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Percutaneous Valve Therapies

Transcatheter aortic valve replacement/implantation

Transcatheter aortic valve replacement (TAVR) is a minimally invasive heart procedure to replace a thickened aortic valve that can’t fully open (aortic valve stenosis). The aortic valve is located between the left lower heart chamber (left ventricle) and the body’s main artery (aorta). If the valve doesn’t open correctly, blood flow from the heart to the body is reduced.

Types of TAVR Approaches

A transfemoral approach is done through a small incision in the skin at the top of your thigh (groin), and the catheter goes into your femoral artery. The doctor uses a dye and a specialized X-ray (fluoroscopy) to guide the new valve through the catheter to the diseased valve.

The procedure is done using conscious sedation. This is the most commonly used approach, and about 90% of TAVR patients have a transfemoral procedure.

The transapical approach is done through a 4-inch incision between the ribs. The new valve is inserted through the incision and placed directly inside the diseased aortic valve.

The doctor uses a dye and a specialized X-ray (fluoroscopy) to guide the new valve to the diseased valve. The procedure is done using general anesthesia while the patient is asleep.

The direct aortic approach is done through a J-shaped incision at the top of the breast bone (sternum). The catheter is guided into the aorta and the valve is put in place.

The procedure is done under general anesthesia.

The subclavian approach is done through a small incision near the shoulder, and the catheter goes into the subclavian artery.

The new valve is guided through the artery into the aorta and put in place. This procedure may be done with general anesthesia or conscious sedation.

Types of TAVR Approaches
Aorto-Ostial Lesions

Types Of TAVI Valves

The Medtronic CoreValve and Edwards’ SAPIEN are the most commonly used TAVR prosthetic valves.

  • SAPIEN VALVE
  • CORE VALVE

Before the procedure

  • Before the day of surgery, you will have a physical exam and tests. These tests include X-rays, CT scans, lung tests, and blood tests.
  • You will have an echocardiogram to check your aortic valve. You may also have a cardiac catheterization.
  • Tell your doctor if you are allergic to any medications.
  • Nil by mouth for a few hours before surgery.
  • You will be asked to remove jewellery and other objects that may interfere with surgery.
  • You will change into a hospital gown and empty your bladder before the procedure.
  • A surgical team will position you on the operating table lying on your back and give IV medications and fluids. Additional catheters may be placed in blood vessels to monitor your heart and blood pressure.
  • Before your surgery, you may receive general anesthesia to put you into a pain-free sleep. In many cases, the procedure is performed under moderate sedation, where you are heavily sedated but not completely asleep and do not feel pain.
Pre Procedural Imaging
Aorto-Ostial Lesions

During the procedure

  • Transcatheter aortic valve replacement (TAVR) involves replacing a damaged aortic valve with one made from cow or pig heart tissue (biological tissue valve).
  • Sometimes, the biological tissue valve is placed into an existing biological tissue valve that is no longer working.
  • To perform TAVR, doctors insert a catheter into a blood vessel, usually in the groin or chest area, and guide it into the heart.
  • Moving X-ray images or echocardiogram pictures help the doctor place the catheter into the correct position.
  • A replacement valve made of cow or pig tissue is passed through the hollow catheter and placed in the area of the aortic valve.
  • A balloon on the catheter tip inflates to press the new valve into place. Some valves expand without the use of a balloon.
  • The doctor removes the catheter once the new valve is securely in place.
  • The anesthesiologist continuously monitors your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • You do not need to be on a heart-lung machine for this procedure.

Pacemaker

  • Every patient receives a temporary pacemaker during the TAVR procedure. A pacemaker is a device that uses electrical impulses to regulate your heart rhythm.
  • This involves a small wire passed through a vein in your leg into your heart, which is most often removed immediately after the procedure.
  • Sometimes, a permanent pacemaker may be needed after a TAVR procedure.
  • If a permanent pacemaker is required, it is usually placed while you are in the hospital, typically the day after your TAVR procedure.
Pre Procedural Imaging
Aorto-Ostial Lesions

After the procedure

  • You may spend the night in the intensive care unit (ICU) for monitoring after your procedure.
  • How long you need to stay in the hospital after TAVR depends on several factors. Some people who undergo TAVR may go home the next day.
  • Before you leave the hospital, your treatment team will explain how to care for your incisions and how to watch for signs and symptoms of infection.
  • Warning signs of infection include:
    • Fever
    • Increased pain
    • Redness
    • Swelling
    • Drainage
    • Oozing at the catheter site

TAVR Overview

  • Age
  • Heart infection
  • Rheumatic fever
  • Calcification – calcium deposits on the aortic valve as you get older
  • Other factors

  • Shortness of breath with exertion
  • Shortness of breath when lying flat
  • Fatigue
  • Palpitations
  • Swelling in your legs, abdomen, and veins in your neck
  • Chest pain or tightness with exertion
  • Rapid weight gain due to fluid retention

  • Chest X-ray
  • Transthoracic echocardiogram
  • MRI
  • Pulmonary function tests
  • Computerized tomography
  • Angiogram
  • Transesophageal echocardiogram
  • CT scan of chest, abdomen, and pelvis

  • Excellent alternative to open-heart surgery
  • Decrease in mortality rate
  • Prevents further damage or infection
  • Shorter hospital stay (around 3–5 days)

  • Bleeding during or after surgery
  • Problems with the replacement valve, such as slipping or leakage (regurgitation)
  • Blood vessel complications
  • Pneumonia
  • Pancreatitis
  • Stroke
  • Heart rhythm problems (arrhythmias) and the need for a pacemaker
  • Kidney disease
  • Heart attack
  • Infection
  • Death

  • ECG
  • CT angiogram
  • Angiogram
  • Stress test
  • Chest X-ray
TAVR Overview

Contraindications

  • Life expectancy less than 12 months
  • Myocardial infarction within the last 30 days
  • Congenital unicuspid
  • Bicuspid
  • Cardiomyopathy
  • Short distance between the annulus and coronary ostium
  • Need for emergency surgery
  • Severe pulmonary hypertension
  • Echocardiographic evidence of intracardiac mass
  • End stage renal disease

Management Therapy

  • Blood thinners (anticoagulants): Blood-thinning medication is prescribed to prevent blood clots.
  • Antibiotics: Artificial heart valves can become infected with bacteria. Good dental hygiene helps prevent infections.

Follow-up Appointments

  • Within one week
  • One month – Echocardiogram before cardiology consultation.
  • One year – Echocardiogram and cardiology review with additional testing if needed.

Lifestyle Modification

  • No smoking
  • Regular exercises
  • Maintain a healthy weight
  • Eat a healthy diet rich in fruits and vegetables
  • Low salt intake and reduced trans fats

Self Care

  • You may shower
  • Do not scrub your incision site
  • Pat the incision site dry, do not rub
  • Do not use ointments or perfumes
  • No pools or hot tubs for one week
  • Practice deep breathing exercises
  • Monitor and record your weight daily

Food to Avoid

  • Fatty meats
  • Fried food
  • Refined carbohydrates
  • Sugary drinks such as soda
  • Fatty oils such as butter
  • Processed foods
  • High cholesterol foods
  • Full-fat dairy products

When to Call Your Doctor

  • Red, swollen, warm, or draining incision
  • Temperature above 101°F
  • Severe incision pain
  • Abdominal pain with firm abdomen
  • Unable to pass gas
  • No bowel movement
  • Change in color or temperature in limbs
  • Numbness
  • Trouble breathing
  • Unusual pain or swelling in legs
  • Back pain
  • Any questions or concerns