What Is A TAVR (TAVI)?
TAVR is a revolutionary new heart valve treatment most commonly used to treat a tight aortic valve, otherwise known as aortic 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 treating mitral regurgitation.
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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. Over decades 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 considered too 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.
The artificial valve is advanced into place through a small tube known as a catheter.
The new valve is then expanded in the correct position.
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-heart surgery. 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 a conventional operation, open-heart surgery is the preferred method of treating aortic valve disease such as aortic stenosis. TAVR is reserved for 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.
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.
Part 2: TAVR Procedure In Depth
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.
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.
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.
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.
Aortic valve replacment has small leak does that lesson the length the new valve will last ?
In general a small leak should not cause an issue. Trivial leaks are relatively common. Larger leaks may lead to symptoms and may need to be treated. There is no good evidence that presence of a small leak will affect the length the valve will last.
Hi Dr. Ahmed-
Very informative and well written article. I have been researching TAVR because I am interviewing for a heart valve coordinator position tomorrow. Do you utilize heart valve coordinators at your facility? If so, any advice?
Heart valve coordinators are in my opinion amongst the most critical parts of a structural heart operation. A good, driven, coordinator that takes pride in the smooth running and seamless coordination of a true heart team approach, with attention to detail, avoidance of shortcuts, and patient experience is priceless. Communication and work ethic is everything.
My dad had this procedure, next dr comes down 3 hrs later to inform us dad is on life support and there doing open heart surgery, 5 more hrs total of 8 hrs, he made it until we went in to see him, his arm swollen, right side paralyzed and then one eye moving not sure if he is inside of himself, 6 days later we were told see his Mir head scan stroke on left side but they forgot to say also right plus kidneys slowing, but they wanted to put him on dialysis and put a pace maker in, No, we stopped there bull, to only watch him die a horrible death and to hear the nurse say his heart stopped 2 days prior and the wall pace maker was keeping him alive, when she pushed the button he die terrible, I gave last rights with holy water, we were never told about his heart stopping 2 days prior or a pacemaker on wall keeping his heart going, he was stuck in his body from stroke never to eat,swallow talk again but they talked about therapy, really? I’m going to go after these bastards for screwing this up and killing my father and I won’t stop, oh the prior cather the day before surgery they screwed up caused abdominal bleeding and that night dads speech changed, called nurse to check for stroke she didn’t give a dam. Anyone have a comment for this? Would love to hear from you, dad had arorta stenosis severe age 85 leukemia and COPD and they opened him up when someone screwed up bad
my moms heart valve co -ordinator was amazing, the entire team was. I thank god we were led there. she had previously been strung along by her previous cardiologist that never told her it was life or death, kept saying when you are ready. Take heed all who are reading , if you have a bad valve don’t wait like we did out of fear! and risk other problems find the dr who will tell you the truth and has a good record. all the best
We had an amazing coordinator who was calling us and keeping up to date on everything. Mitzi was involved with the final check-up and saw that all of the bases were covered. My husband had a very good out come and is doing well.
Excellent informative article…
In conventional open heart surgery, a tissue valve is typically placed.
Can the valve that is placed with TAVR also be a tissue valve?
In conventional open heart surgery either a tissue or a mechanical valve is placed. In the TAVR procedure the valve that is placed is similar to a tissue valve. TAVR procedures can be performed in suitable cases even in patients with an existing tissue valve. This is known as a valve in valve procedure.
My platelets are 37 K and I will need surgery but need a Miracle due ton Platelets z!
Should not be an issue if managed appropriately in the peri-operative period
Great information Amazing
Approximately what percentage of patients who are evaluated for TAVR candidacy are selected?
In our center (Princeton Baptist Medical Center, Birmingham, Alabama) all patients are referred to the structural heart clinic where decisions are made after the necessary evaluations. In order to qualify for TAVR as per current countrywide guidelines the following criteria need to be met, 1) severe symptomatic aortic stenosis 2) High risk for conventional surgery. If these criteria are met then due to advanced techniques and a large experience, almost all patients evaluated will qualify. Those that aren’t selected are those felt to have a poor prognosis due to other co-existing illnesses that would limit their survival even if a successful TAVR were to be performed.
Dr. Ahmed,
I understand the desirability of a strong heart team to perform the procedure, but does this mean always gravitating to a big-name tertiary hospital (like the one in Minnesota, or Cleveland, OH) ?
Thanks.
RECENTLY, I MADE MY APPOINTMENT TO MY TAVR DOCTORS. HAD ALL THE TEST MADE BEFORE THE PROCEDURES. TOLD THAT MY BLEED VESSEL WAS NOT LARGE ENOUGH.
THEY SUGGESTED THAT TO DO THE BALOON PROCEDURE. QUESTION, IS IT RISK SAFE?
I HAVE TO LET THEM KNOW IF I WANT TO THAT.
MY VALVE OPENING ARE SMALL .
THANK YOU
Hi, there are several options available if the vessels of the leg are not large enough, i suggest you get a second opinion from an experienced TAVR team.
CORRECTION ON BLEED, SHOULD BE BLOOD, LOL
Does your body have to accept the valve and could the procedure cause high and/or erratic blood pressure after placement?
There are no reported issues with valve rejection. Issues with blood pressure should actually improve and be easier to manage after the valve replacement.
I had my TAVR procedure on Oct 21 2015. I am doing great. I am 65 years old. I started riding a 3 wheel adult tricycle June 3 2015. I ride 6 days a week.avg 5 miles a day. It is cold weather here so i am riding bike at gym..avg 5 miles 6 days a week. Question..will i wear out my TAVI quicker if i continue this exercise plan?
After reading articles it appears kufe span is 5 years for TAVI..what then..thsnk you..m
[email protected]
Exercise should not at all affect your valve, and it would be encouraged that you keep very active. The life span for a TAVR is likely a lot longer than 5 years. The good follow up in terms of clinical outcomes is at least 5 years, but experience with TAVR is much longer than that and more and more data collected over the years will add to that and give us a good idea about the long term outcomes. Its possible they will routinely last 10+ years. If the TAVR degenerates, an option is to simply place another TAVR valve within that, and there is good experience with that also.
Hi Dr! I’m also concerned if the tavr can be repeated if need be years down the road. My hubby is 68 years old and after researching your’s addresses my concern.
Had Tavr procedure in Aug,2019.Day after surgery while still at hospital,, I am doing a bowel movement and feel a pop in my groin. Immediately had extreme pain. Lucky for me 3 nurses and head of ICU immediately knew how to stop the internal bleeding. I’m send home next day still in pain. Have blackbruising accrossgroin area and into genital area. It remaind painful and black for 6 weeks.Both sides if groin area. I worry that it could open again. Sure I would have died if not at hospital. Never told potential for bleeding from arteries Never told to be careful when doing BM. Now, 2 months later I still have breathing problem I had before surgery. Dr says my opening was too small.Gradient high, like before surgery Don’ want another surgery. How long can I live (am ex-marathoner, want to have active life. Am 76. Should have had Dr perform surgery to increase opening.? Have been on aspirin and Plavix. Think I should limit Plaviix, since my platelet count has come down from my usual low 100,s to 80? Help please
Hi Dr. Mustafa –
Thank you for your extremely helpful tutorials and information.
I have an existing bioprosthestic valve, which will wear out, at which time a TAVR procedure may be possible.
Can the TAVR be done only once? What if I live longer and the TAVR wears out (I have the genetics to live a long time)? Then what?
I am sure many are in this situation and would love to understand their long-term options.
Thanks!
Hi Ron,
I can tell you from experience that the valve in valve procedure can work very well for bioprosthetic valve degeneration although sometimes success can be limited by the type and size of the valve. Technically the valve in valve procedure can become a valve in valve in valve procedure although that would be less than ideal, particularly with small valves as it would lead to an automatic degree of stenosis (tightening). Depending on your health status at the time, if you require another valve, it may be done conventionally if you are considered low risk. Technology is advancing rapidly and we can expect a whole new range of options over the next decade.
Dr. Ahmed — THANK YOU! – Rich
As per two separate echocardiograms, my 88 yr old mother’s heart function decreased from 55 (in October) to 25 (in December)- a month after having the Lotus Valve implanted through TAVR. She is doing great now. She exercises and her lungs are clear. I would like to know if it is common for cardiac function to decrease after TAVR and if the decrease is permanent.
Cardiac function should not drop after TAVR. In fact in those with low function it should improve.
My mother’s cardiac function dropped from 55 to 25 in two months. The only thing that happend during that time is the implatIon of the Lotus valve (through TAVR) and a permanent pacemaker- received the next day. Since my mother is breathing fine, not retaining fluids and going to her exercise classes twice weekly, I thought that the cardiac function decrease might perhaps be a short term issue that would improve as her heart healed from the TAVR procedure. Any thoughts?
I would suggest you make sure of the pre procedural heart function, it really would be very odd for function to drop from 55 to 25. The first step here is to obtain records and ensure the accuracy of the function, if it has indeed dropped there should be a thorough search for the underlying cause. Its good that she is not symptomatic, but once again that casts doubt upon the reported drop in ejection fraction.
Dr. Ahmed,
The same thing happened to my 79 year old father after the TAVR procedure with a pig valve this year. Pre-surgery his cardiac function was approximately 35% and post surgery it had dropped over the course of several months all the way to only 15%. There were other co-morbid factors in play but his Cardiologist stated it is very possible that in a very high risk patient with previous history of severe cardiac disease that the procedure could in fact “shock” the heart and cause reduced cardiac function. Any thoughts on this?
I don’t know of a good reason why function should drop after a TAVR unless there were specific procedural issues. The procedure should not shock the heart. I would need more details of the procedure itself to comment further.
Thank you so much for your quick response Dr. Ahmed. I really appreciate it your time and effort.
I just went for a TAVR on Jan11. I feel great & I was off BP medicine. I went back on, cause my BP was 164/80. My internist said ok. Went to Cardio on yesterday he said heart pumping down to 50. I hv no symptoms.Is this something to be worried about. He is sending me for an other Echo, this one while walking.
Id need to know a lot more detail to comment usefully. What was the function prior, how are your arteries, was the procedure complicated.
Dear Dr Ahmed,
I am 51 years old female with 2 children with Caesarian , suddenly discovered through medical check that I have Biscupid Valve with aortic regurgitation happening . I have been a exercise walking 5 km daily,With no BP or ailments, with a cholesterol a little higher side.
Kindly advice , thank you
HI, can you provide more detail from your echocardiogram regarding the valve, any tightening, the amount of leakage and also the function and size of the heart. All important factors in answering your question.
I am six weeks out of having TAVR procedure and unable to lay on my side to sleep at night. I still have to be in a recliner to sleep. Will that get better? Also, I feel tired and lack energy during the day and have shortness of breath when walking around. I am taking metroprolol 25 mgs every 12 hours and nifederpine 30 mgs once a day. I am in a-fib and was before the procedure. I do not feel as good now as before the TAVR, and am wondering if it might be metroprolol as that is the different drug, and I was used to taking Nifederpine 60 mgs per day and Lisinopril 5 mgs per day. I am in close touch with my doctors, but thought I would ask for another opinion. I am a male 78 YO with chronic a-fib. I will start my cardiac rehab soon.
You should certainly not feel worse after the TAVR procedure in fact that would be strange. Its important to rule out complications such as paravalvular leak and these should be seen on the echocardiogram. Metoprolol can cause a lack of energy in some and you may wish to try another drug under the supervision of your doctor although the dose you are on is relatively small.
Dear Dr. Ahmed
My name is Kayla Davis and I am currently doing a research paper on TAVR. I was wondering if I could possibly email you a few questions that I have regarding this procedure. I feel it would benefit me greatly to gather insight from a professional such as yourself. Thank you for taking the time to read this and I hope to hear from you.
Kayla Davis
Sure. No problem.
My 60 year old mother recently had the TAVR. It was discovered last fall that she was born bicuspid and had aortic stenosis. The first valve that was placed leaked. The physician thought best to place a second valve which would not deploy. They then changed the valve brand and when removing the catheter, noticed a tear in her aorta. She underwent open heart surgery and ultimately was unable to be weaned off of the bypass machine. Is it normal procedure to make three attempts during the procedure and what is the likelihood that the valves malfunctioned. Is this common? Could this be physician error? Or more likely failed valves?
That is unfortunate and without seeing specifics of the case its difficult to give you an accurate answer. The bicuspid valves typically have a higher chance of leak than non bicuspid however accurate sizing and valve selection can help to minimize that. Im not sure why the second valve would not deploy in that case. Again i would have to see specific aspects of the case to know. Was it an experienced center? Did you have a chance to discuss at length with the physicians involved? Im sure they can give you better insight in to the difficulties encountered.
my mum (86) is waiting for a TAVI. We are going on holiday in 4 months. If she has not had the TAVI can she still go on the holiday and fly a 2 hour flight?
Hi Kim,
With regards to flying and heart disease, if there are active symptoms and the disease is felt the cause of those then it would of course be taking a chance. The line from most the societies would be that flying until the disease is stable or treated would not be advised, simply as the risk of requiring medical attention is greater. Interestingly why would she be waiting that long for a TAVR? Surely she can be fit in quickly to any decent sized TAVR center without having to wait that long.
