May 21, 2019
Transcatheter Aortic Valve Replacement (TAVR) has come a long way since it was introduced in the U.S. in 2007, as doctors’ experience and technological advancements have improved. But the medical community still has work to do. Dr. Toby Rogers discusses the current and future state of TAVR.
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. Thank you for joining us, Dr. Rogers.
Dr. Rogers: It’s a pleasure to be here.
Host: Today we’re discussing the future of transcatheter aortic valve replacement, or TAVR. TAVR is a treatment for patients with aortic stenosis, or narrowing of the aortic valve. Dr. Rogers, could you discuss how a doctor can replace an aortic valve without open-heart surgery?
Dr. Rogers: That’s a great question and it’s one that every patient wants to know. So, I think open-heart surgery makes sense. You open the chest, you stop the heart from beating, you cut out the old valve, you sew in a new one, you restart the heart beating again, you sew the chest up, and you have a new heart valve. TAVR is very different. In fact, we don’t actually take the old valve out at all. And, what we do is we thread a new valve through the artery from the leg, all the way up to the heart, and then we open the new valve inside the old one, just pushing the old one out of the way, and we leave the new valve behind, opening and closing inside the old one. And, the beauty of this is that obviously we’re able to that, as I said, thread it from the leg, without having to do open-heart surgery, without having to stop the heart from beating, without having to even put the patient asleep. And so, it’s much less invasive and much less of a stress on the body.
Host: What are some of the improvements in TAVR that you’ve witnessed or been a part of in your practice?
Dr. Rogers: So, I think you can divide the benefits into two broad areas. The first is technology. So, we are now on to the third generation of TAVR valves, meaning that the companies that develop these, and the doctors and scientists that work with them, have gone through three iterations now, or improvements, on the valve technology. And each iteration, each new improvement, has brought dramatic improvements to the whole procedure. Specifically, the catheters that we deliver the valves through from the groin have gotten smaller and smaller. And the smaller a catheter, the less invasive the procedure and the more patients are able to have this procedure because even patients now with very small...even patients with some blockages in the arteries down to the legs, are able to have TAVR whereas in the past they wouldn’t have been able to do so. There’ve also been some key technology improvements that reduce the need for pacemakers after the procedure, that reduce the risk leaking of blood around the new valve after the procedure. And, we know that all of these things put together make for a much more durable and lasting result. And then, the second area that there’ve been improvements is just in our comfort and our experience with the procedure. To the point that when we started doing TAVR, we actually used to put all the patients asleep with general anesthetic. We used to have an echo probe, an ultrasound probe, down the esophagus so that we could monitor the heart very, very carefully during the procedure. And, with experience, we’ve learned that those things are actually not necessary. And so now we do TAVR, as I mentioned before, under just a little bit of sedation. We don’t put patients to sleep. And we don’t even need the ultrasound probe to guide the procedure anymore. We can do the whole thing using x-rays, which is must less invasive. And so, if you put these technology advances and the procedural advances and experience together, it makes for a much less invasive...in fact, we use the word “minimally invasive” approach to TAVR now, and all of those things put together make for better outcomes, faster recovery, shorter time in hospital, and overall better results.
Host: Even with all of those amazing benefits, what do you think should be improved in the next generation of TAVR?
Dr. Rogers: So, we have great devices to replace TAVR valves that are tight, meaning they’ve gotten tighter and tighter over time. We see a lot of patients who have leaky valves, and actually, we don’t have great technology for those yet. That technology is just coming along and MedStar is actually one of just two hospitals in the country that is testing a new valve for this specific problem. But up until now, we’ve really been in a bind in that these patients with leaky aortic valves, we’ve had to say, “Sorry, we don’t have a minimally invasive treatment for you. Open-heart surgery is your only option.” So, that’s one area where I think there is definitely room for improvement. I mentioned the size of the catheters. Smaller catheters are always better because it makes for an even more minimally invasive procedure, so I anticipate that in years to come these catheters and devices will get even smaller, and I think that’s only a benefit for patients. There’s been a lot of work to improve how well these heart valves sit inside diseased aortic valves that aren’t completely round, and aortic valves that had a lot of calcium in them, which is something that we commonly see. And, those patients are particularly prone to having electrical conduction problems after TAVR, and needing pacemakers. And so, there’s still a lot of work to be done, I think, to improve the technologies so that patients really don’t need pacemakers after TAVR because again, if you do need a pacemaker, that often extends the time you’ve been in hospital and it’s an additional procedure that you have to undergo.
Host: What do you think will be the biggest challenges or barriers in improving or providing TAVR in the future?
Dr. Rogers: So actually, I think the answer to that question doesn’t have much to do with TAVR technology or the procedure itself. It’s about access and availability to TAVR. If you live in a big city that has a hospital like MedStar Washington Hospital Center that does TAVR, and you have aortic stenosis, then there is a hospital just down the road that can provide you this treatment. If you live far from a big city, then often your local hospital doesn’t have access to this technology because it is still a specialist procedure. And so, there are a lot of patients out there across the country who live far from hospitals and don’t have access to this. And so, I think there are a lot of patients who could benefit from this treatment, if only it was close to them. So, one of the big challenges we have going forwards, is finding a way to give patients access, to educate patients that TAVR is available, that open-heart surgery isn’t the only choice and then also, find ways to either bring the technology closer to where they live or find ways to make it easy for them to travel to where the technology is.
Host: How will you and your colleagues help overcome these challenges?
Dr. Rogers: The first answer has always got to be education. We have to educate other doctors that this is available so that doctors outside in the community, when they see patients, know that these options are available. As I said, this technology is moving very quickly and, those of us who work in this day to day, have to work very hard to keep abreast of all the new advances and the new technologies. And so, we have to work very hard to help other doctors who aren’t TAVR doctors to understand what’s available, what’s changed, what’s new. And then, that allows those doctors to teach their patients, “Look. These are the options for you.” As I said to you before, there are many areas in the country where patients live many hours from a hospital that offers TAVR and so, those patients may be tempted to say, “Well, I’ll stay close to home and have open-heart surgery,” when we all know that if you’re an elderly patient with lots of other medical problems, TAVR is a better option for you. And so, I think education’s got to be the first try. And then, at a bigger level, we have to think, as a society, “How do we improve access to these technologies?”
Host: Why is MedStar Washington Hospital Center uniquely positioned to offer TAVR?
Dr. Rogers: So, MedStar Washington Hospital Center has been at the forefront of TAVR since it was first introduced to the United States over a decade ago. And, we have great experience with all of the TAVR technology, right from the very early days. We’ve been involved in all of the major clinical trials of TAVR. We’ve run our own clinical trials, most recently in low-risk patients, so patients who would otherwise undergo surgery. And, we also - because of this - we have access to all the new technologies, so when a new valve becomes available, either under clinical trial or for just commercial use, as a hospital, we get access to that very early. And clearly that gives us an option when a patient comes to us to say that we have not just one option we have many options for you. And, I think research drives our day-to-day mission and that can only make patient care better.
Host: Thanks for joining us today, Dr. Rogers.
Dr. Rogers: Thank you.
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.