If you have valve disease and are not a candidate for certain types of heart surgery, TAVR may be an option to discuss with your physician.
Bradenton Cardiology Center offers the minimally invasive Transcatheter Aortic Valve Replacement (TAVR) procedure to patients with severe aortic stenosis.
The new TAVR procedure is an alternative to traditional open-heart surgery and can offer an improved quality of life for patients. In this procedure, a collapsible aortic heart valve is placed at the site using a thin, flexible tube called a catheter and it can give new hope to patients who have aortic valve stenosis and are at high or extreme risk for open-heart surgery.
Joining the show to discuss treatment options for valve disease and the TAVR procedure is S. Jay Mathews, MD, MS, FACC. He is a cardiologist and TAVR Medical Director at the Structural Heart Clinic at Manatee Memorial Hospital.
Selected Podcast
Transcatheter Aortic Valve Replacement (TAVR) Procedure at Manatee Memorial Hospital
Featured Speaker:
Learn more about S. Jay Mathews, MD, MS
S. Jay Mathews, MD, MS
S. Jay Mathews, MD, Cardiologist and TAVR Medical Director, Structural Heart Clinic at Manatee Memorial Hospital.Learn more about S. Jay Mathews, MD, MS
Transcription:
Melanie Cole (Host): Over time, tissue heart valves can degenerate and eventually fail, requiring the need for replacement. My guest today is Dr. S. Jay Mathews. He’s a cardiologist and TAVR medical director at the Structural Heart Clinic and Manatee Memorial Hospital. Welcome to the show. Explain to the listeners a little bit about heart valves and how a valve can fail.
Dr. S. Jay Mathews, MD, MS, FACC (Guest): The aortic valve, which is the one we're talking about today, over time as you get older the valve can degenerate. One of the most common forms of degeneration is what's called age-related calcific aortic stenosis. The valve literally becomes quite hardened by calcific deposits. These are associated with aging. Less commonly, rheumatic fever and also congenital abnormalities you were born with can cause problems as well. The most common cause of this is age-related calcific disease.
Melanie: How is it identified? When does it become apparent that a valve is failing? What would somebody notice?
Dr. Mathews: There are a lot of symptoms that are associated with this – shortness of breath, chest pain. In very advanced cases, some folks can go on to have congestive heart failure as well as passing out spells, or syncope. The most common symptom that we hear about is a murmur that is heard on examination or shortness of breath.
Melanie: People hear about leaky valves and failed valves and typically we've heard about valve replacement. What's been the standard of care for a failed valve?
Dr. Mathews: For many years, aortic valve replacement surgery was the gold standard for these types of failed valves. When the valves would become very stenotic or blocked up over time, the only way to fix this was with an open-heart procedure. Now we have potentially another option for patients that are of at least intermediate risk or high risk for any type of surgery and we can potentially offer them an endovascular approach for replacement of these valves.
Melanie: Before we talk about the TAVR approach, for certain populations, you said people who might be at high risk for open heart surgery. Who is a candidate and who might those people there are high risk be?
Dr. Mathews: It’s not just high risk because when the valve was first offered, it was really only for the patients that were deemed too high risk for open heart surgery. With the recent FDA guidelines, they’ve now opened it up to intermediate risk patients, so there's a risk calculation that surgeons will do to figure out what is your risk of mortality and morbidity – that means the risk of having death associated with an open-heart procedure – and also the risk of complications and other problems that can happen post surgeon. They come up with a risk calculation and this is called the STS score, the Society of Thoracic Surgery risk calculation. If we have an STS score of 4% or greater – 4% falls into the intermediate risk range – those patients are a candidate potentially for the transcatheter valve replacement procedure.
Melanie: Tell us about this procedure and what's involved and what kind of expertise it takes to perform it.
