's different participants in this heart team. The patient is at the centre of this heart team and the whole goal of this is to have a fantastic, personalised outcome which is individualised to the patient to ultimately improve their long-term outcome, their cardiac and overall health. Now listeners can visit the resources listed in this module to find out further information. Next up, we're going to be looking at when treatment is needed and what the options are. Voice Over The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 8 of 10 on heart valve disease. In this unit we are going to explain how aortic stenosis typically progresses, at what stage your doctor will consider treatment, what the main treatment options are, how risks, benefits and recovery can differ between people or procedures, and some questions to ask your heart team about which option is best for you. Dr. Yudi, can you please refresh our listeners on how aortic stenosis worsens progressively over time and at what stage you would want to start treatment? (Y) Aortic stenosis is just a stiffening of that aortic valve and that gets worse as we age, but it gets worse very slowly. The most important thing is to get a diagnosis of aortic stenosis and then follow that through and be on the lookout for symptoms such as breathlessness when you're walking, exercise intolerance, chest pain or feeling dizzy and lightheaded. And also, you'll be having ultrasounds over a period of time, echocardiograms, which will also look at the valve and seeing how the heart is coping with that restriction. And when we've got symptoms and we've got markers that the valve is severe, that is when it is time to intervene. Before then, you're not going to get great benefit out of this at some risk. And if you pick the right spot, you'll have minimal risks with the maximum benefit, both in terms of symptoms, so you'll get better, and also you will live normally without any treatment, unfortunately patients do very poorly over the next one to two years. (H) Okay, so we've talked about how aortic stenosis is a structural issue and so the main treatment is aortic valve replacement. What are the options and how do they differ? (Y) Aortic stenosis needs to have that aortic valve replaced. And traditionally we'd only do this with surgery, which would mean a cut in the front of your chest, open heart surgery, take out the valve and put a new one in. What's great now in 2026 is there's been huge development in technology over the last two decades. And now we have transcatheter aortic valve replacement, which is minimally invasive, we put a tube in the femoral artery or a blood vessel in your groin and we're able to feed the valve from the leg to the heart and get you a new valve that way. And that's revolutionised the way that we can treat this condition because this can now be done under sedation. So, you don't need to have a general anaesthetic. You don't have to be intubated. You don't go to ICU. And most of our patients go home within 24 to 48 hours. So, this has been a game changer, particularly when we think about the patients that are getting treated, which usually tend to be elderly and who do not want to have major upfront risks from any more invasive procedure, such as open-heart surgery. (H) And who makes the decision as to whether a surgical aortic valve replacement or a transcatheter aortic valve replacement is most appropriate? (Y) That is a sensational question, the key to how well patients do is that they become part of a heart valve team. They have the whole work up and then they get discussed in a big multidisciplinary team meeting where we ascertain what are the best treatments for that patient. Like you said, based on their age, their health, their anatomy and their personal preference. And we look both at the risks now and also for the rest of their lives. And that's how we come up with a conclusion whether that patient would do better with something minimally invasive or something more extensive, like surgical aortic valve replacement, that may have other benefits for them down the track. (H) Let's divide it into those two surgeries now and I'll get you to explain each one individually. So, can you let the audience know what happens during a surgical aortic valve replacement first? (Y) This is the traditional way that we use to treat severe aortic stenosis. So, this is performed by cardiac surgeons, and this is done in an operating theatre under general anaesthetic, so you are completely asleep during this procedure, and you have a lung machine breathing for you. The surgeon then opens the chest, the breastbone at the front of your chest, and they can see the heart directly and then you go on bypass. So, you have a machine pumping blood to the rest of the body. The surgeon removes the valve and then he puts a new one in place and stitches it at the right place between the left ventricle and the aorta. And then they close up your chest. You tend to go to ICU for a day or two, and then you come down to a step-down ward. And you're usually home within seven to ten days. (H) Okay. And what about recovery? So, what's the recovery time? What does that look like with the open chest surgery or the surgical aortic valve