Advances in Aortic Valve Replacement
Your heart’s aortic valve plays a crucial role in helping your heart function properly. The aortic valve pushes blood out of your heart and into the rest of your body, and then closes temporarily to keep the blood from moving back into the heart.
When this valve malfunctions, it’s called aortic valve disease. The aortic valve can develop aortic stenosis (narrowing of the valve) or aortic regurgitation (the valve doesn’t seal properly and allows blood to flow back into the heart).
Sometimes, aortic valve disease doesn’t need immediate treatment; your doctor may choose to wait and see if symptoms worsen. But for many people, it’s imperative that they undergo an aortic valve replacement. Until recently, that meant surgical aortic valve replacement (SAVR) through open-heart surgery.
The idea of having open-heart surgery can be frightening. It’s a major procedure and recovery can be long and painful. Some people have risk factors like other severe health conditions, and their doctor may decide that open-heart surgery isn’t the right path forward. Luckily, aortic valve replacement can now be performed with minimally invasive techniques, which means that doctors don’t always have to open the chest to access the heart. New procedures like minimally invasive SAVR and transcatheter aortic valve replacement (TAVR) allow surgeons to help more patients who otherwise may not have been able to undergo aortic valve replacement.
Minimally Invasive Surgical Aortic Valve Replacement
In open-heart surgery, the surgeon will spread the breastbone to expose the heart, creating a large incision which can take months to heal. In minimally invasive SAVR, the surgeon will make smaller incisions in your chest without opening your whole chest. This strategy reduces blood loss, trauma, and recovery time. A surgeon may use robotic assistance, a small camera, and special surgical tools during the procedure to access the heart and replace the aortic valve.
Transcatheter Aortic Valve Replacement
Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure used to treat select patients with aortic valve stenosis. Some facilities may call it a transcatheter aortic valve implantation, or TAVI. The procedure is used for people who are considered not to be strong enough for open-heart surgery but whose symptoms are severe enough that they need treatment. This includes people at intermediate to high risk of surgical complications.
In a SAVR procedure, the failing aortic valve is removed from the heart and a new one, either mechanical or tissue, is sewn into its place. If you undergo TAVR, however, your old valve is not actually replaced; a new valve is placed inside the old one using a catheter (tube), and the new one takes over the work—it’s a valve inside a valve.
Your surgeon will insert the catheter in one of three possible areas: through an incision in your groin area to reach the femoral artery (the transfemoral approach), through an incision in your chest between your ribs (the transapical approach), or through an incision in your upper chest (the transaortic approach).
The Transfemoral Approach
Your femoral artery runs from your abdominal aorta down through your groin area. This large artery is frequently used for heart procedures, such as angiograms and cardiac catheterizations. It is the most commonly used approach for TAVR. If your surgeon is using this approach, he or she will make a small incision or opening in your femoral artery and insert a long, flexible catheter, which will be threaded through your artery up to your heart and the aortic valve.
Inside the tip of the catheter is a collapsible replacement valve. When the tip of the catheter is in the right spot, the valve is placed inside your own valve. Once it is in place, your surgeon will inflate a balloon inside the new valve to open it and secure it place. The balloon will then be deflated and removed, along with the catheter. The new valve covers the old valve and the new flaps start working immediately to control the blood flow from your heart.
The Transapical Approach
In this approach, your surgeon will make an incision between your ribs to access the lowest part of your heart, called the apex. Through the apex, he or she will have access to your aortic valve, and using special surgical tools, your surgeon will place the new valve inside the old one, just like with the transfemoral approach.
The Transaortic Approach
In the transaortic approach, your surgeon will make an incision in the upper part of your chest and use surgical tools to access your heart. He or she will then follow the same steps as the other approaches to insert the replacement valve inside the failing valve.
These newer minimally invasive approaches to replacing an aortic valve are not for everyone. They are usually reserved for people who doctors feel will not tolerate or will not recover well from open-heart surgery. That being said, research has shown that they are very effective for people who in the past may not otherwise have been able to have their valves replaced.
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- What Is TAVR? American Heart Association. http://www.heart.org/HEARTORG/Conditions/More/HeartValveProblemsandDisease/What-is-TAVR_UCM_450827_Article.jsp#.VvBik7SqyQI
- Transcatheter Aortic Valve Replacement. UCLA Health. http://heart.ucla.edu/body.cfm?id=170
- Aortic Valve Replacement. Heart & Vascular Institute. Johns Hopkins Medicine. http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/treatments/valve_aortic.html
- Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Prosthesis. N Engl J Med 2014; 370:1790-1798. May 8, 2014. DOI: 10.1056/NEJMoa1400590 http://www.nejm.org/doi/full/10.1056/NEJMoa1400590