Heart surgery breakthrough: Toronto surgeon Kevin Teoh
Making life better for patients through innovative procedures is what it’s about for pioneering Canadian cardiac surgeon Dr. Kevin Teoh
In the history of medicine, cardiac surgery is a fairly recent innovation.
“On a relative scale, it’s a baby, a very young sub-specialty,” says Dr. Kevin Teoh, a leading-edge cardiac surgeon at Southlake Regional Health Centre in Newmarket, Ont.
“Heart surgery started in the fifties, so we’re talking about 60 years,” Teoh says. “That said, heart surgery is one of the most common operations in the world these days, due to the prevalence of heart disease. And, it’s amazing how much heart surgery has evolved over the 60 years.”
It’s the excitement of this evolution and ability to extend the spectrum of care for patients that has defined Teoh’s career to date and led him to Southlake, where he’s recently been pioneering a new-to-North America sutureless aortic-valve replacement procedure.
Teoh became interested in medicine while still in high school and enrolled in sciences at University of Toronto, moving on to medical school a couple of years later. But it was a surgical elective under Dr. Richard Weisel, a cardiologist active in both surgery and research at Toronto General Hospital, that cinched his decision to pursue a career in cardiac surgery.
It led to a long educational road for the young Teoh. He obtained his medical degree in 1982 and enrolled in the post-graduate Gallie Program, providing residency training in all surgical specialties, completing his residency in general surgery in 1988 and his specialization in cardiovascular and thoracic surgery in 1990.
While he allows that it was a long schooling Teoh sees the value in it.
“Basically, we’re taking patients, their lives, into our hands every day. Every operation. So you have to be very well-trained and qualified to do that.”
After completing his training, Teoh joined the cardiac surgery group at Hamilton Health Sciences and McMaster University, remaining there for the next 20 years and leading the Division of Cardiac Surgery for 11 of those.
“I built the program up and basically established a good program and good practice,” he says.
Then, in 2011, Southlake beckoned.
“I saw an opportunity in their vision and strategic plan that was in line with what my next steps were,” he says. “Southlake wants to be very innovative and cutting-edge. And that’s the direction that, at this stage of my career, I would like to go.”
Teoh attributes some of Southlake’s predilection for innovation to its CEO, Dave Williams, a former Canadian astronaut who participated in three space flights.
“Clearly his career has always been cutting-edge innovation and he brings that to our hospital,” Teoh says. “Therefore, he’s encouraging innovation and cutting-edge stuff.”
The new heart valve procedure is just one aspect of the impetus to evolve the cardiac sub-specialty to benefit patients, he maintains.
“We’ve been replacing and repairing heart valves for a long time and the results have been very good. But there is, still, room for improvement. Our patients are becoming more complicated. The population is aging, so we’re operating on patients who are much older than in the past and have more medical issues that make the surgery and recovery more complicated. We continue to be challenged by our patients, who come to us with great expectations.”
In October, Teoh presented preliminary findings for use of the sutureless valve at the Canadian Cardiovascular Congress in Toronto. He told his colleagues that the procedure is a cost-effective option when compared to valves used in minimally invasive implant surgeries that are more than double the cost.
Says Teoh: “The whole goal is to maintain a quality of life and hopefully, at the same time, extend somebody’s life. Those are the two major reasons we operate on people.”
Today’s older population has greater expectations than previous generations, he notes.
“They say ‘I can’t play tennis anymore’ and that is not good enough. It’s fantastic when they’ve had their surgery and they can play tennis again and they’re very, very happy!”
WOW Factor Surgery
When he started out, Dr. Kevin Teoh says replacing a heart valve in a 60-year-old carried something of a “wow” factor. Today, that operation is commonplace for 70-, 80-and even 90-year-olds. Most recently, 94-year-old Thunder Bay resident Victor Lawrence got a new lease on life from the sutureless procedure.
“We couldn’t believe my father was back in his room 13 hours after surgery and walking the next day,” says his son, Doug Lawrence. “For somebody who’s five-and-a-half years away from 100, it really makes you stop and think.”
Sutureless heart valve surgery quicker, less invasive
A new sutureless aortic valve being pioneered for replacement surgery, is both “evolutionary and revolutionary,” says Dr. Kevin Teoh, who has performed more than two dozen of these surgeries at Newmarket’s Southlake Regional Health Centre.
“It takes us to the next step, making the operation easier, faster and less complicated,” he says.
“It’s a big step from the conventional (surgery),” agrees Dr. Ray Guo, a cardiac surgeron at London (Ont.) Health Sciences Centre (LHSC) where 12 of the new valves have been implanted. “It’s a lot quicker operation. You don’t have your hand in the aorta so the chance of causing damage is minimal. It’s a small incision and you just put the patient on the (heart-lung) pump for 15 minutes.”
Southlake and LHSC are two of five Canadian centres where the new valve is being used, others being the Montreal Heart Institute and Toronto’s Sunnybrook Health Sciences Centre and Trillium Health Centre.
The conventional surgery to treat aortic stenosis, where the valve narrows and becomes stiff, restricting blood flow out of the heart, performed for more than two decades, involves opening up the chest, putting the patient on a heart-lung machine, cutting out the old valve and sewing the new one into place with about 12 to 15 sutures, a procedure that can take several hours.
With this new product, a much smaller incision – opening only half the breast bone instead of the entire breast, Teoh says – is required. The old valve is removed and the new one inserted and a titanium alloy frame expands, holding it in place.
Another procedure that’s been performed for about five years is the TAVI (transcatheter aortic valve implementation) inserting the replacement valve via a catheter in the femoral artery through small incisions in the groin.
While this procedure is the most minimally invasive, it does have some drawbacks, says Guo. A major one is the fact that the old valve is left in the chest, simply pushed aside and often it has become calcified over time. Thus there is a risk of pieces of calcium breaking away and getting into the bloodstream, potentially causing a stroke.
The target group for the new device, at this point, is the 75-plus population. These patients may require other procedures such as a bypass, prolonging the surgery time. “It’s not unusual to have to deal with both at the same time,” Teoh says, explaining that the sutureless valve can make the operation shorter and safer.
In time, he says, it may become the standard. But it will take time to produce the necessary evidence that it’s as durable as the conventional valve.
Both Teoh and Guo believe this will be the case.
It’s a natural tissue valve, made from bovine pericardium, a strong, fibrous material that forms the sac around the heart in cows. In addition to specially harvested pig valves, sutured valves are now also made with this material.
“That, hopefully, will translate into the durability we’ve already seen,” says Teoh. He’s encouraged that initial concerns that the valve might not stay in place or that the lack of sutures might result in blood leakage have not been issues in the more than 100 operations performed to date.
The valves are approved for general use in Europe, but currently available here under Health Canada’s special access program, meaning physicians must apply for approval for each use, while the government assesses the risks and benefits.
As with most new technologies, there is a price premium.
Guo notes that the cost of the sutureless valves – at $7,000 to $12,000 – can be twice that of the conventional ones.
However Teoh notes that with time and competition, as market forces coming into play, it’s likely the prices will go down.