replacement? (Y) Yeah, look, it's a bigger upfront risk investment. I think it is important to know that you do spend a day or two in the intensive care unit. Then you still have a big wound in your chest and that takes about three months to heal. So, during that time you cannot do excessive lifting because you don't want that breastbone to be moving and you want it to heal as well as possible. You tend not to feel quite yourself for a good four weeks. But after that, you do get your strength back and you start doing normal activities. And by three months, you're completely back to normal. (H) Now, you talked about this other procedure, the TAVI procedure. Again, can you walk us through what actually happens with that procedure and what is the expected recovery look like? (Y) TAVI is very different to a surgical valve replacement. You'll feel in a much more relaxed environment because you'll be awake. You'll be talking to the anaesthetist who will be giving you some light sedation. Your interventional cardiologist will be there, and they'll be performing the procedure. They'll put local anaesthetic over your femoral artery, which is the artery in the groin of your leg, and then they put in a catheter or a small tube inside that blood vessel, and that would lead to the aortic valve. Using an x-ray machine, we take different photos, different pictures, and then we release the valve in the right place, and the valves that we have push your old valve aside, so they have a stent frame, and inside there you have very beautiful leaflets that are very thin and mobile, not the heavily calcified leaflets that you have in severe aortic stenosis, and they start to function straight away. Once the valve is deployed and we see it functioning well, then we remove that tube that we use to deliver the valve, and we put a little stitch in the leg and you're out of the interventional cardiology suite. And that usually tends to take about 60 minutes. You go back to a cardiology ward and the only annoying thing of this is that you tend to lie flat on your back for about four to six hours. You don't want to have any major bleeding problems for when those tubes went in. But you're usually out for the next big meal and you're walking around that night and the next day you have an ultrasound of your heart, an echocardiogram, you get a blood test. And if everything looks good, we're pretty comfortable at letting you at home at that point. The recovery is, I encourage my patients to get up and about and do normal walking. For the first week I don't want them to be doing any heavy lifting or any running, just so that wound in their leg heals. But after that, I'm very, very happy for them to do everything and really test out the new valve. And they should feel a lot more energy and a significant decrease in their symptoms because they're no longer pumping blood through a very narrowed calcified valve. (H) Dr. Yudi, are patients sedated and how heavily are they sedated? (Y) One of the great advantages of the TAVI procedure is that it is no longer done under general anaesthetic. So, you don't have the risks associated with that and you don't have the aftermath of general anaesthetic as well. But in saying that, you are sedated so you feel comfortable, you feel sleepy, and most importantly, you don't feel pain of the procedure, the anaesthetist gives you something for that through the drip in your arm, and also the cardiologist puts plenty of local anaesthetic in the leg where they're going to put the tubes and deliver the valve from. So even though you may hear some things, you're not living through the procedure bit by bit, which is very reassuring, although some patients do love to know what's going on. But the key is for you to be comfortable and to get a great outcome. (H) Dr. Yudi, I know that sometimes it can be challenging to know whether a TAVI or a SAVA is the most appropriate procedure. And we hear about some new technology and with the TAVI interventions, and we lean towards that. Why is SAVA still offered, the surgical procedure still offered? And is that sometimes the better or the preferred procedure than TAVI? Or should every patient be looking to have this TAVI procedure? (Y) Rob, that is a sensational question and it's something that we encounter from patients all the time. If you had to choose between having a big cut down your sternum, being in an ICU, not being right for three months versus coming in and out in 24 hours, you will choose the minimal invasive approach every time, and this is why we've got these heart teams, is that we are not looking at things in isolation. We want to work out what is the best thing for you, for the patient, both now and in the future, based on so many factors, including your age, what other heart abnormalities you may have, what other risk factors you have, what other comorbidities you have. So the treatment for, let's say, my grandma who's 85 with severe aortic stenosis, we want her to get to 90 and beyond, minimally invasive, is completely different to what we think about when we've got a 55-year-old with a bicuspid aortic valve where the TAVI hasn't been tested in this kind of condition. So even though they both have severe aortic stenosis, they're completely different