Dr. Mathews: Typically, these procedures are offered at centers that have open heart surgery capabilities already. The specialists that are doing this procedure typically consists of a team of interventional cardiologists who have expertise in structural heart disease. These doctors may have done fellowships specifically in the structural heart or have gone on to do advanced training afterward, and they also partner with surgeons, cardiac surgeons who do the procedure, the open procedure as well. These do these together as a team and the centers typically have a lot of expertise in open valve procedures and also percutaneous valve procedures as well. The procedure itself is done typically in what's called a hybrid operating room, or a hybrid cath lab. This cath lab has special capabilities of not only being able to do the endovascular procedures but also able to do the open-heart procedure as well too. The way it is done is done through an endovascular approach. Rather than cutting the chest open as you would typically do with a traditional open-heart surgery, we go typically through the groin, through the common femoral artery, and more rarely alternative access sites such as the subclavian artery in the arm or even in the neck or just above the chest called a transaortic route, very rarely do we go straight through the chest, which is called the transapical route. With these newer approaches, they're minimally invasive, the complications that occur afterward are significantly less, and the recovery time is significantly less as well. Through this vascular route in the groin, we advance a catheter that has a balloon mounted valve on a stent cage, and this stent valve gets placed across the aortic valve and it is deployed either in a balloon expandable fashion or in a self-expanding fashion. These two different ways allow for a new valve to be placed over the old valve.
Melanie: This is really fascinating for people to hear. The new valve is placed over the old valve. You don't take the old valve out, you just put this new one in and the balloon opens it up and it closes up any leaks or fixes it. What happens to the old valve?
Dr. Mathews: The old valve is just there behind the new valve. It serves as an anchor for the new valve that’s placed and we mash it out of the way. This is very quickly done in the cath lab when it’s deployed, either in a self-expanding fashion where no balloons are involved or in a balloon expandable fashion. If there's any leak afterward that we see, we can typically touch that up with an additional balloon inflation. A lot of these newer valves also have a special skirt around the outside of the valve to seal off any leaks that might happen. When you look at the valve on ultrasound, it actually looks like it a brand new valve, there's no further obstruction seen and it’s actually much for physiologic, meaning it’s a lot more functional than sometimes even the surgical procedure.
Melanie: Is this something that might have to be redone or is the valve that you put in pretty much there now for the rest of the patient’s life?
Dr. Mathews: For most people, we’re looking at a valve that lasts the rest of their lives. The newer generation valves have very good longevity, even now to 10-15 years. It’s unclear and we’ll see how long some of these values last, especially the newer generation ones. In the situation where you have a degenerated TAVR valve, it is actually possible to place another TAVR inside one.
Melanie: That’s valve in valve. That is incredible what you guys are able to do now. What's life like for somebody who’s gotten this new valve? Are they still on medication? What's the follow-up plan?
Dr. Mathews: Most of these patients have lots of other medical issues, so there are still medicines that are involved, but some of these patients who get the procedure done feel great right away. In fact, if they had significant congestive heart failure, a lot of those congestive symptoms are gone. Sometimes if you have chest pain issues associated with it, this is improved significantly because we do it percutaneously and we have a minimally invasive route. A lot of times, what happens is the patients are actually able to get up and walk around fairly quickly after the procedure and feel quite well. I had a patient just last week tell me that they haven't felt this good in 6 to 12 months.
Melanie: Fascinating. Wrap it up for us with your best summary and information about the TAVR procedure and what you would want patients to ask their doctor if they're told they have a failing valve?
Dr. Mathews: The first thing is to have options available. Now that it has been opened up to intermediate risk patients and eventually we expect that low-risk patients will be included as well once the low-risk trials are completed later in the next year or two, you want to be able to go to a center that has options for both the surgical valve and also the transcatheter aortic valve procedure. You have to find out whether or not you're an appropriate candidate for either type of procedure. There are some patients that will benefit from TAVR. There are some patients that will benefit from a surgical valve. We make these decisions as a team approach with the surgeons and also ourselves to find out what's best for the patients. In general, the technology continues to advance and we continue to bring new features to these valves over time and I think patients should understand that this is an evolving field and we will have new offerings as the technology advances also potentially new options and other vascular beds as well. Just understand, I think this is a rapidly advancing field and I'm really excited for the future when it comes to these types of structural heart technologies.
Melanie: Tell us about your team.
Dr. Mathews: Our team consists of several TAVR implanters, so we have approximately six physicians that are implanters in addition to a couple surgeons as well, cardiothoracic surgeons who team up with us as well. We have several imaging doctors. We have three doctors that are involved with providing us the pictures that allow us to advance these valves into the appropriate position. We have a team of anesthesiologists as well. We have an OR team as well that’s ready to help us in case we need to do an open-heart type procedure, but most of the time nowadays, they're there just to give us some reassurance, but we haven't, fortunately, had to do that yet. This team approach is what's offered us to have excellence success and really great outcomes. In fact, the outcomes at our facility exceed that of the national average, so we're doing very well when it comes to the transcatheter procedures.
