In patients with severe aortic stenosis, there are multiple techniques that can be used to replace the aortic valve. These include traditional “open heart” aortic valve replacement, minimally invasive surgery, and transcatheter aortic valve replacement described here. The decision to perform a specific type of surgery is complex, and involves a complete evaluation of the patient to determine which method will have the best outcome. One advantage of Raney Zusman medical group is that our surgeons are familiar with each of these techniques, and can offer the best option for each patient.

It is critical that the surgeon, cardiologist, or endovascular specialist performing transcatheter aortic valve replacement has the most up to date equipment and a strong supporting team. A hybrid operating room is essential. In the hybrid operating room, a minimally invasive procedure can quickly be converted into a full “open heart” procedure if problems arise. The surgeons of Raney Zusman will be performing the procedure in the recently opened Hoag Hybrid Cardiovascular Operating Room. This state-of-the-art facility has highly sophisticated imaging equipment to facilitate the procedure. Hoag Heart and Vascular Institute also has an established multi-disciplinary team involving cardiac surgeons, interventional cardiologists, cardiac anesthesiologists and perfusion team for potential cardiopulmonary bypass. They work in close contact with support staff, including cardiac nurses and physicians specializing in cardiac intensive care after the procedure has been completed.

Not all patients are a candidate for transcatheter aortic valve replacement. In general, TAVI is generally used for patients who are considered “too sick” for open heart surgery. Aortic valve replacement through traditional approach is still considered the “gold standard,” with excellent outcomes that have been proven over long periods of follow-up. To determine if you are a candidate for TAVI, you should speak with your cardiologist or contact us to schedule an appointment with one of our surgeons.

In transcatheter aortic valve implantation, the patient is “put to sleep” with general anesthesia. In traditional aortic valve replacement, the patient is placed on a heart-lung machine, also known as cardiopulmonary bypass. The chest wall is then opened, and the patient’s heart can be directly accessed to remove the old valve and implant a new valve. With TAVI, a balloon is used to expand the patient’s own aortic valve to make room for the transcatheter valve. The new transcatheter heart valve is then inserted across the patient’s own aortic valve, and another balloon is used to expand the valve in place. There are two main methods used to place the valve, the transfemoral and transapical approach. The decision to use a particular approach is complex, and best discussed with a physician.

In the transfemoral approach, an incision is placed in the femoral artery in the groin area. A wire is then advanced upwards towards the heart and across the aortic valve. The transcatheter SAPIEN valve is then expanded in place, as shown below.

In the transapical approach, a small incision is made between the ribs in the chest wall. The valve is then directly inserted across the apex of the heart and into position across the native valve. The valve is then deployed in place, again using a balloon. The incision is then closed with sutures.

There are a large number of risks associated with any invasive procedure. The transcatheter valve is also a relatively new procedure, which carries additional risks. Important risks and precautions to consider with transcatheter aortic valve replacement include:

• There may be an increased risk of stroke in transcatheter aortic valve replacement procedures, as compared to balloon aortic valvuloplasty or other standard treatments.
• Long-term durability has not been established for the transcatheter valve (compared to other valves, where patients have been followed for a long period of time).
• Safety and effectiveness have not been established for patients who are candidates for surgical aortic valve replacement (studies have only focused on patients who were not candidates for traditional open heart surgery)
• The procedure uses contrast media, which may lead to renal failure (especially in patients with pre-existing kidney disease).
• Regular medical follow-up is advised to evaluate transcatheter valve performance.
• Transcatheter valve recipients will require antiplatelet and anticoagulation therapy.  If a patient has bleeding problems, or adverse reactions to these medications, they may not be a candidate for transcatheter valve replacement
• The safety of the bioprosthesis implantation has not been established in patients who have certain characteristics (i.e. a pre-existing prosthetic valve, other valve disease, blood problems, bleeding problems, issues with platelet medications, other problems with the structure of the heart or blood vessels in the body)  

A comprehensive list of potential adverse events can be found at the Edwards Lifesciences website. It is important to note that many of these risks are also seen with traditional open heart replacement of the aortic valve.