Hi there, my mother is 66 and currently struggling in hospital in Melb has a lot of health problems due to her heart, fluid in the legs in one arm, recent ultrasound showed congested liver.. All that has improved in the past 2 weeks but she constantly sleeps 🙁 they are deciding whether to do this procedure or not? She had a quad by pass 12 yrs ago but 3 failed. Is it too risky to let my mum go through this???? Our family are so confused and upset please help 🙁 her kidneys have been at stage 4 for 14 months
Hi Joanne, the majority of patients undergoing a TAVR procedure have historically been in a very sick group. In many ways the procedure allowed treatment for this group where there was not one prior. Over the years experienced centers have been able to select the patients who will do well and benefit from the procedure. It sounds like she is in heart failure and if she has critical aortic stenosis on the imaging studies and clinical exam adressing the valve may help. One option to consider is that if she is felt too sick a candidate for TAVR by the center there then a balloon aortic valvuloplasty is a procedure that may help in decision making while not having to use contrast dye that could affect the kidneys, and she may improve after that thus providing impetus for a TAVR procedure if felt suitable. If you are at the Alfred Hospital there then I suggest obtaining an opinion from Professor David McGiffin, head of cardiothoracic surgery.
Hello,
I am 26 years old and had TAVR (valve in valve) 6 weeks ago. I have congenital aortic and pulmonary stenosis. I had my aortic valve replaced in 2008. My aortic arch is also enlarged from a life time of on going stenosis but since my procedure the enlarging has stopped. My doctors thought tavr would be a good option for me to help me through pregnancy without the added complication of blood thinners used with traditional medcanical valve replacement. Prior to the procedure the pressure across the valve was almost 100 when I left the hospital the echo estimated that the pressure was lowered to only about 50. At my one month check up the pressure had only fallen to about 40 and my heart muscle is still severely thickened. Is it possible that the pressure will fall more and the muscle will become more supple with more time? The team is not comfortable with the idea of a pregnancy with the way everything looks now but are hopeful and more time is needed for my heart function to stabilize, is this common? (I know I’m a special case) I feel really great and exercise feels much easier but I’m worried about what might be going on.
Hello, sounds like you have been through a lot! Do you have a little more detailed info? When you refer to pressure are you referring to pulmonary artery pressure or aortic valve pressure? is the pressure the mean or the peak gradients? also which valve sizes did you have originally in the aortic position? Which tavr prosthesis did you have placed? and do you have the dimensions on the cardiac thickness?
My pulmonary valve hasn’t been touched since birth, it’s not good but the doctors don’t want to touch it until my next open heart. I’m referring to the aortic gradients (the blood moving across the valve) the first replacement was a 21mm Edwards and the TAVR was an Edwards as well but I’m unsure of the size but it’s small and I do not have measurements on the thickness
it may be a mean gradient if implanted a TAVR into a 21 SAVR
Sara, curious to hear your outcome. I also have aortic and pulmonary stenosis. When I was around the same age as you my husband and I also wanted to have a baby. My only surgery at that time was on my pulmonary valve. My cardiologist was supportive on the condition I have the baby at his Hospital so he could be present for labor and delivery. The high risk group at his hospital turned my case down. Too risky. He went above and beyond reviewing my case with all the high risk groups locally and the closest one who would take my case was in NYC, seven hours away. My husband was very scared and that was just not possible for us. Hoping for the best for you.
Hello, my 81 year old mom just found out she has mild narrowing of the Aorta. Shortness of breath is what lead to her getting tests done. Her EKG and chest x Ray were normal. She has high blood pressure and is on Metropolol. She was on 25 mg and over time it was raised to 100 mg.. At that time her shortness of breath got very bad and her oxygen was at 89. The doctor reduced her to 50. Mg and sent for echo. In one week on 50 her breathing got better and her oxygen went up to 96. We have to wait a month to see a cardiologist! Could the metropolol still be causing the short of breath. At 25 mg she did not have it. She is healthy otherwise so after reading your informative article I don’t think she is a candidate for the Tavr unless they go by her age. We do have a big teaching hospital here with a Tavr team.
Hi,
Its not typical for metoprolol to alone cause shortness of breath unless the heart function is significantly impaired although in severe aortic stenosis patients can be more sensitive than usual to medicines such as beta blockers. If your mother has a mild narrowing only then that is not going to be the cause of her symptoms, it would typically have to be in a moderate to severe range to begin to have an effect on someone. A month to see a cardiologist seems a long time! however if the narrowing is truly mild and her heart function is normal there is not likely much cardiac-wise to worry about.
My 86 year old Mom had a TAVR through the groin on March 28th after having a heart attack on Jan 7th. Her opening in her aortic valve was like the size of a pin. They got her approved quickly and got her to the top of the TAVR LIST. She has a very bad case of spinal stenosis and this procedure kicked it into overdrive having to lay in the hospital bed & lay on flat steel tables, etc. However spinal stenosis pain has worsened. She has recovered great from the TAVR. She’s been released taking Plavix. She didn’t have high blood pressure before but now she does.She came home on metoprolol which she was on before procedure. Her blood pressure became high so they increased the metoprolol. Didn’t work so prescribed 2-200 mg Labetalol’s a day. Was still high so added on 3 -25 mg hydralazine a day. Still high so added clonidine .01 mg and told her to take when bottom # gets to 100 up to three times a day. She doesn’t want to take the third med. Shes already on muscle relaxers, pain med & anti anxiety for the spinal stenosis pain. BP is sometimes low but most of the time 150 top number & above and lower number usually past 60&70. Sometimes in the 30’s. No headaches, dizziness. What could all of a sudden be causing this?
Thank you very much!
Difficult to know whats causing the hypertension its likely multifactorial. I would recommend seeing a blood pressure specialist. The obvious cause of high blood pressure here is pain from spinal stenosis, i would make sure that is adequately treated also and the BP may come down some. Also important not just to treat office blood pressures, a diary with a few readings a day over time would help ensure not treating isolated values. If there is a wide gap between the top and bottom numbers then would also ensure that there is no significant leak around the valve also.
Thank you very much Dr. Ahmed!! I greatly appreciate your advice and your time!!!
11:50 June 1, 2016
My Father is 91. Yesterday a cath. identified the opening of his Aortic Valve is the size of a pencil point. No other negative health conditions. We have been told that he first has to be rejected for open heart before TAVR can be approved? He will still need one blood path opened prior to TAVR. What is the oldest person that you know who has had TAVR. How would you project the chances for a 91 year old for TAVR vs living out the last 1-2 yrs. without TAVR? Which type of TAVR would you recommend Balloon or self-expandable? respectfully
I have done TAVR and many other procedures on several people older than 91 without issue, the age is not a specific issue, rather taking the entire patient status in to account is. There is 91, then there is 91! If someones life expectancy is not at least a year, i would very much question the utility and role of TAVR. A 91 year old who is living independently, performing activity, and or enjoying a quality of life is different than a 91 year old bedridden patient and a huge list of medical issues. These are important discussions. If there are concerns i would recommend going to an experienced center where patients are not simply operated on to add numbers to a low volume program. In terms of how would i project the chances, i would say in this age group, if cases are selected well and the procedural outcome good, then its often another issue that ends life, not the TAVR, as expected in this age group. With regard to the type of valve used, I think there are merits to centers that use a good volume of both types of valve so the experience is there to allow the best choice. In my opinion there are advantages and disadvantages to either type of valve and the decision needs to be made on a case by case basis taking many factors in to account that are beyond the scope of this answer such as valve characteristics, calcium, ventricular function, vessel caliber, and others.
June 1, 2016
Is it worth traveling distances– a few to several hundred miles to a TAVR location that has performed a greater number of TAVRs–we live near Ocala, Florida. The Mayo Clinic is about 2 hours away in Jacksonville, FLA. I have not yet checked the TAVRs at hospitals in Ocala, Florida
Respectfully
Its totally dependent on patient preference. I regularly see patients from hundreds of miles away and I feel there are advantages and disadvantages. The advantage is experienced team and operators and hospital care, which are tied in to outcomes. The disadvantage is that often patients in this age group simply don’t want to travel away from home and a large extended family don’t want to travel that far. It honestly depends on a decision by the patients and caretakers / family regarding whats most important to them.
Dr. Ahmed,
I’m 67 years old and going in for TAVR on Mon. June 6th, 2016. My doctors decided on this because of my sever arthritis. I plan a hip replacement after the TAVR. I’m wondering about exercising after the TAVR procedure. I use a walker, but try to exercise daily. Because of fatigue due to my heart, I have stopped going to the pool ( my very favorite exercise). Do you think I can return to that after the TAVR?
If you have severe symptomatic aortic stenosis that is the main cause of fatigue, and you undergo a successful TAVR procedure then there is no reason you won’t be able to return to the activities that you couldn’t do due to those symptoms. If all goes well during ,then after the procedure, the hospital stay should be short. We usually have patients sitting in a chair a few hours after the procedure and walking the same day.
It is day five after my TAVR. I was able to come home the day after it was done. I am feeling so great! I go back in a few days to be checked. I can’t believe the difference in my energy and outlook. I’m looking forward to going back to the pool in a few weeks. Also, as soon as the doctors say I’m ready, I’ll go in for my hip replacement . I feel so blessed, and happy to have this second chance.
I’m a 61 year white male w/ 3rd degree AV Heart Block and a bi-v ICD, 3 stents, and moderate (closing in on severe) AS attributed primarily to calcification of a bicuspid aortic valve. I have several questions regarding TAVR technology. Based on what I’ve been able to find, AR is an issue for bicuspid valves. Can they “slice” the valve prior to implantation to improve the “fit” of the device? Does/will the Sapien 3 reduce the AR? What is the life of a TAVR device? Is a TAVR device coated so warfarin isn’t necessary? (I am not on warfarin but have taken Plavix now for 6 years.) If they were to do valve in valve, does it double the life or is there a life expectancy reduction ratio for the device? Thank you for your time.
What is your ejection fraction?
AI is more prevalent after TAVR in bicuspid anatomy however there have also been good results demonstrated in that population, careful device selection,sizing and evaluation can help case selection to minimize that risk. TAVR has decent durability and the newer devices are lasting longer, there is data to suggest that at 8yrs over 1/2 valves still function well, it is likely better than this, warfarin is not required unless there is another indication for this, i.e. the patient was on it already then they typically continue to take it. if valve in valve is required, that result is typically durable also, we will obtain better data to answer that over the years.
This is fairly recent, so I am sure those numbers are still accurate, over half the valves are functioning after 8 years? That may be fine if you are in 70s or older, but I am in my 40s and being considered for TAVR. I have a lot of medical history but I wouldn’t think anything that would prevent an open heart. I think i need to ask a lot of questions, maybe get a second opinion. Or tell my husband he will need a new wife to enjoy retirement with because I am not going to get there. So thankful to find this before surgery.
The technology for TAVR has been evolving and will continue to do so. Also its important to note a TAVR isn’t the final throw of the dice, valve in valve, and even valve in valve in valve TAVR is an option. Also you may be a candidate for open surgery if so young although i would need to know a lot more to comment accurately. I think your future is likely a lot more bright than you think if things are handled correctly!
Ask as many questions as you need to and be comfortable with the decisions and the team knowing the risks and benefits. I find that complex decision making is common given all the options available and allows us to give patients options that were deemed not even possible just a few years ago. The fact is there is always a degree of uncertainty but thoughtful decision making can mitigate that. Also remember that technology is advancing faster than we could have imagined so in 10 years a whole host of new technology would be available.
Thank you for your encouraging comments!!!
If I could ask another question. I am confused and feel like I require some guidance regarding surgery. I have had 3 echos in the last 7 months. 1st echo revealed moderate tricuspid regurgitation and mild aortic stenosis with bicuspid valve and moderate/severe pulmonary Hypertension, i have a history of pulmonic valvuloplasty. From that it was assumed I would require pulmonary replacement and tricuspid repair or replacement. 2nd echo 3 months later showed moderate/severe aortic stenosis, mild PS, no tricuspid regurgitation and no pulmonary hypertension. I was symptomatic at that time. I have since lost 37lbs and feel better than I have in a long time. Today 3 months later I had a TEE. They plan to do echos every 4 months until surgery. Today indicated severe aortic stenosis and moderate/severe pulmonic stenosis. The gradient across my pulmonary valve is 6 times higher than estimated on previous echo. I was told no surgery as I am asymptomatic. I follow up in 1 month with cardiologist. The structural heart specialists will review my case again between now and then. I am terrified of surgery, however I am not sure how comfortable I am with waiting with 2 severely stenotic valves. Again, with such different results each time I feel like I need more info to make an informed decision. With 2 valves to be replaced in was told open surgery is my only option. Not sure of status of tricuspid today. It’s leaky, not sure how much. Is replacing 2 valves and possible repair of a 3rd make for a difficult, complicated surgery? What tests can be done to get clearer answers? Right, left heart catheridaztion? Also I was told aortic valve is not bicuspid today, it’s just so severely diseased it’s difficult to make out the 3rd leaflet.
Are you being evaluated in a center that has the capability to assess such complexity? the echocardiographic progression suggests calculation error to me as opposed to rapid progression, do you have number details of the progression.