Melanie: Thank you so much for being with us today. An absolutely fascinating segment. Thanks again. You're listening to Manatee Talk Radio with Manatee Memorial Hospital. For more information, please visit manateememorial.com. That’s manateememorial.com. Physicians are independent practitioners who are not employees or agents of Manatee Memorial Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive procedures might be right for you. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Over time, tissue heart valves can degenerate and eventually fail, requiring the need for replacement. My guest today is Dr. S. Jay Mathews. He’s a cardiologist and TAVR medical director at the Structural Heart Clinic and Manatee Memorial Hospital. Welcome to the show. Explain to the listeners a little bit about heart valves and how a valve can fail.
Dr. S. Jay Mathews, MD, MS, FACC (Guest): The aortic valve, which is the one we're talking about today, over time as you get older the valve can degenerate. One of the most common forms of degeneration is what's called age-related calcific aortic stenosis. The valve literally becomes quite hardened by calcific deposits. These are associated with aging. Less commonly, rheumatic fever and also congenital abnormalities you were born with can cause problems as well. The most common cause of this is age-related calcific disease.
Melanie: How is it identified? When does it become apparent that a valve is failing? What would somebody notice?
Dr. Mathews: There are a lot of symptoms that are associated with this – shortness of breath, chest pain. In very advanced cases, some folks can go on to have congestive heart failure as well as passing out spells, or syncope. The most common symptom that we hear about is a murmur that is heard on examination or shortness of breath.
Melanie: People hear about leaky valves and failed valves and typically we've heard about valve replacement. What's been the standard of care for a failed valve?
Dr. Mathews: For many years, aortic valve replacement surgery was the gold standard for these types of failed valves. When the valves would become very stenotic or blocked up over time, the only way to fix this was with an open-heart procedure. Now we have potentially another option for patients that are of at least intermediate risk or high risk for any type of surgery and we can potentially offer them an endovascular approach for replacement of these valves.
Melanie: Before we talk about the TAVR approach, for certain populations, you said people who might be at high risk for open heart surgery. Who is a candidate and who might those people there are high risk be?
Dr. Mathews: It’s not just high risk because when the valve was first offered, it was really only for the patients that were deemed too high risk for open heart surgery. With the recent FDA guidelines, they’ve now opened it up to intermediate risk patients, so there's a risk calculation that surgeons will do to figure out what is your risk of mortality and morbidity – that means the risk of having death associated with an open-heart procedure – and also the risk of complications and other problems that can happen post surgeon. They come up with a risk calculation and this is called the STS score, the Society of Thoracic Surgery risk calculation. If we have an STS score of 4% or greater – 4% falls into the intermediate risk range – those patients are a candidate potentially for the transcatheter valve replacement procedure.
Melanie: Tell us about this procedure and what's involved and what kind of expertise it takes to perform it.
Dr. Mathews: Typically, these procedures are offered at centers that have open heart surgery capabilities already. The specialists that are doing this procedure typically consists of a team of interventional cardiologists who have expertise in structural heart disease. These doctors may have done fellowships specifically in the structural heart or have gone on to do advanced training afterward, and they also partner with surgeons, cardiac surgeons who do the procedure, the open procedure as well. These do these together as a team and the centers typically have a lot of expertise in open valve procedures and also percutaneous valve procedures as well. The procedure itself is done typically in what's called a hybrid operating room, or a hybrid cath lab. This cath lab has special capabilities of not only being able to do the endovascular procedures but also able to do the open-heart procedure as well too. The way it is done is done through an endovascular approach. Rather than cutting the chest open as you would typically do with a traditional open-heart surgery, we go typically through the groin, through the common femoral artery, and more rarely alternative access sites such as the subclavian artery in the arm or even in the neck or just above the chest called a transaortic route, very rarely do we go straight through the chest, which is called the transapical route. With these newer approaches, they're minimally invasive, the complications that occur afterward are significantly less, and the recovery time is significantly less as well. Through this vascular route in the groin, we advance a catheter that has a balloon mounted valve on a stent cage, and this stent valve gets placed across the aortic valve and it is deployed either in a balloon expandable fashion or in a self-expanding fashion. These two different ways allow for a new valve to be placed over the old valve.
