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Scott Webb (Host): Aortic stenosis is the narrowing of the valve in the large blood vessel branching off from the heart. And if not treated in a timely and appropriate manner, it can be fatal. And joining me today to discuss the latest treatment options, including transcatheter aortic valve replacement, better known as TAVR, is Dr. Justin Fox. He's an Interventional Cardiologist with Hamilton Cardiology and the Co-Director of the TAVR program at St. Francis Medical Center. This is Word on Wellness, the podcast from St. Francis Medical Center. I'm Scott Webb. Doctor, thanks so much for your time. We're going to talk about TAVR today and I'm going to have you explain what that is and when it's indicated but as we get rolling here, just a little baseline, what is aortic stenosis?

Justin Fox, MD, FACC, FSCAI (Guest): Aortic stenosis is a medical condition related to the aortic valve. So all of us have in our hearts four valves and the aortic valve is the tissue that opens and closes with each heartbeat to let blood pass out of the heart. And what aortic stenosis is, is where the valve becomes thickened and it doesn't open as well and blood cannot pass out as freely from the heart, as it gets pumped to the body. And the medical condition of aortic stenosis then has all these other consequences to a person, where they can have symptoms. And in the ultimate cases life-threatening to some people when it gets to be very severe.

Host: Yeah, I was going to ask you that when you mentioned consequences. So obviously one of the more serious consequences besides the other signs and symptoms, is that it can be fatal. So it's important that it be diagnosed and treated. And when we think about the treatment options, I'm assuming TAVR is probably at the top of the list.

Dr. Fox: Nowadays it is, but if we were having this conversation 20 years prior, the only option would be open-heart surgery. And for some of those folks due to their age and frailty, that would not be reasonable. It would not even be considered to, you know, do a major open heart surgery operation on a 90 year old patient who's somewhat frail.

For the past 10 years or so, this technology of TAVR has been on the market as an FDA approved, you know, standard of care technique, where we can replace the valve without open heart surgery. And for that reason, it really is at the top of the list of treatments for the condition.

Host: Yeah, so let's dig in here. We know that TAVR is short for transcatheter aortic valve replacement. And we certainly understand why it's abbreviated because much easier to say, take us through this, you know, and as best he can in audio form, how do you perform this really, you know, groundbreaking, minimally invasive procedure?

Dr. Fox: The procedure is done in what we call at St. Francis, the hybrid operating room. with all the bells and whistles and gadgets needed to do complex procedures like this.

And the procedure is done just incidentally, as a collaboration between cardiologists like myself and cardiac surgeons. And we have a really nice team of cardiac surgeons, very experienced and skilled team at St. Francis. The procedures are collaborative, where both specialties work together and the procedure is done, as I started to say, instead of open heart surgery, instead of a big incision in the patient's chest, we do the procedure in most cases through the blood vessel at the top of the leg, the femoral artery. So, from the patient's experience, they are in that operating room under deep anesthesia in most cases. So, they're asleep, but usually without a breathing tube and we end up putting catheters or these thin flexible plastic tubes in through the blood vessels at the top of the leg, femoral artery and vein. And through the femoral artery, we advance a catheter, which has the new valve crimped down or squished down on it. And we deliver that catheter across the patients diseased stenosed aortic valve. And we then implant the new valve, squashing the old valve aside. And we refer to that procedure being percutaneous. Cause it's all done through the blood vessels. No incisions are needed.

There's no cutting. And there's no sewing by the doctors. It's all done, You know, through the blood vessels, through these catheters. And then at the end of the procedure, the catheters come out and the patient wakes up.

Host: Amazing. You know, when we have specialists like yourself on, just how easily you can explain this, it's almost as simple as well, here's how you make a PB and J you get a couple of pieces of bread and some peanut butter. I mean, it's really amazing and easy to hear now why this has become, you know, really the gold standard, as you say, years ago, it wouldn't have been, but today it is especially for older patients.

And when we think about sort of who and how the decision is made when TAVR's indicated what's that process like?

Dr. Fox: Yeah. That's an excellent question. So, a process of evaluating a patient with aortic stenosis, you know, it may start with a primary care doctor who either sees a patient who has some symptoms. Like and we didn't specifically talk about the symptoms yet, but most commonly would be getting short of breath with exertion.

Some patients with aortic stenosis have chest pain or dizziness or fainting, and in the more extreme cases, the patient may present or show up in a state of congestive heart failure, where their body is overloaded with extra fluid, as a consequence of the valve problem. But whatever form it may take or whatever form of symptoms may be there, or it may be that the primary care doctor hears a murmur is a sound that you can hear with the stethoscope.

And in this case, it's a harsh whooshing sound with each heartbeat that we would hear that when the doctor hears it there, they can almost immediately say, oh, I think this patient has aortic stenosis. So it may start like that with a primary care doctor or another physician in the community. And then when that's identified, they would refer the patient to a cardiologist. Which, you know, similar to myself or my partners. And we would evaluate the patient in our office and the way to truly diagnose the condition is starting with an ultrasound of the heart called echocardiogram, which is non-invasive kind of like what you imagined for pregnant women with the ultrasound jelly and the technologist taking pictures. And that technique usually is sufficient to establish the diagnosis. You see what you see and you take measurements and we can, after that test, you know, know whether the patient has severe aortic stenosis or not.

So, from there as a cardiologist, we then, you know, I can go through it in more detail, but we can go take the patient through other testing to confirm the diagnosis and get the cardiac surgeons on board because it's a collaborative evaluation and a collaborative procedure. And then if it is the right treatment for that particular patient, then the procedure would move forward.

Host: Yeah. And I'm just thinking through here, you've mentioned a couple of times the, that sort of great team approach. So, you've got this older hospital with the state-of-the-art facilities, and you've mentioned that team approach, maybe, you know, in terms of the lens of how it benefits patients, why is that team approach so important?

