TAVR - FAQ's Answered by a Cardiologist - myheart.net (2022)

Table of Contents
What Is A TAVR (TAVI)? How Is TAVR different From Conventional Aortic Valve Surgery? How Does TAVR (TAVI) Work? Who Is Eligible For a TAVR? Why Can’t All Patients With Aortic Valve Disease Have TAVR? Who Performs TAVR – Where Should You Have It Done? Is TAVR safe? What Are the Possible Complications? How Long Does a TAVR Valve Last? What Tests Are Required For TAVR? How Long Will a TAVR Patient Have To Stay In the Hospital? What Medications Are Required After TAVR? Getting the Patient Ready for the TAVR procedure Type of Anesthesia for TAVR procedure General Anesthesia TAVR procedures Conscious Sedation TAVR procedures Minimalist TAVR procedure Accessing the Leg for TAVR and Inserting the TAVR Sheath Inserting a Temporary Pacemaker and Passing a Pigtail Catheter up to the Valve The Edwards S3 TAVR valve The Medtronic Corevalve Evolut TAVR Valve Crossing the Diseased Aortic Stenosis Valve Passing the TAVR Valve In to Position Deploying the Edwards S3 TAVR Valve Deploying the Medtronic Corevalve Evolut TAVR Valve Taking out the TAVR sheath and Securing The Access Site TAVR Post Procedural Considerations More TAVR procedure FAQ’s How Long Will I stay in Hospital for After the TAVR Procedure? What Are My Limitations After a TAVR Procedure? What Happens to the Old Valve When a TAVR valve is placed? Can the TAVR Valve Move Out of Place One Day? Will I be able to hear my TAVR valve when I Sleep? Will I Need to Take Blood Thinning Medications after my TAVR procedure? What If a Patient Already Has a Surgically Placed Heart Valve? What Happens When the TAVR Valve Stops Working One Day? I’ve Been Told I Have Leak Around My TAVR Valve, Now What? Which TAVR Valve Should I Choose? Can I Have MRI Scans after my TAVR procedure? FAQs Videos

What Is A TAVR (TAVI)?

TAVR is a revolutionary new heart valve treatment most commonly used to treat a tight aortic valve, otherwise known asaortic stenosis,TAVR stands for ‘transcatheter aortic valve replacement’, it is also commonly referred to as TAVI, which stands for ‘transcatheter aortic valve implantation’. TAVR and TAVI are the same thing. Transcatheter aortic valve replacement means that the procedure is done through a small tube (or catheter), rather than performing open-heart surgery. TAVR is similar to the mitraclip procedure for treatingmitral regurgitation.

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TAVR - FAQ's Answered by a Cardiologist - myheart.net (1)

The aortic valve is the structure that resembles a fish’s mouth opening and closing. See how the aortic valve doesn’t completely open? This is called Aortic Stenosis, the condition TAVR is intended to fix. Credit: Alliance for Aging Research

Most commonly the catheter is inserted through the groin and passed up through the blood vessels to the heart. The new heart valve is then advanced through the tube into the correct position within the existing aortic valve. Sometimes, when the blood vessels in the leg are not suitable, the TAVR is done through different access points, such as the chest wall.

How Is TAVR different From Conventional Aortic Valve Surgery?

TAVR (TAVI) is without a doubt one of the biggest advancements in modern medicine. Since the 1950’s surgeons have been able to operate on the aortic valve with open-heart surgery. Overdecades surgical techniques have evolved to make open-heart aortic valve surgery safe and effective in those that require it. Typically aortic valve surgery requires patients to have a sternotomy incision (chest cracked open) and be placed on a heart-lung machine to provide access to the aortic valve. No matter how safe or effective this is, it is clearly a big ordeal for the patient and physician. Because open-heart surgery carries serious risks, a large group of patients – particularly the elderly – are consideredtoo high risk to undergo open-heart surgery. Unfortunately this group would die from their aortic valve disease.

That was until the transcatheter aortic valve replacement technology was developed. Unlike open-heart surgery, TAVR (TAVI) does not require patients to be placed on a heart-lung machine, and in the vast majority of cases, patients will not need their chest cracked open because the TAVR procedure is performed a catheter inserted through the skin. As you can imagine TAVR is generally much less of an ordeal than open-heart surgery, and so the patients that were previously felt too high risk for an operation now have an option that can improve symptoms and extend their length of life.

How Does TAVR (TAVI) Work?

In conventional open-heart surgery, when the aortic valve is replaced, the old valve is removed, and a new valve sewn into place. In the TAVR procedure, the new valve is simply placed inside the existing valve, crushing it out the way. Since the TAVR procedure is done through a relatively small tube, the TAVR valve is compressed before put entering the body so it can fit into the tube. The new, artificial valve is then passed up to the correct position through the tube to the existing diseased aortic valve. Then the TAVR valve is expanded into its working size crushing the old valve out of the way.

TAVR - FAQ's Answered by a Cardiologist - myheart.net (2)

The artificial valve is advanced into place through a small tube known as a catheter.

TAVR - FAQ's Answered by a Cardiologist - myheart.net (3)

The new valve is then expanded in the correct position.

TAVR - FAQ's Answered by a Cardiologist - myheart.net (4)

The new valve functions as a fully working aortic valve replacement.

There are two main types of TAVR valves, balloon-expandable and self-expandable. In the balloon expandable type, the compressed valve is mounted on a balloon. When the balloon-expandable TAVR valve is in the correct position the balloon is inflated, enlarging the valve in the process to its normal working size. In the self-expandable type, the valve is contained within the tube like a compressed spring. As soon as the self-expandable TAVR valve is moved out of the tube it automatically expands into its natural position. The technology underlying these valves is simply incredible.