Dr. Ahmed, I really can’t say if this Center has the capability to assess my situation. I am beginning to have doubts. My cardiologist has indicated to me that my condition is maybe unusual? Referring to me as the “movie star” of the practice, however I don’t feel that way. I have never been told they aren’t able to treat me. However, when TAVR was being considered I was able to find that as of last summer there had 200 TAVRs done there. That didn’t seem like a significant number to me. I live in a very rural area and this is the leading heart Center in the area. As far as numbers go, the information I received the other day was rather vague. It will take 2 weeks for results to be posted to my chart. This is what I do know… 1st echo done at a small hospital with a vague report. Estimated AVA 1.6 sqcm. Moderate tricuspid regurgitation with estimated RVSP of 56. No good view of pulmonary valve. 2nd echo at large teaching Hospital AVA 1.0 cm2. PVA 1.15cm2. Trace tricuspid regurgitation with RVSP of 39.2. 3Rd echo…This is what I was told by cardiologist who performed TEE (not my usual dr) AVA has had slight progression, it is close to the same, pulmonary valve is much more stenotic than originally thought. I asked if it was moderate, he said at least moderate. He said losing weight was the best thing I could have done, it has bought me time, if I hadn’t and still felt SOB, surgery would be indicated. I was told to call my cardiologist for any further questions. He will call me when the structural heart drs have reviewed. And I have follow up in a month. I would think complex cases are referred to the Cleveland Clinic about 4 hour drive from me. With all the emails I get from the Cleveland Clinic trying to sell me a new valve I am sure they would be happy to see me.
I should mention that prior to these 3 echos I have not had one in 8 -10 years because I was non compliant with follow ups.
I have had a lengthy phone conversation with my cardiologist today and feel better about my situation and have a great deal more information. I have 3 serious conditions going on with my heart. Moderate/severe aortic stenosis w/ AVA .96, mean gradient 31, Velocity 3.4. Moderate pulmonary stenosis, moderate pulmonary regurgitation and moderate subvalvular pulmonary stenosis. This is the first I have heard the term subvalvular pulmonary stenosis, I am not at all familiar with this. They seem less significant than the aortic stenosis. My heart is functioning well with an ejection fraction of 78%. Up from 60% last echo most likely related to 42 lb weight loss since last echo. They feel strongly I am not an open heart candidate due to health history. He had requested a bubble test to rule out hole in heart, this was overlooked. Another TEE will be done in 9 months. If gradient goes above 40 or ejection fraction drops TAVR will be performed at which time an attempt at pulmonary valvulotomy/dilation will be made. They do not perform pulmonary valve replacement minimally invasive. Confirmed 3 leaflets to the aortic valve. I couldn’t understand why this has degenerated at an early age. He seems to think it’s related to congenital disease Noonan Syndrome effecting the tissue of the valve. Are there questions I should be asking? Are there centers that can perform pulmonary valve replacement minimally invasive if dilation fails? I feel relieved about what I have heard today, but it seems bittersweet at the same time. I want to make sure I know what options are available.
Ask if you are a candidate for a transcatheter pulmonary valve replacement. These are now performed routinely.
Would a pulmonary valve replacement also treat the subvalvular pulmonary stenosis?
Id need to know a lot more about the case and see the images to be able to comment.
If I were considering traveling for another opinion, should it be been done prior to when surgery is needed or at the time surgery is needed? After meeting with my cardiologist and getting a better understanding of the complexity of my issues, I am really, really scared. These 5 issues are of concern, moderate/ severe aortic stenosis, moderate pulmonary stenosis and regurgitation, moderate tricuspid regurgitation, moderate dilation of pulmonary artery above the valve, moderate subpulmonic stenosis, pulmonary hypertension. Pretty sure thats more than 5. My cardiologist explained that he has had several meetings about my case. With surgeons, other cardiologists, there is going to be a case study done. Currently researching to see if they can find any similar cases. At this point I was told swelling of the abdomin and legs, SOB with stairs, some dizziness should be expected. All yes. Surgery is not going to be considered until I have SOB walking across a room. Then aortic valve will replaced, if heart failure doesn’t improve after that, surgery for pulmonic and tricuspid valves will be done. For now focus is on blood pressure control (excellent), reduced salt intake and no exercise above a walk. I honestly I can’t even begin to wrap my head around all this but i feel like another opinion on how things could be done should be considered. Dreading getting that sick and in a way I wish I didn’t know it was coming.
If you are truly concerned or uncomfortable with your current opinion, you should seek opinion prior to the onset of a treatment plan.
My husband is 83 years old. Has had three stents so far, the last one,last week, in right artery to leading to his heart. The cardiologist is now recommending TAVR. However, his blood pressure is maintained with lisinopril. He had shortness of breath when mowing the lawn. Now since the last stent was inserted last week, no shortness of breath if mows lawn.
He has stage 3 kidney disease, so I am leary of more dye for catheterizations. His catheterization report says he has aortic valve stenosis, severe. He has Aortic valve insufficiency of Grade 1. An article from Montefiore Hospital in N.Y. says TAVR should not be done if valve is not calcified.
Report does not indicate if valve is calcified. Might it be better to stay as he is?
The indication for the TAVR procedure would be for severe aortic stenosis, the initial evaluation should center around ensuring that is indeed the diagnosis and that it is the cause of any symptoms or that there is another good indication to fix the valve. In an 83 year old the cause will almost certainly be calcification of the valve with restricted movement of the aortic valve leaflets.
If there is a good indication to fix the valve then it is reasonable to consider the procedure as the risk of leaving it alone may be greater than the risk of leaving it, this needs to be determined by and discussed with the evaluating valve specialist that should make the risks and benefits clear. Then the work up needs to be commenced to see the best route of access and the technical feasibility of the procedure. There will be likely some contrast dye used, they will need to be careful that they minimize the amount used due to the kidney disease.
In all, if he is a good candidate, and he is in good hands, even with the issues noted, the procedure should be able to be done in a safe manner with a good outcome. Its just important to have a good and clear understanding of the risks and benefits of the procedure.
My father is 87 and underwent TAVR Last week. He had never been diagnosed as having COPD but we were told while in hospital that he does have it. He was released three days after procedure. He is still week and short of breath. Is this to be expected or coming from the COPD? He also is having issues with swollen ankles and groin. Doctor sent him home on low sodium diet and we were told to call if swelling worsens. Is this normal recovery?
A lot of factors to be taken in to account. One of the problems with TAVR is that now the technology is available, i personally feel specialists are more likely to perform a TAVR without truly ensuring it is the underlying issue. If there is significant COPD then this will not be made better from the TAVR. the pre TAVR lung function tests should have shed light on the issue. It sounds like from his presentation that fluid overload from heart failure may be an issue. From a valve perspective, a leak around the valve can cause symptoms, however this should have been noted in the immediate post op period. If he’s stable, some of these issues may settle down over the coming weeks if the valve was the issue. I would be sure to mention these issues to the implanting team if they persist at 1 week or 1 month post TAVR to see if medication changes may be helpful in making him feel better. If he truly has COPD, medicines can help that also.
My husband had the TAVR procedure performed at a VERY HIGNLY RESPECTED Hospital in December, 2014. During his 3 month pre-op multiple testing process I continually asked if the procedure was a “trial” and had requested a background history of the procedure. As you are very much aware, TAVR was relatively new in Southern California. Long story short, we were told the named brand of the valve was not quite the right size but that they can make it fit. Again I asked, “is this a trial”. Well, the valve leaked, my husband went on life support for 3 weeks, but fortunately survived with limited functions for 18 moths. Long story short, his Medicare statement came in the amount of $479,200. DENIED, A TRIAL STUDY. Fortunately, because I had asked several times, and the doctors fluffed me off whether or not it was a Trial, and I proved it to Medicare that I had made inquiries several times whether it was a Trial, that we were not held responsible. I am not aware if the procedure is now covered by Medicare, where 99% of the patients that are being touted on TAVR would be on, PLEASE use due diligence and let them know whether the procedure is covered by Medicare. Fortunately I asked, otherwise I would be bankrupt. The valve used on my husband was an Edwards valve, the Hospital that was also doing a study at the time that had a Medtronic valve, that would have been a proper fit was 100 miles away. Thank you for allowing me to share this with you.
Sorry for the experience you had there. Its not something i can say I’ve come across, but unfortunately I’ve heard similar things from time to time. The TAVR is a known procedure for medicare and is not experimental in most settings. It is actually a preferred treatment. The art of valve sizing has improved tremendously since then largely due to advances in CT science. The situation you mentioned is one of the reasons i ensure a high level of experience with both major valves in out center. It is certainly not a case of one size fits all when it comes to TAVR.
Hi,
My father had open heart surgery in order to get an aortic valve replacement. The valve is now failing, he has CHF and they are saying that he will require another valve. He had originally been told that he could have a TAVR or similar procedure. At his last appt. his primary care doctor told him that he will require open heart surgery. My dad goes to the Veterans Hospital in Asheville, NC, he has mentioned that some of the doctors are from Duke (maybe residents?). Do you know of anyone at that hospital that performs these surgeries? Can a veteran ask for a referral to see you? My dad was born in 1948 and they say he should make it through the surgery despite his current condition and other diagnoses. Thank you, Shannon Carroll
Im not sure of the TAVR situation in NC. Was the original valve a mechanical or bioprosthetic aortic valve? I would be happy for our team to review the imaging and records, then comment further regarding suitability for any required procedure.
Im a 29 year old female and currently 7 weeks pregnant. I was born with aortic valve insufficiency, had my valve replaced with a pig valve at age 16. Fast forward to today my valve has severely deteriorated and now have sever stenosis of my prosthetic valve. So sever that I have to get my valve replaced while still pregnant. My doctors are highly recommending a valve in valve procedure rather then traditional open heart surgery due to my pregnancy. I would like your thoughts on the matter. Has this procedure been performed successfully in early pregnancy like my self? If so what is the success rate? Also the doctors will go to great lengths to protect my tiny jelly bean from x-ray during the procedure. But I would like to know if there has ever been a case where the fetus still develops malformation in-spite of the extra precautions?
Importantly, although I am a valve expert, i haven’t seen you or any specifics of your case, and so this answer is limited and not to be used for medical decision making. This answer requires considerable thought, these situations are complex and first and foremost ensure you are being managed by experts with experience in high risk obstetrics and valvular heart disease, with experienced operators.
The fact that aortic valve intervention is being considered would suggest your valvular heart disease is severe, and also of risk to both you and the baby. It needs to be very clearly evident the aortic valve disease is significant. Careful evaluation and accurate diagnosis is key.
When i see young women with significant and symptomatic aortic valve disease, i typically counsel against pregnancy until the valve intervention, however this is of course not possible here. In asymptomatic disease, the risk to the mother in severe aortic stenosis is not super high, especially if it can be demonstrated on an exercise stress test for example that there are no symptoms or ill effects. If there are symptoms or adverse findings on stress then the risk is of course elevated. There is elevated risk of intrauterine growth retardation, low weight baby, and pre-term delivery.
If its decided that something needs to be done, then there are 2 options surgery or interventional technique such as TAVR or balloon valvuloplasty. Surgery is of course not ideal, the need to go on cardiac bypass and the use of high amounts of blood thinning medicine are generally prohibitive. In native valves the use of the quicker and easier balloon valvuloplasty has been described and successful. TAVR has been performed in pregnancy, however there is of course limited date. You already have a valve however and so you would be having a valve in valve procedure. A balloon valvuloplasty is not typically used in prosthetic valves although would be possible in an emergency.
In the TAVR, you would of course require the use of X-ray, and being in the first trimester or pregnancy the fetus is theoretically at greater risk, this diminishes as time goes on, and may play in to the decision making regarding the timing of the procedure. They key to the procedure will be very minimal use of fluoroscopy (x-ray) and also the use of specific shielding apparatus. In a TAVR, x-ray will have to be used however, there is no way to avoid it. The key being experience operators, good echo imaging, and obsession to minimizing X-ray where possible. In reality, the risk from a small amount of x-ray with precaution is small, certainly smaller than the risk of pregnancy progressing with critical aortic stenosis.
X-ray procedures have been used widely around the world for valve disease in pregnancy, a good example is balloon valvuloplasty for mitral stenosis, a tight mitral valve. Many of these have been performed and been associated with good outcomes often. Here is a link related to x-ray exposure and risk. https://hps.org/hpspublications/articles/pregnancyandradiationexposureinfosheet.html
The way to approach it is as follows. If you have critical disease that is putting you and the baby at risk and its been determined by experts with experience in valve disease and high risk pregnancy that an intervention is required, then to not proceed with a valve intervention may be associated with significant risk. No one will be able to pinpoint the exact risk from X-ray or the procedure, it is not likely to be very large if care is taken, however you must proceed knowing there is of course a risk even if its small. That risk, in any procedure must of course be smaller than the risk of doing nothing. Just understand the decision making and make sure you are in good hands who are confident in your diagnosis and approach.
I had my aortic valve replaced with a19mm bovine, the surgeon told me he would have preferred to have put a larger size but my heart is small and the 19 was the only size that would fit. My question is this size to small for a tavr in the future if I would need a valve replacement. I am 74 female.
