Transcatheter aortic valve replacement or TAVR, is an advanced, minimally invasive procedure currently recommended for individuals who are considered too sick to undergo traditional surgical aortic valve replacement.
A significant portion of patients who need a valve replacement for a narrowed aortic valve (stenosis) would be at excessively high risk if undergoing conventional open-heart surgery, due to their advanced age, frailty or other medical conditions.
Dr. Steven Kernis is here to explain how TAVR has emerged as a procedure that that provides the same life-extending benefits to these patients that open surgical aortic valve replacement would—and Lourdes has helped lead the way in providing TAVR to patients.
Transcatheter Aortic Valve Replacement (TAVR)
From the Show: Lourdes Health Talk
Summary:
Air Date: 2/1/16
Duration: 10 Minutes
Transcription:
Melanie Cole (Host): Transcatheter aortic valve replacement or TAVR is an advanced minimally invasive procedure currently recommended for individuals who are considered too sick to undergo a surgical aortic valve replacement. My guest today is Dr. Steve Kernis. He is an interventional cardiologist with Lourdes Health System. Welcome to the show, Dr. Kernis. Tell us what is TAVR and who is it for?
Dr. Steven Kernis (Guest): Good afternoon. Thank you for having me. TAVR stands for “transcatheter aortic valve replacement.” It’s a mouthful but it’s had a lot of publicity and a lot of buzz now for the past really few years. Our European colleagues call it “TAVI” whereas we call it “TAVR,” but it is the same procedure. It’s basically a way of giving someone a new valve without having to do an open heart surgery. In TAVR, it is the aortic valve that we are replacing. We don’t take the old one out, we have a new valve that is inside a stent, a big stent. The stent goes through the catheter, which is like a long straw, that we snake up from the groin or sometimes from other areas, and we advance it inside the old valve in the heart that isn’t working well. When you open the stent, there is a balloon that you inflate, the stent opens, the balloon deflates, you take out the balloon and what’s left behind is the opened stent that has inside of it a new tissue valve. Hence, you now have a new fully functioning valve immediately. That’s the procedure.
Melanie: Wow! That is absolutely fascinating. How does this differ from the standard valve replacement?
Dr. Kernis: The standard surgical valve replacement which, again, has been around for a long time, involves traditionally or conventionally sternotomy--opening up the breast bone. The patient, of course, is under general anesthesia, is on a bypass machine, their heart is stopped, it’s cooled down, the surgeons open up the chest and the heart, get to the old valve where they can see it. They actually cut it out and then take either a tissue or mechanical, more commonly a tissue valve, and sew it into place in the heart. That’s the surgical way. The surgeons have other surgical options which don’t necessarily require opening up the breast bone, but in any way that they do it in terms of a surgical valve replacement, it involves some type of chest incision, going on a bypass machine, stopping the heart and all of the risks that go along with that; whereas, the TAVR allows us to give someone a new heart valve. It’s a heart valve which, by the way, we have found works just as well, sometimes better, but at least as well in terms of duration, how well it performs, as the old surgical valves. With the TAVR, most patients now--probably about 90%--are getting these through the groin, no incisions required. At Lourdes, most people are not requiring any general anesthesia, just simple sedation and they are up walking around later in the day with really nothing but a little needle stick in the groin which is mildly uncomfortable, certainly nothing like opening up the breast bone.
Melanie: How long, Dr. Kernis, does the valve last?
Dr. Kernis: Good question. The TAVR procedure was first done in 2002. There has been getting close, if not already, about one million of these put in worldwide now over the last many years. But, because the TAVR valve experience is still 14 or so years old, no one knows for sure is this valve going to be, let’s say, 30 or 40 years down the line – still working. The surgical counterparts, the tissue valves, tend to last in the 10-15 years. That’s sort of an average length of time that many surgeons will tell a patient, “Hey, this is about how long on average valves will function normally.” The TAVR valve, we have seen it’s probably going to be the same, if not better. It is a very, very durable valve. Could it last longer than our surgical counterparts? It’s certainly possible but we have no reason right now to see that it is anything less.
Melanie: Who’s a good candidate for this type of valve surgery? Are there certain people who you would say are not candidates for TAVR or certain people that are definitely?
