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TAVI/TAVR

Complications with the aortic valve are increasing in people across the world. Under normal conditions, this valve opens up when blood is pumped from the heart to various parts of the body. However, sometimes the aortic valve cannot open and close in a proper fashion and blood flow is hampered as the valve becomes stiff. This condition is known as aortic stenosis. It is obvious that when this happens, extra pressure is exerted on the heart, as blood is pumped through a small valve opening. Swollen ankles, dizziness, breathlessness, chest pain and even blackouts in some cases, are a few of the symptoms.

Generally in cases like this, open-heart valve surgery is recommended. But this treatment isn’t always suitable for all kinds of patients. Older patients, those who are too ill or those who have various other kinds of medical issues might not be able to undertake open-heart valve surgery as it will be too risky for them. Transcatheter aortic valve implantation (TAVI) is the treatment procedure that works in cases like this.

Transcatheter aortic valve implantation is a procedure where an aortic valve is implanted with the use of a long narrow tube, known as a catheter. In general, the catheter is inserted into a large blood vessel in the groin or through a small incision which is made in the chest of the patient.

Special transcatheter aortic valves are designed for surgical purposes. For implanting the valve to the heart, the valve is squeezed inside or around the catheter. The catheter is then inserted and guided to the location of the aortic valve opening in the heart. After the implantation of the new valve, over the existing valve, the catheter is removed. The working of the new valve starts immediately after implantation.

Patients who suffer from progressive heart failure due to aortic stenosis, but are not fit for traditional open-heart aortic valve replacement surgery will need TAVI. Here are some of the conditions in which open-heart surgery might prove to be dangerous:

  • Advanced age
  • History of stroke
  • Weak heart
  • Kidney ailment
  • Chronic obstructive lung disease (COPD)
  • Previous heart surgery
  • Diabetes

Calcium deposits in blood vessels, which carries blood from the heart to other parts of the body

The surgical and medical team will first ascertain the overall health of the patient. The doctor will carry out various kinds of tests and investigations on the patient to understand better if they will benefit from the TAVI procedure. Some of the tests include blood tests, x-rays, CT scans, electrocardiograms, 2D-Echo and so on. With an 2D-Echo, it is possible to create images of the heart for evaluating the aortic valve. For some patients, cardiac catheterization might also be done, in order to evaluate the heart. Other preparations, which need to be taken include.

  • Informing the doctor about all the medicines that you take, including over the counter medicines
  • If you smoke, ask the doctor how soon should you quit before the surgery
  • In case the doctor asks you to stop certain medicines, do that as per instruction
  • Don’t eat and drink after midnight, before the surgery

The methods sometimes vary depending on the condition of the patient and on the practice that the doctor follows. This is generally the procedure that is followed.

  • The patient needs to be admitted to the hospital the day before the surgery or on the morning of the surgery date.
  • On the arm or hand, an intravenous (IV) line will be started. Additional catheters are inserted in the wrist and neck for monitoring the status of blood pressure and heart.
  • In the operation theater, you will be made to lie on your back.
  • The anesthetist will monitor blood pressure, heart rate, blood oxygen level and breathing during the surgery. Once anesthesia is applied, a breathing tube is inserted into the trachea so that the lungs get oxygen. A connection to the ventilator is also established which regulates breathing during the surgery.
  • A catheter is inserted into the bladder for draining urine.
  • A Transesophageal echocardiogram (TEE) probe is inserted in the esophagus for helping in visualizing the valve.
  • An incision is made in the groin area for locating the femoral artery. This artery helps in carrying blood from the heart to the leg below.
  • A catheter is placed into the artery and threaded to the heart through the aorta for reaching the aortic valve.
  • Other catheters are also placed in the heart for taking x-ray pictures and measurements during the procedure.
  • The replacement valve is guided, which is inside an expandable balloon, up into the femoral artery catheter and through the old aortic valve.
  • Once the balloon is positioned properly, the cardiologist expands it and implants the new valve for replacing the old one.
  • Before removing the catheters, the doctor will check that the new valve is working properly by monitoring the same and by taking frequent pictures of the same.
  • The femoral artery and the groin incision will then be closed with clips or sutures.

After the surgery, the patient is moved to the intensive care unit of the hospital so that they can be monitored all the time during recovery. As the recovery process continues, the various tubes in the arteries and veins are removed gradually. The hospital stay will continue for a few days. But normal diets can be resume quickly.

Once the patient is home, which happens after a few days, depending on the speed of recovery, they must follow all the instructions regarding medicines, diet, pain control, activity and wound care. Also, maintain all the follow-up appointments.