You would require a valve in valve procedure. The valve you have is small and the concern with TAVR would be that a valve inside a valve would leave an even smaller valve area. It depends on a number of factors and careful evaluation is required. These include the size of the heart muscle underneath the valve known as the outflow tract, your body size, valve type and profile, the valve area and other factors. Having said that when done correctly, with careful patient selection, in people who have clear symptomatic disease, we have had several people do well despite a valve in valve with a small prosthesis. A lot will also depend on your state of health at the time.
My 91 year old mother has been going through a series of tests to determine if she is a good candidate for the TAVR procedure. She has been told by the surgical team that she is not a candidate for this and open heart surgery is her only choice.They also stated that the risk for open heart surgery would considerable. They did however mention getting a second opinion on this. I assume there are teams that have more experience with this procedure than others. With this experience perhaps comes knowledge that might open a seam of light in this dark diagnosis. Would a second opinion be a good thing now and being from Ohio, where would be the best place to go for it?
Experienced teams are key. What is the reason given for her not being a TAVR candidate? Do you have details of her echo report and or ct scan? I can’t imagine a situation where open heart surgery is a good idea for a 91 year old.
Hi, my 84 year old father was originally recommended to have open heart to replace his valve, but prior to surgery he was diagnosed with a tumor at his bile duct. For that, he just completed a course of low-dose radiation/chemo as surgery was not an open due to his aortic stenosis. Prior to radiation treatments, he had a PET scan and was told the cancer did not appear to have spread and the radiologist gave him high hopes that he could possibly be a candidate to have his heart valve replaced again (which of course was cancelled at the dx of cancer). However, his current heart surgeon has indicated that he will not even consider TAVS anymore. Currenty, he has no sx’s in his GI that would be related to cancer and his main medical complaint is weakness associated with his heart functioning. My dad wants TAVS despite what his current cardilogist and surgeon are saying. So my question to you is, would a recent history of this type of cancer always rule someone out as a candidate for TAVS? Or might he still be a possible candidate (of course considering other factors)? We are trying to balance helping him pursue a second opinion or accepting the inevitable. Thank you for any information you can give.
Patient selection for TAVR is key. If the procedure can performed in a manner where the risk would outweigh the benefit and there could be improvement for someones quality of life then it should be performed. If however there will be no clear benefit and the risk prohibitive then it shouldn’t. In my center we perform amongst the most technically difficult procedures in the country, including those others who have been refused elsewhere, however that doesn’t mean i say yes to every case. Let me give you some recent examples from my experience. A patient who has a severely tight aortic valve was recently sent for a TAVR procedure. On talking to the patient and his family it became apparent he had significant dementia and the family were having significant issues managing that alone. We decided that it would not be in his best interests to proceed as the dementia was already advanced and would progress, potentially worsen and was felt to be a terminal condition. In another more pertinent example a patient with a kidney tumor and severe AS had been sent to us as they were turned down for the procedure elsewhere. I had the patient seen by the oncologist and the urologist. The oncologist felt that with treatment the survival would be greater than a year. The urologist felt that although the tumor could be operated on, the valve made the operation too high risk. I decided to fix the valve, then the patient underwent the kidney surgery. In this case the valve procedure was able to allow advancement of treatment and the situation not hopeless at all. I don’t know the specifics of your case, however, in my opinion a discussion should take place with all involved parties including the oncologist, GI surgeon, heart team, the patient and their family. Then an appropriate decision can be made.
I am a 67 year old female. In May of this year Dr told me I have server aortic stenosis. I had a TEE done a few weeks ago along with an echo. Was was supposed to have a catheterization in my wrist to look and my right and left heart, but it was canceled. I am told I am to sick for open heart surgery, but not yet sick enough for the TAVR. I have to have a TEE done again in Jan. How bad to I need to get before I can have the valve replaced with the TAVR procedure?
To give you accurate advice i would need a lot more information. What are the factors that make you high risk for open surgery? You are relatively young at 67. TAVR is typically used for those considered high risk for surgery. The most likely reason for delaying would be that your aortic stenosis is not considered severe enough to need an intervention. I suggest you contact the place you were evaluated for a clear answer, and if you can’t get one then you should seek a second opinion.
My husband,age 72, has been informed he would be a candidate for a TAVR procedure. Three yrs ago he had a cardiac work up and all was good. They did change his BP meds from lisinopril to metropolol and that stopped his coughing. Even with a good cardiac check up, he has not felt well. increased SOB, fatigue,fluid retention, so he went to a new physician who took him off metropolol and started lasix 20 daily, he has been increase to 40 mg daily. He is also diabetic taking metformin and glipizide. They also requested a cardiac work up, and the echo showed the aortic valve stenosis and we were sent for cauterization and that is when it was decided to do the procedure. We just don’t understand how a good check up turned this serous in a short time. He use to take darvocet for about 25 yrs following several back surgeries..since it is off the market, could this be a cause? Thank you for any comments you may have.
I would recommend you ask the following questions.
1) Does he have evidence of severe stenosis? Is the valve area low / is the gradient accross the valve high and what methods were used to convince the of that fact. I feel they should be able to confidently answer that, if not you need another opinion
2) What are the features that make him high risk for conventional surgery?
3) Are they convinced that fixing the valve will make him feel better?
4) What do they think led to a rapid progression?
The answers to all of the above need to be confirmed and answered confidently. This will start to clarify the picture. If he has severe symptomatic aortic stenosis and is considered higher than usual risk for conventional surgery then TAVR can be an excellent option, if the risk is felt to be acceptable.
I was recently told that TAVR could not be done as I was born with only two valves. Is this true? Thank you in advance
I think you are referring to a bicuspid valve, where the aortic valve has only 2 leaflets instead of 3. This predisposes the valve to degeneration. In our center we have successfully performed many TAVR on patients with bicuspid valves. The presence of a bicuspid valve is not by itself prohibitive for TAVR if careful planning is done.
In March, 2016, my checkup with my doctor has suggested that I should have TAVI surgery which would be safe for me. 13 years back I had my By-pass surgery and also has my Matral valve replaced 11 months after my By-pass surgery.
for the last 18 months I have to take 1- 40mg lacix in the morning to drain water from my body..
I like to know if I have my TAVI surgery, will that help me from taking 40mg lacix on daily basis.
The lasix is taken to help improve symptoms of heart failure. If your heart failure is confirmed to be secondary to severe aortic stenosis then you would likely benefit from valve replacement with a TAVR. With your history of 2 heart surgeries, TAVR would be the best option for sure.
Dr. Ahmed. I am having TAVR on Sept 20th as a result of severe AO and moderate mitral regurg. I had 6 way CABG 20 years ago, have 7 stents and a 1 year old pacemaker. I am 70 years old and in the last 6 months I have increasing SOB and rapid heart rate on exertion. I had Hodgkins 30 years ago that was, then, treated with high intensity radiation across the upper chest to the lower mesentery and exploratory lap that resulted in a splenectomy. The radiation and abdominal trauma resulted in mesenteric panniculitus. 5 years ago I had a right adenalectomy caused by a Conn’s tumor. Despite all of this medical history and experience with procedures I am anxious about TAVR. My concerns are the general anesthetic and the expected symptomatic relief. In your experience, can I expect a significant improvement in the SOB and improved EF ? and will that result increase the potential for the failure of the previous CABG grafts. My concern is that fixing AS stresses the grafts leading to more stents ?
It seems you have been through a lot, have a complex medical history, and you are certainly high risk for conventional surgery, i think if you have severe symptomatic aortic stenosis the TAVR procedure is certainly an excellent option if it can be performed safely.
With regard to TAVR and the bypass grafts, i am assuming coronary angiography has been recently performed and the status of these grafts well known. In general, coronary disease if significant is addressed before the TAVR procedure with stents for example if required. Its important to know the coronary anatomy prior to proceeding. Once the TAVR is done trebled flow will improve and if anything there should be less stress on the bypass grafts as the heart muscle will be under less stress and ‘myocardial oxygen demand’ should decrease.
With regard to the anesthetic, our program has moved towards a more minimalistic approach whereby conscious sedation can be applied rather than general anesthesia, this is something you may wish to discuss with your team to see if it is feasible. Regardless, the anesthetic team will assess you prior and determine your risk and you can make an informed decision.
Dr. Ahmed: Could you explain the term “trebled flow” ? What is the downside risk of conscious sedation assuming there is actually a choice for the team. I have had conscious sedation on all of my stent procedures and my pacemaker procedure without any difficulties. I presume that the general anesthesia choice makes the assumption that the patient is at risk for complications in the tavr process and that it is better to have him fully under from the beginning. My personal preference, of course , would be to have the least anesthesia . Also, have you found that post tavr, the heart remodels beneficially ?
Trebled was a typo! I meant forward flow to the body. The specific term is after load on the heart is decreased which means the heart has to pump against less resistance thus reducing the stress on the heart.
Your stent procedures and pacemaker were not conscious sedation, they were likely to have been moderate sedation. In terms of general anesthesia, it really depends on your team and how experienced they are and also their expertise in imaging and being able to do cases without the need for anesthesia. If the team is not experienced with conscious sedation, you shouldn’t push it, i would suggest going what they are most familiar with. one of the advantages of a large volume center such as ours is the experience with a wide range of procedural conditions.
Post TAVR, beneficial remodeling, symptomatic benefit, and survival advantage have all been well reported.
Dr. Ahmed. My dad is 92, he has congestive heart failure and had severe aortic stenosis. He had the TAVR procedure and the doctors reported that he did great. This was on the 24th of August. He went home and felt fine. He was doing great, seemingly feeling better than he had in quite awhile, but on Monday (the 29th) he became very dizzy, weak and nauseous (this happened quite suddenly). He went to emergency and seemed to recover and they released him. Once again, he felt fine, great appetite, working in the garden, etc. Then on the 31st of August, boom! He was watching a ballgame in his recliner, fell asleep, then woke up feeling dizzy and extremely weak. Once again, he was feeling good, and then he wasn’t. Called an ambulance, his vitals seemed ok, he went to the emergency room, they gave him some fluids, after awhile he felt better and they sent him home. Does any of this sound familiar?
Interesting. It is not at all normal and warrants investigation.
What immediately needs to be ruled out is the development of some form of heart block, particularly post TAVR. If he has a pacemaker this will not be an issue. If he doesn’t I suggest that a wearable monitor is placed to ensure no development of intermittent high grade heart block that would necessitate pacemaker insertion.
Dr. Ahmed,
Thanks for getting back to me. They said the replacement looked good and they don’t think it has anything to do with the procedure (he doesn’t have a pacemaker). His blood pressure is low. The doctors said that he is suffering from vertigo. He has never experienced vertigo before – but – when this happened again (Sept 1st), we did these vertigo exercises and the dizziness seemed to go away, but he still is weak. I’ll ask about the monitor. Again, thank you.
My father is 92-years-old, he had the TAVR procedure on August 24th. The doctors said he did great! He went home after 48 hours. He was feeling great, better than he has in a long time. On the 29th he went from feeling fantastic and joking to feeling extremely weak, dizzy with nausea and vomiting. This happened literally in the blink of an eye. He went to the emergency room and they could not figure out what was wrong with him. He got to feeling better, in fact, he got very hungry. They released him and he seemed fine. Same thing on August 31st. He was feeling great, was gardening and toodling around. He sat down to watch a ballgame, fell asleep, woke up and boom – extremely dizzy and weak. The ambulance came and his vitals seemed fine. They took him in, did a blood test and a CT scan. Everything looked fine, he started to feel better and they sent him home. Any ideas? Thank you.
I forgot to mention that he has congestive heart failure.
(Please see the answer to the duplicate post)
Hello,
I am kinda confused. I am 33 years old I have a medium hole in my heart and was told it needs to be sealed with a balloon and that I was born with it (even though I’ve had my heart looked at by cardiologists a few years back when I was having discomfort and no one said anything about a hole of any size) and they will go through my leg so I guess that is a TAVR?. My doctor said its gonna be ok and that I can return to work and even drive ( My commute is more than an hour in heavy traffic) within a few days. My question is, how do I know my incision site at my leg will not open and I will bleed out driving after a few days? I am kinda scared and confused. I can’t take too many days off of work but I also don’t want to put myself in a life threatening situation by putting pressure on my leg.
I started having symptoms a few months ago (dizzy, fainting, passing out) and when I went to ER I was leaking troponin (spelling) so they admitted me but they said I was fine when they discharged me. I am wondering is this procedure really going to help?
My apologies where are my manners? Thank you in advance for any assistance with this matter I truly appreciate it in advance I am desperate for answers as I have young children and family that depend on me. Thank you!
Hi, can you get me a little more information on the procedure and the valve issue that you have. I’ll be happy to answer any questions, i just don’t want to provide inaccurate information.
Hello,
I’m not sure this is a valid question for this site, but I will try. My brother in Russia was told that he needs TAVR procedure. He asked me to find out how much approximately this procedure costs in USA if the person has no insurance.
Thank you,
Peter
With no insurance, from abroad, paying out of pocket, i would think over 40, 000 dollars, the main expense is the valve itself that costs 30,000.
Dr. Ahmed:
I wrote in late August that I was having TAVR on Septemember 20. I had that done and am recovering quite well. I was a little sore at the access points in both femoral arteries but that has abated. My ejection fraction has improved to 55 to 60 .I have yet to have my 30 day follow-up but I have a question. After the TAVR I read the Doctors report and discovered that I had a dissected right external femoral artery. This dissected artery apparently was apparently caused by one of my prior stent procedures over 1 year ago. The report says that it is a chronic dissection and is not not flow limiting. I do not know why is was not dealt with in the TAVR procedure and my regular cardiologist does not appear to be particularly concerned about it today. He said he can fix it after I have healed from the TAVR. I wanted to know if you feel that repair is more urgent than that. I am a bit uncomfortable with having an unrepaired dissection.
