Feb 19, 2019
In the past, the only way to treat aortic stenosis was to perform open-heart surgery—a very invasive procedure. Discover how TAVR, a new minimally invasive surgery, can replace a heart valve without surgery, allowing patients to recover faster.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: We’re speaking with Dr. Toby Rogers, an interventional cardiologist at MedStar Washington Hospital Center. Thanks for joining us, Dr. Rogers.
Dr. Rogers: It’s great to be here.
Host: Today we’re discussing high, medium and low risk transcatheter aortic valve replacement, or TAVR. Dr. Rogers, could you start by discussing what TAVR is?
Dr. Rogers: That’s a great question, and a lot of patients are quite confused by this terminology. So, aortic stenosis is a condition that is very common, particularly in older patients. And, it’s caused by a narrowing or blockage of the main heart valve through which blood flows from the heart to the rest of the body. And, as that gets progressively tighter with time and with age, patients can start to get very symptomatic, particularly when they’re trying to be active. So, they get very short of breath, they can get dizzy, they can even get chest pain when they’re trying to be active, even just walking across the room. And, historically, the only way to fix this problem was to do open-heart surgery and literally stop the heart from beating, cut out the old valve, and surgically sew in a new valve. But you can imagine, open-heart surgery is a big deal and it’s very stressful on the body and, the older you are, the more stressful a big surgery is. And so, TAVR is an amazing new technology that over the last decade has revolutionized cardiac surgery, in that we can now replace that heart valve through a little tiny catheter in the groin, with the heart still beating - in fact, with the patient awake. We don’t even have to put the patient asleep. And, we can replace the heart valve and improve the blood flow to the rest of the body.
Host: What do you mean when you say high, medium and low risk TAVR?
Dr. Rogers: So, again, this is a concept that we use very freely in medicine, but patients often get confused by that. And, what we’re actually saying is, ‘What would the risk be for that patient to undergo the old fashioned open-heart surgery?” Meaning, if they were to have open-heart surgery tomorrow, would that be a low risk procedure, an intermediate risk procedure or would it be a very high-risk procedure. And that’s not really determined by the heart at all. It’s often determined by other medical problems they have. And obviously, older patients are more likely to have more than one medical problem. So, if you have trouble with the kidneys, if you have trouble with your lungs, if you have trouble with your liver - then all of those things will make a big procedure, or a big surgery, more high risk. And so, for every patient that comes along with aortic stenosis, we make an assessment based on a whole barrage of tests, looking at all the different organs in the body, as well as the heart, to say, “What would your risk of surgery be?” And that, then, helps us judge whether the open-heart surgery is the best treatment for them or if, in fact, they’d be better to have a procedure like TAVR, which is less invasive.
Host: Who would you consider to be an optimal candidate for TAVR?
Dr. Rogers: Well, certainly anyone who is very high risk for surgery. So, if undergoing open-heart surgery would be very high risk, and there would be a risk of not making it through the procedure, then clearly those are patients who should have less invasive procedure. And certainly, that’s the way TAVR started. It was really only available to patients who were so high risk that they just couldn’t have surgery. But then, as we’ve gotten more comfortable with the technology, and we’ve gotten more data for the technology and as we’ve run clinical trials - very rigorous clinical trials - across the US and across the world, we’ve actually demonstrated that TAVR’s actually a very good option for anyone with aortic stenosis. And, I think within the next 12 months, we’ll expect that the FDA will approve TAVR so that we can offer it to anyone with aortic stenosis. So, for sure if you’re high risk, but the truth is, moving forwards and in years to come, I suspect that TAVR will be the first line treatment for anyone with this condition.
Host: You mentioned inserting the catheter through their groin and replacing the artery that way. Could you describe how TAVR is performed?
Dr. Rogers: Yes. So, of course, each procedure is slightly different for different patients. But, a typical TAVR is performed with a patient under conscious sedation. By that we mean we give you some medication to make you relaxed, make you a little bit sleepy, but you’re breathing for yourself, you’re not on a ventilator and, in fact, some of these patients even sort of, you know, are able to talk to us and are fairly awake during the procedure. And that has a lot of advantages because putting a patient on a ventilator and breathing for them with a mechanical ventilator under general anesthetic increases the risk of the procedure. There’s more risk of picking up a chest infection, needing to be in hospital longer after their procedure, whereas if it’s all done under conscious sedation and with local anesthetic, then patients bounce back much faster and are able to get up and about much faster and that speeds up the recovery. So that’s the first step - it’s done under conscious sedation. And then, what we actually do, is we take the heart valve, the new heart valve, and we crimp it down or we’ll crush it down onto a catheter. So, we squeeze it down so it’s small enough to now go through the artery and the groin. We all have big arteries that go from the heart all the way down through the belly, down the legs, and so, we actually access one of those arteries and thread the catheter, with the new valve on it, all the way from the artery in the groin, all the way up to the heart and then position it inside the heart using x-rays and ultrasound so that we know we’re in the right place. And then, we open up the new heart valve inside the old one and “Hey, Presto” - you have a new heart valve.