Who Is Eligible For a TAVR?

TAVR (TAVI) is a classic example of a continually evolving technology. Initially, TAVR was only approved for patients that were considered truly inoperable. Basically those patients that were being left to die from their aortic valve disease because the risk of operation was simply too high. Then as new research became available the indications for TAVR were expanded to include those at high surgical risk. Currently in the US, TAVR is indicated for patients at high risk for open-heartsurgery. Ongoing trials are investigating the use of TAVR in a healthier ‘intermediate-risk’ group. As things stand, for a patient with low or intermediate risk of undergoing aconventional operation, open-heart surgery is the preferred method of treating aortic valve disease such as aortic stenosis. TAVR is reservedfor higher risk patients.

So how is risk determined? In order to classify a patient as high risk, a TAVR heart team assesses aortic valve disease patients sent for consideration of TAVR. This team consists of cardiologists, cardiac surgeons, and imaging specialists. Together this team looks at each patient on a case-by-case basis and based on a number of factors decides if the patient fits into a high-risk category. Once the patient is determined to be high risk, they are assessed to determine their suitability for a TAVR procedure. Features that would make patients move towards a higher risk category include previous operation, lung disease, kidney disease, advanced age, and others.

Why Can’t All Patients With Aortic Valve Disease Have TAVR?

As discussed above, the current indications for undergoing a TAVR procedure are for high-risk surgical patients; however, TAVR will liekly be available for patients deemed an intermediate risk in the next few years. But if the procedure is so non-invasive compared to conventional surgery, why aren’t we performing TAVR on everyone with aortic stenosis, even the low-risk patients?

The reason is that it’s important as the technology expands to ensure that it is backed up by evidence. As tempting as it sounds to replace all aortic valve surgery with a TAVR procedure, there needs to be evidence that is beneficial and not harmful, not only in the short-term, but also the long-term. The good news is that trials in high-risk patients with aortic stenosis have demonstrated that, when compared to open-heart aortic surgery, TAVR is not only safe but results in improved quality and length of life. There are ongoing trials looking at TAVR (TAVI) vs. open-heart aortic valve replacement in intermediate risk patients. When those trials complete, it is likely that TAVR will also be used on the intermediate risk group.

(Video) TAVR: Everything You Wanted to Know

So why not use TAVR in low-risk patients? When it comes to standard surgical aortic valve replacement, it has been tried and tested over time, and proven to be safe and effective with long-term durability. Until TAVR has been proven in studies to have good long-term durability and long-term outcomes it cannot be recommended routinely for lower risk patients with aortic valve disease.

Who Performs TAVR – Where Should You Have It Done?

TAVR is a unique procedure in that it requires a unique approach called a heart team. A heart team includes cardiologists, cardiac surgeons, imaging specialists and other specialists to work in combination. The procedural selection, planning, and performance rely on these specialists working together. For this reason, TAVR should only be performed in a place with an established heart team in place and strong cardiac surgery and cardiology programs. Every part of the procedure is critical, including the pre-procedural selection and imaging, and all contribute to achieving a positive outcome. The stakes are high in a TAVR procedure. Having a heart team with TAVR experience is important.

Is TAVR safe? What Are the Possible Complications?

As far as major heart procedures go, TAVR can be considered relatively safe; however, a significant risk of complications exists. Careful planning, good patient selection, an experienced team, and careful attention to detail minimize the risk of TAVR complications. The following are a selection of some well-recognized complications associated with the TAVR procedure. Although uncommon, patients should be aware of these risks prior to the procedure.

Death

The risk of death during the procedure itself is low and likely in the <2-3% range. A higher risk patient will be at higher risk of poor outcomes. What is clear however is that the procedural risk of TAVR is lower than that of open-heart surgery as per current high-risk indications. This is the same for intermediate and long terms outcomes. TAVR is a proven life-saving procedure, with the benefits outweighing the risks.

Stroke

Although it’s becoming less common, stroke is one of the most feared complications of the TAVR procedure. Most strokes happen in the procedure itself or in the few-days thereafter, and this is thought to be due to having to pass the valve up through the great vessels to reach the heart and potentially dislodging small plaques that have formed on the walls that then fly up to the brain. The chance of stroke in the short term after the TAVR procedure is likely in the 3-5% range. Research is ongoing to try and minimize the occurrence of TAVR associated stroke.

Valve Leak

The valve leak associated with TAVR is not in the valve itself, but rather around the valve, and is known as a para-valvular leak. The reason for this is that the valve may not have expanded as much as hoped, it may be too small, or there may be calcium around the valve leaving areas prone to leak. The amount of leak is important as it has been proven that the more the leak, the more the chance of poor outcomes. Fortunately advances such as improved technology combined with improved patient and valve selection has led to significant leak becoming less and less common.

Need For a Pacemaker

When the valve is expanded in place during the TAVR procedure it may press on the electrical conduction system of the heart. Particularly when a lot of calcium is noted. The risk of pacemaker implantation depends on the type of valve used. In the case of a balloon expandable valve it is likely around 5-10%, whereas with a self-expandable valve it may be as high as 25%.

Kidney Failure

As part of the TAVR procedure, there is a need to inject contrast dye into the area around the valve to ensure correct positioning of the valve and also to assess the vessels through which the TAVR is performed. Any time contrast dye is used there is a risk of kidney damage, particularly in those patients where large amounts of contrast dye are required and where there is pre-existing kidney failure. The chance of kidney injury is likely <20% and in most circumstances it is reversible.