It’s difficult to answer accurately without seeing the images myself. If I see a dissection after TAVR, whether acute or chronic the first question is whether it is flow limiting. If it is it needs fixing. The next part of the evaluation is to assess for features that would indicate high risk of vessel compromise. If these are absent, the flow in the vessel is such that it should heal over time and does not necessarily require intervention. If you have no symptoms, and the team felt it was not an issue then conservative management may well be appropriate.
Dr. Ahmed:
Thank you for your response. I am sorry but my description of the dissection had a typo…the dissection was in the right external iliac not the femoral. I am sure the Doctors made those decisions at the time of the TAVR. They , apparently, had previously identified the dissection by CT. As to symptoms… I have had some bottom of foot and calf pain on exertion…that mostly goes away at rest. Do dissections actually heal over time ? If so how long might that take ? Wouldn’t a dissected artery always be a future risk for the elderly ? Since , as understand it, the repair is relatively straightforward with either a stent or a sheath, why wouldn’t one always prefer a repair ? Sorry for the chain questions…I am just trying to be a smart patient and active in my care before and after TAVR. I am sure that many patients who visit this very useful site wonder what even the rare potential side effects of TAVR might be.
I AM 50 YEARS OLD MALE I WAS UNDERGONE CMV 10 YEARS AGO NOW ECHOCARDIOGRAPHY REPORT TELLS MILD MS WITH TRACE MR AND SEVERE AORTIC STENOSIS WITH MODERATE AR HAVING MEAN GRADIENT 55 (MM OF HG) CLINICAL DIAGNOSIS TELLS RHD. CAN I AM I ELIGIBLE FOR TAVR .
What do you mean by CMV?
Do you have symptoms?
You have severe aortic stenosis
At the age of 50, in general, if healthy otherwise, conventional surgery would typically be advised as you are clearly low risk.
CMV MEANS CLOSE MITRAL VALVETOMY . IS TAVR POSSIBLE IN INDIA . Please suggest me
I think very few TAVR have been done in India up till this point.
I am just shy of 66 years old and diagnosed with severe aortic stenosis. My cardiologist is recommending traditional valve replacement. I also have been previously diagnosed with one non-functional kidney due to an occluded artery. I have one heart stent in LAT and a AAA stent in place and a neurogenic bladder. Would I be considered a moderate or higher risk for the conventional surgery in your opinion?
From the sounds of it you are likely in the intermediate risk category and would qualify for TAVR, you would also be scored via a traditional scoring system such as the STS or Euro. I recommend you be evaluated in a good quality TAVR center.
Hello Dr.,
My father has Aortic Valve Regurgitation. His doctors told him he needs a valve replacement but he is NOT a candidate for TAVR because he is not high risk. Two questions: 1) can he seek to have a TAVR in the US for Aortic Valve Regurgitation? 2) if so, can he seek to have a TAVR even though he is low risk?
Thank you!
The risk is not the only issue. Now it is common to do both high and intermediate risk. Low risk is still being studied and is not recommended as of yet.
If aortic regurgitation is the primary pathology then TAVR is less well studied and evidence is limited, the exception being for leakiness of an existing valve replacement in which case TAVR can be remarkably effective. When a TAVR is placed, it is essentially anchored in place by existing calcium. In the case of aortic stenosis, there is heavy calcification and so this acts to seat the valve. In the case of aortic regurgitation the problem is the lack of calcium makes the valve harder to anchor and therefore much more prone to a leak around the valve known as paravalvular aortic regurgitation. We are working on valves that are differently designed to help prevent this but they are not commercially approved as of yet.
If he is low risk, and he has aortic regurgitation, i recommend conventional surgery, albeit get it done minimally invasive buy a very experienced team.
My 96 year old father recently had a tavr procedure at a well respected hospital. He was in good health except for his aortic stenosis and was told ct angiogram showed clean arteries. Unfortunately,during the deployment of the valve, his aorta ruptured, he was put on bypass, his chest was cracked to stop the bleeding and seat the valve. He died less than 24 hours later due to bleeding and probably suffered an anoxic brain injury. We were told that this catastrophic event almost never happens, but it happened to him due to calcification. How could this have happened with a clean ct angiogram? Did the doctors not know of the calcification? Was the valve deployed incorrectly or the size wrong? What is your opinion? I feel like we were misled when we were told he was such an excellent tavr candidate.
My dad had this procedure, dr comes down 3 hrs later to inform us dad is on life support and there doing open heart surgery, 5 more hrs total of 8 hrs, he made it until we went in to see him, his arm swollen, right side paralyzed and then one eye moving not sure if he is inside of himself, 6 days later we were told see his Mri head scan stroke on left side but they forgot to say also right plus kidneys slowing, but they wanted to put him on dialysis and put a pace maker in, No, we stopped there bull, to only watch him die a horrible death and to hear the nurse say his heart stopped 2 days prior and the wall pace maker was keeping him alive, when she pushed the button he die terrible, I gave last rights with holy water, we were never told about his heart stopping 2 days prior or a pacemaker on wall keeping his heart going, he was stuck in his body from stroke never to eat,swallow talk again but they talked about therapy, really? I’m going to go after these bastards for screwing this up and killing my father and I won’t stop, oh the prior cather the day before surgery they screwed up caused abdominal bleeding and that night dads speech changed, called nurse to check for stroke she didn’t give a dam. Anyone have a comment for this? Would love to hear from you, dad had arorta stenosis severe age 85 leukemia and COPD and they opened him up when someone screwed up bad, dad was walking, talking, active person until this procedure. I recommend knowing more then they tell you, from Wisconsin
My 96 year old father recently had a tavr procedure at a well respected hospital. He was in good health except for his aortic stenosis and was told ct angiogram showed clean arteries. Unfortunately,during the deployment of the valve, his aorta ruptured, he was put on bypass, his chest was cracked to stop the bleeding and seat the valve. He died less than 24 hours later due to bleeding and probably suffered an anoxic brain injury. We were told that this catastrophic event almost never happens, but it happened to him due to calcification. How could this have happened with a clean ct angiogram? Did the doctors not know of the calcification? Was the valve deployed incorrectly or the size wrong? What is your opinion? I feel like we were misled when we were told he was such an excellent tavr candidate.
Maria,
Firstly, sorry for your loss.
In general TAVR is a safe procedure, the rate of significant life threatening complications is around 5% and this of course rises higher as patients are sicker and higher risk. Age per se isn’t the most important factor, I’ve seen many 90-100 year olds do well, the key being appropriate patient selection.
Your father had aortic stenosis that was deemed to be severe by tests such as the echocardiogram. Its also likely he has symptoms. Therefore the diagnosis would be severe symptomatic aortic stenosis which is the primary indication for TAVR. It is not generally indicated for asymptomatic patients. In severe symptomatic aortic stenosis, life expectancy is significantly shortened, and therefore the TAVR is indicated for both length of life and quality of life purposes. This means he certainly likely a good indication for TAVR.
The option of conventional surgery in a 96 year old is not a good option with a remarkably high risk of post operative bad outcomes. For this reason, this entire population was simply watched and left untreated in the past. The advent of the TAVR procedure has meant that there is now a good option, that can be done relatively safely with an overall low risk of complications, but not zero risk.
In your fathers case, he had one of the most feared complications, which although uncommon, is a known risk, particularly in patients with heavily calcified aortic roots. This would typically be known on the CT scan, however it does not prohibit the procedure, rather certain precautions are taken such as valve size and method. For example, one may prefer to use a self expandable prosthesis as opposed to a balloon expandable. The art of CT sizing is very advanced and I doubt a miscalculation was made with regard to the valve choice. Even when every precaution is taken, from time to time, albeit rare, there will still be complications given the nature of working in the hearts of an elderly population.
I like to think you weren’t misled regarding his candidacy for TAVR, if he had severe aortic stenosis and was symptomatic (fatigue, slowing down, shortness of breath, chest symptoms etc.) and the fact he was healthy otherwise made him an even better candidate. I cant comment on the technical aspects with regard to the valve choice etc as I am not familiar with the case, maybe you can discuss this with the implanting team. Unfortunately he had a catastrophic complication and once annular rupture occurred, even opening his chest would be of little use. This is a known complication of TAVR that is fortunately very rare nowadays. On the other hand, if he had left the valve alone and not had anything done, a decline in his health status as quality of life would almost be certain so I don’t think you should feel bad for trying to do something in the first place as that is what the medical guidance would be.
I hope that helps clarify some.
I posted a comment last night,(maybe even twice, sorry!) but do not see it. Is there a way to see where my post is and if it actually went through? Thank you!
Thank you so much for your very informative and kind response . My father was fainting and falling at home, breathless with severe symptoms, so there was no choice. I only wish they did not open his chest and just let him die in OR, but I know this goes against what most surgeons will do, unfortunately.
I am a candidate for TAVR and am eagerly awaiting a date for the procedure. I underand that the procedre may have been developed in France and would like to read about its history and current use in Europe. I’d be grateful for recommended reading.
http://circres.ahajournals.org/content/114/6/1037
Try that link, it is in depth and fairly scientific in nature however it is a comprehensive review of the development of the technology and the underlying evidence.
I will write a piece on the history of TAVR at some point, good idea.
Would like to write to Dr.Mustafa .Can I have his E mail address.Thanks
Please feel free to write here
Dr .Mustafa,
I am 84 years old .Underwent CABG (Grafts) in 2002. Did well after the surgery and led life as before for 14 years. Early in the current year suffered badly from Aortic Stenosis and was advised TAVI .Underwent TAVI.
The experience after the procedure was miraculous ,all the symptoms of the disease having vanished physically.Almost four months have passed and I am continuing to do well and gaining strength .Presently I have moved to New York from India for good as my children are US Citizens. I am a green card holder.
During and after my procedure the Doctors were investigating and watching the need for a Pace Maker and advised me that I do not need it now but am likely to need in future.
I walk indoor for 40 minutes and do some light standing aerobic exercises . I have noticed that halfway to my walk I develop slight giddiness or whatever in the forehead and eyes region . Wonder whether PACE MAKER will do me good.
May I have your opinion please? Thanks Ramesh
I would suggest that your next step is to have an echocardiogram to ensure valve function is preserved and a wearable monitor to rule out any significant rhythm problem that could be causing the symptoms. If you are having episodes of symptomatic bradycardia (low heart rate) then a pacemaker may be useful.
Thanks doctor for a prompt response. I have the report of my last 2 D echo done three weeks ago. Could I give the details from the report for your advice? Ramesh
Feel free to.
REF :Previous Mail ,Reply Long though”2 D Echo Doppler Report Dated 7th Oct 2016 ( TAVI JUly 4th,2016)
HR 64 BPM
1 Normally Functioning CORE VALVE with MEAN PG 6mm.Hg @HR 65
Trace Paravolvular Aortic Regugitation
2 Dense Mitral Annlar Calcification.Moderate Mitral Resurgitation
MVA by 2 D Planimetry is 2.0 Cm2 and by PHT is 1.8cm2
Mean PG across Mitral Valve is 7 mmHg @HR 65 BPM
3. Other cardiac Valves are normal
4.LV is normal in size .LVEF :30 -35%
5LA is dilated (4.5 cms)
6 Trace Tricuspid Regurgitation( PASP 30 mm Hg.
RA /RV size and RV systolic function are normal
7No Intracardiac Clot/Vegitation Mass
8 No percardial Pathology
9TVC is normal with Normal Respiratory variation.
Left and Right ventricles are normal LVEF 30-35%
Aortic Valve ;Normally functioning CORE VALVE at aortic position
M mode and measurements calculations:
IVSd:1.2Cm,IVSs:1.5cm, LVIDd:4.6 cm,LVIDs :3.9 cm,LVPWd:1.2 cm ,LVPWs :1.5cm
LA Dimension : 4.5 cm
Doppler Measurements and Calculations:
MV V2 max 186 cm/sec, MV max PG 14mm Hg, MvV2 mean 130 cm/sec,MV mean PG 7.0 mmHg
Ao V2 max172cm?sec,Ao max PG 12 mmHg,Ao V2mean :115cm?sec, Aomean PG 6mm Hg
TV V2 max 47 cm?sec and PA V2 Max :113 cm?sec
Kindly advise regarding Pace Maker
Ramesh
I think its a little more complex than simply needing a pacemaker. Your ejection fraction is impaired. If it remains impaired after the valve replacement which it appears to be you would be a candidate for a defibrillator to reduce your risk of sudden death. Your EKG is important, if it shows QRS widening you would be a candidate for resynchronization therapy to potentially improve the function.
Can the TAVR procedure be done if you’re allergic to contrast dye? My 82 year old father is in the ICU and has many problems. Also, do any of these disqualify him? Dialysis for 16 years, heart murmur, irregular heartbeat, pacemaker, epilepsy, history of stroke, aortic abdominal aneurysm, anemia, cirrhosis of the liver, history of tremors, kidney stones trapped in the kidney, constipation that leads to bleeding, history of bleeding from Coumadin. I’m hoping these issues, plus the dye won’t rule him out. Not 100% sure if it’s the aortic valve or the mitral valve. Does it matter? Are they similar procedures?
