Narrowing of the aortic valve, called aortic stenosis, is a common and serious heart valve problem. Without treatment, it has a prognosis worse than most cancers. Once symptoms occur, they continue to worsen and few sufferers are alive in five years. Valve replacement can reverse the effects of aortic stenosis, relieve symptoms and return life expectancy to normal. Unfortunately, that option was not open to 40-60 percent of patients because they were considered too old or frail to withstand traditional open heart surgery. Now there’s an FDA approved, minimally invasive procedure called transcatheter aortic valve replacement (TAVR) that provides medical teams with an effective treatment option to consider for intermediate and high risk patients.
The aortic valve opens to allow oxygen-rich blood to flow from the left heart ventricle out to the body. This valve is subject to wear and tear typically due to aging. When this happens, the heart must work harder to pump blood through the narrow opening. Over time the heart muscle thickens, prevents an adequate flow of blood to the body, and creates congestion in the lungs.
The symptoms of aortic stenosis become worse over time and can include:
- Lack of energy
- Shortness of breath
- Chest pain
- Syncope (fainting) and
- Heart failure
Replacing the faulty aortic valve with a new valve, typically created with tissue harvested from a pig or cow suspended inside a synthetic frame, or one made from synthetic materials, can return the heart to normal function and make the symptoms go away. Traditionally, these treatments required open heart surgery which involves use of a heart-lung machine. The demands of this surgery, including the time for the breast bone and incision sites to heal, often make this option too risky for certain patients including those who:
- Are in their late 80s and 90s
- Are frail
- Have severe pulmonary disease
- Had previous heart operations that would make reoperation more risky
- Had chest radiation
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TAVR, an alternative way to replace the heart valve, was first approved in the United States in 2011. Since then, TAVR procedures have been carefully studied and the technology has continued to improve. It has enjoyed excellent record of success with mortality rates now reaching slightly less than 3 percent, on par with traditional aortic valve replacement for the appropriately selected patient.
The TAVR procedure is similar to the insertion of a coronary stent in that it’s performed through a small puncture in the leg (alternative entry sites include the shoulder and the neck) to access a main artery. Fishing a catheter through the aorta, the surgeon inserts a compacted replacement valve within the damaged aortic valve. When the replacement valve is in position, the valve is expanded to fit the heart opening. Imaging technology assures the valve is working properly before the procedure is concluded.
TAVR is not without risks, but several steps help assure the patient’s safety. First there is a thorough pre-operative review process involving a valve coordinator who orders tests to evaluate the condition of the candidate’s circulatory system and anatomy. In addition, a dedicated heart team meets to discuss pre-operative test results and agree on the best treatment course for each patient. And finally, the surgical team includes a heart surgeon, structural and interventional cardiologists, imaging specialists, cardiac anesthesiologists and other specialized professionals who perform the procedure in a hybrid operating room, which combines the qualities of a traditional operating room and a cardiac catheterization lab.
Because TAVR is a minimally invasive procedure, recovery times are often dramatically shorter than those for the traditional heart valve replacement patient. Compared to a five day hospital recovery for open heart surgery patients, the TAVR patient can expect to be discharged within two days, often with no limitations. Regular follow-up not only affirms continued success of the replacement valve but also provides important data about the treatment.
While the traditional valve replacement method is still considered safer and more durable for low risk candidates, TAVR provides an option for treating aortic arterial stenosis for patients with intermediate to high risks.
Michael Lazar, MD, is a cardiothoracic surgeon and executive medical director of UPMC Susquehanna’s Heart & Vascular Institute. He specializes in minimally invasive and robotic-assisted procedures, including Coronary Artery Bypass, tumor removal, lung resection and ASD / PFO repair. For more information on heart health or the Heart & Vascular Institute, click here.
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