Dr. Kernis: That’s a great and critical question. That’s probably the biggest thing we do when evaluating patients is to see just that, is this appropriate for the patient? Is it indicated? If somebody has a severely dysfunctional valve, what we would call a severe aortic stenosis, number one. Number two, is that valve causing them symptoms? Are they symptomatic? That’s number one and that’s number two. Then, in 2016, and, by the way, this is likely to change very soon, but to date the commercial availability – and when I say commercial, I mean outside of research trials. There are research trials, whether it be at Lourdes or other hospitals, but the on-label indicated commercially available TAVR valves are for what we call “high” or “excessively high risk” patients. That’s been the case for a few years now. But, most of us are confident that within the next six months or so, that indication is going to come down to include intermediate risk patients as well. Of course, we have definitions of what constitutes intermediate or high risk. Then, of course, we do testing to see if someone is physically and anatomically appropriate. I think the real important part of your question is that for a while now, this valve was really only indicated or available for those at the highest risk level and that is changing rapidly. In fact, most of us have thought for a while and it looks like it is going in the direction that this procedure and this valve may very well replace, entirely, the surgical valve. You can imagine for patients, it’s much less invasive. They are out of the hospital in a day or two and it is something that most of us would probably want for ourselves and our family if it was as good of an outcome.
Melanie: What do you want, Dr. Kernis, as far as aftercare for this valve? How soon can people resume activity? Are there any limitations once you’ve got this great valve?
Dr. Kernis: No. The recovery, on average, for the people that get the valve put in through their groin which, again, is the majority now, those patients if the procedure went well, they are up walking around the day of the procedure or the next day in the hospital walking around, the same; are home, on average, two to three days after the procedure is completed. The ones that are not requiring any incisions, which is the majority, are really able to regain any and all activities within reason that they were doing before. We have them avoid very heavy bending and lifting and long car rides for really up to probably a week. But, for practical purposes, people are back to doing everything they were before and feeling better, of course.
Melanie: How soon can they get back to activity?
Dr. Kernis: Really, within a couple days, probably maximum a week.
Melanie: Wow. That is absolutely fascinating. In just the last minute here, give your best advice about people considering valve replacement, why they should consider TAVR and why they should come to Lourdes for their healthcare.
Dr. Kernis: Anyone, whether they are recognizing that their breathing is not good; they can’t do physically or aerobically things that they could do six or twelve months earlier; having chest discomforts; feeling excessively tired and weak – those sorts of symptoms. They should absolutely first see their main doctor, of course. If that doctor sees that they may have this valve problem, they usually go and see a cardiologist and testing may determine, yes, they do have that valve problem and they are usually shuttled to someone like me. I think that everybody should be considered these days for the TAVR. If they qualify—terrific. If they don’t, like I say, there are still surgical options. As far as Lourdes, I think that our program is a bit unique. One, our outcomes have been far superior then the national outcomes. There is a lot of data, a lot of reporting, so, this is all very objectively reported and we’ve been fortunate about our outcomes, our volumes, our 200th case is going to be within the next week or two – in a few years, which is a pretty good outcome. We have a big team and a lot of different docs from groups that participate. We get people in and out pretty quickly as well. I think that is a very strong point.
Melanie: Thank you so much for being with us today. It is absolutely fascinating and we applaud all the great work that you’re doing. You’re listening to Lourdes Health Talk and for more information, you can go to LourdesNet.org. That’s LourdesNet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Transcatheter aortic valve replacement or TAVR is an advanced minimally invasive procedure currently recommended for individuals who are considered too sick to undergo a surgical aortic valve replacement. My guest today is Dr. Steve Kernis. He is an interventional cardiologist with Lourdes Health System. Welcome to the show, Dr. Kernis. Tell us what is TAVR and who is it for?
Dr. Steven Kernis (Guest): Good afternoon. Thank you for having me. TAVR stands for “transcatheter aortic valve replacement.” It’s a mouthful but it’s had a lot of publicity and a lot of buzz now for the past really few years. Our European colleagues call it “TAVI” whereas we call it “TAVR,” but it is the same procedure. It’s basically a way of giving someone a new valve without having to do an open heart surgery. In TAVR, it is the aortic valve that we are replacing. We don’t take the old one out, we have a new valve that is inside a stent, a big stent. The stent goes through the catheter, which is like a long straw, that we snake up from the groin or sometimes from other areas, and we advance it inside the old valve in the heart that isn’t working well. When you open the stent, there is a balloon that you inflate, the stent opens, the balloon deflates, you take out the balloon and what’s left behind is the opened stent that has inside of it a new tissue valve. Hence, you now have a new fully functioning valve immediately. That’s the procedure.
Melanie: Wow! That is absolutely fascinating. How does this differ from the standard valve replacement?
Dr. Kernis: The standard surgical valve replacement which, again, has been around for a long time, involves traditionally or conventionally sternotomy--opening up the breast bone. The patient, of course, is under general anesthesia, is on a bypass machine, their heart is stopped, it’s cooled down, the surgeons open up the chest and the heart, get to the old valve where they can see it. They actually cut it out and then take either a tissue or mechanical, more commonly a tissue valve, and sew it into place in the heart. That’s the surgical way. The surgeons have other surgical options which don’t necessarily require opening up the breast bone, but in any way that they do it in terms of a surgical valve replacement, it involves some type of chest incision, going on a bypass machine, stopping the heart and all of the risks that go along with that; whereas, the TAVR allows us to give someone a new heart valve. It’s a heart valve which, by the way, we have found works just as well, sometimes better, but at least as well in terms of duration, how well it performs, as the old surgical valves. With the TAVR, most patients now--probably about 90%--are getting these through the groin, no incisions required. At Lourdes, most people are not requiring any general anesthesia, just simple sedation and they are up walking around later in the day with really nothing but a little needle stick in the groin which is mildly uncomfortable, certainly nothing like opening up the breast bone.