Thank you for your time.
It matters which valve it is. If it is the aortic valve then the procedure, when done in specialist hands can be done with essentially no dye, we have done several such procedures, it requires a specially tailored approach. The mitral valve is not a TAVR procedure, it does have approaches through a catheter however.
Hello Dr Ahmed,
I got a better understanding on which valve or valves are causing my father the problem. He has severe aortic stenosis and severe tricuspid regurgitation. He was in the ICU for almost 3 weeks for cardiogenic shock. He’s in recovery right now. The doctors are saying there’s nothing they can do. The tricuspid will continue to leak and this will happen again. He’s 82 and high risk for open heart surgery. They don’t even think he should do the TAVR procedure. They think the outcome won’t be good, as far as surviving, and he’ll still have the severe tricuspid regurgitation to deal with. Do you think there’s anything that can be done? Is there a minimally invasive alternative procedure for the tricuspid, like the TAVR procedure? If not, should he still do the TAVR procedure? Would it benefit him, or are there no options?
Thank you for offering this forum for all of us to ask you these questions! This is a wonderful thing you do.
Im sorry for your predicament. Do you know his ejection fraction of his heart? If they cant do a TAVR procedure, is he at least a candidate for a balloon aortic valvuloplasty procedure as a bridge?
I finally got a hold of my father’s cardiologist. He was on vacation last week. He gave me some hopeful news. He said my father’s echocardiogram back in May showed his valves as moderate and he thinks the pneumonia he caught is what made it look severe and caused the shock. He said it shouldn’t have went to severe this fast and he should go back to normal once the pneumonia clears up. He wants him to do another echocardiogram after he gets better. I hope he’s right. He didn’t have the echocardiogram from this hospital visit in front of him and my father had already been placed in a nursing home yesterday when he tried to see him. I’m worried there’s something he doesn’t know and that’s why the other doctors were giving us such bad news. I will give you the results of his test when he has it done. I still wish he could do the TAVR, so his symptoms he’s been having for awhile would go away.
Thank you for your previous advice and I would appreciate your thoughts on what the cardiologist said.
It doesn’t fully make sense to me. Do you have a full copy of the details of the echo report.
Thank you Doctor, I appreciate your advice. Would like to see you personally if possible. Let me see,
Regards
Ramesh Pitre
Hello Doctor,
I sent you a message about 10 hours ago about my 82 year old father being allergic to contrast dye. I forgot to note that after the second allergic reaction they gave him medication for the third to try to prevent the allergic reaction, but he still had one. These were all separate hospital visits. The reaction was similar to a seizure, or passing out. I believe he stopped breathing. They gave prevention medication right before. Not sure if taking it a lot sooner would have helped. Doing this procedure is his only hope, so I’m praying there’s a way around this.
Thank you so much for your response. Then, if it’s the mitral valve, there’s no way around the contrast dye? It has to be used? If so, any suggestions on premedication, since he had a reaction when they tried using it? Is there a name for the mitral valve procedure? Also, are all of my father’s health problems I listed ok to do either procedure?
Hello Doctor,
May I continue with my last communication following your advice on the 9th Nov. 2016?
I have two questions .
1. Post Green Card Status my mefical Ins,Plan is in process .Mostly it would be medicaid
In case I wish to go ahead with the Defibrillator Procedure as suggested by you at your facility despite the fact that I am in NY,on my own, how much would the entire thing cost me? How long will it take or in other words need me to hospitalize if necessary?
2. In case I get medicaid ,will the hospital accept it even for partial consideration?
I would prefer to take an early decision if possible.
Kindly advice.
Ramesh Pitre
Im not sure of the specifics, i typically have our office deal with that, I’m happy to put you in touch with them to help you come up with a plan.
Whom should I contact/ write at your office? Can I have the details please?
Ramesh Pitre
I will pass on your email address to the office. Even if you don’t travel, we will help you where we can.
Do you think my 89 year old mother’s fluid accumulation in her legs will be helped by having the TAVR procedure performed?
It depends on many factors. If there is a confirmed diagnosis of severe aortic stenosis, and it is felt the swelling is from heart failure then the TAVR may help to improve the situation. If the swelling is due to venous insufficiency and dependent edema it is unlikely to help.
I sent you this last week, but it didn’t go through. It wouldn’t let me reply to your post, so this is a new post. Here are 3 echocardiograms for my dad. The March 9th is from an office visit with my dad’s cardiologist and the other two are hospital visits. After you review this, please let me know if you think he is severe or still moderate and the pneumonia is what made it look severe according to my dad’s cardiologist.
March 9, 2016
Both M-Mode, two-dimensional echocardiographs, color flow, and Doppler studies were accomplished. The technical quality of this study is good.
Aortic Valve
AO Peak Vel. (1 – 1.7) m/sec
LVOT Peak Vel.
Insufficiency
Tricuspid Valve
RVIT Peak (.3 – .7) m/sec
RV Systolic Pressure
Regurgitation
Trileaflet aortic valve, which shows velocities at 3.2 m/sec with a mean gradient of 26 mmHg consistent with modest aortic valvular stenosis are seen. No evidence of aortic regurgitation.
Tricuspid leaflets appear to move normally. There is mild-to-moderate tricuspid regurgitation noted with a right heart pressure is calculated at 44 mmHg.
——————————
April 27, 2016
The study quality is fair.
Aortic Valve
AV Pk Vel 3.7 m/sec
AV Mn Grad 29 mmHg
AV VTI 68.5 cm
LVOT Diam 1.8 cm
LVOT Pk Vel 1.3 m/sec
LVOT Pk Grad 6.8 mmHg
LVOT Pk Mn 3 mmHg
LVOT VTI 24.2 cm
EST (2D-Teich) 61 ml
AVA (VTI) 0. 9 cm2
Tricuspid/Pulmonic Valves
TR Pk Vel 3.89 m/sec
RAP 3 mmHg
TRMaxPG 61 mmHg
RVSP 64 mmHg
PI End dias Vel 1.69 m/s
PV Pk Vel 1.43 m/sec
PV Pk Grad 8 mmHg
—————————————–
October 23, 2016
The study quality is good.
Aortic Valve
AV Pk Vel 3.7 m/s
AV Mn Grad 31 mmHg
AV Max PG 61.7 mmHg
AV VTI 63.5 cm
LVOT Diam 1.9 cm
LVOT Pk Vel 1.2 m/sec
LVOT Pk Grad 5.8 mmHg
LVOT Pk Mn 4 mmHg
LVOT VTI 20.5 cm
ESV (2D-Teich) 58.09 m/l
CO 4.3 1/min
AVA (VTI) 0.91 cm2
Tricuspid/Pulmonic Valves
TR Pk Vel 3.43 m/sec
RAP 15 mmHg
RVSP 62 mmHg
TRMaxPg 47 mmHg
PI End dias Vel 1.29 m/s
PV Pk Vel 1.56 m/sec
PV Pk Grad 10 mmHg
Chambers
RVIDd 4.3 cm
IVSd 1.6 cm
LVID 3.7 cm
LVIDs 2.2 cm
LVPWd 1.4 cm
SV Teich 41.9 ml
LV FS 40.5 %
EF (Teich) 72 %
LA Diam 5.3 cm
AO Diam 3.6 cm
LA AO ratio 1.47
AV Cusp SeP 0.6 cm
LV Mass (M-M) 208.69 gm
Let me know if you need any other information from the echocardiograms.
Thank you.
Also, my father has an appointment this Thursday 12/1 with his cardiologist to have another echocardiogram. If there’s anything you think I should ask, please let me know.
Thank you
Hello Dr. Ahmed,
Just wondering if you received my last two comments. I sent two back on November 28th and you have responded to two other people who posted after that. They show on your site, but I’m not sure if you got them. My father went back in the ICU today. He had very low blood pressure and they had to intubate him, because his oxygen saturation level was low. Curious on what you thought of my father’s echos I sent you to see if he has any options. Whether you thought his valves were moderate or severe. Please let me know. Thank you.
Hello, i just looked at those echo reports, of course i would need to see and review the images to be entirely accurate. As things stand the valve disease looks to be in a more moderate range. I suspect the symptoms he is unfortunately going through are multifactorial in nature and not the primary driver. What is the consensus opinion from the specialists at your facility that are familiar with the case?
It is very good to know you think it’s in the moderate range. My father’s cardiologist said the same thing at his appointment back on December 1st. He said he thought it was close to severe, but still moderate. He’s not sure if my dad is at the point where a procedure needs to be done. The problem is a ICU doctor said that both valves are severe and there’s nothing they can do. That he can’t do the TAVR procedure, because he’s allergic to the dye, and there isn’t a minimally invasive procedure for the leaking Tricuspid Valve. He basically is saying we should let my dad pass away. He said the valves were what caused the cardiogenic shock and all the fluid to build up a month ago, and not the pneumonia. He’s in the ICU again and his scan showed a little pneumonia. That’s what they’re treating him for. I’m so confused. It seems like the pneumonia is the problem, and you and his cardiologist think the valves are moderate, but that doctor thinks it’s severe and isn’t giving us much hope. Is it even worth doing the TAVR procedure when there’s supposedly nothing that can be done for the Tricuspid Valve? Also, he’s been sleep talking every night. I’m not sure if that means anything. Moving forward, what would you recommend? Thank you so much for your response!
I really do need to emphasize that any opinion i give here, particularly without reviewing every detail of the case, is simply a comment on what i see. In cases that are complex i really would need to be treating the patient primarily to feel comfortable with an opinion. I am an expert in this area, but it would be irresponsible of me to direct any treatment decision. Without seeing the images themselves, i cant for certain grade the severity of the disease. I think you need to sit with the cardiologist and ask all these questions and ask for an explanation. The questions you are asking are good questions and show that you are insightful.
Dr. Ahmed,
It is so kind of you to answer questions of those that are not even your patients. Thank you in advance. I wanted to get your opinion on the case of our family friend. He is an 80 year old man who was scheduled to have an aortic valve replacement. They opened his chest but aborted the surgery, saying that there was more plaque on the aortic valve than what they were able to see beforehand on the CT scan. So, the “plan B” now is to get the TAVR procedure after he recovers from having his chest opened, which will be performed with a different surgeon at a different hospital.
Based on what I’ve read from your article, shouldn’t the TAVR procedure have been the first attempt, due to his age? What risks were posed by this plaque that would require them to abort the surgery? And does it make sense that whatever risk this plaque posed, it’s more avoidable with the TAVR procedure (giving another reason that TAVR should have been the preferred method initially? Based on my (limited) understanding, I am wondering if the doctors opened his chest for no reason.
Thank you for your time.
It all very much depends on the center you go to when it comes to the approach taken. I cant comment on the exact right thing to do as this is not set in stone. Ive heard if similar situations before. I suspect they have determined that he has a porcelain aorta. One way of looking at it is from the viewpoint couldn’t they have known this before, but in many places a routine CT isn’t done prior. Another way of looking at it is at least they didn’t cross clamp a porcelain aorta thus avoiding a bad outcome and they have come up with a suitable alternative. In my program we routinely obtain CT as this provides information for the minimally invasive approaches we use such as mini-sternotomy. In non minimally invasive centers though this isn’t routine and so its always possible to have the situation you encountered. The risk of them doing the procedure with the porcelain aorta is prohibitive and the correct move is to abort given the risk of stroke and aortic damage. I cant comment too much on TAVR risk without seeing the specific details of the work up. The landscape is changing, and in the years ahead every 80 year old and probably 70 year old will have a TAVR approach. As technology improves, we can expect TAVR to replace open AVR in the years ahead. As for the time being however the patient has to be considered at least intermediate risk to be approved for TAVR. If your family friend was determined low risk for whatever reason, then maybe they felt he didn’t qualify? Discuss the risks of TAVR and his anatomy prior to proceeding so you are well aware the benefits offered and the risks entailed.
Dr Ahmed,
My Dad is scheduled for the TAVR procedure after recently receiving CT scan reports qualifying him for the procedure. On the report, under other findings, bronchiectasis was discovered. Is this a concern?
Thank you for your time.
Hi Sue, the bronchiectasis is not a contraindication, he would have had lung function tests most likely that demonstrate the lung function and can determine the risk of anesthesia and the breathing machine, in many ways TAVR is the preferred approach in those with bad lungs.
Hi,
I have a moderate leaky valve. Due to a bicuspid value that caused me to have my aorta dissect at 40, now at 54 I get checked yearly. In fact I have my echo tomorrow. I am curious if I would be able to have a valve replacement w/o open heart? Or is that my only option?
As things stand there is no good percutaneous option for aortic insufficiency inside a native valve.
Hello. I would like your opinion on the TAVR procedure for my mother. She is elderly, 87 yrs old and was recently diagnosed with aortic stenosis after a fall and broken elbow. She has become increasing short of breath over the last couple of years. She is very tiny (4′ 10” and 105 lbs), has severe kyphosis from osteoporosis, has broken her ribs and hip in 2 previous falls, and has had several vertebral fractures, also from osteoporosis. She also has dementia (most likely vascular) that has progressed over the last 5 or so yrs.
