Faculty Spotlight: Sammy Elmariah, MD

Dr Sammy Elmariah
Dr. Sammy Elmariah
Photo credit: Andrea Rowe

Interventional Cardiology: New Treatments for Valve Disease

“Valve disease is a common problem with tremendous morbidity and mortality, and truly impacts day-to-day life for patients,” said Sammy Elmariah, MD, MPH. He recently joined the UCSF Division of Cardiology as chief of  Interventional Cardiology in the Division of Cardiology and medical director of the Adult Cardiac Catheterization Laboratory.

The recent advent of less invasive treatments is transforming care of these patients, and Dr. Elmariah (pronounced “el-MARE-ee-ah”) helps lead this revolution. Besides his expertise in repairing and replacing faulty heart valves without surgery, he heads groundbreaking research on new devices and is improving access to these lifesaving therapies.

Interventional cardiologists insert catheters into a blood vessel, threading them into the heart to diagnose and treat various forms of heart disease. For decades they have used catheter-based tools to visualize blood flow in the heart, open blocked arteries, and place coronary stents.

Two decades ago, the field took a dramatic leap forward with transcatheter aortic valve replacement (TAVR). It uses a catheter to deliver a new aortic valve to patients with aortic stenosis (AS), in which narrowing of the aortic valve reduces how much blood the heart can pump to the body. Because AS becomes more common with age, TAVR has greatly expanded treatment options for older patients who might not survive open-heart surgery.

Transcatheter heart valve therapies are now expanding to the mitral and tricuspid valves, and Dr. Elmariah is pioneering innovations in this burgeoning field. “All my research focuses on improving management and clinical outcomes for patients with valvular heart disease who are undergoing transcatheter or surgical valve interventions,” he said.

Dr. Elmariah previously served on the faculty of Harvard Medical School, building a robust interventional cardiology research program at Massachusetts General Hospital. He was assistant director of trial design at the Baim Institute for Clinical Research, partnering with industry on trials of new cardiovascular devices. Dr. Elmariah was also director of interventional structural heart disease at the VA Boston Healthcare System and established their TAVR program.

Earlier Diagnosis and Treatment

Part of his research focuses on finding biomarkers to help diagnose valve disease and inform treatment decisions. Valve disease is underdiagnosed, and its symptoms may develop quietly, especially in older patients. “If a young, active individual develops chest pain, feels lightheaded, or faints, hopefully we detect the problem quickly,” said Dr. Elmariah. “But older, relatively sedentary patients often say, ‘I’m slowing down because I’m 80.’ They don’t think something is wrong until things really go wrong.” This problem spurred him to use proteomic and metabolomic technologies to identify biomarkers in the bloodstream that suggest the heart is struggling, enabling faster diagnosis and guiding optimal timing of valve procedures.

Historically, cardiologists waited to fix faulty valves until patients developed symptoms, both because the treatment was open-heart surgery – an invasive, high-risk procedure – and because valves have a shelf life. “When we put in a valve the clock starts ticking, and ten to 15 years later the patient will probably need another valve,” said Dr. Elmariah. “We haven’t wanted to do the procedure too early, when the patient might need a second or even third valve.”

However, delaying treatment comes at a cost: patients receive less benefit if their aortic valve is replaced after AS is far advanced, because their heart has already suffered irreparable damage.

“All this has recently changed,” said Dr. Elmariah. “Because patient outcomes have gotten so good with TAVR, people are now asking whether we should treat any patient with severe aortic stenosis, regardless of whether they are symptomatic.” He helps lead the TAVR UNLOAD trial to determine whether earlier intervention is warranted in patients with moderate AS and weakened hearts.

Improving Care of Aortic Stenosis

Dr. Elmariah has highlighted the significant undertreatment of AS, especially among underserved populations. He recently published two studies analyzing electronic health record data from thousands of patients at Massachusetts General and Brigham and Women’s Hospital over 18 years. “It was absolutely incredible to find we only treated about half of patients with symptomatic severe aortic stenosis, even though 50 percent die within two years without receiving aortic valve replacement,” he said. “Racial and ethnic minorities in particular often lack access to specialty care, and don’t see the right type of clinician to manage their valve lesion. These observations were made in a top academic medical health system, but if you expand that nationally, we’re doing a dismal job at treating valve disease patients.”

To help remedy this, Dr. Elmariah leads the DETECT AS study. “We provide electronic notification to providers, essentially flashing a big, bright sign saying, ‘Your patient has severe aortic stenosis,’ and encouraging them to refer those patients to heart valve teams to diagnose and manage the problem,” he said. “This has been highly impactful and has gained lots of attention. We’re trying to determine how to modify physician behavior to ensure patients are appropriately referred for lifesaving therapy.”