people outside of their aortic stenosis, and our goals completely different. That is why it's so important to be part of a great heart valve team that has your best interest at hand, both for your best outcome now, but also into the future, taking into account so many other factors. And sometimes, unfortunately, the best long-term solution for a patient is to have open heart surgery. (H) And Dr. Yudi, are there any new medications or medication changes that happen after either of these two procedures? (Y) Usually there's no major changes. If you are on a blood thinner for other reasons, for example, if you have atrial fibrillation and you need a blood thinner for that, then you go back on that normal blood thinner. If you're not on any blood thinners at all, you tend to go on aspirin, 100 milligrams, a little baby aspirin. And that is the only new thing. But most people are on some type of blood thinner for other conditions before they get to us. (H) Now, I mean, patients probably have lots of questions when they're confronted with aortic stenosis and potential surgery. What are some good questions about treatment that listeners can ask their cardiologist about the procedures and about the workup for this and the recovery as well? (Y) Yeah, look, I think we've touched on a few of those already, but I think as a patient, it is important to really take your own view and your own preferences into account, and make sure you have that at the forefront of the questions that you have for your treating team. More generically, I think you need to ask what are the risks with the interventions, both short and long term, and how long the valves are going to last for. And I think that's very important if you're a younger patient. It's very different if you're in your 80s to in your 50s because you may need multiple interventions in your lifetime. The benefits are really, really important for you to ask and also to have clear in your head that you're doing this for symptoms but also to live longer and there's different alternatives as we've talked about between surgery and minimally invasive transcatheter aortic valve implantation. Ideally, you would have gone through a heart team, a very good heart team that does a lot of surgery and lots of TAVI and have experience with multiple valves, so they're able to choose the best treatment and the best valve for you. It is important to have a good idea of the small risks associated with both procedures and a timeline of what recovery looks like. And then lastly, look, we do consent all patients for a blood transfusion, whether you're having surgery or minimally invasive TAVI. And if you for some reason, do not want to have a blood transfusion, it's important to make that very, very clear. And if you have any concerns, and something hasn't been explained to you properly, remember that you're the patient and you're the one who has to undertake this. If you feel uncomfortable, feel free to get a second opinion or ask for another appointment to discuss other issues in more detail or do your own research and then come back with a list of questions with both you and your family so you can make sure that you're all on board. (H) Thank you, Dr. Yudi, for going through the surgical options that our patients have when it comes to aortic stenosis. Listeners can visit the resources listed in this module to find out further information. Next up, we'll be looking ahead to life after treatment. Voice Over The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 9 of 10 on heart valve disease. In this unit, we are going to explain what your life could be like after treatment compared to without treatment, looking at the recovery and rehabilitation after surgical aortic valve replacement or transcatheter aortic valve replacement, the importance of ongoing follow-up, potential complications that your team will look out for, and if you will need any new or change in medications. So, Dr. Yudi, if someone has had a surgical aortic valve replacement or transcatheter aortic valve implantation, how could this change their life? (Y) I think the most important thing here is that severe aortic stenosis, if it's left untreated, carries a worse prognosis or people do worse than those with most cancers. So, I guess that is the most important point here. And then with treatment, obviously there's a small upfront risk, but if that goes very well, which it does in 99% of cases, then you should feel better, so you'd have improvement in your symptoms, and most importantly, you'll be able to live a normal life. I think we've touched upon it beforehand, that without any treatment over the next one to two years, people do very poorly. Surgery and TAVI have very, very good success rates, but the important thing here is to choose that best treatment for the particular patient and weigh up the risks and the benefits. Once you have recovered from the actual operation, you should feel much, much better, have a greater quality of life and, as we said, greater longevity in life. (H) So, let's look at the recoveries of each of these individual procedures. So, first of all, I'll ask you about surgical aortic valve replacement. What does it look like in the hours, days, weeks and months after