The cardiac surgeon who diagnosed the heart valve issue was did an echocardiagram and attempted a trans-esophageal echocardiagram (TEE) but was unsuccessful in inserting the tube due to her severe kyphosis and small frame.
Would you suggest any further pursuit of evaluation for a TAVR procedure or are her comorbidities too severe to even consider the risk?
This is a very complex issue, in terms of patient selection and i would need to see her in a clinic setting and go through her full history as well as seeing her and getting a feel for her prognosis and ability to handle a procedure. Its key to realize that dementia itself when advanced is a terminal process also and i personally don’t perform the procedure in those with advanced or end stage dementia as I’m not sure its in the best interests of the patient. The TEE itself isn’t a deal breaker, in our center we offer the procedure under moderate sedation only and a transthoracic echo. Also given the fact she is so small a CT scan needs to be performed and her leg vessels evaluated, they may well be so small that the trans-femoral access that is preferred is not an option in her. Its reasonable to seek an opinion from a true expert center. However think long and hard about the risks and benefits and discuss this at length with the team prior to proceeding.
Thank you, Dr. Ahmed. Your comments are exactly on par with what the cardiac surgeon said to us 6 weeks ago. His comment on the dementia was concern for her “quality of life” and her ability to recover from the procedure.
My thought was that although she has dementia, her quality of life is still good. She knows all her family and is pleasant and alert (when on oxygen). She just has no memory of anything but the last couple of minutes and has no awareness of time or place. But since she doesn’t know she is like that, it doesn’t bother her. However, I am deeply concerned about her ability to recover since she is on oxygen almost full-time, cannot adhere to any instructions and would not know what happened to her or be able to participate in her own recovery.
One followup question….they did do a transthoracic echo on her in the CCU but were not able to see the valve function due to fluid retention in the lungs which is why they attempted (unsuccessfully) the TEE procedure. The surgeon recommended a subsequent transthoracic echo once she completed rehab from the elbow surgery (which was 6 weeks ago). Does a transthoracic echo require moderate sedation or were you referring to the TEE when you mentioned the sedation above?
I appreciate the caution in your words. She is clearly not an ideal candidate for TAVR, but it is our only option which is why I wanted to explore and thoroughly consider it. Even as one who believes strongly in the procedure, your concern for appropriate patient selectivity and the best interest of the patient is very much appreciated.
My mother had TAVR and 2 weeks later died. The procedure itself was reported to us as a success. An hr later she was in icu with blood in her left lung. It cleared a little then 2 days later had a near heart attack. The lung filled up again and never recovered. Over the next 2 weeks she also started bleeding in her chest and suffered a perforated bowl. It was to much for her.
She had copd ,lupus and low platelets ~ 115. The cardiologists said the lupus was at fault but the rheumatologists disagreed, said the lupus was under control and it was only 1 lung.
No problem, I understand you can’t give completely accurate advice just by the numbers of the echo. I told that ICU doctor that my dad’s cardiologist said he felt the valves were in the moderate range. The ICU doctor said moderate and severe was the same to him. That didn’t make sense to me. He said that the TAVR procedure wouldn’t help him or his low blood pressure, because his heart pump is pumping at 30%, which is why he has the pacemaker. Doesn’t his pacemaker help the pump? He said opening up the aortic valve won’t matter, because of the pump. Is that true? Opening it should allow a good amount more flow, which should help his symptoms.
Doctor, Thank you so much for your article and posts! My dad is 87 and he has been approved for a TAVR. I have a few questions that are obviously time sensitive. Since he will need an angiogram to determine any blockages, it has been suggested that the angio be done literally just prior to the TAVR (the same day). First, is this less invasive and even advantageous in that only one set of “tubes” would have to be inserted thru the arteries as it would be used for both procedures? Second, concerning the kidneys, (he has a minor elevation of creatinen), would less CONTRAST have to be used (or is it the opposite, in that MORE CONTRAST will have to be absorbed in one day to accommodate TWO procedures. Finally, his echo revealed that he is .7. While you may not be able to answer this because you don’t know all the particulars about his health and his case, my dad, excepting this major issue with his heart valve , (although so far- there has been no feinting, and just occasional shortness of breath, ) do the benefits of a TAVR out-weigh the risks in terms of his life expectancy? As I said, you may not be able to answer this as it’s such a personal question, especially without any other familiarity with his particulars. Thank you again Doctor!
In terms of the angiogram, would recommend taking a radial approach (through the hand) and typically i wouldn’t do it the day before, rather would leave some time as its unknown what will be found and how it will impact the plan. I would distance the cath in this instance as the contrast dye usage would accumulate in a short period.
In patients with elevated creatinine, would if possible hydrate prior and minimize contrast usage.
The third question in my opinion is on a case by case basis and can only be determined when meeting the patient and their family.
Elizabeth Thorpe,
Hello Doctor,
I had a Subaortic stenosis resected back in 1971 aged 17 years old. I am now 62 year old and have been inform that a know need a Aortic value surgery and left ventricular re=modelling surgery also. I have not had a problems only in the last year with getting out of breath walking
Severe Aortic stenosis with narrowed left ventricular outflow tract has now been indentified
in general health very good with slight high blood pressure. had all test. I am now waiting for an appointment with the Congential Team to discus this. they say this is complex. I slightly worried. can you advise a little on this
I would need to see details of the case and the images to comment accurately. Sub aortic stenosis in this case means that the tissue below the aortic valve was thick and basically getting in the way of blood leaving the heart, obstructing it. In your operation the tissue was cut out relieving the obstruction. You now appear to have a narrowed aortic valve and also regrowth of the tissue below the heart. The aortic valve will need adressing by replacement and the tissue below the valve causing the obstruction will need resecting if that is an issue also. Lets see what the evaluation shows and how severe these issues are.
My 80 year old mother had 2 stints put in July 16, 2017. We have been waiting for them to schedule her TAVR surgery. We received notice on January 22, 2017 that her surgery is scheduled for January 26, 2017 . On Jan. 22 they told her to quit taking her Plavix, is 4-5 days long enough for her to be off of her Plavix to safely have TAVR surgery on Jan. 26?
It depends on local policy. In my program we do not stop plavix in the vast majority of TAVR procedures as we feel we can perform the procedure safely on plavix.
Hello, Doctor!
Are there any complications of temporary PMK using, especially, non-surgical?
Is there any information on its effect on blood vessels?
What is PMK referring to?
This website is so helpful! I am 76 and quite healthy except for severe aortic stenosis and arthritis. I live in the Seattle area and am really hopeful that I will be a TAVR candidate. I’m feel frightened by the invasive open-heart surgery. What are my chances to avoid it at my age? Should I wait until I get older?
It depends if the aortic stenosis is severe and there are symptoms. If severe, generally the presence of symptoms mean its time to replace the valve. At the age of 76, it depends on your other history, but if no other history then you would be considered low risk. As things stand the TAVR is only approved for high and intermediate risk. Low risk only in the setting of a clinical trial. If you have symptoms you should generally not wait, if you don’t it may be reasonable. If you are a surgical candidate, in the right hands the risk can be very low and the outcomes good if you are done in the right place.
My mother just had the TAVR procedure done and the surgeon came out and told us that everything went well. 20 minutes later she went into full cardiac arrest and they tried to revive her for almost an hour before declaring her dead. We were initially told it was a blood clot that blocked the coronary artery but later were told it was a leaflet that had torn and blocked the coronary artery. This was from 2 different doctors. According to your above article the reason for occlusion of the coronary arteries is if the valve is placed too high or placed incorrectly.
How do I determine if the valve was placed incorectly or too high?
Is this something that is common or extremely rare?
How can I get honest answers on what happened during this surgery?
My mother just had the TAVR procedure done and the surgeon came out and told us that everything went well. 20 minutes later she went into full cardiac arrest and they tried to revive her for almost an hour before declaring her dead. We were initially told it was a blood clot that blocked the coronary artery but later were told it was a leaflet that had torn and blocked the coronary artery. This was from 2 different doctors. According to your above article the reason for occlusion of the coronary arteries is if the valve is placed too high or placed incorrectly.
How do I determine if the valve was placed incorectly or too high?
Is this something that is common or extremely rare?
How can I get honest answers on what happened during this surgery?
Very sorry for your loss, I’m sure you have a lot of questions.
Firstly its not fair to either you or the team performing the case that i comment specifically on technical aspects of the case. I don’t know enough about the given case or the intra-procedural technical aspects. Ill make some general comments.
In general the procedure is safe and has a low complication rate, however when performing such procedures in the heart, particularly on those that are fairly elderly and have multiple medical conditions there is always a risk. The risk can be minimized by use of an experienced team and precautions however there will always be a risk. Don’t forget however that the procedure is performed as it would have been felt that without it her life expectancy would have been significantly reduced. Patients that have severe and symptomatic aortic stenosis, who have been assessed appropriately and felt to be suitable candidates should be referred for the procedure. There is no such thing as a risk-less procedure and having done hundreds and hundreds of these things i can tell you i always maintain the same caution and discuss the risks at length.
If a coronary blockage is felt to be the cause, then the mechanism is typically coverage of opening of the coronary with the old leaflets of the valve, or sometimes by the new valve itself. Typically that can be predicted and appropriate precautions taken. If there was a high suspicion of this i suspect the team would have taken an appropriately cautious approach. Im not sure of the valve used (self expandable vs. balloon expandable). In terms of technicalities the valve can be placed a little too high which can exacerbate the problem. In some cases the coronary will be wired prior to the procedure to protect it. I some cases the narrow aorta and sinuses can contribute. I suspect if coronary occlusion was a major concern prior to the procedure, In general if it is considered as the cause of death it would have occurred immediately, it would seem a little odd to me that this could occur 20 minutes after the procedure, coronary occlusion is typically something that would be noticed immediately.
In terms of if it was too high, i suggest you discuss this with the implanting doctors. Sometimes there can be minor movements even if there is a good initial placement due to a number of factors. This is something they can discuss with you. With regard to the question “is it common,” the answer is no, it is rare, with the caveat that it does happen. You can get honest answers by asking the team involved to go through the case with you, maybe looking at the pictures, and make clear that you simply wish to understand what happened.
Its a high stakes field, and should be treated as such, no matter how good one is or how many they have done. Even when i have 100 in a row without a complication i treat the 101st in the same way that something can go wrong no matter what we do. I know that doesn’t make it easier and I’m sorry for your loss. I do feel that if you have a discussion with the implanting team, you will have a familiarity with aspects of the procedure that may make it a little easier to understand.
Hi I’m very grateful for your thorough exploration of this procedure. My 73 year old mother has had one knee replaced and one hip replaced. She recently visited her cardiologist to get cleared to have her OTHER knee and OTHER hip replaced, which have completely deteriorated (she is in agony and can barely drag herself around on the walker). We learned before she can have those done she MUST have the aortic valve replaced. She’s a candidate for TAVR; the surgeon has given her the ration of tests (pending the cardiac cath) and so far, so good. My question is, if the surgeon likes the results of the cardiac cath and she does get the TAVR surgery, when (or can she ever) have the joint surgeries? I am really worried about putting her body through all this. She has high blood pressure and a high SED rate (arthritis). I know she must have the valve replaced and the idea for the TAVR is that the recovery is easier, especially since she can hardly walk (which would make recovery from open heart extra difficult). Thank u kindly for any insight you could provide.
To give you specific answers i would have to see her and understand the entire situation, it differs on a case by case basis. In general the first question is – does the aortic valve need replacing? Aortic stenosis if asymptomatic doesn’t necessarily need emergent attention, particularly if stress testing demonstrates clinical stability, and the surgery is emergent. In some cases however it does need replacing, and in those cases, if all goes well the hospitalization for TAVR need only be 2 days, and surgery technically can be performed after that. If possible i like to wait a month, however there are cases where i have done the TAVR, and surgery for whatever reason performed within days of the procedure. It differs in every case.
can edwards aortic valve be placed in the opposite direction????
Yes, i do that in the mitral position.
The clearest explanation I have found for the procedure – thank you.
My 71-year-old father had his TAVI (at The Royal Sussex Hospital in Brighton, UK) a month ago and unfortunately there is some leaking as his valve is unusually large and despite the largest prosthetic been placed in it, there was still room. They decided not to repair it at the time, but will do in the next month or so. As a result of the leak, he did not experience the boost of he did after the BAVI for example and has been put on very powerful diuretics as the oedema onset was significant. He feels much better since those worked and is optimistic about the patch procedure, which will happen under general anaesthetic. What will they ‘patch’ with and how effective is it? Is there anything we should be asking about?
Many thanks again.
https://myheart.net/articles/paravalvular-leak-patient-guide/ see if that sheds some insight. The need for diuretics and the known leak suggests that it is significant in nature, its difficult to be able to comment on specifics without seeing the images however if done in experienced hands these leaks can be repaired. It depends where the leak is and how large it is as to the approach required. The patch is likely actually a plug such as an Amplatz Vascular Plug. i have found those to work best if selected appropriately.
Hello,
I am a 55-year-old male who was born with a bicuspid aortic valve. Thankfully the valve was repaired 9 years ago with open heart surgery.
Just returned from my regular cardiologist visit and echocardiogram, he informed me that the valve was leaking to the point that surgical advice was needed and something would need to be done. I have no other health problems, but REALLY do not wish to have open heart surgery again if other options are available. Could I get TAVR.