Vessel Damage

TAVR is typically performed through the vessels in the leg and involves placement of a tube in these vessels through which the procedure is done. This leads to a risk of complications including bleeding or direct artery damage. Careful TAVR patient selection can help minimize the risk. In the majority of vessel complications, it can be repaired through either catheter techniques or open vascular surgery.

Rarer Catastrophic Complications

Rarely there may be valve dislodgement, rupture of the aorta or occlusion of the coronary arteries that supply the heart with blood. Valve dislodgement is where the valve is misplaced, or is too small and in the worse case scenario ends up flying around the heart. This is associated with very poor outcome and needs open-heart surgery in an attempt to retrieve the valve. Rupture of the aorta is where the expanded valve causes tearing of the walls of the aorta allowing leakage of large amounts of blood around the heart and the aorta and is almost always catastrophic if there is significant rupture. Occlusion of the coronary arteries can occur because the aortic valve is near the coronary arteries and can potentially cover the opening of them if placed too high or placed incorrectly. This leads to occurrence of a large heart attack and is often fatal. These complications are rare however as TAVR experience grows, as we can typically predict patients at risk and modify the procedure as necessary.

How Long Does a TAVR Valve Last?

Over 150,000 TAVR valves have been implanted over the last decade worldwide and data regarding the durability of the TAVR valves is accumulating. What we do know is that there is good evidence that the TAVR valve is durable at up to 5 years as suggested by heart scanning evidence from survivors. Of course this doesn’t tell us about the non-survivors. Conventionally placed heart valves, especially the metallic valves have excellent long-term durability and as of yet it is unknown whether the TAVR valves will have this. For this reason, TAVR is not indicated in relatively younger, non-high risk patients. Before that can happen long term durability and good outcomes need to be shown.

What Tests Are Required For TAVR?

Firstly the diagnosis of severe aortic stenosis will need to be made using a heart ultrasound test known as echocardiography. Once that has been determined then other tests are performed to assess suitability for TAVR.

A heart catheterization is performed to rule out significant coronary disease. If coronary disease is found and determined to be significant then this may require fixing with a stent prior to the TAVR procedure.

Next CT scanning is performed to allow assessment of the heart to determine valve type and size, and also to assess the vessels of the body to see if they are large enough to accommodate the TAVR valve being passed through them.

Other tests may include, assessment by a neuropsychologist and/or a geriatrician along with tests to assess frailty. Patients deemed too frail may end up with more harm than benefit from any procedure and it may be best avoided in that case.

How Long Will a TAVR Patient Have To Stay In the Hospital?

As TAVR technology and experience continued to evolve the length of hospital stays are growing shorter and shorter. There is a trend towards patients leaving the hospital within the few days after the procedure. If the TAVR procedure requires a chest incision then the stay may be longer. It used to be the case that all patients were put to sleep under general anesthetic for the procedure, however there is a growing movement to perform TAVR for suitable candidates under sedation only. This combined with the smaller size of the newer valves is leading towards reduced length of hospital stay.

What Medications Are Required After TAVR?

Aspirin is recommended life long after a TAVR procedure. It is currently recommended a further blood thinning medicine called Plavix also be taken for 3-6 month after the procedure. Some people will be on these medicines long term anyway; such as those patients that have had a previous stent.

Getting the Patient Ready for the TAVR procedure

TAVR is also known as TAVI or transcatheter aortic valve replacement. It is a treatment for aortic stenosis, or a tight aortic valve. Patients will typically arrive the morning of the procedure. The assessment by the heart valve specialists would have been done before hand, however at this point the patient will meet the anesthesiologist who will discuss some aspects of the procedure such as specifics of being put to sleep for the TAVR procedure. The type of valve, the way it will be placed and other procedure related specifics should already have been made very clear by this point. The patient will be taken to the procedure room and at this point either be given some sedation/relaxation medicine or be put to sleep under anesthesia depending on what has been chosen. Once asleep the patient will be prepared, in a very standard sterile manner, and draped with surgical sheet to prevent any infection risk. We can now start the transcatheter aortic valve (TAVR / TAVI) procedure.

Self-expandable (TAVR) transcatheter aortic valve fresh out the container. The TAVR valve is stored in a container and is fresh. Here it is see immediately as it is taken out the container in its expanded position. It will next be crimped on to the valve so it can be passed in to the body.

Balloon-expandable TAVR valve fresh out the container. This is a picture of a balloon-expandable TAVR valve fresh out of the container before it is loaded on to the delivery system.

(Video) Transcatheter Aortic Valve Implantation (TAVI)

Type of Anesthesia for TAVR procedure

Some patients undergoing the TAVR procedure for aortic stenosis will be under general anesthetic and so fully under. Others will be under what we call conscious sedation, which means they will not be fully under but will not really be aware of what is going on. Nowadays we even adopt a truly minimalist approach to the TAVR procedure and some patients are given some local numbing medicine only. The key is to adopt a patient specific approach to the TAVR procedure, which means the best option is chosen on a case-by-case basis depending on what is best for that patient undergoing the transcatheter aortic valve replacement.

General Anesthesia TAVR procedures

In TAVR procedures under general anesthesia the patient will be given medicines to be put fully to sleep and have a breathing tube inserted and a breathing machine used during the case. In most cases the breathing tube will be removed in the operating room as soon as the case is finished and the patient woken up. Advantages to this approach are that an ultrasound probe known as a TEE (transesophageal echocardiogram) can be inserted in to the food pipe allowing close monitoring of the diseased aortic valve and other structures during the procedure. Although this isn’t a necessity in all TAVR procedures, I find that in some cases it allows a much more accurate approach to transcatheter aortic valve replacement. In those cases I will suggest general anesthesia be used. Another advantage of general anesthesia is that in cases considered to be very complex or challenging, it allows a much more controlled situation.