Melanie: How long, Dr. Kernis, does the valve last?
Dr. Kernis: Good question. The TAVR procedure was first done in 2002. There has been getting close, if not already, about one million of these put in worldwide now over the last many years. But, because the TAVR valve experience is still 14 or so years old, no one knows for sure is this valve going to be, let’s say, 30 or 40 years down the line – still working. The surgical counterparts, the tissue valves, tend to last in the 10-15 years. That’s sort of an average length of time that many surgeons will tell a patient, “Hey, this is about how long on average valves will function normally.” The TAVR valve, we have seen it’s probably going to be the same, if not better. It is a very, very durable valve. Could it last longer than our surgical counterparts? It’s certainly possible but we have no reason right now to see that it is anything less.
Melanie: Who’s a good candidate for this type of valve surgery? Are there certain people who you would say are not candidates for TAVR or certain people that are definitely?
Dr. Kernis: That’s a great and critical question. That’s probably the biggest thing we do when evaluating patients is to see just that, is this appropriate for the patient? Is it indicated? If somebody has a severely dysfunctional valve, what we would call a severe aortic stenosis, number one. Number two, is that valve causing them symptoms? Are they symptomatic? That’s number one and that’s number two. Then, in 2016, and, by the way, this is likely to change very soon, but to date the commercial availability – and when I say commercial, I mean outside of research trials. There are research trials, whether it be at Lourdes or other hospitals, but the on-label indicated commercially available TAVR valves are for what we call “high” or “excessively high risk” patients. That’s been the case for a few years now. But, most of us are confident that within the next six months or so, that indication is going to come down to include intermediate risk patients as well. Of course, we have definitions of what constitutes intermediate or high risk. Then, of course, we do testing to see if someone is physically and anatomically appropriate. I think the real important part of your question is that for a while now, this valve was really only indicated or available for those at the highest risk level and that is changing rapidly. In fact, most of us have thought for a while and it looks like it is going in the direction that this procedure and this valve may very well replace, entirely, the surgical valve. You can imagine for patients, it’s much less invasive. They are out of the hospital in a day or two and it is something that most of us would probably want for ourselves and our family if it was as good of an outcome.
Melanie: What do you want, Dr. Kernis, as far as aftercare for this valve? How soon can people resume activity? Are there any limitations once you’ve got this great valve?
Dr. Kernis: No. The recovery, on average, for the people that get the valve put in through their groin which, again, is the majority now, those patients if the procedure went well, they are up walking around the day of the procedure or the next day in the hospital walking around, the same; are home, on average, two to three days after the procedure is completed. The ones that are not requiring any incisions, which is the majority, are really able to regain any and all activities within reason that they were doing before. We have them avoid very heavy bending and lifting and long car rides for really up to probably a week. But, for practical purposes, people are back to doing everything they were before and feeling better, of course.
Melanie: How soon can they get back to activity?
Dr. Kernis: Really, within a couple days, probably maximum a week.
Melanie: Wow. That is absolutely fascinating. In just the last minute here, give your best advice about people considering valve replacement, why they should consider TAVR and why they should come to Lourdes for their healthcare.
Dr. Kernis: Anyone, whether they are recognizing that their breathing is not good; they can’t do physically or aerobically things that they could do six or twelve months earlier; having chest discomforts; feeling excessively tired and weak – those sorts of symptoms. They should absolutely first see their main doctor, of course. If that doctor sees that they may have this valve problem, they usually go and see a cardiologist and testing may determine, yes, they do have that valve problem and they are usually shuttled to someone like me. I think that everybody should be considered these days for the TAVR. If they qualify—terrific. If they don’t, like I say, there are still surgical options. As far as Lourdes, I think that our program is a bit unique. One, our outcomes have been far superior then the national outcomes. There is a lot of data, a lot of reporting, so, this is all very objectively reported and we’ve been fortunate about our outcomes, our volumes, our 200th case is going to be within the next week or two – in a few years, which is a pretty good outcome. We have a big team and a lot of different docs from groups that participate. We get people in and out pretty quickly as well. I think that is a very strong point.
Melanie: Thank you so much for being with us today. It is absolutely fascinating and we applaud all the great work that you’re doing. You’re listening to Lourdes Health Talk and for more information, you can go to LourdesNet.org. That’s LourdesNet.org. This is Melanie Cole. Thanks so much for listening.
