When your aortic valve starts to narrow, you may not notice your heart pumping a bit harder to push blood out to your body. But, over time, as the valve opening between your heart and aorta shrinks, the extra pumping required leads to shortness of breath, fatigue and other problems. So your doctor will say you need a new valve. Is a minimally invasive procedure an option for you?
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“Those who develop symptoms from severe aortic valve stenosis have a 50 percent chance of dying within one to two years if they don’t have their aortic valve replaced,” explains interventional cardiologist Amar Krishnaswamy, MD.
Aortic valves can be replaced either surgically or through a catheter procedure — transcatheter aortic valve replacement (TAVR).
In deciding whether to recommend TAVR or surgical aortic valve replacement, doctors will consider a number of factors. “Either way, valve replacement will relieve symptoms and should lead to greater longevity,” he says.
What makes you a good candidate for TAVR?
Currently, doctors recommend TAVR if you fall into one or more of these categories:
- Your symptoms are severe (shortness of breath, lightheadedness, chest discomfort and fatigue).
- An anatomic analysis (with CT and/or MRI scan) shows that TAVR will be helpful for you.
- You’re at medium or high risk for open heart surgery or can’t undergo open heart surgery at all.
- Your other serious medical conditions (such as emphysema, orthopaedic problems, prior stroke and/or prior heart surgery) increase the risk of surgery.
“Research suggests that TAVR is just as good as — or better than — surgical aortic valve replacement for patients who are considered inoperable, or who are at high or medium risk for open heart surgery,” says Dr. Krishnaswamy. “As a result, the U.S. Food and Drug Administration has approved the procedure for these groups.”
Can patients at low risk of surgery have TAVR, too?
Small U.S. and European trials have also suggested that surgery and TAVR have equal benefits for patients who are younger, healthier and considered at low risk for open heart surgery.
“Importantly, the large U.S. PARTNER-3 trial of low-surgical-risk patients was recently completed, and results will be available in 2019,” he says. Cleveland Clinic is involved in the trial and its leadership.
Although investigators stopped enrolling patients in PARTNER-3 earlier in 2018, “we can still offer TAVR to selected low-risk patients through its continued access registry,” he says.
To determine if you’re a good candidate for TAVR, you’ll get a thorough evaluation, which is best done by a team of interventional cardiologists and cardiac surgeons. They’ll study your anatomy and carefully review your health status before recommending surgery or catheter replacement.
What is it like to have the TAVR procedure?
“We essentially push aside the original aortic valve and leave the new valve in place,” Dr. Krishnaswamy says.
The new prosthetic valve is mounted on the end of a catheter, which is then inserted in the femoral artery at the top of your thigh. This catheter is guided up to your heart, positioned within the original aortic valve, and then opened.
You’ll be awake and under conscious sedation. “Sedative medicine given through an IV will keep you comfortable,” he notes. “This is how we perform the procedure 90 percent of the time.”
Sometimes, however, the leg vessels aren’t large enough to accommodate the catheter. So the catheter will be passed through an artery in your shoulder or chest instead.
“In these cases, you’ll need general anesthesia and a breathing tube, which the anesthesia team usually removes before you leave the OR,” says Dr. Krishnaswamy.
There is a risk of stroke during TAVR, so cardiologists use the special SENTINEL® device to filter out and remove any material that’s dislodged from the artery walls or the valve during the procedure. Cleveland Clinic is among the few centers with access to this device and use it in every case.
How long does it take to recover from TAVR?
The TAVR procedure typically lasts 45 minutes to one hour. Most patients leave the hospital the next day, or the day after that.
“You should notice relief from your symptoms shortly after the procedure,” says Dr. Krishnaswamy.
Many patients can walk and do their normal daily activities as soon as they get home. But it’s important to take it easy for about a week, so the catheter insertion site can heal properly.
“If you’ve been weak for a long time prior to the procedure, it may take longer for your body to get stronger,” he says. In these situations, physical therapy will be beneficial.