Conscious Sedation TAVR procedures

In conscious sedation TAVR procedures, the patient will be given medicines that put them almost all the way under, but still allows them to breathe on their own, therefore a breathing tube will not be required. The advantage to this is that the patient can avoid general anesthetic and the waking up after the case will be almost immediate. This is important as in older patients avoiding anesthetic if possible may be desirable as it is less stress to the system. The disadvantage to this is that the ultrasound probe known as a TEE (transesophageal echocardiogram) will not usually be inserted in to the food pipe that would usually allow close monitoring of the valve during the procedure. But that’s ok in the majority of transcatheter aortic valve replacement cases since the ultrasound probe placed on the chest provides more than adequate pictures. There is a greater and greater move towards conscious sedation TAVR procedures becoming the norm, particularly for routine cases.

Minimalist TAVR procedure

In particularly experienced centers such as Princeton Baptist Medical Center, a truly minimalist approach to transcatheter aortic valve replacement may be adopted whereby the patient is simply given some local numbing medicine and some sedation medicine to relax them during the case. The entire procedure can be done in this manner and is generally minimal stress to the patient as the recovery is almost immediate.

Accessing the Leg for TAVR and Inserting the TAVR Sheath

The overwhelming majority of TAVR procedures will be performed through the artery in the leg. For that reason I will cover only leg access for transcatheter aortic valve replacement in this article. To advance the valve up to the heart we have to insert the valve over a wire through the artery of the leg known as the femoral artery. This can be done either by just going through the skin, known as the Seldinger technique, or by surgically cutting to obtain access to the artery. In experienced centers the default option for the TAVR procedure is the Seldinger option that doesn’t require surgical cutting.

Firstly a needle is used to obtain access to the artery. We will know where the artery is by feeling the pulse, sometimes an ultrasound machine is used for accuracy, and also the procedure is watched under live X-ray guidance. Once the needle is in the artery we will see blood pulsating backwards through it. A small wire is placed through this and then a larger tube is placed over this. At this point we will generally take a picture of the leg artery using contrast dye to ensure there is nothing problematic. Once we are happy we have accessed the leg in the best place, we will use something called the pre closure technique to place 2 stitches in the artery. These will be left in place until the tube is taken out at the end of the TAVR procedure and then the stitches will be tightened.

Micro-wire. A small needle is used to puncture the skin and gain access to the blood vessel. A wire is passed through the needle and now tubes can be passed over this wire in to the vessel.

Micro-angio. Typically a picture will be taken with dye to ensure the vessel has been accessed in the correct place.

The tube used to place the transcatheter aortic valve through is known as a sheath. It is a relatively large tube, and so before placing it we will dilate up with a series of smaller tubes known as dilators. In patients with aortic stenosis that are older, sicker and have a lot of narrowing and calcium in their arteries it can be challenging to pass the sheath. There are a number of tips and tricks however that can be used to facilitate sheath placement gained though experience. I personally have found that the TAVR procedure can be performed through the leg in almost all cases, which avoids the need to cut the chest.

Dilator and sheath. This is a picture of a dilator and a sheath for a TAVR procedure. The dilator is the long thin white tube that is inserted in to the artery over a wire and dilates the artery preparing it for the large sheath. The sheath is the blue tube that is placed in the body through which the TAVR procedure valve is passed in to the body.

Sheath passed in to body. The sheath is the tube through which the TAVR valve is passed in to the body. We already placed a wire in to the vessel. Here we are passing the sheath over the wire in to the body.

Inserting a Temporary Pacemaker and Passing a Pigtail Catheter up to the Valve

When we perform a TAVR procedure we need to ensure that the transcatheter aortic valve is placed in exactly the correct position inside the old diseased aortic valve. One of the ways to help this positioning is to place a marker inside the old valve, typically a pigtail catheter. This catheter is usually placed through the artery of the leg on the opposite side to the one used for the valve. It gives us an idea exactly where the bottom of the original aortic valve is and thus tells us where to place the new valve in addition to other helpful factors. Accuracy is key in transcatheter aortic valve placement to help avoid complications.

Also in TAVR procedures, a temporary pacemaker is placed through the vein of the leg, although in some patients who already have a pacemaker this is not required. The pacemaker is used to speed the heart up very rapidly during some critical phases of the transcatheter aortic valve placement to prevent movement of the valve. This pacemaker is removed after the valve is deployed typically. In some patients, who develop heart block during the TAVR procedure, the pacemaker is left until a permanent one can be placed.

The Edwards S3 TAVR valve

The Edwards S3 TAVR valve is one of the two main types of transcatheter aortic valve used as things currently stand. This is known as a balloon expandable valve. The valve itself is assembled on to the delivery system outside the body where it is placed over a deflated balloon catheter. Once in the correct position in the body, the valve is deployed by inflation of the balloon that expands the valve that then stays in place as a fully functioning valve.

(Video) Transcatheter Aortic Valve Replacement (TAVR) Treatment for Aortic Stenosis

Crimping of the valve. The valve is loaded on to the delivery system in a process called crimping where it is tightly compressed on to the system with a low profile so that it can be entered in to the body.

