TAVR (also known as TAVI) stands for Transcatheter Aortic Valve Replacement (in term TAVI, ‘I’ stands for ‘implantation). TAVR is used for the treatment of severe Aortic Stenosis. As the name implies, this procedure involves implanting a new valve in place of old aortic valve using plastic tubes called catheter by a minimal invasive (suture-less) approach.
Valve is a “device that regulates, directs, or controls the passage of fluid or air by virtue of opening and closing”. We all have encountered valves in our lives. Tire valve is one such example which allows air to be injected into the tire and doesn’t allow air to escape unless the valve is tampered with or is leaky. The human heart has four such valves which allow unrestricted unidirectional blood flow from one chamber to another. When open, heart valves allow unrestricted blood flow and when closed, they prevent blood from leaking back into the previous chamber. When valves don’t open properly (a condition called ‘stenosis) they put undue stress to the heart by adding resistance to the blood flow. On the other hand, when valves don’t close properly, blood may leak back which makes flow dynamics within the heart less efficient. This condition is called ‘regurgitation’.
The four heart valves are named as Aortic, Mitral, Tricuspid, and Pulmonic. The current discussion is related to the Aortic valve.
The Aortic valve (AV) can be regarded as the most important valve of the human heart. It is located between the main pumping chamber of the heart (called Left Ventricle) and the main conduit that carries blood to rest of the body (called Aorta). The human heart beats about 1,00,000 (1 lakh) times a day and with each heartbeat, the Aortic valve opens to allow unrestricted blood flow from Left Ventricle to Aorta. The blood now travels to the rest of the body organs supplying necessary oxygen and nutrients. More than 7000 litres of blood flow across the Aortic valve per day. Heart valves get functional even before birth and, in most situations, are able to withstand this high demand for more than 50 years without any issues.
In some situations, altered flow dynamics across the Aortic valve leads to micro-injury of the valve tissue. As with any injury, the body heals by depositing extra tissue on it.
Over the period of time (usually years), continued micro-injury and healing lead to significant tissue/calcium deposition over the valve. This renders the valve stiffer, less mobile, leading to a restricted opening, hence ‘stenosis’. This is more commonly seen in people with:
Aortic Stenosis (AS) is a condition where Aortic valve gets narrowed making it difficult for blood to pass through it. Heart muscle has to work harder to overcome this resistance. The heart is able to compensate for this additional workload for many months to years during which a person may not notice any symptoms. When the ‘stenosis’ gets severe, the heart gives up eventually by becoming weak. This leads to heart failure and eventual demise.
People with a mild or moderate degree of aortic stenosis typically don’t have any symptoms. Severe aortic stenosis may have the following symptoms:
Many of the times, symptoms of severe aortic stenosis may not be very obvious. Patients typically slow down in their life to adjust to the disease. They find themselves getting tired too early in activities which they were able to do a few months back. Such limitations are easily attributable to normal ‘ageing’ process. For these reasons, symptoms largely get unnoticed or ignored.
Unfortunately, most of the preventative strategies which work for coronary blockages (the one that causes a heart attack) like controlling diabetes, cholesterol etc. don’t seem to work in prevention of Aortic stenosis. Still, it is recommended that people should engage in a healthy lifestyle that includes:
Aortic stenosis is a mechanical problem and needs to be fixed mechanically. Medications may improve symptoms by altering the body’s blood flow dynamics but have no effect on the degree of stenosis. Replacing the diseased valve with a new one is the best way to resolve this problem. Standard treatment for severe AS had been replacing the diseased valve with a new artificial valve via open heart surgery.
Heart surgery involves opening the chest, putting the patient on a heart-lung machine, removing the old valve, and stitching a new bioprosthetic valve in place. Patients typically spend 2-4 days in the intensive care unit and another 3-5 days in the general ward. There is 6 weeks rehabilitation period post-surgery. Open heart surgery is highly effective in resolving most of the issues related to severe AS. But as many as 40% of patients for whom surgery is indicated don’t go for surgery due to the increased risk associated with open heart surgery. 10 years ago, these patients were left with no viable alternative, until recently.
TAVR is an effective alternative to surgery for patients with severe AS. Using TAVR therapy, a cardiologist is able to implant a new valve in place of the old diseased aortic valve, all without surgery.