New Mitral Valve Treatments

TAVR was the first success in the transcatheter space, and is evolving to treat patients without symptoms and those with less severe disease. That laid the foundation for transcatheter therapies for other types of valve disease. For example, mitral valve regurgitation occurs when the two mitral valve leaflets fail to close properly, allowing blood to leak backwards. Until recently, the only transcatheter device approved by the U.S. Food and Drug Administration (FDA) has been the Abbott MitraClip. Like a binder clip, it fastens the edges of the two leaflets together to create a tighter seal.

In 2022, the FDA approved a second transcatheter edge-to-edge repair (TEER) therapy, the Edwards PASCAL device for patients who are too sick or at high risk for surgery. Similar to TAVR, interventional cardiologists are now studying whether TEER of the mitral valve is appropriate for patients thought to be at lower risk for surgery. Dr. Elmariah is also involved with the PRIMARY trial, a head-to-head comparison between surgical repair and devices like the MitraClip and PASCAL. “Even healthy patients over the age of 65 can enroll in this trial,” he said. “This is a huge advance with the potential to dramatically change how we treat mitral valve disease.”

For patients whose valve anatomy is not well suited for mitral valve repair, UCSF offers the SUMMIT trial, providing access to a new transcatheter mitral valve replacement device called the Abbott Tendyne. Dr. Elmariah and his colleagues are exploring other transcatheter mitral valve replacement technologies they can bring to UCSF.

Forgotten No More

Dr. Elmariah has been at the forefront of discovery for the tricuspid valve. Located between the right atrium and right ventricle, it is sometimes called the “forgotten valve.” “In medical school I learned that you could cut out a tricuspid valve, give patients diuretics to treat swelling in the legs, and people would be fine,” he said. “That mentality is absolutely not true.”

Previously, surgery was the only treatment option, and complication rates were relatively high. “Combining a valve problem that was not considered a big deal with a high-risk fix meant people were rarely sent to surgery,” said Dr. Elmariah. An estimated 2.2 million people have tricuspid valve disease nationally, but less than 1 percent are referred for surgery. “Ninety-nine percent receive no treatment beyond diuretics,” he said.

That is changing. “Thanks to the evolution of the transcatheter space, we’re starting to treat patients with tricuspid valve disease,” said Dr. Elmariah. “Even modest reductions in the severity of tricuspid regurgitation – for example, going from torrential to severe – seem to correspond to fairly significant improvement in quality of life. That’s why there’s so much excitement about transcatheter therapies in development – it’s a true unmet clinical need. The potential benefit is much greater than previously expected, and hopefully we’re also introducing much lower-risk ways of treating this problem.”

There are two tricuspid TEER devices currently in clinical trials: the Abbott TriClip, which is similar to the MitraClip and is being studied through the TRILUMINATE trial, and the Edwards PASCAL device, which is being studied through the CLASP II TR trial, now active at UCSF.

However, TEER devices are not for everyone. “This technology is best suited for patients whose valve leaflets are relatively close together, so you can grab and clip them together,” said Dr. Elmariah. “Because we’ve done a poor job as a medical community of treating tricuspid regurgitation, many patients are much further advanced in their disease.” Untreated regurgitation fuels a vicious cycle: as the heart pumps less efficiently, the muscle enlarges in an effort to improve its output. That pulls the leaflets even further apart, reducing blood flow even more.

In those cases, replacing rather than repairing the tricuspid valve may be a better option. UCSF is part of the TRISCEND II trial, which is investigating the Edwards EVOQUE valve. “Patients are left with a brand new, functioning valve which works beautifully,” said Dr. Elmariah. “Based on initial results, there’s a lot of excitement about this technology.”

“We need to change the tricuspid valve disease paradigm,” said Dr. Elmariah. “It impacts not only heart function, but also the liver and kidneys in patients with severe disease.  Intervening has a dramatic impact on patients’ quality of life and health. Hopefully that initial impression will be confirmed by these ongoing randomized trials.”

Shared Decision-Making

The rapid explosion of treatment options is exciting but creates new dilemmas. “Patients face a very complex decision between a transcatheter procedure, which is easy and straightforward but has uncertain long-term durability, versus open-heart surgery, which has a prolonged recovery but has a lot more history behind it,” said Dr. Elmariah. “That’s a very challenging decision. All the [professional] societies have endorsed that physicians include patients in a shared decision-making process. Unfortunately, nobody has clarified what that actually means, and consequently shared decision-making is very poorly implemented. We all think we’re explaining things and allowing patients to decide, but frequently decisions are made without active patient engagement.”