Melanie: This is really fascinating for people to hear. The new valve is placed over the old valve. You don't take the old valve out, you just put this new one in and the balloon opens it up and it closes up any leaks or fixes it. What happens to the old valve?
Dr. Mathews: The old valve is just there behind the new valve. It serves as an anchor for the new valve that’s placed and we mash it out of the way. This is very quickly done in the cath lab when it’s deployed, either in a self-expanding fashion where no balloons are involved or in a balloon expandable fashion. If there's any leak afterward that we see, we can typically touch that up with an additional balloon inflation. A lot of these newer valves also have a special skirt around the outside of the valve to seal off any leaks that might happen. When you look at the valve on ultrasound, it actually looks like it a brand new valve, there's no further obstruction seen and it’s actually much for physiologic, meaning it’s a lot more functional than sometimes even the surgical procedure.
Melanie: Is this something that might have to be redone or is the valve that you put in pretty much there now for the rest of the patient’s life?
Dr. Mathews: For most people, we’re looking at a valve that lasts the rest of their lives. The newer generation valves have very good longevity, even now to 10-15 years. It’s unclear and we’ll see how long some of these values last, especially the newer generation ones. In the situation where you have a degenerated TAVR valve, it is actually possible to place another TAVR inside one.
Melanie: That’s valve in valve. That is incredible what you guys are able to do now. What's life like for somebody who’s gotten this new valve? Are they still on medication? What's the follow-up plan?
Dr. Mathews: Most of these patients have lots of other medical issues, so there are still medicines that are involved, but some of these patients who get the procedure done feel great right away. In fact, if they had significant congestive heart failure, a lot of those congestive symptoms are gone. Sometimes if you have chest pain issues associated with it, this is improved significantly because we do it percutaneously and we have a minimally invasive route. A lot of times, what happens is the patients are actually able to get up and walk around fairly quickly after the procedure and feel quite well. I had a patient just last week tell me that they haven't felt this good in 6 to 12 months.
Melanie: Fascinating. Wrap it up for us with your best summary and information about the TAVR procedure and what you would want patients to ask their doctor if they're told they have a failing valve?
Dr. Mathews: The first thing is to have options available. Now that it has been opened up to intermediate risk patients and eventually we expect that low-risk patients will be included as well once the low-risk trials are completed later in the next year or two, you want to be able to go to a center that has options for both the surgical valve and also the transcatheter aortic valve procedure. You have to find out whether or not you're an appropriate candidate for either type of procedure. There are some patients that will benefit from TAVR. There are some patients that will benefit from a surgical valve. We make these decisions as a team approach with the surgeons and also ourselves to find out what's best for the patients. In general, the technology continues to advance and we continue to bring new features to these valves over time and I think patients should understand that this is an evolving field and we will have new offerings as the technology advances also potentially new options and other vascular beds as well. Just understand, I think this is a rapidly advancing field and I'm really excited for the future when it comes to these types of structural heart technologies.
Melanie: Tell us about your team.
Dr. Mathews: Our team consists of several TAVR implanters, so we have approximately six physicians that are implanters in addition to a couple surgeons as well, cardiothoracic surgeons who team up with us as well. We have several imaging doctors. We have three doctors that are involved with providing us the pictures that allow us to advance these valves into the appropriate position. We have a team of anesthesiologists as well. We have an OR team as well that’s ready to help us in case we need to do an open-heart type procedure, but most of the time nowadays, they're there just to give us some reassurance, but we haven't, fortunately, had to do that yet. This team approach is what's offered us to have excellence success and really great outcomes. In fact, the outcomes at our facility exceed that of the national average, so we're doing very well when it comes to the transcatheter procedures.
Melanie: Thank you so much for being with us today. An absolutely fascinating segment. Thanks again. You're listening to Manatee Talk Radio with Manatee Memorial Hospital. For more information, please visit manateememorial.com. That’s manateememorial.com. Physicians are independent practitioners who are not employees or agents of Manatee Memorial Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive procedures might be right for you. This is Melanie Cole. Thanks so much for listening.