Transcatheter Aortic Valve Replacement (TAVR)
Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure to replace the aortic valve in patients who have severe, symptomatic aortic stenosis. Traditionally, aortic valve disease has been treated with open heart surgery, and initially the TAVR procedure was only approved for patients who were felt to be too high risk to survive surgery—such as older and frailer patients, patients with significant lung disease, or multiple prior open heart surgeries. But since its initial FDA approval in 2012 for extreme risk patients, the valve has performed so well that it is now used routinely for intermediate and high risk patients. TAVR has revolutionized the treatment of aortic valve disease in patients of all risk levels, but especially in older patients and those who have other significant medical problems.
During a TAVR procedure, most patients receive mild sedation, and the valve is inserted into the heart through a tube (also called a catheter sheath) that is placed through the patient’s leg artery. These patients often do not require a breathing machine, and are oftentimes in the hospital for only 2 or 3 days. If a patient’s blood vessels in the legs are too small to accommodate the sheath, the valve can be placed through an artery underneath the collar bone, or directly into the apex of the heart, although these latter approaches require general anesthesia and a breathing machine.
Who is eligible for a TAVR?
All patients who have symptoms due to severe aortic stenosis are considered for aortic valve replacement—either a surgical/open heart aortic valve replacement or a transcatheter aortic valve replacement (TAVR.)
Patients with severe aortic stenosis who do not have symptoms are encouraged to undergo treadmill stress testing if possible to prove the absence of symptoms. Multiple trials are taking place to evaluate whether asymptomatic patients benefit from early intervention. At UNC REX, we are currently taking part in a national trial examining the benefits of transcatheter aortic valve replacement in asymptomatic patients with severe aortic stenosis.
Younger patients who are at low risk for surgery are still often treated with an open heart, surgical valve replacement. In addition, patients that need other surgical procedures in addition to the aortic valve replacement, such as coronary artery bypass grafting, additional valve replacement/repair, or aorta surgery, still are best treated with open heart surgery.
However, most patients over the age of 65-70 regardless of their surgical risk are considered for TAVR as first-line therapy for aortic valve replacement.
In general, TAVR is favored in:
- Older patients, because recovery is faster
- Patients who have had prior open heart surgery or bypass surgery
- Patients with significant lung disease who may not tolerate intubation or chest wall surgery
- Frail patients, who may have difficulty convalescing from open heart surgery
What kind of preparation and recovery can be expected?
Prior to receiving an aortic valve replacement, patients undergo an in-depth assessment by a Heart Valve Team which includes both cardiac surgeons and cardiologists.
- Each patient is evaluated by both a cardiologist and a cardiac surgeon, to determine whether the patient is best served by surgical or transcatheter aortic valve replacement
- Each patient will undergo heart catheterization to assess the heart arteries for blockages
- Each patient will undergo transthoracic echo to assess the heart pump strength and the severity of the valve narrowing
- Each patient will undergo CT scanning of the heart and the arteries in the legs and the abdomen. CT scanning is critical to allow appropriate sizing of the valve replacement, and very careful assessment of the leg arteries is needed to ensure that the valve delivery system can safely fit through the leg arteries
- Each patient meets with an anesthesiology team prior to the procedure to ensure that sedation will be adequate and safe for the procedure
Both the heart catheterization and CT scan will require x-ray dye, or contrast. Sometimes too much of this dye can stress the kidneys, and therefore the studies need to be separated, usually by a week.
After the procedure:
- The patient usually goes to a stepdown bed or, possibly, the ICU for a night
- If there are no complications, patients can expect to go home one to two days after the procedure
- Patients attend follow-up appointments in the clinic one to two weeks post procedure, 30 days post procedure, and one year post procedure