Aortic stenosis can also be treated by balloon valvuloplasty, a procedure where a balloon is inflated within the diseased Aortic valve. As the balloon inflates, it produces cracks and tears within the Aortic valve. While this procedure increases the valve opening, the benefit is short lasting (usually 3-6 months) as the body heals off the injury by that time leading to restenosis.
While TAVR is an attractive minimally invasive alternative to open-heart surgery for the treatment of severe Aortic stenosis, patients should be selected based on certain criteria to ensure a good clinical outcome. Here is a simple checklist that one can follow to determine candidacy for TAVR. The list below is intended to provide basic guidance and by no means is complete. One should always seek the opinion of an expert before making a decision.
1. Diagnosis of severe aortic stenosis should be confirmed, AND
There should be evidence that severe aortic stenosis is affecting the heart function, or is likely to cause a major issue in the future
2. There should be some reason to choose TAVR over open heart surgery:
Patients who are either older than 60 years of age or have other medical issues that put them at higher risk for open heart surgery can be taken up for TAVR
Patients with severe aortic stenosis are screened by the heart team to determine their candidacy for TAVR. This involves confirming the diagnosis of severe aortic stenosis, looking at other medical problems, and doing specific investigations to plan the procedure.
Necessary investigations are obtained beforehand to ensure appropriate therapy options are chosen. Such tests can be:
TAVR is a minimally invasive procedure which means no major incision is required. The doctors’ team typically comprise of interventional cardiologist, cardiac anaesthetist, cardiac imaging expert, and a cardiac surgeon. The procedure is typically carried out in Cardiac Catheterization Laboratory (same laboratory where coronary angiography and angioplasty is done). The procedure is mostly done under local anaesthesia, but general anaesthesia can also be used based on the patient’s clinical profile. A small incision is made in the upper thigh through which a plastic tube carrying an artificial heart valve is inserted. The valve is taken to its designated spot and implanted. TAVR obviates any need of opening the chest, putting on a heart-lung machine, prolonged anaesthesia or intensive care etc. The procedure takes about 1 hour to perform and is done with x-ray and echocardiogram guidance. The procedure, to some degree, is similar to getting a stent placed in the heart.
A typical patient is able to talk to family members immediately after the procedure, is able to sit and eat within 4-6 hours of the procedure, and can walk that evening itself. The patient is typically observed in intensive care for 24 hours after which he/she is transferred to a regular room. Patients are typically discharged home within 3-4 days. They are able to resume their routine activities within a week and are able to enjoy a scar-free life without any major physical restriction. Many patients were able to go shopping by the second week, and travel abroad within a month.
Majority of patients do not require blood thinners or any other special medicines after the procedure. In fact, they might be able to get off some of their previous heart medicines.
The TAVR valve (or THV) is made from animal pericardium (human or animal heart is covered by a thin rim of tissue called ‘pericardium’). The pericardial tissue is laser-cut into small pieces that are sewed together on a metal platform to take shape of a valve. The metal platform helps the valve anchor at its designated place. The THV is pre-treated with chemicals to increase its longevity and withstand continuous blood flow across it. These valves undergo rigorous testing outside the human body before they are brought into the market. Since they are tissue valves (as compared to metal valves that can only be placed by open heart surgery), they are expected to degenerate over time. Since TAVR is a new technique, studies are ongoing regarding their average lifespan. So far, these valves are shown to be functioning very well 8 years after the implantation and are expected to last about 15 years.
TAVR has been extensively studied in over 10,000 patients to evaluate its efficacy and safety. In the majority of the studied population, TAVR has performed similar or better than open heart surgery. TAVR offers similar benefits of implanting a new valve as in open heart surgery, minus the surgical risk.
While TAVR is a much safer alternative compared to open heart surgery in a patient with higher surgical risk, just like any other procedure TAVR is not free of complications. Few of the potential complications may include:
TAVR can easily be regarded as the most disruptive innovation in cardiovascular medicine in the past decade. First TAVR was successfully performed in humans in the year 2002 in France. Since then, more than 2 lakhs valves have been implanted across the world with excellent success. TAVR is not for everyone. A thorough discussion between patient/family and treating physician is necessary to understand a patient’s health condition and eligibility for TAVR. As it stands today, TAVR is a life-saving treatment alternative for many patients with severe AS who till now had no option other than to undergo open heart surgery.
