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|Watch this animation to learn more about a new, less invasive procedure for replacing the aortic valve called transcatheter aortic valve implantation or TAVR. (Animation provided courtesy of Medtronic.)
Transcatheter aortic valve replacement (TAVR or TAVI, with the “I” standing for Implantation) is a minimally invasive procedure used to replace the aortic valve in patients with aortic stenosis. The aortic valve is a “one-way check-valve” that allows blood to go from the left side of the heart to the brain and the rest of the body. As we get older, calcium may build up on the valve, causing it to narrow and not open as well. Aortic stenosis refers to the narrowing of that valve so that it does not fully open and less blood flows to the rest of the body.
Symptoms of aortic stenosis occur as the heart works very hard to try to squeeze blood through the restricted valve to the rest of the body. The most common symptoms of aortic stenosis are:
- shortness of breath on exertion (exertional dyspnea)
- chest pain
- fainting (syncope)
- gradual decrease in the ability to exercise feeling fatigued
- heart palpitations.
Often the diagnosis is made after the doctor hears a heart murmur with his stethoscope and orders an echocardiogram to investigate further.
Sometimes aortic stenosis can be present, but the patient has no symptoms. In these cases, patients should follow up with a cardiologist closely for symptoms and findings of aortic valve disease progression.
Once symptoms appear, the disorder tends to advance quickly and it’s important to treat it. If left untreated, aortic valve stenosis can lead to more serious disorders, including heart failure and eventually leading to death.
After the onset of symptoms, a timer starts, at 2 years, 50% of patients are not alive, and at 5 years about 80% are not alive.
TAVR is a less invasive option to conventional open heart surgery. Instead of opening the chest, and cutting out the old valve and replacing it with a new one, TAVR uses a flexible tube called a catheter, that reaches the heart through the artery in the groin (like the heart catheterization) to access the faulty valve and implant a new artificial valve inside the existing valve, which is pushed to the side once the new valve is deployed.
Is TAVR Right for You?
There are essentially three treatment options for aortic stenosis: surgical valve replacement, TAVR, or medical therapy. The best treatment for you depends on how severe your condition is, what other medical conditions you might have, as well as the best option for you, a decision made by your heart team which involves cardiologists and heart surgeons.
Surgical aortic valve replacement or SAVR was previously considered the only treatment for most patients with symptomatic aortic stenosis, as long as they weren’t too sick to undergo the procedure. Unlike the surgical option, TAVR is performed on a beating heart and does not require opening the chest, stopping the heart and being placed on a heart and lung machine.
Based on recent studies that directly compared TAVR to surgical aortic valve replacement, TAVR currently is considered an equal or better option for many patients who are considered at high or intermediate risk for complications from SAVR.
In some patients, medical therapy may be the only option. While medications won’t “cure” your aortic stenosis, it can be used to reduce your symptoms and the risk of certain complications. Even if you undergo TAVR or SAVR you will likely also be given medications to treat your high blood pressure, which is seen in a majority of patients with aortic stenosis.
There are a number of reasons why you may be at higher risk for a surgical heart procedure or SAVR. When your doctors consider your treatment options, they will valuate your risk of complications during or after the procedure. This is by inserting all your data in a calculator that uses a national database to calculate the risk in someone like you undergoing such procedure. Complications after surgery are increased in older and frail patients as well as patients with abnormal lung or kidney function or have an extensive history of other diseases such as stroke, heart attack and heart failure. If you are medically debilitated due to non-heart-related issues (such as radiation to the chest for cancer treatment), you may not be a good candidate for traditional open-heart surgery to replace a valve.
In such high-risk patients, TAVR may be a better option to treat aortic stenosis. It may be variable between hospitals, but most patients can go home as soon as the next day after the procedure. With TAVR there is no “recovery period” unlike surgical aortic valve replacement which requires a longer hospital stay and longer recovery period that may take up to months. With TAVR, you can go back doing what you were doing the day before the procedure, with no limitations apart from avoiding heavy lifting for several days.
Patients Are Living Longer with TAVR
TAVR was first tested in patients with symptomatic severe aortic stenosis who were either not considered candidates for surgical aortic valve replacement or were considered to be at high risk for complications from surgery. When TAVR was compared to medical therapy in these patients, patients that had the TAVR procedure felt significantly better and lived longer. However, compared to the surgical option, TAVR was also associated with an increased risk of early complications after the procedure, including stroke and bleeding.
In the last 10 years, several other trials have confirmed that TAVR is at least as good as surgical aortic valve replacement in patients at high and intermediate risk for surgery.
Since it is an overall simpler procedure to undergo, TAVR is now being considered for a wider range of patients, including those who have symptomatic aortic stenosis but are at low risk for surgical complications, currently being studied with results to be released later this year. It is important to note that unlike some of the valves used in surgical procedures, do not require patients to take anticoagulants (“blood thinners”) for life.
A recent comparison of TAVR and surgical aortic valve replacement using real-world information available in nation-wide databases indicate that in intermediate and high-risk patients, the two procedures offer similar one-year survival rates and similar rates of stroke, but that TAVR patients were more likely to be discharged to home after their procedure than SAVR patients.
Researchers continue to expand the use of TAVR to more and more patients. As an example, in one recent study, TAVR was used to treat a group of patients who had previously undergone aortic valve surgery but whose surgically-implanted valves had failed to function properly. The results showed that the outcomes in this group are very similar to those seen in ‘regular’ TAVR patients (where the TAVR valve is implanted into a native aortic valve) and support the use of TAVR as the treatment of choice in these patients.
Promising New Developments
Since the first TAVR procedure was performed in 2002, its use has grown throughout the world at a startling pace. The popularity of the procedure is directly related to its ability to improve symptoms and survival, its attractiveness to patients, and faster recovery.
In addition, almost 20 years after its appearance, TAVR is still a rapidly evolving field, with ongoing advances and refinements in technology and procedural technique. Better devices and new approaches are helping to make the procedure a good option for more people.
About Your Procedure
To determine if TAVR is a good option, your doctor will order several tests, including an ultrasound of the heart or an echocardiogram, a cardiac CT scan (CCT), and a cardiac catheterization. Based on your medical history, physical examination, and the test findings, your doctor will make a determination as to whether you are an appropriate candidate for TAVR.