A lifetime of valves

21 years ago, that is when Dr. Donald O’Neill’s difficult heart health journey began. The patient, who is also a longtime orthopedic surgeon in Hampton Roads, Virginia, was diagnosed with a bicuspid aortic valve in 2004 along with an associated aortic aneurysm. The appropriate treatment at that time was an aortic root replacement, which he underwent successfully at Sentara Norfolk General Hospital. These were the days before transcatheter aortic valve replacement (TAVR). When a surgically implanted valve failed, the only option was another open-heart operation.

Dr. O’Neill’s initial porcine valve lasted from 2004 until 2018, an impressive 14 years. That durability was no accident; it reflected the deliberate planning that went into selecting the right valve for him at the time. By 2018, however, the valve was predictably showing signs of failure. He was evaluated by the structural heart cardiology team and cardiac surgery team at Sentara Heart Hospital to determine whether he should undergo redo surgery or a transcatheter valve-in-valve procedure.

Due to the heavy calcium that had developed around the valve, he was deemed inoperable. The plan was to proceed with TAVR. However, he arrived back at the hospital with acute heart failure from a ruptured valve leaflet, a known but dangerous complication. Dr. O’Neill was spiraling into cardiogenic shock and would not have survived without immediate intervention.

It was a holiday weekend, and TAVR procedures require a highly specialized team and are rarely performed in the off-hours. Recognizing the gravity of the situation, Clinton Kemp, M.D., a cardiothoracic surgeon, mobilized the group and together, they performed their first urgent weekend TAVR. Since then, several more have been completed in similar circumstances, but this remains incredibly rare nationwide. Few centers can assemble a team and execute this level of care at night or on a holiday weekend.

The patient survived and did well.

Another emergency

In 2022, Dr. Kemp was again on call when he received an overnight “aortic alert” page, indicating an acute Type A aortic dissection. These are true surgical emergencies. Untreated, the mortality rate approaches 1% per hour and is nearly universally fatal without surgery. Even with surgery, mortality can be as high as 20%

Dr. Kemp immediately recognized the patient’s name, Donald O’Neill, M.D.

Repeat surgery for dissection after prior cardiac operations is exponentially more complex. His greatest concern was that the TAVR valve implanted in 2018 might need a replacement, putting the team back into the very scenario previously deemed too risky.

Thankfully, the valve was functioning perfectly. Dr. Kemp later told the patient, “You’ve got 99 problems, but the valve isn’t one of them.” The team repaired the dissection, and the patient recovered well.

The challenge of progressive heart failure

Over the following years, Dr. O’Neill developed worsening heart failure. He was managed by John Herre, M.D., director of advanced heart failure, who optimized guideline-directed medical therapy. Although there was some improvement, it wasn’t enough.

Dr. Herre referred him to Erich Kiehl, M.D., director of electrophysiology at Sentara, to evaluate whether upgrading his pacing system might help. Dr. Kiehl is a national leader in complex lead extraction and revision, procedures that carry substantial risk and always require a cardiac surgeon on standby. At the request of both the patient and Dr. Kiehl, Dr. Kemp was present. Fortunately, the procedure went flawlessly, and surgical intervention was not required.

Despite these efforts, Dr. O’Neill’s heart failure progressed. The team began to suspect that the 2018 TAVR valve, now eight years old, might be failing. TAVR valves generally last 8–12 years, often less in valve-in-valve configurations.

Working with Structural Heart Imaging Specialist Joshua Cohen, M.D., the team performed a transesophageal echocardiogram. This more invasive imaging revealed what a standard transthoracic echo had not: The valve was leaking and needed replacement.

A valve inside a valve inside a valve

What came next was extraordinarily complex: a TAVR placed inside a TAVR placed inside a prior surgical valve, known as TAVR-in-TAVR-in-SAVR. These cases are rare, with only a handful performed at the Sentara Heart Valve Center.

Matthew Summers, M.D., an invasive interventional cardiologist with Sentara, has been instrumental in bringing advanced AI-based simulation technology known as DASI to the program. He helped introduce it to Sentara and played a key role in its broader commercial launch. DASI allows physicians to simulate complex valve procedures before entering the operating room, modeling anatomy and predicting outcomes with remarkable precision.

After the simulation was complete, not only did the model predict an excellent outcome for this TAVR-in-TAVR-in-SAVR procedure, but it showed that the patient would likely have enough room anatomically for yet another valve in the future if needed. That level of forward planning in such a case is exceedingly rare.

The team proceeded according to the DASI-guided plan. Dr. O’Neill recovered beautifully and is now home doing well. He has had three valve interventions and is positioned to potentially have a fourth if he requires it.

“My improvement is unbelievable”, said Dr. O’Neill. “I was really going downhill and could not walk 75 feet before getting out of breath. Now, I am walking 2 ½ miles, biking, and traveling with my wife.”

Lifetime valve management

This case exemplifies the importance of valve durability and, more importantly, lifetime management strategy. For every patient who comes through the valve center, a long-term plan is developed, not just for the current valve, but for future interventions as well.

For some older patients, that may mean one durable solution. For younger patients, it may mean staging multiple interventions over decades. Technology like DASI enhances the team’s ability to individualize care and think strategically across a patient’s lifetime.

Collectively, the team has presented nationally, supported international cases, and contributed to advancing the field.

The power of the heart team

Dr. O’Neill’s journey reflects the strength of a true heart team all working seamlessly together: structural heart specialists, cardiothoracic surgery, advanced imaging, heart failure, electrophysiology, intensivists, and cardiac anesthesiologists.

You often hear about the “heart team.” Few places embody it as cohesively as the Sentara Heart Hospital. Cases like this highlight the need for continued collaboration across specialties, ongoing investment in leading-edge technology, and a commitment to individualized lifetime care.

If Dr. O’Neill needs a fourth valve, he will have that option, because the team planned for it from the very beginning.

That is the power of teamwork, innovation, and long-term vision in structural heart care.