Our Patients. Their Stories. Barbara Goldman.
A leaky heart valve brought Barbara Goldman to Dartmouth-Hitchcock (D-H) in early 2016. The 85-year-old resident of Brattleboro, Vermont, had been feeling increasingly breathless and was having difficulty doing regular activities, such as cleaning her house. Dr. John Glick, MD, her primary care physician in Brattleboro, first detected that her heart valve wasn’t closing properly, which may have been contributing to her breathlessness. After a referral to D-H from a local cardiologist, Goldman was first seen by D-H cardiologist Edward Catherwood, MD, MS, and then D-H interventional cardiologist Megan Coylewright, MD, MPH. Coylewright, the associate director of D-H’s Structural Heart Disease Program in the Heart and Vascular Center, specializes in a procedure called MitraClip, which she trained in at the Mayo Clinic.
“For many years we’ve had a very successful transcatheter aortic valve replacement, or ‘TAVR’ program, here at D-H, and that’s one piece of a larger structural heart disease program that seeks to provide solutions to patients with heart disease without doing surgery,” Coylewright. “I was brought here to expand that program and one of those tools is MitraClip.”
Goldman and Coylewright recently shared their patient-physician story with D-H Today.
Coylewright: Barbara Goldman underwent MitraClip, which is a type of transcatheter mitral valve repair. In this minimally invasive procedure, performed through a large IV in the upper leg, we are able to reduce the amount of leak from the mitral valve, which is also called mitral regurgitation. Patients are up and walking as early as 4 hours after procedure, and often stay 2-3 days in the hospital without restrictions on discharge home. Patients need to be considered high-risk for surgery, and thus they meet with one of my surgical partners in the initial evaluation. This procedure has been used in over 35,000 patients around the world and was officially approved in the U.S. in 2013 after a decade of research.
Goldman: I had many tests and then set up a time in April to do a MitraClip procedure. I was the fourth patient that they did Mitraclip on at D-H. I was a little scared, but I didn’t have any other choice but to do the procedure. I couldn’t have open heart surgery because of other health conditions, and I was slowing down too much to not do anything about it.
Coylewright: I think Barbara exemplifies a lot of the patients that are good candidates for MitraClip. They are patients who are in their 70s, 80s or 90s who have noticed that they can’t do the same activities that they used to be able to do. Many people in the Upper Valley enjoy walking and being outdoors and find they are having difficulty with those activities. A lot of patients come in with shortness of breath and fatigue. Some patients, like Barbara, find they have trouble with their basic chores at home.
Goldman: I just wanted to do as I've always done—take care of my home, my cat, be able to work in my garden, go get groceries and live my life.
Coylewright: Barbara had very specific goals in mind and wanted to maintain her independence. That is one of the important features of the minimally invasive approach: patients do not have a one to three month of recovery where they need someone to take care of them.
Goldman: My recovery was fine. It was a little slow in the beginning. The procedure was on a Wednesday afternoon and I went home around noon on Saturday. I think the worst part of it is all the tests that you have to go through prior to the procedure. I was amazed at how many doctors were there during the procedure, helping and doing things.
Coylewright: I have an outstanding team, and we could not achieve the excellent outcomes we have without working so closely together. Tim Beaver, MD, associate director of the echocardiography laboratory, and Terrence Welch, MD, provide the imaging expertise, both in identifying appropriate patients before the procedure, and guiding the actual procedure itself. Because we don’t open the body, the only way we can look inside is with an echocardiogram, which is a specialized ultrasound. The MitraClip can take anywhere from two to four hours. You can put in more than one clip in order to further reduce the degree of leak. The procedure varies depending on how many clips you need, which is typically one to three, and we individualize our approach to each patient.
Goldman: I felt better fairly quickly. I’m not feeling breathless like I was before. I’m able to take care of myself and my cat, Peaches. I go out shopping. I can still drive. As far as my heart goes, I feel as well as I can. I’ve continued my life as I was before. I garden in the summer. I knit for RSVP (Retired Senior Volunteer Program). I’ve been knitting since I was 13.
Coylewright: The consistent statement I hear after Mitraclip from my patients is this: “I had no idea how poorly I felt before.” People in this area are very stoic and they are also aging, so it’s often hard for patients to be able to discern whether their shortness of breath or their fatigue is them “slowing down” or actually due to a heart problem that can be improved with a procedure. It is important for patients to see their doctor and talk to them so we can help sort through those symptoms. Shortness of breath and fatigue are very common and people don’t necessarily have to live with that.
Goldman: The nurses that took care of me did a good job of making me comfortable. Dr. Coylewright is a very special lady. She is warm hearted. When I was leaving she gave me a hug. I don’t do that too often with doctors.
Coylewright: We get so many notes about our nurses and how wonderful they are. People write and say, “I felt like I was with family.” The reason that I came to Dartmouth-Hitchcock from Mayo Clinic is because D-H is known for having a unique patient-centered approach, from our clinic schedulers, to our nurses, and including our heart team of surgeons and interventionalists. From a research perspective, we also specialize in the field of shared decision-making. The idea behind studying shared decision making is that we, as clinicians, could do a better job of finding out what’s important to our patients, and using patient preferences to guide clinical care. We partner with The Dartmouth Institute to learn how best we can provide care for patients, especially elderly patients, who are facing a complex array of choices. Not all choices are appropriate for this approach: when I am placing a stent for a major heart attack, we don’t stop to review all of the options. However, in heart valve disease, like Barbara’s, there are many reasonable options, and we are committing to meeting with each patient and their family in a careful approach to ensure their voices are heard. I think that’s what Barbara is responding to—she saw that I wanted to learn what is important to her. And that’s important to me as a clinician because only then can I look back and say confidently that this was the right decision for Barbara.
Click here to read about another one of Dr. Coylewright’s patients.