that? How quickly are people getting back to work, for example? (Y) Yeah. So, look, surgery and surgical aortic valve replacement carries a higher upfront risk and a longer recovery. But this is something that has been perfected over many, many decades, and overall, people do very, very well. But you do stay in the intensive care unit for one to two days. Then you go to a cardiology or a cardiothoracic ward, and you tend to be in hospital around seven to 10 days. Some people go to rehabilitation if you're feeling particularly weak, but most people go home, but they're not feeling quite themselves over the next four weeks. And during that time, the first 30 days, you're not allowed to drive. With time, particularly your breastbone that's been cut open heals. And that usually takes about three months. So, in that time, you're not allowed to do any significant heavy lifting. And that is really, really important because you want your sternum or your breastbone to heal really well. And you will have some medications for that definitely when you're in hospital and then when you get home at first. Cardiac rehabilitation is sensational because you learn a lot about yourself, about the heart and about looking after yourself over the longer term. And you have supervision in your exercise capacity. But I think overall, by three months, you should be feeling back to your usual self and have had all the benefits from having this surgical aortic valve replacement. (H) And what about TAVI, so transcatheter aortic valve replacement? How does the recovery process differ with that particular procedure? (Y) Transcatheter aortic valve replacement is minimally invasive, so it's very different to surgery in the upfront risk and the hospitalisation. Patients usually get admitted on the day of their procedure. They have their procedure under sedation, as we've previously talked about. So, they're mildly sedated, but they're breathing by themselves. The first four hours are probably the hardest after the procedure because they're lying flat, because you don't want to have any issues with bleeding from when we put the tubes in the leg. And then they're usually sitting up, eating, talking to their friends within six hours. Most patients will have an echocardiogram next day. And if everything looks great, they normally go home. And I would say, you know, 90 plus percent of patients go home within two days. So, it's a completely different trajectory. Once you're home, you are back to your usual activities in the first week. And the current regulations that you can't drive for 30 days, that is because they're treated at this point in time the same as a surgical aortic valve replacement. But even though the procedure and the recovery is significantly different, I do expect that to change as the law changes, but here, that is the law for VIC Roads. And you are invited to cardiac rehabilitation, which I always encourage people to do. In both surgery and in TAVI, you will need ongoing follow-up for general cardiovascular health and also to ensure that your valve keeps functioning very well for a long period of time. Even though technology is amazing, we have never been able to create a valve as good as the one we were born with. So, the longevity of the valves, all valves will fail at some point, whether they'll be in 10, 15, 20, 30 years, but they'll never last as long as the one you were born with. (H) Now, Dr. Yudi, you've touched on some of this already, but after treatment, what level of follow up should patients with aortic stenosis expect and who will be involved with that process? And maybe will there be any investigations that are done in the preceding weeks and months? (Y) Yeah, look, follow-up is very important whenever you have an intervention. In our institution, I think this is quite common around Australia, is that before you go home, after a TAVI, you have a 30-day appointment with the interventional cardiologist and the heart team, and also you have an echocardiogram to look at how the valve is functioning. If that looks really, really good then you tend to have follow-up once a year thereafter. I do encourage patients to see their GP within two weeks of them leaving the hospital just to touch base with them and to make sure that there's no minor concerns in their recovery. And obviously the GPs are great. If there's any issues, they tend to call us and our valve coordinators directly. After this initial 30 days, Like I said, you should be able to do the normal things that you've been doing. And you won't be burdened for another appointment for that 12 months unless symptoms change. I guess the one thing that it is important that if you're having any dental work, the heart valves are a foreign body, and if there's any bacteria floating around when they're doing dental work, you can go to the heart valve. So, it is important to tell your dentist that, and if they're doing anything major, you will need antibiotics given before they do anything to you. The great news about the 30-day review, if you're a rural patient, is that you don't have to come back to see us. We normally organise for you to have an echocardiogram close to home, and then we'll be able to see you on video via telehealth consultation