CARE Hospitals started its TAVR program in September 2017. As of this writing, the Heart Team at CARE Hospitals is the highest TAVR performer in this region and is the only centre to have rights to perform this procedure independently (without the need for external proctor assistance). We take pride in team dynamics and doing TAVR the CARE way where everything is meticulously planned, discussed, and executed without leaving anything to chance. Our Heart Team comprises of physicians and surgeons from different specialties who add value by bringing their respective expertise in their particular area of interest. At least 4 senior level cardiologists are involved in every TAVR procedure along with cardiothoracic surgery and anaesthesia team. Based on guidelines from the American College of Cardiology and European Society of Cardiology, we have our homegrown patient flow-sheets and algorithms tailored to local needs which help us achieve procedural outcomes that match international standards. Our patients are our biggest advocates, words of a few of which you can find in the testimonial section.
Started TAVR program in September 2017September
1st case on September 20 2017
7th case on august 17, 2018 marking highest volume TAVR centre in TelangnaAugust
1st and the only centre in this region to have independent operative privileges Evolut R TAVR implantation
1st center to implant a 34 mm Evolut R TAVR valve - largest size availableAugust
Finished 10 cases in first year since program started, highest in the region
When it became clear that my dad(S.Mar Reddy) had to undergo surgery for bicuspid valve, we were aware of two option: open-heart surgery and TAVR. Given that my dad is a diabetic patient for about 25 years, we as a family decided to opt for TAVR as the recovery time compared to other surgery was short. Dr. Anoop explained to us both the options and also every detail about TAVR. Since we knew that he was a certified specialist in TAVR, we had faith in his ability. His team of doctors and staff were friendly and assisted us at every step. In the ICU too, when I went to se my dad, there was an emergency situation and i noticed how everyone sprang into action and handled the situation. Hospital service is of excellent quality. On behalf of my Family, I express sincere thanks to Dr. Anoop, his team and the entire Care Hospital for the wonderful treatment and care. It is almost four Months now and my dad is in good health and has resumed his normal activities. I would highly recommend this procedure to whoever can bear with the cost of TAVR.
For patient Mar Reddy (son): (66 Years, Male)
I was not well-breathlessness, too much breathlessness. I can't sleep, scared of everything, was always holding my husband's hand and did not allow him to go anywhere... from last 4 years I was not at all moving anywhere, not climbing stairs nothing and was very scared... I went so many hospitals these 4 years in Hyderabad. Dr. Shastri did the initial screening and suggested to meet Dr. Anoop at Care Hospital, Banjara. Before I couldn't even walk up to bathroom. After TAVR I'm completely happy with all my issues resolved. Now I'm okay and enjoying my life. I'm feeling really good and am grateful to Care Hospitals.
Mrs. Vasu Pradha (70 years, Female, patient)
I had undergone Angioplasty during the year 2003 followed by heart Bypass surgery in 2009 .During the year of 2016, I faced problems of periodic shortness of breath, and chest discomfort, I used to get tired within a few minutes of walk. I consulted Dr D. N. Kumar, senior Cardiologist, Care Hospitals (Nampally), and after few examinations it was found that the Aortic Valve was calcified and thickened and is unable to supply sufficient blood Dr Kumar suggested immediate surgery also suggested the new TAVR procedure which does not require any surgery and suggested to consult Dr. Anoop Agarwal, Interventional Cardiologist who specializes in this procedure. As the procedure is new, I and my family.were a bit hesitant to undergo the same. But one consultation with Dr Anoop Agarwal was sufficient to dispel our fears and decided to undergo the same the procedure was done by Dr Agarwal on 8th of Nov 2017. There was no surgery nor any pain. I was in ICU for a day for observation Second day I was walking slowly and was discharged on 13th Nov 2018. I was ready to resume office work in the next week, Since ther Tam normal and leading normal Life. There is no heart related complaint cannot forget the care which Diskumar and Agarwal had taken during the period was in Hospital Even now, Dr Kumar and Dr Agarwal contact me periodically to enquire about my health. Heartfelt thanks to them. As a patient undergone TAVR procedure. I do recommend it for patients requring such treatment as spanless.idoes not require prolonged rest and effective.
TEC Rao (66 years, Male)