Dr. Fox: So. There's a few reasons. And one of them is that for some patients, particularly those who are younger with aortic valve stenosis, it may be the case that a surgical valve replacement, the more old fashioned way of doing it, may have some advantages for technical reasons in some of those patients. So, having a cardiac surgeon involved is important to come up with that collaborative decision, as to whether the patient should have open-heart surgery or the TAVR procedure.

In addition, the collaboration is very useful in the procedure itself. When we're doing the procedure, many of the skills involved are driven by the interventional cardiologists like myself, you know, we have the techniques and the skills using catheters. Cause we use it in our other procedures, but the skill and the eye of the cardiac surgeon is also very important. In the operating room, they have a great eye for the aortic valve anatomy, and I really do rely on their expertise to help guide us to be very precise with the placement of the valve in exactly the right spot at the right angle at the right time. So, they have an eye for that from their surgical experience that is very valuable. And then the other aspect of it is, you know, not that we want to dwell on it, but having a cardiac surgeon, there is a great safety valve God forbid, there's ever any complications of the procedure because some of the complications that could occur can be corrected through surgical means and the patient can still have an excellent result and treatment.

For that reason it's collaborative. And I'd also like to add, you know, before we do the procedure, part of that collaboration is that we have, and I know a lot of hospitals do this, we have a committee meeting where all the key players involved, talk about the procedure. We game plan it basically. We use the testing that's already been done to really talk through the whole procedure and try to identify any possible nuances or pitfalls that may be challenging during the case and troubleshoot them beforehand so that we can, you know, really strategize and have the procedure planned out.

And the other thing I'd like to share is that the team is more than just myself and a surgeon. I just want to be clear. So there's cardiac anesthesiologists involved and they have an important role of managing the patient's anesthesia and blood pressure and vital signs during the procedure. We also have all of our nurses and technologists from the cardiac cath lab, as well as the operating room who participate in the procedure and we need their skills to manage the equipment, and all the details in the room to have everything where we need it, to set up the procedure properly. And lastly, I want to highlight that we have a coordinator for TAVR. So, most programs have this as well. In our hospital, it's a Nurse Practitioner named Lisa Cass who has a role called TAVR Coordinator. And she basically coordinates all of these moving parts before and after the procedure to make sure that the patient is set up properly, that all their needs are met before the procedure, to make sure all the right people and equipment and technologies are in place in the room so that we have everything we need and then helps manage the patient afterwards as well.

Host: It's really amazing, you know, and I've heard from speaking with other providers, you know, this collaborative approach, having these conferences. Everybody being on the same page and that team approach and having someone like Lisa coordinate, all of this, kind of be the point guard. It really does sound like patients are in good hands at St. Francis. And as we get close to wrapping up here, we've covered really a lot of the benefits. Now let's talk about after the surgery, assuming it was successful, you know, what's the prognosis, what are the expectations? When can people get back out to playing golf or whatever it is they do?

Dr. Fox: With regard to benefit, just to be very clear, the procedure has both a quality of life benefit that you alluded to. Patients will feel better and their symptoms will improve almost immediately in most cases, you know, the shortness of breath or congestive heart failure can be largely alleviated, just as soon as the procedure is completed. The other benefit that's been proven in the research studies is that patients who have this condition, who have TAVR, live longer and feel better as they live longer.

So there is a survival benefit from having treated. And then as far as the aftercare, after you know, the procedure, the patient will go to our ICU, just for close monitoring. Although many of them are not in a critical condition. That's where we have the most resources to monitor the patient overnight.

And in the ideal setting, the patient may be up and about six hours after the procedure, out of bed. And many of the patients go home the next day. That may not apply to everybody. Some patients are older and frailer, may require a few days in the hospital, but some go home the next day. And as far as strenuous physical activity, golf isn't strenuous, but there's some twisting and torquing of the body.

I would probably say give it a couple of weeks. But I've had a patient who was in their garden on a Monday telling her neighbor through the fence I'm going to have my valve replacement tomorrow. And then the next thing the neighbor knew it was Thursday and the patient was back gardening. And the neighbor said, did you have your valve replacement? And she said, yeah, I had it the other day. So, some of those activities can be resumed immediately, actually.

Host: It's really amazing is you say the strenuous activities, I guess it depends on how good of a golfer you are, but you know, people are going to want to know, when you have this important and major and life saving surgery; they're going to want to know when they can get back to doing their stuff.

And you know, you just think about how far things have come. You talked about kind of the old school, old days, where we are today, where a few hours after having this, you know, amazing procedure, folks are up walking around and they go home the next day, they get back to gardening. Really easy to see how this has become the gold standard.

And you know, as we put a period at the end of the sentence here today, doctor, when it comes to aortic stenosis, what are your takeaways?

Dr. Fox: Well, my takeaways are that, you know, I'm just so impressed with the way the field has advanced. We're taking some of our older, frailer and sicker patients who like I said a couple of decades ago, there was no hope for. Their condition would just deteriorate over time. And there was nothing that medical science could do.

And now the field has really advanced that we can take care of these folks in a very minimally invasive way with that very quick recovery time. And get these amazing results and really help people enjoy, you know, extra time in their life and they have more time and they have better quality of life during that time.

So, I'm really pleased and proud to be part of that at St. Francis. I think we do a good job there and I've really been so happy to see, you know, the results with our patients and the lives that we've helped improve.

Host: Pleased and proud. I love it. And this has been so educational. I really appreciate your time today and you stay well.

Dr. Fox: Thank you so much, sir. Thank you.

Host: And to learn more, please visit StFrancismedical.org or HCAhamilton.com. And thanks for listening to Word on Wellness from St. Francis Medical Center. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.