To meet this challenge, Dr. Elmariah co-leads the national IMPACT SDM study, which recently received more than $5 million in government funding through the Patient-Centered Outcomes Research Institute (PCORI). They will test the effectiveness of a decision aid, combined with teaching providers shared decision-making techniques, to help patients decide between open-heart surgery or TAVR. “We’re looking for strategies to improve patients’ buy-in and involvement to ensure they are fully educated and make the right decision for themselves,” he said.

Service and Humility

Dr. Elmariah grew up in Florida, where his father was an orthopedic surgeon. He chose medicine, combining his love of science with the opportunity to help others. “In addition to touching the lives of individual patients, impacting the field through researching novel technologies and improving care delivery was very exciting,” he said. After earning his bachelor’s degree in biology from Emory University, he completed his medical degree at the University of Pennsylvania School of Medicine, followed by internal medicine residency at the Hospital of the University of Pennsylvania and chief residency at Lankenau Hospital in the Jefferson Health System.

Dr. Elmariah chose interventional cardiology because of his fascination with hemodynamics and the chance to perform procedures to immediately fix a patient’s problem. He completed fellowships in cardiology at Mount Sinai Hospital in New York, interventional cardiology and structural heart disease at Massachusetts General Hospital and Harvard Medical School, and clinical biometrics at the Brigham and Women’s Hospital. He also earned his master of public health degree from the Harvard School of Public Health.

One memorable lesson came from a fellowship mentor. “As doctors, we often think we work harder than everyone else, but our mentor said, ‘The taxi drivers outside and the person who cleans the cath lab work nonstop to sustain their families. We work hard, but so does everybody else,’” recalled Dr. Elmariah. “That brought us down to earth and has stuck with me.”

Synergy and Partnership

Dr. Elmariah enjoyed his work in Boston, but decided to join the UCSF faculty in September 2022. “It’s exciting to be part of a program that is growing, innovating and pushing the boundaries,” he said. “I appreciate the opportunity to mold the [Interventional Cardiology] program and hopefully make it one of the top in the country.”

Dr. Elmariah co-leads a multidisciplinary team at the UCSF Heart Valve Disease Clinic in partnership with Tom Nguyen, MD, chief of the Division of Adult Cardiothoracic Surgery, and echocardiographer and Associate Chief of Ambulatory Cardiology Kirsten Tolstrup, MD. “We have a very thoughtful group that includes cardiac surgeons, echocardiographers, cardiac imagers from radiology, and interventional cardiologists,” said Dr. Elmariah. “We collectively review each of our patients to make sure treatment decisions are personalized with patients’ best interests at heart. Putting all those minds together improves patient care.”

He appreciates the synergy of working with Dr. Nguyen, who was recruited to UCSF in 2021. “A transcatheter program needs a strong and very successful partner on the cardiac surgical side,” said Dr. Elmariah. “The best programs have robust engagement from both specialties. That’s the model I hope will continue to evolve at UCSF, and so far, our two specialties work together seamlessly. We have a highly talented group, and there’s a tremendous amount of collegiality. Everyone is focused on improving care delivery, which pushes us to higher levels.”

“Dr. Elmariah is a world-recognized structural interventionist,” said Dr. Nguyen. “He brings unique expertise in managing patients with complex valve pathology, but also helps push the envelope and advance science by participating in and leading landmark trials. We are very fortunate to have him here at UCSF as a colleague, friend and partner.”

The heart valve team not only develops tailored treatment plans, but considers long-term strategy. For example, most patients can receive up to two transcatheter valves in their lifetime. “It’s like Russian dolls,” said Dr. Elmariah. “You can put one valve in; if it wears out, you can place a second transcatheter valve inside the first one. But usually there isn't space to put in a third. If someone is young enough to potentially outlast three valves, we might recommend starting with TAVR, then doing a surgical replacement of a valve, then another TAVR. We consider their age, health and how long we think they might live. We want to avoid situations where they are 90 and still healthy, but have already had two TAVRs and now need open-heart surgery. The field is shifting to focus on lifelong management of valve disease.”

Besides medicine, Dr. Elmariah enjoys hiking and photography. He is married to Sarina Elmariah, MD, PhD, MPH, a dermatologist who also recently joined the UCSF faculty. Together they have two sons.

Dr. Elmariah is excited to be at UCSF. “It’s a true privilege to improve not just a patient’s health, longevity and well-being, but also see the effect on their family and friends,” he said. “The innovations and rapid evolution within this field allow me to touch patients with valve problems around the country and worldwide. To have a hand in that, however small, is incredibly humbling and rewarding.”