The Medtronic Corevalve Evolut TAVR Valve

The Medtronic Corevalve Evolut R is a self-expandable TAVR valve that is one of the main 2 forms of valve used as things stand. This means that it is spring loaded and once the cover is removed in the body it naturally takes its normal form and expands in to place. Advantages of the Corevalve transcatheter aortic valve include not needing rapid heart rate during the procedure, and the fact it can be recaptured and re-positioned if its felt to not be in an optimal position.

Preparing the self-expandable TAVR Valve on the table. The valve is assembled on to the delivery apparatus outside the body on the table.

Crossing the Diseased Aortic Stenosis Valve

Next comes crossing the diseased aortic valve (aortic stenosis). In order to pass the TAVR valve up to the heart a wire needs to be placed from the leg to the heart so that the valve can be passed over it. In order to get the wire through the diseased valve in to the heart specialized technique must be used. Think of having to pass a thread through a moving pinhole, in some cases this can be very difficult. Specialized wires and catheters are used to do this. The catheter allows steering towards the valve opening. The wire that is ultimately placed in the heart has to be curved in a manner that will not cause damage to the heart structures. This wire has to be stiff enough to support the transcatheter aortic valve being passed over it also.

Balloon Valvuloplasty. A balloon is passed up to the valve. Then the heart is paced rapidly and the balloon inflated. This helps to crack open the tight valve in preparation for the new valve.

Passing the TAVR Valve In to Position

The chosen TAVR procedure valve is passed through the sheath in the leg over the wire that is now in the heart. The transcatheter aortic valve is passed up to the level of the old diseased valve, and in to the desired position. Typically at this point the x-ray cameras will be oriented in an optimal position. Its important to watch the valve as it is passed up to the heart, and different x-ray angles are used to pass the valve up and over the arch of the aorta in to position ensuring the transcatheter valve travels smoothly. The position at this time needs to be almost exact as placing a TAVR valve too high or too low can lead to significant problems.

TAVR valve passed around aortic arch. The valve is passed from the leg up to the top of the aorta then around the arch of the aorta to the valve as demonstrated.

Balloon-expandable valve in position. The valve is placed in the old valve and positioned accurately using landmarks to within millimeters and assumes the desired position.

Deploying the Edwards S3 TAVR Valve

The S3 TAVR valve is a balloon expandable valve, that means when it is time to be deployed in to place, a balloon is inflated which results in the valve taking its full form. With this transcatheter aortic valve, everything has to be almost perfect on initial deployment as once its been positioned, it cant be repositioned. Once the valve is in place, the heart is sped up to 180-200 beats per minute to ensure there is minimal blood flow and therefore minimal movement of the valve. Once the heart rate is high and the position stable, some contrast dye is injected to once again ensure perfect positioning. When happy with the positioning, the balloon holding the valve is inflated resulting in the valve expanding in to position. All of this process is done within seconds, after which there should be a fully functioning TAVR valve in position.

Balloon-expandable valve position check. In this image, the balloon-expandable TAVR valve position is being checked. A small puff of contrast is used to highlight the old valve and ensure that the TAVR valve is in correct position inside it.

Deployment of the balloon-expandable TAVR valve. In this image, the valve is seen expanded in to place by inflating a balloon. This is done under rapid pacing of the heart to prevent movement of the valve. We now have a functioning valve.

Deploying the Medtronic Corevalve Evolut TAVR Valve

The Corevalve is a self-expandable transcatheter aortic valve that is essentially spring loaded inside a sheath, which when removed enlarges in to its natural expanded form. The Corevalve is released in a slow and controlled process that allows repositioning of the valve if the position is suboptimal prior to release. Typically fast pacing of the heart is not required with deployment of the Corevalve. Contrast dye can be injected at various points of the valve deployment to ensure optimal positioning during the TAVR procedure.

(Video) Sansum Clinic Cardiology Leads in TAVR (Transcatheter Aortic Valve Replacement)

Self-expandable valve position check. In this image, the self-expandable TAVR valve position is being checked. A small puff of contrast is used to highlight the old valve and ensure that the TAVR valve is in correct position inside it.

Deployment of the self-expandable TAVR valve. This is a picture of a self-expandable TAVR valve being placed inside an old surgically placed valve. The valve is gently expanded in to place and then released in a secure position.

Taking out the TAVR sheath and Securing The Access Site

Once the TAVR valve has been deployed, the valve delivery system is taken out of the body and the wire in the heart removed also. There is still a good-sized tube in the leg however and this needs to be removed before the case is over. If you remember from reading above, at the beginning of the case we had placed 2 stitches in the artery. Now when we take the tube out, we tighten these 2 stitches together and this seals the hole made by the tube. Often we will take an x-ray picture of the leg with contrast dye just to make sure everything is ok with the leg vessel.

Aorta-iliac angiogram. A picture is taken at the end of the case just before closing the hole in the vessel to make sure no damage has been done to the vessel prior during the procedure.

Once the tube is taken out a firm pressure dressing is typically applied for a few hours. In the few cases where a surgical cut was made to gain access to the vessel, the surgeon will then directly stitch the hole and then the skin, sometimes leaving a drain in for a day or two after the procedure. When most people come back to clinic for their 1 week check up, its often very difficult to see where we went in the first place as it has entirely healed and there is no scar.

TAVR Post Procedural Considerations

After the transcatheter aortic valve procedure is finished, often the breathing tube is taken out in the room for those that were under general anesthesia. At Princeton Baptist, we generally like our TAVR procedure patients to be kept overnight in the intensive care unit simply as we feel that patients will be watched very closely in the first few hours after the procedure with a dedicated nurse. It is important that lines and tubes are aggressively removed and the patient be sitting in the chair if possible very early after the procedure, often a number of hours. This encourages early mobilization and often can allow the patient to go home within 48 hours of the TAVR procedure. In some patients that have developed complete heart block after the TAVR procedure, a pacemaker is placed, often the day after the procedure and not the day of, simply to see if the patient can recover their own rhythm.

