The Role of TAVR in Treating Aortic Stenosis
The aortic valve is the most important valve in the heart. All of the blood circulating in the body gets passed through this valve—it sends oxygen-rich blood to your brain and the rest of your body. That’s why, when this valve is not working properly, treatment is necessary; without a functioning aortic valve, people will get sicker and may die after a short period of time.
When the aortic valve becomes blocked or narrowed, we call that aortic stenosis. Typically, there are three leaflets, or flaps, that open to allow blood to flow through the valve, and then close to prevent blood from flowing backwards. Sometimes these leaflets get damaged, and plaque builds up along them; eventually, the leaflets fuse together, making the valve opening very narrow. Over time, this hole becomes smaller and smaller, so blood can’t pass through easily to the rest of the body. And because the aortic valve is the main heart valve, this problem can lead to serious cardiovascular events or even death.
There are two main causes of aortic stenosis. You can be born with it, which we call congenital aortic stenosis, or you may develop it over time, which we call senile degenerative aortic stenosis. This second type of aortic stenosis is the most common valve disease in people over the age of 65. It’s very common because people are living longer and the aortic valve takes a lot of punishment over time. As we get older, the aortic valve may become more and more damaged until we develop aortic stenosis. And unfortunately, at this point in time, there is no way to prevent aortic stenosis from occurring or delay its progression once it’s found. Once it’s detected and it becomes severe, it’s crucial that we treat aortic stenosis as soon as possible.
Treating Aortic Stenosis
The only treatment option for severe aortic stenosis is to replace the valve altogether. In the past, there was only one way to do this—through open-heart surgery. However, some patients are too sick or have too many other health conditions for open-heart surgery to be a good option—for these patients, open-heart surgery is just too risky. Until recently, patients that weren’t candidates for open-heart surgery would get sicker and sicker, and eventually die. In fact, studies have shown that 50% of patients who don’t treat severe aortic stenosis die within two years. Fortunately, in recent years, surgeons and cardiologists have been using a procedure called transcatheter aortic valve replacement (TAVR) in these high-risk patients, and the outcomes are excellent. As of August 2016, TAVR is also an option for people at intermediate risk of complications from open-heart surgery.
TAVR is a great option because it’s much less invasive than open-heart surgery--it doesn't require the patient's sternum to be cut, and the patient doesn't need to be placed on the heart bypass machine--which means it’s quicker, less painful, and recovery is easier and shorter. TAVR is performed by a surgeon and cardiologist together. First, they make a small incision and guide a tube, called a sheath, into place. Then, they slide a catheter containing a small, deflated balloon into the sheath and direct the catheter into the heart. The balloon is inflated to widen the narrow opening of the aortic valve, and then the balloon is removed. Next, the surgeon and cardiologist guide a replacement valve, placed around another balloon, through the catheter to the heart. Once the new valve is inside the old valve, the balloon is inflated and the new valve is opened—it immediately pushes the original valve aside and replaces it.
There are three approaches to TAVR as far as where the surgeon and cardiologist make the initial incision. In the preferred approach, called the transfemoral approach, they make an incision in your groin to access your femoral artery. This artery leads up to the heart, so the sheath is inserted and catheter guided all the way through the artery to the heart. The transfemoral approach is ideal because it’s the least invasive, least painful, and has the best outcomes when compared to other approaches and open-heart surgery.
The second-best approach is called the transaortic approach. In this method, the surgeon makes a small incision at the top of the sternum and insert the sheath into the aorta so we can work on the aortic valve. This technique is still less invasive than open-heart surgery and has good outcomes, although it’s a bit more painful and the patients may need to stay in the hospital for one to two extra days when compared to the transfemoral approach.
The last TAVR approach is still a better option as far as recovery time when compared to open-heart surgery. It’s called the transapical approach because the incision is made between the ribs and the sheath is passed through the tip of the heart, called the apex. This approach is more surgical and may be more painful than the other two options, with an average of five days spent in the hospital.
Even the day after the TAVR procedure, patients may experience a lot of relief due to their new valve. We tend to see patients one month after their procedure and most patients feel markedly better. Depending on the approach used, they may experience little to no pain during their recovery, and typically are very happy to be active and less short of breath.
TAVR has played a life-saving role in treating aortic stenosis—we’re helping more patients than ever before now that TAVR is an option. It is allowing qualified patients to avoid a difficult, painful recovery after open-heart surgery and get back to their lives more quickly and easily.
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