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Transcatheter Aortic Valve Replacement (TAVR)

What is TAVR?

TAVR is also called Transcatheter Aortic Valve Implantation (TAVI). TAVR is a minimally invasive procedure that involves placing or inserting a new valve inside the diseased or a damaged heart valve. The old valve is retained and not removed. After the new valve is placed inside the old, damaged valve, it expands, pushing the old valve’s leaflets out of the way.  

Why is the TAVR procedure recommended?

Transcatheter Aortic Valve Replacement (TAVR) is recommended for intermediate-risk patients with aortic stenosis. Aortic stenosis is a condition that involves blocking or narrowing of the aortic valve opening restricting the flow of blood from the left ventricle to the aorta. Severe aortic stenosis can result due to congenital heart defect (bicuspid aortic valve), or due to ageing as plague, calcium deposits, etc., can damage the heart valve, preventing it from opening fully. Chest pain, palpitation, shortness of breath, dizziness, fatigue even after walking for a short distance, difficulty falling asleep, etc are some symptoms of aortic stenosis. These symptoms are not common unless the blood flow is greatly reduced. It is, therefore, worth a visit to your doctor if there is even a slight decrease in your routine activities due to fatigue. The procedure is also recommended for high-risk patients, who are inoperable and cannot tolerate the surgical valve replacement (SAVR) procedure. 

How is TAVR performed?

The Transcatheter Aortic Valve Replacement Procedure is performed under general anaesthesia. Throughout the procedure vitals including blood pressure, heart functions and heart rhythm are constantly monitored. Any one of the two approaches, whichever is safe is chosen by your cardiologist or surgeon:

  • Transfemoral approach: A small incision in your groin is made to create an opening in the large artery called the femoral artery. This is known as a transfemoral approach. This approach does not involve making an incision in the chest. 

  • Transapical approach: A small incision in your chest is made to create an opening in the large artery. 

After deciding on the best and safest approach to access the heart valve, a guidewire through a flexible tube called an introducer sheath is introduced. Followed by this, a flexible tube called a catheter which is attached with a balloon is passed through the guidewire into the aortic valve. Advanced imaging techniques help in guiding the catheter into the aorta. The aortic valve is widened with the help of an inflated balloon. Once the valve is widened and pushed towards the sides, the balloon is deflated, and the catheter is retracted. Another catheter fitted with a balloon and a folded prosthetic new heart valve covered with a wire mesh (stent) is introduced into the aorta. After the new valve is placed inside the old, damaged valve, the balloon expands, pushing the old valve leaflets out of the way. The catheter along with the guidewire is removed and the incision is closed and dressed. 

Advantages of the procedure:

  • TAVR is a safe and effective procedure that can relieve the symptoms of severe aortic valve stenosis. 

  • The patient can breathe normally, feels energetic and is less anxious. 

  • It improves the chances of survival in patients with severe symptoms.

  • It results in fewer chances of infection, lower chances of blood loss, and no trauma to the breastbone, ribs and heart muscles.

  • Due to improved transcatheter design, the risk of vascular injury is low. 

  • Due to the use of advanced imaging technology, and better transcatheter design, the procedure results in fewer complications, such as stroke, paravalvular leakages, etc.

  • The breastbone and rib cage are spared and remain intact. 

Who benefits the most from TAVR?

The procedure is beneficial for patients:

  • With aortic stenosis, severe symptoms like shortness of breath, chest pain, fatigue, swelling of the leg, etc are caused. 

  • With any risk categories especially those with an intermediate or high risk of complications from open-heart surgery or surgical aortic valve replacement (SAVR).

  • Who are inoperable and cannot tolerate open-heart surgery.

  • Who already has a biological tissue valve implanted, but has failed to work well.

What are the risks of undergoing TAVR?

Although the risks of TAVR is safe and effective, it may still carry some risk, such as:

  • Leaky valves: Sometimes if the prosthetic valve used for replacement is not of the correct size or if it does not fully expand, the chances of blood leaking around the prosthetic valve is high. 

  • Vascular access-site complications: These complications mainly occur when there is a mismatch between the access artery and sheaths of the delivery system due to calcification of the access artery or if the diameter of the delivery system is larger. 