More TAVR procedure FAQ’s

How Long Will I stay in Hospital for After the TAVR Procedure?

In an uncomplicated TAVR procedure, for someone who has come from home after the procedure it is standard to be discharged within 48 hours of the procedure in our center. Most experienced centers will discharge patients within a few days. Of course the patients undergoing TAVR in general are elderly and have several medical problems and so a longer stay may be necessary. For those patients who are transferred from other hospitals with aortic stenosis for emergency procedures and in critical condition the stay will be longer.

What Are My Limitations After a TAVR Procedure?

A big advantage of the transcatheter aortic valve procedure for aortic stenosis over traditional surgery is of course recovery time. In general the activity limitation is dependent upon the access site in the leg. Patients typically sit up a few hours after the procedure, and can walk some the same day. The day after we have patients working with the physical therapist. A few days precaution regarding heavy lifting may be advised. But in general there are no other specific limitations after the procedure.

What Happens to the Old Valve When a TAVR valve is placed?

In a TAVR procedure, the new valve replaces the old diseased aortic valve by literally being put directly inside the old valve and crushing the valve leaflets out the way when it is deployed. The leaflets of the old aortic valve are pushed up against the sidewall of the aorta, the main blood vessel that leaves the heart. This is advantageous as it also ensures the new valve is nicely seated in position.

Can the TAVR Valve Move Out of Place One Day?

I am often asked by patients if they need to be careful with activity after the transcatheter valve is placed as they are concerned that of they exert themselves too much the valve might move out of position. The fact is that once the valve is deployed and seen to be functioning it is almost impossible to migrate, and no amount of exertion can move it. This should stay in position life long.

Will I be able to hear my TAVR valve when I Sleep?

I am asked this question frequently. You will not hear the TAVR valve after it has been placed; it will not click with each heartbeat like a metallic valve would.

Will I Need to Take Blood Thinning Medications after my TAVR procedure?

Aspirin will typically be prescribed daily. For a few months after the procedure patients may be prescribed a blood thinning medicine known as Plavix after the procedure. This can typically be stopped after that time unless the patient needs it for another reason. Some patients will be taking a blood thinner known as Warfarin, Coumadin, Xarelto, Eliquis or Pradaxa already before the procedure. In these patients this will typically be resumed as usual after the TAVR procedure and Plavix will not need to be prescribed.

What If a Patient Already Has a Surgically Placed Heart Valve?

A TAVR procedure cannot be performed in someone with a metallic surgical valve, but it can be performed in patients with a bioprosthetic valve such as an animal valve. When placed in an old valve replacement this is known as a valve-in-valve procedure. These must be evaluated carefully prior to a TAVR procedure to ensure the valve-in-valve procedure does not leave the patient with a tight valve.

What Happens When the TAVR Valve Stops Working One Day?

The good news is that TAVR valves are being proven to be durable. There is no reason to expect that they will not last as long as the surgically placed bioprosthetic valves that are known to last 10-15 years. There are of course cases of early degeneration as with any heart valve, and in these cases a good option can be to place another TAVR valve inside the existing one known as a TAVR valve in TAVR valve procedure.

I’ve Been Told I Have Leak Around My TAVR Valve, Now What?

In the early days of the TAVR procedure, leak around the valve known as paravalvular leak was a significant problem. However with the improving technology and experience with the valve this is becoming less of an issue, however in some cases is not avoidable. When there is a leak noted in the procedure, the team will often take a balloon and inflate it in the valve that can often minimize the leak. Sometimes however, due to the presence of calcium, the leak persists. In highly experienced centers such as Princeton Baptist Medical Center, a procedure performed through the leg to place a device in the leaking area, getting rid of the leak can be performed which can often result in excellent clinical patient improvement.

Which TAVR Valve Should I Choose?

In my opinion there are clearly advantages and disadvantages to whichever valve is used and its important to make the decision on a case-by-case basis. The best valve for the patient needs to be chosen. Unfortunately this decision is often forced by the fact the center in question may only have access to, or experience with one kind of valve only. The valve team taking all factors in to account should make the decision regarding the valve used. At Princeton Baptist Medical Center we generally use each different type of valve equally which has allowed us to be experienced enough to perform each type of valve efficiently.

Can I Have MRI Scans after my TAVR procedure?

There is generally no restriction to scans after a TAVR procedure and to the best of our knowledge the valve cannot be adversely affected by scans. It is of course always a good idea to make healthcare advisors aware of the fact a procedure has been performed.

4.93/5(767)

(Video) Dr. Nezar Falluji, Interventional Cardiologist on Transcatheter Aortic Valve Replacement

FAQs

What is the most common complication of TAVR? ›

Undisputedly, post-procedural stroke remains the most-dreaded complication following TAVR. Experiencing a major (disabling) stroke is more feared than death itself by many of the elderly patients undergoing TAVR.

What is the success rate of a TAVR procedure? ›

These results are similar to Deeb et al24 where post-operative outcomes of TAVR valves were compared to SAVR valves; the 3-year all-cause mortality rate for TAVR valves was 32.9%, with a corresponding survival rate of 67.1%.

Why is TAVR not recommended? ›

As with any medical procedure, there is a possibility of risks. The most serious risks of TAVR include death, stroke, serious damage to the arteries, or serious bleeding.

What is the average age of a TAVR patient? ›

In terms of patient characteristics, the mean age of those younger than 70 years referred for TAVI was 65 while the average age in the older cohort was 82 years.

