by Jonathan Roberts MD FACC

TAVR is not recommended for everyone with Aortic Stenosis

Patients who
have the condition should discuss treatment options with their physician.

UNTIL recently, patients with severe aortic stenosis had just one option: openheart surgery along with the use of a heartlung machine. For those with high-risk factors, however, such a procedure was out of the question. And without treatment, about half of those with severe aortic stenosis die within two years from the time that their symptoms became manifest. Transcatheter Aortic Valve Replacement (TAVR), also known as Transcatheter Aortic Valve Implantation (TAVI), offers life-prolonging treatment to patients who were previously considered inoperable.

TAVR is not recommended for everyone with aortic stenosis, so patients who have the condition should discuss treatment options with their physician. In doing so, patients should be helped to understand the answers to the following questions.

What is aortic stenosis?

Aortic stenosis is a condition in which the valve that regulates the flow of blood from the heart cannot open fully, causing excess stress on the heart and weakening its ability to perform. Sometimes narrowing of the heart valve is due to a birth defect, rheumatic fever, or radiation treatment. Most often, however, aortic stenosis is the result of age-related calcium buildup. Over time, mineral deposits form on the leaflets of the aortic valve, restricting adequate blood flow. Whatever the cause, it is estimated that aortic stenosis afflicts more than 1.5 million people in the United States, and about a half million have severe aortic stenosis.

What are the symptoms?

Symptoms of aortic stenosis usually include shortness of breath, fatigue, and chest pain. Some patients feel as if they are going to faint. Because the heart is working harder to pump blood, the body is not receiving sufficient oxygen-rich blood.

How is aortic stenosis diagnosed?

A general physical exam sometimes reveals the presence of a heart “murmur,” which may indicate the need for an echocardiogram (ultrasound).  Echocardiogram images usually reveal whether or not stenosis is present.

What is the treatment for aortic stenosis? 

Patients who have aortic stenosis usually undergo aortic valve replacement. During this surgical procedure, the defective valve is replaced with a mechanical or tissue valve.

Is surgery for everyone?

For some patients—for example, the elderly or those with a history of heart disease—open heart surgery may be too risky.

Is there an alternative?

Transcatheter aortic valve replacement (TAVR) is a less invasive procedure in which surgery is performed on the heart while it is still beating and does not require cardio-pulmonary bypass. (The defective valve is replaced without
opening the chest.)

What happens during TAVR?

The procedure is performed in the cardiac catheterization laboratory with a team of an interventional cardiologist and a cardiac surgeon.  The patient is given general anesthesia, after which the surgeon makes a small incisiot (usually one or two inches), in the groin, or chest. A catheter (plastic tube) with an artificial valve collapsed on a balloon is then guided into the heart, within the diseased native aortic valve. The balloon is then inflated, causing the new valve to expand, and in the process push aside the diseased calcified native valve. The balloon is then deflated and removed, and the new valve immediately begins to function normally!.

Are there risks?

Risks associated with TAVR include the possibility that blood can stop flowing to the brain, resulting in a stroke.  There can also be vascular complications, such as a tear in a blood vessel or even in the heart. Patients should discuss with their physician the risks and benefits of TAVR to make an informed decision about whether this procedure should be performed.

Which patients would not be candidates for TAVR?

That would include patients who have a prosthetic valve or implanted repair device in a heart valve, as well as those who have only one or two leaflets on the aortic valve. Normally, patients who can have open-heart surgery would pursue that as a preferred treatment.

What is the future for TAVR?

In November 2011, the FDA approved TAVR for use on people who are not able to have open-heart surgery, perhaps for the reasons cited earlier. More than 50,000 patients have already received TAVR. As a result, they have hope for a longer life—and an improved quality of life.

In the future, TAVR may be used in a broader context. “The first group of patients now receiving TAVR are those considered to be high risk for traditional surgical aortic valve replacement, or even inoperable” says HeartWell interventional cardiologist Dr. Ramon Quesada.  “Our hope and expectation, is that as TAVR technology matures, TAVR will become the routine choice for aortic valve replacement in the majority of patients afflicted with aortic
stenois,” concludes HeartWell interventional cardiologist Dr. Jonathan Roberts.