to see how you're going. We discuss your progress, we discuss your ultrasound, and we review your medications. and then you'll have a chance to ask us any questions or concerns that you have at the time. But you'd be very happy to know that after coming to the city for this procedure, you usually do not have to return for routine follow-up. (H) And in this recovery phase, are there any complications that our listeners should be looking out for? (Y) The common complications from the TAVI would be having pain, usually at the site where the tubes went into your groin. And it is important for you to report if you have increasing pain or if there is any signs of bleeding or any infection. From a valve perspective we do look at the valve the day after your TAVI, and there shouldn't be any concerns that are not picked up on the echocardiogram at that time, so we would be pretty happy with that. But you can develop other heart rhythm issues or some signs of fluid retention. So, if you get any swelling of your legs or you're feeling breathless or faint, then you should come back and get checked out for other associated cardiac concerns. (H) Now, Dr. Yudi, patients are often taking a handful of medications before this procedure. My question is, do these medications, will they change or are there any other new medications that patients may be required to take after a heart valve repair or replacement? (Y) Unfortunately, at this point in time, there is no medications that can treat aortic stenosis or reverse the narrowing. So, there's no specific aortic stenosis medications. So, patients are usually on other medications for other cardiac and non-cardiac conditions, such as blood pressure, cholesterol, diabetes, and they usually tend to go back on those medications. Sometimes if your blood pressure is a little bit lower than normal in the first few days, we do withhold your blood pressure medication and then that's something that we could look to restart at your follow-up. The only thing that we may add would be some blood thinners and particularly if you've been on no blood thinners such as aspirin, that would be the one medication that we do start after TAVI. But most patients are either on aspirin or other blood thinners for other reasons, and we do restart that for them before they go home. (H) Thank you, Dr. Yudi. So, we can see that the follow-up is slightly different depending on whether patients have a surgical aortic valve replacement or a transcatheter aortic valve implantation, but both require follow-up by the heart team and the GP in the ensuing weeks and months. Listeners can visit the resources listed in this module to find out further information. Next up, when to seek help before or after treatment. Voice Over The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.

Host: Dr Robert Hungerford (H), Guest Expert: Dr Matias Yudi (Y) (H) This is unit 10 of 10 on heart valve disease. In this unit, we are going to explain the symptoms that need urgent medical attention, signs that you should see your doctor straight away, what's normal during recovery versus signs that something is wrong, encouraging you to trust your instincts and know your own body, and where you can find further information and support. Dr. Yudi, to start, what are the key symptoms that should prompt someone to seek medical advice, either before or after treatment? (Y) The most important thing, Rob, is to make sure that you listen to your body. And if you're not feeling right, get it checked out. From a cardiac perspective, it is paramount that you never ignore if you're getting any severe chest discomfort or have any problems breathing, or if you're getting symptoms when you're doing minimal activities. Other symptoms to be concerned about if you're having heart racing, if you're feeling palpitations, when you're feeling like you're going to faint or pass out. I think they're the key in general. If you're having those symptoms, you need to get checked out straight away because it could be something very significant. Particularly after having an intervention like a TAVI or surgery, if you have any fever, any redness over either your sternal wound or your femoral groin axis site, you need to get that checked out straight away. And again, if you're having any of those symptoms of breathlessness, chest pain, dizziness or light headedness and heart racing, you should go back to your team straight away. (H) How can people tell the difference between expected symptoms during recovery and something that needs medical attention. Often that's something that we see patients struggle with. Is this normal or is this abnormal? Because obviously they haven't been through this before. (Y) 100%. Look, what's common is to have some soreness from where you've had any sort of incisions or whether it be a major surgery in your breastbone or in your femoral groin access site. So that is common and expected. But if you have those symptoms of chest pain or breathlessness, feeling faint or dizzy, that is not okay and you need to get checked out. And other symptoms such as a fever, so you're feeling hot, signs of an infection, you need to get treated straight away. Your heart team or your GP, they will never get upset if you see them