Transcatheter Aortic Valve Replacement (TAVR)

Overview

Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), is a medical procedure designed to replace an aortic valve that is too narrow and unable to open fully. The aortic valve, located between the left ventricle of the heart and the main artery that supplies blood to the body, can become constricted in a condition known as aortic valve stenosis. This constriction impedes the flow of blood from the heart to the rest of the body.

TAVR is a less invasive approach compared to traditional open-heart valve surgery, utilizing smaller incisions. This makes it a viable option for individuals who are unable to undergo conventional heart surgery for aortic valve replacement. By choosing TAVR, patients may experience alleviation from symptoms associated with aortic valve stenosis, such as chest pain and difficulty breathing.

The decision to proceed with TAVR involves comprehensive discussions with a collaborative team of cardiologists and cardiac surgeons. This team evaluates the patient’s condition to recommend the most suitable treatment pathway.

Reasons for undergoing the procedure

The human heart comprises four valves, each responsible for guiding blood flow in a specific sequence. The aortic valve, being the last of these four, plays a pivotal role in circulating blood from the heart to the rest of the body. Transcatheter Aortic Valve Replacement (TAVR) is an innovative medical procedure designed to replace the aortic valve without the need for extensive surgical intervention.

Aortic stenosis, characterized by the narrowing of the aortic valve or its surrounding area, is the primary condition that necessitates TAVR. This narrowing is predominantly caused by calcium deposits on the valve and the natural degeneration associated with aging, particularly in individuals over 70 years old. Aortic stenosis may also result from various other medical conditions. The restricted blood flow due to valve narrowing compels the heart to exert more effort, potentially leading to significant heart muscle damage and eventual heart failure.

Doctors might recommend TAVR for patients who exhibit:

• Severe aortic stenosis, manifesting symptoms like chest discomfort and breathing difficulties.
• A malfunctioning biological tissue aortic valve.
• Pre-existing conditions such as diseases of the lungs or kidneys that render traditional open-heart valve surgery a high-risk option.

Risk

Every surgical or medical intervention, including transcatheter aortic valve replacement (TAVR), carries certain risks. These may include:

• Bleeding.
• Blood vessel injury.
• Infection.
• Stroke.
• Heart attack.
• Hypotension or low blood pressure.
• Issues with the replacement valve, such the valve slipping or leaking.
• Pacemaker requirements and issues with cardiac rhythm.

Before the procedure

Before undergoing Transcatheter Aortic Valve Replacement (TAVR), several diagnostic tests are essential to ensure the procedure’s safety and success. These tests provide your healthcare provider with critical information about your heart’s condition and overall health, allowing them to plan the best approach for your TAVR procedure.

• Blood tests: Blood tests are vital for identifying any issues with blood clotting, kidney function, and other health indicators that might affect the procedure.
• Echocardiogram: An echocardiogram utilizes ultra-high-frequency sound waves, similar to sonar, to create detailed images of your heart. There are two methods for conducting an echocardiogram:
• Transthoracic echocardiogram: A non-invasive procedure where a device is held against your chest, transmitting sound waves to produce heart images.
• Transesophageal echocardiogram (TEE): Involves lowering an ultrasound device into your throat to get a closer view of your heart through the esophagus. This method is not commonly required for all patients.
• Electrocardiogram (ECG or EKG): The electrocardiogram records the heart’s electrical activity using sensors attached to the chest. The resulting wave pattern helps determine the heart’s electrical system’s functionality.
• Other imaging tests: A computed tomography (CT) scan is the most likely additional imaging test. It compiles a series of X-ray images into a detailed 3D image of your heart and surrounding structures.
• Left heart catheterization: This diagnostic procedure shares similarities with the TAVR approach but focuses on assessing blood flow within the heart without valve replacement. It involves inserting a catheter into a major blood vessel, typically in the thigh, and navigating it to the heart. This test provides valuable insights into the heart’s condition and identifies any necessary interventions or alternative treatments.

Following these diagnostic tests, your healthcare provider will discuss the TAVR procedure with you, including what to expect during and after the surgery. You’ll receive advice on whether general anesthesia or moderate sedation is more appropriate for your case. This consultation is also an opportunity to address any questions or concerns you may have about the procedure.

During the procedure

TAVR procedures are typically completed within about an hour.

Anesthesia options:

• General anesthesia: Involves inducing sleep with special medications, under the supervision of a certified registered nurse anesthetist (CRNA) and/or an anesthesiologist. This method ensures you feel no pain by placing a tube in your throat for mechanical ventilation, which is removed post-procedure.
• Moderate sedation: A lighter form of sedation that also aims to prevent pain without the need for mechanical ventilation. It’s less intense compared to general anesthesia.

Procedure steps:

• Access site: The procedure begins with a minimally invasive approach, typically through small incisions in the groin or chest to insert a catheter into a blood vessel.
• Navigation and placement: Under guidance from X-ray or other imaging techniques, the catheter is carefully navigated to the heart’s aortic valve.
• Valve deployment: A biological tissue valve, derived from cow or pig heart tissue, is advanced to the aortic valve’s location through the catheter. The valve is then expanded, either by inflating a balloon at the catheter’s tip or through self-expansion, to secure it in place.
• Monitoring: Throughout the procedure, the medical team closely monitors vital signs, including blood pressure, heart rate and rhythm, and oxygen levels, to ensure patient safety and the success of the procedure.

TAVR offers a less invasive alternative to traditional open-heart surgery for aortic valve replacement, significantly reducing recovery time and offering a viable option for patients who are considered at high risk for standard surgical procedures.

After the procedure

Following your TAVR procedure, you may be required to stay in the intensive care unit (ICU) for close monitoring. The duration of your hospital stay post-TAVR varies based on several factors, and it’s possible for some individuals to be discharged as soon as the next day.

Upon discharge, your healthcare team will provide instructions on managing any surgical sites and identifying signs of infection. Key infection indicators include fever, heightened pain or redness, swelling, and discharge or leakage from the catheter insertion point.

Post-TAVR, you may be prescribed a range of medications, such as:

• Anticoagulants (blood thinners): These are important for preventing blood clots. Follow your healthcare provider’s instructions on the duration and dosage of these medications.
• Antibiotics: To prevent and treat bacterial infections, especially since bacteria from the mouth can adhere to or infect a synthetic heart valve. Maintaining oral hygiene and regular dental visits are crucial for preventing such infections. Antibiotics might also be recommended before certain dental procedures.

Continual follow-ups with your doctor and routine imaging tests are crucial to ensure the new valve is functioning correctly. Report any new or worsening symptoms to your doctor, including:

• Dizziness or feeling faint.
• Ankle swelling.
• Sudden increase in weight.
• Fatigue during physical activities.
• Any signs of infection at the catheter insertion site, such as swelling, redness, or tenderness.

In case of severe symptoms like chest discomfort, acute shortness of breath, or fainting, seek immediate medical attention.

Outcome

Transcatheter aortic valve replacement (TAVR) can alleviate symptoms associated with aortic valve stenosis, potentially enhancing quality of life. Recovery from TAVR emphasizes the importance of adhering to a heart-healthy lifestyle to not only aid in recovery but also to prevent further heart-related issues. Key recommendations include avoiding smoking, consuming a diet abundant in fruits and vegetables while low in salt, saturated, and trans fats, engaging in regular exercise after consulting with a doctor, and maintaining a healthy weight, with guidance on what constitutes a healthy weight provided by the healthcare team.