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Transcatheter Aortic Valve Replacement

NMMC is home to Mississippi's first TAVR and remains the only hospital in north Mississippi to provide this lifesaving procedure.


Replacing heart valves without the need for open heart surgery

Since 2012, physicians at North Mississippi Medical Center in Tupelo have been replacing stenotic aortic valves without the need for traditional surgery. Patients who have been deemed ineligible for surgery because of co-existing medical conditions are now being considered for transcatheter aortic valve replacement (TAVR).

Since the first procedure in February 2012, the NMMC valve team has been perfecting the necessary techniques and treated multiple patients with a high rate of successful patient improvement. Two cardiothoracic surgeons and three cardiologists have been through extensive training to perfect not only the procedure itself, but also mastering procedures that are integral to good patient outcomes. The entire team meets regularly to discuss patients being considered for the procedure and plan for their cases. A patient-oriented team approach combines the expertise of both surgeons and cardiologists in a state-of-the-art hybrid operating room. This operating room offers the capability for heart catheterization, echocardiography, radiological, surgical and cardiopulmonary bypass procedures to be performed in one location.


The TAVR Procedure


The transcatheter valve can be inserted two ways. The most common way is to place a sheath into the femoral artery, much the same way that a heart cath is performed. The sheaths are, however, much larger to allow the insertion of the transcatheter valve that has been crimped down tight on an inflatable balloon and passed through the sheath. Because of the sheath sizes currently available, not everyone is a candidate for the femoral approach. For many of these patients, a transapical approach may be used. In this approach the catheter is placed directly into the tip of the heart through a small incision just below the breast using direct visualization of the heart. Both procedures are done in the hybrid operating room, where CT scanning, transesophageal echocardiogram (TEE) and angiography are performed in preparation for valve placement. Patients are placed under general anesthesia and monitored. Both femoral arteries and both femoral veins are used to guide catheters into position. One of the femoral veins is used to place a temporary pacemaker into the heart. Using a special catheter and balloon delivery system, the valve is guided into position either by femoral or direct ventricular puncture, using a guide wire, and position is confirmed using fluoroscopy and TEE.

Using rapid ventricular pacing (about 150 beats per minute) for the next 10 seconds blood flow across the aortic valve is essentially brought to a halt. This allows for balloon expansion of the transcatheter valve inside the existing diseased valve and wedges the new valve permanently in position. The balloon is deflated and rapid pacing stopped. Confirmation of valve position and function is then confirmed using TEE and fluoroscopy. The entry site is then closed and the patient taken to the Recovery Room.


Reduced Recovery Times

Typically the patient goes home in the next day or two from a femoral approach and within two to three days for an apically placed valve.

Following discharge, most patients are seen within the next week. Patients generally continue their previous home medications in addition to Plavix for the next six to eight weeks. Patients have follow-up echocardiography upon discharge and usually yearly thereafter. Complications are generally limited, but the most common are major and minor bleeding from femoral artery access, as well as an initial and late risk of stroke within the early recovery period. Most strokes are mild and are not life-threatening.


Implications

An estimated 1.5 million patients in the U.S. have some degree of aortic stenosis. While 500,000 patients have severe aortic stenosis, only one-half of them experience symptoms. Of those with symptoms, most experience shortness of breath, but chest pain, syncope and heart failure are also present. When these symptoms begin to occur, life expectancy averages less than five years for persons with chest pain to less than two years with heart failure. It is important to note that some patients will die of sudden cardiac death despite having had no reported symptoms at all. Fortunately the risk for aortic valve surgery for “operable” patients is generally low (1-4 percent); however, many patients are at higher risk from having surgery and thus not good candidates for an open heart procedure.


Current guidelines recommend the transcatheter aortic valve for patients with severe calcific aortic stenosis who are deemed to be high risk for a traditional open procedure. Candidates are generally older patients in their late 70s to 90s and often have multiple conditions, including complex cardiovascular disease and lung disease.


Patients with early dementia are not excluded, as this procedure is not generally associated with worsening dementia that can be seen with traditional bypass in this population. Patients with severe renal dysfunction, bicuspid valves, severe dementia and other significant conditions that are expected to lead to death within a year are not considered candidates for transcatheter valves, but some patients may be treated palliatively with a balloon aortic valvuloplasty (BAV) alone.

Two minimally invasive approaches:


  • Transfemoral via the femoral artery
  • Transapical by direct ventricular puncture

TAVR is performed on a beating heart and does not require cardiopulmonary bypass or opening the chest like traditional valve surgery. TAVR is a significant breakthrough for those patients currently suffering from severe aortic stenosis.

The Edwards Life Sciences Sapien aortic valve is the only transcatheter aortic valve currently approved by the FDA.

 

 

Patient Referral

Any patient, surgical or non-surgical, can be referred to our Valve Center. Cardiologists and surgeons through a team approach collaborate to determine the optimal strategy to achieve the best patient outcome. All patients for valve replacement will receive an echocardiogram to confirm severe aortic stenosis and quantify ejection fraction, but also the existence of co-existing valve disease including severe aortic insufficiency that might prohibit a TAVR procedure. Patients will undergo CT scanning of the chest, abdomen and pelvis with contrast to map out aortic and femoral arteries to assess for adequate arterial size for valve placement, as well as having a dedicated gated cardiac CT to determine adequate sizing of the transcatheter aortic valve. A left heart catheterization is performed to assess for co-existing coronary artery disease that may need to be addressed or stented before the procedure.

For more information, call the NMMC Valve Center at (662) 377-3654.