and it turns out to be a minor complaint. But if it's a major complaint that you're missing, then both you and your team will regret this. So, if you have concerns, the key is just to talk to a professional and we'll be able to investigate it appropriately or reassure you and tell you that you're doing very well. (H) I think that's really sage advice. Dr. Yudi, what are some of the key messages that you'd like listeners to take away about seeking help? How can they communicate well and be a good player in their heart team? (Y) The most important thing is that you as the patient, you are the centre of your care. And do not ignore any symptoms that you may have. And don't make excuses such as that you're slowing down because you're getting old. Because this could present something like severe aortic stenosis, which is a very serious condition, but it is a condition that if picked up early, can be treated and you can do very, very well. I think it is important to have a great relation with your GP and voice any concerns you have, and particularly as you age, make sure that you have a heart health check. And if you get diagnosed with any cardiac condition, including valvular heart disease, make sure that you have a plan over your lifespan, whether that would mean ultrasounds every couple of years or more regular checkups for your overall cardiac health or to ensure that you get your aortic stenosis that does get worse with time treated at the appropriate time. Your team that's around you; they'll have your best interest at hand. And sometimes the best thing to do is just wait, even though you may have aortic stenosis. And get treatment at that right time is the key for you. (H) And who should patients contact if they notice changes that are not urgent? And how can they make contact with those individuals? (Y) Let's assume that you have severe aortic stenosis and you're part of a heart valve team. If you've noticed there's any sort of changes, the best person to contact would be your heart valve coordinator. They'll have all your records. They'll know where you are in the disease progress, and they'll be able to touch base with the appropriate cardiologist to be able to organise a review or further investigations quickly. Also, your general practitioner would be a sensational port of contact if you're not part of a heart team because they may be able to expedite other tests or an appropriate referral. If this happens after you've had any sort of interventions, if there are any wound concerns, you would contact your team. And if you're really concerned and it's the middle of the night or the weekend, have a low threshold for going to the hospital that you're getting treated at given your condition either before or after your treatment of severe aortic stenosis. (H) Now do you have any recommendations for where our audience can seek further support? (Y) I think we live in an age where there is a lot of information out there and trusted resources like the Heart Foundation or the Victor Chan Research Institution have great resources that's very pertinent to Australia. There is a lot of information there that you want to verify but be well-educated and ensure that you have the right questions that you can ask your treating team and your GP, and that will lead to make sure that you're very well-informed in your condition and potential treatment options. (H) Fantastic, now we've been through so much information over the 10 units can we end with some tips from you on some simple things that can help people stay on top of their care and feel organised and in control. (Y) Have copies of your surgeries, of your procedures, of your investigations readily available, usually electronic in an email, so if there's any emergencies, you know you have all that information to give to whoever may be looking after you. The key contacts are essential because if there's a deterioration, you'll be able to contact the heart team straight away. And make sure you follow up your appointments, both in the screening phase, so if you have aortic stenosis but you're feeling great, it is important to keep your appointments to make sure that intervention happens at the right time. And aftercare is also very, very important to ensure that not only your valve is working well, but as we've talked about, cardiovascular health in general is going to be paramount to your longevity and your quality of life, long term. So, it is good to touch base with your heart team. And the one tip here is have a sensational GP that you touch base with on a regular basis, who knows you well, and who knows if something changes, who will be able to guide you in the right direction. (H) Thank you, Dr. Yudi, for taking us through all this information about heart valve disease. Listeners can visit the resources listed in this module to find out further information. Voice Over The information presented in this program is for educational purposes only and does not constitute medical advice. It is not intended to replace consultation with a qualified healthcare professional. Always seek the advice of your doctor or other qualified healthcare professional with any questions regarding a medical condition, or before making changes to your treatment.