  • Device landing zone complications are very rarely encountered. Sometimes the device landing-zone ruptures due to aggressive over-sized prosthetic valve, or severe annular, or ventricular outflow tract calcifications.

  • Aortic valve regurgitation: Prosthetic valve-annulus size mismatch or inappropriate placement of the prosthetic valve are important predictors of the paravalvular leak while moderate or severe central leak can occur due to dysfunction in the structure of the valve.

  • Prosthetic valve malpositioning can occur when the aortic annulus is assessed incorrectly or if the prosthetic valve is implanted incorrectly.

  • Coronary obstruction: Obstruction of the coronary ostia due to excessive calcification of the leaflets of the aortic valve, aggressively oversized prosthetic valve etc. are some common causes of coronary obstruction.

  • Cardiac conduction abnormalities

  • Myocardial infarction

  • Cerebrovascular complications

  • Bleeding

  • Need for permanent pacemaker implantation 

  • Kidney damage: The contrast dye used for imaging can damage the kidneys, but this is uncommon and is reversible in most cases.

  • Stroke

  • Death: Very sick patients may sometimes not survive the procedure but this is very rare.

How is TAVR different from standard valve replacement?

During a standard valve replacement procedure, an open-heart procedure is performed which involves cutting open the chest wall (sternotomy) and heart muscles using a larger incision to access the heart valve. Your heart will be temporarily stopped, and a heart-bypass machine is used to keep the blood pumping to the rest of the body. Whereas the TAVR procedure is less invasive and is performed through very small openings thus sparing the breastbone and ribcage. Compared to the standard valve replacement, the time spent in the hospital after TAVR is less. 

What to expect (before, during and after) the TAVR procedure? 

Before the procedure:

  • Notify your doctor about the medicines, and supplements that you are taking.

  • Make sure you do not have an infection in your teeth or mouth as it may spread to your heart. Check with your dentist.

  • You may have to stop blood thinners and other medicines about 2 weeks before the surgery. So that the chances of bleeding may be reduced. 

  • Notify your doctor if you have a fever, cold, herpes etc. before the procedure.

  • Make sure you stop smoking and drinking alcohol.

During the procedure:

  • On the day of your surgery, you will be asked to avoid eating or drinking.

  • You can rinse your mouth or take small sips of water in case you have to take medicine.   

After the procedure:

  • You will be shifted to the intensive care unit (ICU) and your vitals will be constantly monitored for the next 24 hours. 

  • You may have to spend a couple of days in the hospital.

  • You will be expected to move around to strengthen your heart and body.

  • You will be taught some simple exercises and self-care including how to bathe and care for the surgical wound. 

  • You will be provided with a heart-healthy diet. 

  • You will be prescribed certain painkillers and blood-thinning medicines. 

  • Make sure to visit the hospital regularly for your follow-up appointments. 

Frequently Asked Questions:

1. How long do you stay in a hospital after TAVR?

Since TAVR is a minimally invasive procedure, it involves smaller incisions that shortens hospital stay and speeds recovery. Generally, you may be expected to spend about 2-5 days in the hospital and after about 4-6 weeks post-surgery, you will have a follow-up visit with your doctor.

2. How long does a TAVR valve replacement last?

The durability of the TAVR valve depends on the patient’s age, medical condition and the type of prosthetic valve used. A mechanical valve is usually offered to younger patients and may last for the rest of the patient’s life, but it also calls for lifelong use of anticoagulants. Whereas a biological prosthetic valve is susceptible to structural valve deterioration and may last between 5-10 years with proper follow-up care. Valves in younger patients have been reported to last for about 5 years as they are very active. 

3. How long can you live after a TAVR?

TAVR in extreme-risk patients who are more than 80 years with co-morbidities and cannot tolerate open-heart surgery has increased their median life expectancy from 11 months to almost 30 months. Long-term studies on the life expectancy for low and moderate-risk patients after a TAVR are lacking. 

4. How will I feel after TAVR surgery?

After undergoing a TAVR procedure, it is normal to have aches and pains in your incision site. The pain is expected to resolve in some time; however, painkillers will be prescribed as it makes the process of healing and coming back to normal life easier and faster. Make sure to follow the instructions for follow-up care, diet, exercise etc. given by your doctor. It may take about 6-10 weeks for a full recovery. Furthermore, recovering from a TAVR is easier than open-heart surgery. 

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