It might take a few weeks to recover completely.
Mentioned below are some guidelines, which will help in quick healing:

  • After a TAVI, the doctor recommends blood-thinning medicine for preventing blood clots. For ensuring that you are getting the right dose, you must have your blood checked regularly.
  • Make sure that you walk as much as possible.
  • Refrain from lifting anything heavy, but you can do other normal activities.
  • Ask permission from your doctor as to when you can indulge in rigorous working, driving or any kind of sexual activity.
  • Inform the doctor immediately if there is any kind of pain, bleeding, fever or shortness of breath.
  • Keep a close watch on the groin area for any sign of redness, swelling, discharge or bleeding.
  • Maintain a healthy weight.
  • Eat a heart-healthy diet.
  • Refrain from smoking.

More and more cardiologists are getting experience with TAVI and the risks associated with the same are decreasing. However, TAVI is a major procedure in which general anesthesia is required. Some of the common risks which are closely associated with TAVI include the following:

  • Bleeding
  • Damage to the blood vessels
  • Heart attack
  • Lung puncture
  • Stroke because of decreased blood supply to the brain
  • Kidney failure
  • Replacement valve failure
  • Fluid collection around the heart
  • Severe heart failure

There might be other risks as well depending on your health condition. Before the procedure have a detailed discussion with your doctor on these matters.

When handled by a good cardiologist and proper following of instructions, patients undergoing TAVI recover quickly.

TMVR

Transcatheter Mitral Valve Replacement. The mitral valve is important among the four valves in the heart. Just like tricuspid valves, these valves help in controlling blood flow to the ventricles from the atria. The most common problem that is seen in the mitral valve is degenerative valve disease. This valve ailment is progressive in nature and is a slow degeneration from mitral valve prolapse. This is a condition in which there is improper leaflet movement and almost 4-5 percent of the general population is affected by this problem. Over a long period of time, the attachments of the valve thin out. Sometimes, the valve also ruptures and the leaflets become redundant and floppy. As a result, there’s leakage through the valves.

Regurgitation happens when blood flows backward in the valves as there might be leaks in the valve leaflets after they are closed. In such a situation, the heart has to work harder to pump a larger volume of blood. In case there is a leaky mitral valve, blood will flow back to the left atrium from the ventricle when there is a contraction in the ventricles.

Stenosis is also a condition, which might affect the heart valves including the mitral valve. A stenotic mitral valve restricts the flow of blood from the left atrium to the left ventricle.

There are many patients with severe mitral regurgitation, and extensive open-heart surgery might not be possible for all kinds of patients. For such patients, transcatheter mitral valve replacement (TMVR) is an alternative treatment. TMVR can be applied to annuloplasty rings, degenerated prosthetic valves, or other kinds of native mitral valve ailments.

Transcatheter mitral valve replacement is a surgical procedure in which the mitral valve is replaced in the heart, without the need for open-heart surgery. Patients suffering from either mitral valve regurgitation or mitral valve stenosis or a combination of both, who are not able to undergo general open heart surgery are candidates for this kind of surgery.

This is a minimally invasive surgical procedure, which helps in improving the quality of life significantly without any open-heart surgery. For TMVR, a special kind of device is needed, which should be approved. The device is built from polyester and metal, and made in such a way that it provides relief from mitral regurgitation and also helps in preventing hospitalization for heart failure.

A patient undergoing TMVR will have to get admitted to the hospital or nursing facility the day before the surgery. This gives the healthcare team time to prepare the patient for the surgery in a proper manner.

Here is a brief description of what happens during the process of transcatheter mitral valve replacement (TMVR):

  • The patient is made to lie on their back and they are put on a life support system so that they can breathe during the procedure.
  • The surgery is done under complete anesthesia.
  • An opening is made in the femoral vein of the groin. Through this opening, a guidewire and catheter are inserted towards the heart.
  • The guidewire is gradually moved into the left atrium, which is the upper left chamber of the heart and once it reaches there, the guidewire is removed.
  • The clip is eased through the catheter and is moved into the atrium.
  • The arms of the clips are opened and are placed over the two flaps of the valves, which are also known as leaflets.
  • The arms are then closed for clipping the leaflets together in the center. As a result, two small channel-like structures are created. This helps in preventing the flow of blood in a backward direction.
  • The catheter is slowly removed, but the clips remain in place.

The patient is generally released after one or two days of the procedure. After they go back home, they have to follow some rules and regulations and also take the medicines properly as instructed. Follow-ups also need to be done at regular intervals to understand the progress taking place.