How long does it take to fully recover from TAVR? ›

TAVR recovery is much faster than recovery from open-heart surgery, and most patients can resume normal activities within two weeks.

Who is considered high risk for TAVR? ›

TAVR is currently approved for high risk patients, which can include people in their 80's, and people with severe diseases like heart failure and lung disease.

Can you live 10 years after TAVR? ›

Medical literature suggests the lifespan of the tissue valves used in surgical aortic valve replacement is typically about 10 to 20 years. Since TAVR valves are made of the same biological tissue, it is expected they will have the same longevity.

Do patients feel better after a TAVR? ›

There is research that shows patients who undergo TAVR have reduction in symptoms, improvement in ability to take care of themselves, improved heart function, and improvement in overall quality of life at 30 days. Most patients are able to return to work within two weeks after the procedure.

Who is not a candidate for TAVR? ›

For TAVR to be recommended, the evaluation must confirm the following: You have aortic stenosis that is severe in nature and is causing symptoms. You are not a candidate for surgical aortic valve replacement or you're at high risk for surgery and likely would benefit from TAVR therapy.

How long are you in the hospital for TAVR? ›

Typically, a patient can expect to be in the hospital for 3-5 days following a TAVR procedure.

Which is safer TAVR or open heart surgery? ›

Nonetheless, reintervention with TAVR was associated with lower mortality than surgery. Patients who had TAVR performed using a transfemoral approach (from the groin to the heart) and open-heart surgery patients both had better outcomes than patients who underwent TAVR performed through an incision in the chest area.

Which Tavr valve is best? ›

By far the greatest experience and evidence in ViV TAVI is with the use of the CoreValve/Evolut (Medtronic) and Sapien (Edwards Lifesciences) valves. The incidence of coronary obstruction was noted to be 3.5% in the VIVID registry.

Can you live 20 years after aortic valve replacement? ›

Pooled data from 85 studies estimated that 89.7% of people survived for two years after surgery, 78.4% at five years, 57.0% at 10 years, 39.7% at 15 years, and 24.7% at 20 years.

Does TAVR reduce life expectancy? ›

In younger patients, life expectancy was reduced when TAVR durability was 30%, 40%, and 50% shorter than that of surgical valves in 40-, 50-, and 60-year-old patients, respectively.

Can TAVR be done twice? ›

Median time from first TAVR to subsequent TAVR was 154 days, although 10.9% underwent repeat TAVR within 30 days of initial TAVR. Average age of patients undergoing repeat TAVR was 80.8 ± 8.9 years.

How do people feel after TAVR? ›

It is common to have pain at the catheter insertion site (often in the leg) for several days following a TAVR. Pain tends to gradually resolve as you recover and heal. Controlling pain is important because it helps you complete rehabilitation and increase your activities.

Is TAVR a major surgery? ›

However, TAVR is still a major procedure that has risks. Most TAVR procedures are performed with sedation without the need for general anesthesia. The most common risks associated with TAVR include: Damage to your blood vessels.

Can you live a normal life after aortic valve replacement? ›

Patients Can Live a Full and Healthy Life After Heart Valve Surgery | Blog | CHI Saint Joseph Health.

What tests are done before TAVR? ›

Before the day of surgery, you will have a physical exam and tests. These tests include X-rays, CT scans, lung tests, and blood tests. You will have an echocardiogram to check your aortic valve. You may also have a cardiac catheterization.

Does TAVR cure aortic stenosis? ›

TAVR can help restore blood flow and reduce the signs and symptoms of aortic valve stenosis — such as chest pain, shortness of breath, fainting and fatigue. TAVR may be an option for people who are at risk of complications from surgical aortic valve replacement (open-heart surgery).

Are you awake during TAVR? ›

On the Day of Your Procedure

Your TAVR Doctor will perform the procedure at a hospital. Depending on your health, they will determine what type of anesthesia is best for you. You may be fully asleep, or you may be awake but given medication to help you relax and block pain.

Does TAVR extend life? ›

In the base case scenario, standardized difference in life expectancy was <0.10 between TAVR and SAVR until TAVR device failure time was 70% shorter than the SAVR device. At a TAVR device failure time <30% compared to surgical valves, SAVR was the preferred option.

What is the life expectancy of a person with aortic stenosis? ›

Without treatment, a person's life expectancy with aortic stenosis after symptoms develop is 1–3 years. Around 50–68% of symptomatic people die within 2 years. Often, they die suddenly. However, aortic valve replacement surgery significantly increases life expectancy.

How many times can a heart valve be replaced? ›

Two or 3 cardiac reoperations may be required after a 1st successful valvular surgery, due to complications that beset mechanical or bioprosthetic valves, such as degeneration.

How likely is the patient to return to normal function after TAVR? ›

Gotzmann et al. (33) found 21% of 107 patients whose NYHA class did not improve or worsened after TAVR. In another study of 76 patients, 30% reported no change or worsening functional status measured by the Duke Activity Status Index(74) despite successful TAVR, while most patients reported improved NYHA class(75).

Is shortness of breath common after aortic valve replacement? ›

Postoperative dyspnea is common after cardiac surgery, even in low-risk patients.

How do I prepare for TAVR surgery? ›

What to Do Before TAVR
  1. Ask How Much You Can Exercise. Ask your TAVR Doctor what level of activity is appropriate. ...
  2. Talk to Your Doctor About Your Medications. ...
  3. Eat a Healthy Diet. ...
  4. Get a Dental Check-up. ...
  5. Make a Recovery Plan.

