People who have aortic stenosis (a narrowed aortic valve) can find themselves struggling with a host of debilitating symptoms, including fatigue, chest pain, rapid heartbeat, swelling in the legs, and shortness of breath. The condition is particularly common among older people, especially those with congestive heart failure. For years, the only treatment for severe cases was open heart surgery to replace the bad valve, which can start to restrict blood flow. Transcatheter aortic valve replacement (TAVR) is a fairly new procedure that takes a minimally invasive approach to achieve the same results, and it involves less pain and a shorter recovery time.
“Transcatheter technologies have allowed us to take care of patients with valvular heart disease who would never have been able to tolerate traditional open heart surgery,” says Abeel Mangi, MD, MBA, surgical director of the Structural Heart and Cardiac Valve Program at Yale New Haven Hospital’s Heart & Vascular Center. “These include very elderly patients, those who have had many prior heart operations, or those with certain unique conditions. For patients like these, transcatheter valve replacement has been proven to help them live longer. In fact, we are entering an era where transcatheter valve technologies may soon become available to most patients with heart valve disease.”
What is aortic stenosis?
Aortic stenosis is a mechanical problem that can develop in the heart as a result of aging, a birth defect, chest radiation, or rheumatic fever. The heart pumps blood to the rest of the body through four valves. Each of these valves has tissue flaps called leaflets that open and close like gates to control blood flow. Aortic stenosis is a buildup of calcium on a leaflet that makes it stiff—similar to rust on the hinges of a door—and reduces its ability to open and close, preventing or reducing blood flow to the heart. This can lead to fainting, chest pain, or even death.
Some people live with aortic stenosis for years without symptoms, but the disease is progressive and can become life-threatening. So, it’s critical for anyone who starts to experience symptoms to seek treatment.
How is TAVR used to treat aortic stenosis?
Usually both a cardiac surgeon and an interventional cardiologist work together to perform the procedure. First the patient is given some form of anesthesia, which may be general anesthesia. Then the doctors will insert a catheter (a hollow tube) in one of three areas—the leg, or the chest at either the bottom or the top of the heart. The doctors thread the catheter through the defective valve, using X-ray and echocardiography for guidance.
Once the catheter reaches the heart, the doctors use it to put in a replacement valve (made of either biological tissue or man-made materials). The valve, which is collapsible, is inserted into the original valve, then expanded so that it can take over the job of controlling blood flow. In people with stenosis, the defective valve can be so tight that it’s difficult to thread the catheter through it, so the doctor may inflate a balloon to open it up.
What is recovery like from TAVR?
Your doctors may decide to monitor you in the intensive care unit, and you may spend two to five days in the hospital. You will need to take blood-thinning medications for a period of time after the procedure.
Are there other options for treating aortic stenosis?
The traditional treatment for aortic stenosis is open heart surgery, which is not usually recommended for elderly patients. It is a major, high-risk operation that typically involves making an incision across the full length of the breast bone and putting the patient on a heart-lung machine to stop the heart while the valve is replaced surgically. In addition to several days of recovery in the hospital, open heart surgery can involve weeks of recovery outside of the hospital.
What are the risks of TAVR?
TAVR can be a good option for people with severe aortic stenosis who have limited treatment choices. But, as with any procedure, it carries some risks of complications. These include bleeding, problems with the replacement valve leaking or moving, damage to the artery from the catheter, infection, and other challenges. A small percentage of patients have developed a stroke during or after the operation. Your doctor will talk to you about whether the benefits outweigh the risks in your situation.
How is Yale Medicine a leader in TAVR?
Yale New Haven Hospital (YNHH), and Yale Medicine’s surgeons and interventionalists are national leaders in transcatheter aortic valve replacement. YNHH was the first hospital in Connecticut to offer the procedure and now performs an average of 200 TAVRS each year. Our outcomes are well above the national average, and at follow-up visits, our patients usually report that they are enjoying a better quality of life after the procedure.
Each new patient is evaluated by a multidisciplinary team of specialists for TAVR. The team includes interventional cardiologists, cardiothoracic surgeons, echocardiographers, and valve clinic coordinators who work together to come up with a personalized plan. “One of the great advantages of the Structural Heart and Cardiac Valve Program is that patients are assessed simultaneously by an interventional cardiologist and a heart surgeon, both of whom have special expertise and training in the care of the patients with valvular heart disease,” Dr. Mangi says. “We are then able to uniquely tailor therapy for every patient based on his or her specific needs.”
While the TAVR procedure was initially intended for patients for whom open heart surgery would be especially risky, clinical trials at Yale are making it possible for any patient with severe aortic stenosis to consider it as a potential treatment.