Transcatheter Aortic Valve Replacement / TAVR

Transcatheter aortic valve replacement (TAVR) is valve replacement without open-heart surgery. It is also called catheter-based or percutaneous (through the skin) aortic valve replacement.

While open-heart (surgical) aortic valve replacement is the gold standard treatment for severe aortic valve stenosis, there are patients who may not be able to undergo traditional surgery because of factors such as age, history of heart disease, frailty or other health issues. For these patients, TAVR may be an option.

During TAVR, the replacement valve is inserted through a small cut in the thigh into an artery. Doctors use a tube-based delivery system (catheter) to navigate the valve to the heart. Then, the doctor expands the valve into place using a balloon located at the tip of the catheter.

At our center we implant the following TAVR valves. Your physician will determine which valve is best for you:

CoreValve Transcatheter Aortic Heart Valve. This valve is made of natural tissue obtained from the heart of a pig. The valve leaflets are secured to a flexible, self-expanding metal frame (nickel-titanium) for support.

Edwards SAPIEN XT Transcatheter Heart Valve. This valve is a biological valve (made from animal tissue) that replaces aortic valve. Read more about the Edwards SAPIEN XT Transcatheter Heart Valve.

At this time, the procedure is reserved for those individuals for whom an open-heart procedure is too risky. For that reason, most people who have this procedure are older, usually in their 70s or 80s, and often have other medical conditions that make them a better candidate for this type of surgery.

Although relatively new, TAVR can be an effective option to improve the quality of life in patients who otherwise have limited choices for repair of their aortic valve.

The TAVR procedure is not right for everyone. In certain cases, the risks of the procedure may outweigh the benefits. It is best to let us, as your cardiologist or your cardiovascular surgeon, make this determination with the use of various testing procedures. These would include the use of:

• Physical Examination (PE). We will listen for evidence of a heart murmur, examine your vital signs, and check for any other disorders.
• Electrocardiogram. An electrocardiogram (EKG) is used to record the heart's natural electrical currents. This can show the heart's rhythm, the heart's rate, and reviews the electrical currents. 
• 2 Dimensional Echocardiography. (2DE-ultrasound of the heart from the top of the chest wall or transesophageal echocardiography (TEE) within the body). These tests use ultrasound waveforms to pick up sound waves that are moving through the heart, which are then converted into moving pictures.
• Cardiac Catheterization. This is an invasive procedure to determine whether the heart arteries besides the valve are involved in your particular case.
• CT Scanning of the Chest and Abdomen (CTA). These are special x-rays to determine whether your body's arteries are large enough to allow passage of the Edwards SAPIEN Transcatheter Heart Valve system as well as the relationship of your coronary heart arteries to the native aortic valve. 

If both a cardiovascular surgeon and cardiologist determine that you are to high risk for standard aortic valve replacement (AVR), then transcatheter aortic valve replacement (TAVR) may be an alternative.

This is done in our cardiac catheterization suite which has both the availability for cardiologists and surgeons to work together with state-of-the-art equipment. Minimal anesthesia with propofol or general anesthesia will be given to put you into a mild or deep sleep. If you are totally asleep, a tube will be placed inside the trachea (breathing vessel) and promptly connected to a mechanical ventilator (a machine that will help you breathe during the procedure). Otherwise, we will use conscious sedation without a ventilator.

We may also use transesophageal echocardiography (a type of ultrasound) to see your aortic valve inserted while you are asleep and then removed before you are awakened. Patients with minimal sedation will have their valve examined by transthoracic echocardiography (another type of ultrasound).

We will place a temporary pacing wire in the heart so we can control the heart rhythm at various times during the TAVR procedure. This will be placed via a vein in the neck area by our anesthesiologist. This will be turned on and off at various times to allow us to implant the new valve in the exact perfect location without the beating of the native heart getting in the way. After the procedure is done, the temporary pacing wire is removed.

We use fluoroscopy (a type of x-ray) during the procedure as well as a contrast medium (dye) in order to see your aortic valve. Some patients may have kidney problems or an allergic reaction as a result of the contrast medium. Please inform us before the procedure if this has been a problem in the past.

For the TF (Transfemoral) Procedure, after you are put to sleep, we will make a small incision in the femoral artery (groin) just like in the previous heart catheterization procedure to allow insertion of the Commander System into the E-Sheath.

For the TA (Transapical) Procedure, after you are put to sleep, we will make an incision between the ribs on the left side of the chest for the introduction of the catheters.

First, a balloon catheter will be used to open the diseased native aortic valve in preparation for the introduction of the new valve. The Edwards SAPIEN Transcatheter Heart Valve will be placed on the delivery system (a long tube with a small balloon on the end) and compressed on the balloon (using a crimper) to make it small enough to fit through the sheath. It will be about the width of a pencil.

Using our temporary pacemaker, we speed up the heart in order to decrease the chance of the new valve from moving during its placement. We inflate the balloon holding the new valve in the exact position desired and observe its function using angiography and echocardiography. The pacemaker rate is then decreased, the balloon removed, and various pictures are taken to confirm the positioning of the Edwards SAPIEN Transcatheter Heart Valve.

We will make sure that your new valve is working properly before removing the delivery system and closing the incision in your groin area. In the rare instance that your new valve is not working properly, we may need to do something else which may include open-heart surgery, insertion of a second new valve, or other additional surgery as we determine to be necessary.

After the procedure, you will be moved to the cardiovascular recovery unit for careful monitoring. You may be given blood-thinning medicine. These typically include Plavix (clopidogrel) or a similar agent.

While in the hospital after the TAVR procedure, the following examinations are performed for further assessment of the new valve:

• Physical exam
• Chest x-ray
• Blood tests
• Electrocardiogram (EKG)
• Echocardiogram
• Early ambulation and discharge is expected

You will remain in the ICU until we feel that you can be transferred to a regular hospital room, where you will continue to be monitored until you leave the hospital. The average ICU time is one to two days and the average hospital stay for this TAVR procedure is three to four days. You may feel better soon after your procedure.

You will receive specific instructions to help you with your recovery, which may include a special diet, exercise, and medicine. Regular check-ups are very important. It is easier for patients with a replacement heart valve to get infections, which could lead to future heart damage. You will need to take any medicine as prescribed and have your heart checked from time to time with the ultrasound echocardiogram.

Always inform other doctors about your heart valve replacement before any medical or dental procedure. Before undergoing an MRI (magnetic resonance imaging) procedure, always notify the doctor (or medical technician) that you have an implanted heart valve. Failure to do so may result in damage to the valve that could result in death.