Does Medicare pay for TAVR? ›

The Centers for Medicare & Medicaid Services (CMS) will cover Transcatheter Aortic Valve Replacement (TAVR) for the treatment of symptomatic aortic valve stenosis through Coverage with Evidence Development (CED).

Is there an age limit for aortic valve replacement? ›

One study published in the Journal of Cardiac Surgery examined the success of heart valve replacement at age 85 and up. It found that open heart surgery can be performed in patients 85 years and older with good results – though elderly patients are associated with “prolonged hospital stay(s)”.

Can you have severe aortic stenosis without symptoms? ›

No. Many people with aortic stenosis, or AS, don't experience noticeable symptoms until the amount of restricted blood flow becomes greatly reduced. Symptoms of aortic stenosis may include: Chest pain.

What do you look for after TAVR? ›

The site may remain bruised for a few weeks afterwards. Call your doctor if your wound is red, swollen, warm, draining excess fluid, bleeding, or starting to open. After TAVR, you will likely continue many of the medicines you took before the procedure.

Is TAVR worth the risk? ›

“We've now looked at a broad risk spectrum of patients—those at high, intermediate and low surgical risk—and these series of trials have shown that TAVR is better than or as good as surgery in terms of disabling strokes and deaths from all causes.

Why does TAVR cause stroke? ›

Stroke is a devastating complication being confined mainly in the periprocedural and 30-day period following TAVR, with a lower and relatively constant frequency thereafter. Early stroke is mainly due to debris embolization during the procedure, whereas later events are associated with patient specific factors.

What are the side effects of TAVR? ›

The most common risks associated with TAVR include:
  • Damage to your blood vessels.
  • Bleeding.
  • Decreased blood supply to your brain, causing a stroke.
  • Heart attack.
  • Kidney failure.
  • Collection of fluid around your heart.
  • Leaking of the replacement valve.
  • Severe heart failure.

Do you need rehab after TAVR? ›

You Will Need Cardiac Rehab

The good news is that you won't have a chest incision to slow you down, but the rehab may be slower and take longer than you wish. This is mostly because those who qualify for TAVR are weaker at the start.

Do you need cardiac rehab after TAVR? ›

Cardiac rehabilitation is recommended for patients who undergo TAVR just as it is for heart attack survivors and stent recipients. However, their older age, increased frailty, and limited functional capacity compared to traditional CR enrollees call for a gentler approach.

How likely is the patient to return to normal function after TAVR? ›

Gotzmann et al. (33) found 21% of 107 patients whose NYHA class did not improve or worsened after TAVR. In another study of 76 patients, 30% reported no change or worsening functional status measured by the Duke Activity Status Index(74) despite successful TAVR, while most patients reported improved NYHA class(75).

Can you live 10 years after TAVR? ›

Medical literature suggests the lifespan of the tissue valves used in surgical aortic valve replacement is typically about 10 to 20 years. Since TAVR valves are made of the same biological tissue, it is expected they will have the same longevity.

Who is not a candidate for TAVR? ›

For TAVR to be recommended, the evaluation must confirm the following: You have aortic stenosis that is severe in nature and is causing symptoms. You are not a candidate for surgical aortic valve replacement or you're at high risk for surgery and likely would benefit from TAVR therapy.

Which Tavr valve is best? ›

By far the greatest experience and evidence in ViV TAVI is with the use of the CoreValve/Evolut (Medtronic) and Sapien (Edwards Lifesciences) valves. The incidence of coronary obstruction was noted to be 3.5% in the VIVID registry.

Why does the patient need the head of the bed elevated immediately after TAVR? ›

FDA-approved valves for TAVR

If the femoral artery was accessed during the procedure, keep the head of the bed elevated 30 degrees or less to minimize bending at the groin and avoid disrupting the closure device at the puncture site.

Why is a TAVR done? ›

TAVR can help restore blood flow and reduce the signs and symptoms of aortic valve stenosis — such as chest pain, shortness of breath, fainting and fatigue. TAVR may be an option for people who are at risk of complications from surgical aortic valve replacement (open-heart surgery).

Can mechanical heart valve cause stroke? ›

The main drawback of a mechanical valve is the tendency for blood clots to form on its metal surfaces, which can lead to serious complications including heart attack or stroke.

How long are you in hospital TAVR? ›

Typically, a patient can expect to be in the hospital for 3-5 days following a TAVR procedure.

Are you awake during TAVR? ›

On the Day of Your Procedure

Your TAVR Doctor will perform the procedure at a hospital. Depending on your health, they will determine what type of anesthesia is best for you. You may be fully asleep, or you may be awake but given medication to help you relax and block pain.

Is a TAVR considered major surgery? ›

Is TAVR a Major Surgery? It is not! TAVR is a less invasive procedure than open-heart surgery that involves inserting a catheter into small incisions in the large artery of your leg called the femoral artery.

Videos

1. Transcatheter Aortic Valve Replacement (TAVR) – Essentia Health
(Essentia Health)
2. Transcatheter Aortic Valve Replacement - Puneet Khanna, MD, Eisenhower Desert Cardiology Center
(Eisenhower Health)
3. Heart Valve Replacement without Surgery: Transcatheter Aortic Valve Replacement (TAVR / TAVI)
(Doç. Dr. Şükrü AKYÜZ / Girişimsel Kardiyolog)
4. Transcatheter Aortic Valve Replacement (TAVR) - Transfemoral Approach
(Transcatheter Aortic Valve Replacement (TAVR) Information)
5. TAVR Patient Experience
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6. Transcatheter Aortic Valve Implantation (TAVI)
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