Host: What does a patient have to do then to prepare for the procedure?
Dr. Rogers: So, I think we have a great team here that really guide the patients through the whole process, right from the very first contact, through all the testing to work out whether TAVR is the right treatment for them, all the way through the procedure. So, there are a lot of steps to this. This is not just a sort of come in and have the procedure and go home the next day. We always see patients beforehand. We usually bring patients in for a day or two several weeks in advance of the procedure to do all the tests we need to do to make sure that we know everything we need to know about this patient before we embark on the procedure. And then if we’re talking specifically on the (sort of the) day of the procedure, we usually ask people to come in the night before or very early in the morning. There’s a whole series of tests that we do - blood tests, to make sure that there’s...nothing’s cropped up in the meantime. And then, the procedure itself takes 3, 4 hours. And then, the patients typically go to either the cardiac ICU overnight or increasingly, actually, just go back to the normal ward, just to be monitored by the nurses there. And then we try and get people up and about the next day, and the average hospital stay for this procedure now is 2 or 3 days. So, actually, we’ve gone from a process where open-heart surgery patients would be in hospital for a week or more to a process where people are having heart valve replacement and they’re out, sometimes the day after the procedure, which, I think, is a revolution in this treatment.
Host: What are the benefits of TAVR compared to traditional open-heart surgery?
Dr. Rogers: Ok, so the first benefit is that some patients simply can’t have open-heart surgery. They’re too sick. They have too many other medical problems that would make the procedure too high-risk. And therefore, surgery just isn’t an option for them. Whereas, we’re able to perform TAVR safely in those patients because it’s less invasive. For the more general population, TAVR has the clear advantage that recovery is faster. Patients, after surgery, often have longer hospital stays. They end up staying in hospital for a week or so after the procedure. The complications are more common after surgery because it is just a bigger procedure and a bigger stress on the body. TAVR patients, in contrast, tend to go home within 2 or 3 days of the procedure and the recovery after they get home is much faster because they don’t have to deal with the surgical wound, the incision, and all of the problems you can get related to having just had a much bigger procedure. And so, in terms of getting back to normal daily activities, getting back to work, TAVR allows for much faster recovery.
Host: And the recovery process - how does that look for patients?
Dr. Rogers: So, the great advantage - and I think I’ve highlighted it a little bit already - the great advantage to this procedure is it’s not surgery and it doesn’t require cutting the chest open, it doesn’t require general anesthesia. And so, the great advantage of TAVR is the recovery. Patient’s bounce back and recover from this procedure must faster because it’s just less stressful on the body. Now, that being said, it’s still heart surgery, we’re still replacing a heart valve, and so I always try and temper patient’s expectations and say that, “You’re gonna have to take it a little bit slow here at first.” But, it depends. Someone who is in their 60s is going to recover from a big procedure like this much faster than someone who is in their 90s. And so, every patient is a little different. But certainly, the whole goal of doing this procedure is to get someone back to their normal activities, not just what they were like before they had the procedure but what they were like before they had symptoms from the aortic stenosis. So, back to being active, back to playing sports, whatever they want to do.
Host: Could you share the story of a patient who had a particularly successful outcome with TAVR?
Dr. Rogers: Sure. So, one patient, he’d had open-heart surgery to replace the same valve about 10 years or so ago. And, that had been a great success. He felt wonderful afterwards. But, the truth is, prosthetic heart valves don’t last a lifetime. And so, his “new” heart valve started to get tight and he a started to get those same symptoms again. And he was very, very worried about the prospect of having to have open-heart surgery again. He felt like he had done it once; he did not want to go there again. So, when he found out that there was an alternative to avoid having to have open-heart surgery again, he jumped at it. And, he came in the hospital, we did the procedure the same day, we got a great result with the new valve, and he actually went home, I think, the day after the procedure. Now, not everyone goes home so soon but, for him, the difference experienced from the first surgery, where he was in hospital for a week, to going home, literally, 24 hours after his procedure, I think, that’s really remarkable. And certainly, he was overjoyed by the result he got.
Host: Why is MedStar Washington Hospital Center the best place for patients to come for TAVR?
Dr. Rogers: I think that one of the strengths we have is that we’ve been part of the whole TAVR program since it very first took off. The very first procedure was done in France in 2002, and TAVR came to the US in around 2007, and MedStar was part of the first wave of hospitals to perform this procedure. And, we have performed almost 2,000 of these procedures now. We have a great deal of experience with all the different types of technologies which are out there to treat this. It’s not just one valve available. Now we have a whole series of different types of valves, which are...different patients need different valves. And, we’re also very active in research. So, not only do we have access to all of our past experience in research, but we also have access to all of the new technologies. So, when a new valve is made available, we’re one of the first hospitals to get access to it to offer that to our patients.
Host: Thanks for joining us today, Dr. Rogers.
Dr. Rogers: Thank you for your time.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.