Thank’s in advance for your insight.
TAVR may be an option although you may be too healthy for that as things stand. In terms of valve in valve tavr procedures i have done many and they work well.
My husband had TAVR replacement 13 days ago. He has normal bruising but feels much more sensitive in the groin area today. Would appreciate your comments.
Some soreness can be common but shouldn’t generally persist at 2 weeks. It may be a good idea to obtain an ultrasound scan to rule out any vessel complication associated.
Hi Doctor, my father is 82 with severe aortic stenosis, gout, dementia,and adult onset leukemia and problems walking due to severe arthritic knees. We recently took him to see his cardiologist to talk about the possiblity of surgery. He said the traditional method was out and that we should go see the TAVR team to see if he is a candidate for this surgery. My concern with this is would any of these diagnoses prevent him from being a candidate? He didn’t do all that well with his previous surgeries and had longer stays in the hospital and then rehabs to relearn how to walk. any input would be really helpful, thank you
From the information provided TAVR would clearly be the way to go if the work up showed this could be done safely. The advantages of course being less trauma and quicker recovery.
Severe symptomatic aortic stenosis is a dangerous condition, in of itself terminal if not treated, however its important to consider the entire situation. The procedure should only be considered if it is felt that it can offer meaningful increase in quality of life.
Would i do a TAVR in a patient with severe dementia? No. Would I in milder dementia in a patient that is enjoying living? Yes
Would I do a TAVR in a patient with cancer but a hope of treatment and at least a year survival? Yes. Would i do TAVR in a patient with cancer and only a few months life expectancy? No.
The key being, the procedure is an excellent option, but only if used in a sensible clinical context.
I hope that was helpful.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
My 80 y/o friend with AS is contemplating TAVR procedure soon. He has focal 70% stenosis in the LAD and RCA. Can stent placement be combined with TAVR? Thanks.
I typically would stent the arteries in a separate procedure prior to the TAVR procedure as part of the pre-procedural treatment plan.
I have a 94 year old father, who can only walk 50 ft before being breathless. He also has COPD, and we assume some of his SOB is due to that. He had one valve replaced 15 years ago, and it has been suggested that he should be evaluated for TAVR for another valve.
He complains of tiredness and no energy, and always being cold. Will this procedure help an or all of these symptoms?
Bob in CT
If your father has severe aortic stenosis, and is felt to be symptomatic from this, the TAVR may well be an excellent option. It truly has revolutionized the treatment of aortic stenosis and also been instrumental in improving quality of life and survival in hundreds of thousands of patients worldwide. Fatigue and shortness of breath are symptoms that can expect to improve in the majority of severe symptomatic aortic stenosis treated with TAVR.
If you are interested in cutting edge information and therapy for heart disease then follow my twitter at @MustafaAhmedMD
Are you familiar with the Imavalve? I understand it’s great deal in the future. I won’t wait that long for an aortic valve but I have other valves it may help with in the future. Do you know if this is intended only for children or which valves this can be used with?
Its one of many many promising technologies in the valve space. Its not there yet and it needs to be tested in trials with patients and beyond the concept stage. Its niche would likely be the younger patient buy may have applications beyond.
If you are interested in cutting edge information and therapy for heart disease then follow my twitter at @MustafaAhmedMD
hi my name is shila i found out 2 years ago i have mitral valve leaks and narrowing i ask him for TAVR HE STATES I NEED TO HAVE OPEN HEART SURGERY I CAN SENT MY STRESS TEST TO YOU YOU CAN TELL ME WHAT ISUPPOSE TO DO PLEASE.
THANK YOU SO MUCH
Thank you very much. I had my first valve surgery 22 years ago, it was minimally invasive. It had only just started being done at this hospital. I just blows my mind how much things have evolved in that time. I’ve had to completely re-educate myself. I love reading the articles and questions/responses on this website.
Hi Dr. Mustafa Ahmed,
I really enjoyed reading your article.
In your opinion, which heart valve is easier to implant from a user perspective, corevalve or edwards?
The ability to re-locate the self-expanding corevalve seems to give it a huge advantage.
Thank you,
Each valve has advantages and disadvantages and each case is different. When i approach a case i look at features of the valve that may dictate the choice of approach and valve taken. Is there a particular pattern of calcium on the valve/outflow/aorta, is there a certain configuration of the valve, is the aorta calcified, what is the best route of access to the valve, does the patient have a pacemaker etc. All these questions and more are critical in my opinion.
The best operators have a depth of experience with all the valve platforms to a good degree and therefore their choice of valve isn’t dictated by a relative inexperience with alternative platforms. No one valve should be seen as being easier/harder than the other. Most people would find it easier to use the valve they are most used to implanting particularly if they aren’t experienced with the other!
If you are interested in information and therapy for heart disease then feel free to follow my twitter at @MustafaAhmedMD
My father had his mitral valve replaced 2 years ago via the same TAVR procedure (transapical) . He had 2 valves replaces via open heart surgery 9 and 6 years ago. His bio replaced mitral valve suddenly failed with 2 torn leaflets. As a high risk patient, we found the TAVR team. They hadn’t done a mitral valve, but felt they could with the Edwards SAPIEN. It took him about 4 weeks to recover, but he did great and is alive an well at 82 now. After reading all of the posts here I felt compelled to tell folks that these procedures do work very well. My father has enjoyed 2 additional years of life and we hope he will be around more.
Do your homework. Read articles like this one. Ask questions of your doctors. We worked hard pushing hospitals, questioning expert doctors all around the country until we found this procedure. I devoured everything I could about this procedure and made sure I understood everything I could about this procedure, the risks, and who had the best TAVR teams. Its your life, make sure you fight for it and question anything you don’t understand. Thanks Dr. Ahmed for taking the time to answer questions here.
As an employee at a large private dental practice as well as a heart patient, I wonder what your thoughts are on dental work after valve replacement. I see a lot difference in recommendations from cardiologists as well as dentists. Some heart surgeons for stents or bypass will say no dental work for 3 -6 months, same for valve replacements. Some have no restrictions. I had a patient yesterday who was told no dental work for 1 year after valve replacement. She had been in pain for months and finally the tooth blew up. She was Up all night with severe pain and swelling. I spent half the morning jumping through hoops trying to get her cleared for dental work as she was 1 week short of her 1 year anniversary. The dentist told me he would have treated her without clearance, she’s had an ongoing dental infection, bacteria has already entered her bloodstream, it’s in her best interest to extract the tooth (pre-medicated of course). He also believes that not allowing her cleanings for a year is increasing her chance of infection, as any bleeding that may occur with brushing/flossing causes bacteria to enter the bloodstream. No cleanings increases chances of gingival/perio disease. It seems cardiologists and dentists kind of butt heads in this area. I am having OHS for aortic valve replacement soon and wonder if there is truly a correct side on this issue.
Antibiotic prophylaxis would be advised regardless. The rate of endocarditis is around 1% in the TAVR valve which is similar to a surgical valve implant and felt to be due to a variety of causes. Ideally the dentition should be addressed pre procedurally. In those cases where it is performed after valve replacement it needs to be an informed decision. There are no 100% guidelines. Conventional wisdom would dictate that the fabric skirts on the valve would behave as any oyher such implant and endothelialize within 3-6 months post implant of course making the risk of endocarditis theoretically smaller at that point. I would advise treating TAVR like a surgical valve implant for now and make informed decisions.
If you are interested in information and therapy for heart disease then feel free to follow my twitter at @MustafaAhmedMD
Hi Dr. My mom’s aortic valve is operating at ~75% capactiy. She is 71 yo and probably would be characterized as low to intermediate risk for conventional heart surgery bc of her age.
Her current doctor is recommending open heart surgery. He has mentioned that TAVR has not been proven long-term so he is advising against it. My concern is that his perception of the procedure may be based on evidence from a few years ago…and this area is evolving quickly from what I read.
I live in NYC and would like to speak directly with the leaders in the TAVR approach. Can you point me in the right direction?
Thank you.
Lets take a little time to think through it.
Your mother has severe symptomatic aortic stenosis, and I’m assuming the evaluation has been done in good hands and that there is certainty about the severity of aortic stenosis. There is no such thing as the aortic valve is operating at 75% capacity rather a mixture of pressure gradients and area is used to determine the severity of the aortic stenosis common do you watch the valve area is below one sent to me do you mean gradient is about 40 millimeters of mercury the aortic stenosis is designated as being in the severe range, it is very important not to get stuck to certain numbers which is a mistake made by some evaluating physicians and teams.
Once the aortic valve has been confirmed to be severely tight or at least was the severe range and there are symptoms intervention is certainly recommended, is recommended is not only is that a large Improvement in quality of life, but there is a significant survival benefit. Simply those with severe aortic stenosis and symptoms do not do well and have a significant risk of death.
The TAVR procedure has been around a while now, it has been used firstly in inoperable situations, then used in high-risk patients, now commonly used in intermediate-risk situations. It is very important to note that in all of these circumstances that has been high level of trial evidence to suggest that this approach is beneficial particularly when compared to a surgical approach. The surgical approach has been tried and tested over decades and that for if we are to displace it with the routine use of the TAVR procedure we want to make sure it helps patients in the long term not just to provide a small incision or avoid an open heart operation. Ultimately it’s all about making the decision that is right to help people do well in the long-term.
Now we have reached the point with being very comfortable with the TAVR procedure, I personally have performed over 500 of these procedures and can tell you that when performed in experience hands by an experienced team it is an excellent and safe option when the correct candidate is chosen. What we do not know however is in the low-risk population is whether the TAVR approach is superior to the surgical approach. In the lowest population surgery is known to do very well over a long period of time. Furthermore in the lowest population the risk of the surgical operation itself is very low. What we do not know is whether with the TAVR procedure the long-term outcomes will be similar to that of the surgical approach. For this reason trials are currently being performed to find out the answer to this very question. When patients come to me and they are truly low-risk, firstly tell them that he surgical approach is the tried-and-tested method and has long-term outcome data. The TAVR approach is safe however we do not know whether the outcomes will approach that of the surgical outcomes over the long term. For this reason I would currently only recommend that this is performed in the setting of the ongoing clinical trials. And it’s also important to know that if entering such a trial that is going to be a degree of the unknown particularly when it comes to the TAVR approach. Although many of us do feel that ultimately the TAVR will be the preferred approach ultimately even in lowest populations as of this second we need to gather the data to that allows us to say that confidently. Hopefully this provides some insight into the current thinking for you.
If you are interested in information and therapy for heart disease then feel free to follow my twitter at @MustafaAhmedMD
I have aortic stenosis, severe as far valve area is concerned, still in the moderate range as far as pressures. My cardiologist feels TAVR is best due my health history. I am 45 and I prefer open heart, as I feel that is what is best for me. Last month I saw a heart surgeon who says I am low risk and open is my only option. Plans for surgery after next echo in January unless there is no change at all.
11 days ago I had laproscopic lumbar hernia repair. It is healing well, I had no issues with anesthesia, however a day after surgery I developed a rash, 5 days after surgery low grade fever, 9 days after surgery, swollen joints with extreme pain. Last evening I went to ER with severe pain. Jaw, ankle, knee shoulder and both hands hurt to the extent no pain meds helps and I am on a narcotic with ibuprofen around the clock. Today both hands hurt to the extent I can’t take care of myself. My husband has to help me with simple tasks, bathroom, dressing, etc.
I saw my surgeon this morning for follow up. He says I am having autoimmune response to the surgery. He released me from care and told me to follow up with primary doctor if painful joints continue. Fortunately my rheumatologist will fit me in on Monday, it usually takes 6 months for an appointment.
My concern is if this flamitory response could be effecting my heart. Secondly I am concerned that with open heart being such a big procedure, I may have an even worse response. Which would be awful, because I have gone from full time employment in a busy medical office to having to extend my leave and unable to care for myself. Do you think a TAVR procedure in place of open surgery would reduce chances of a response? Are there treatments that can be given to reduce likelihood of a response. Would it be particularly dangerous to have this happen after an open surgery?
If the surgical process is associated for sure with this response then surgery would certainly not be considered low risk given the way it would affect the rehab process and you should re-discuss with the surgeon or seek an alternate opinion. If its the case then TAVR should be strongly considered.
Thank you for your quick and direct reply. My gut instinct told me this could be a game changer when it comes to heart surgery. Of course, I will discuss options with my rheumatologist, cardiologist and cardiothorac surgeon.
While I am thankful this happened with a smaller procedure before undergoing open heart, I can’t help but be very disappointed. At 45, my research indicates an open heart procedure is likely to give me the most longevity. I admit, the heart surgeon was quick to tell me that the valves in open heart are not necessarily better or last longer, they are just tested and proven, whereas there is not enough information with TAVR valves.
What is current expected life of a TAVR valve?
It to be determined, the good news is for many devices its 8 years and still going strong, furthermore the devices are continually improving.
My rheumatologist says my symptoms are an autoimmune response to a medication used during surgery, most likely an antibiotic causing serum sickness. He will get a list of the meds used during surgery and let me know which one to avoid. I have to say this makes me more than a little nervous with my next surgery likely being a heart surgery. I don’t think there’s any way to know for sure. I told him I will be having heart surgery and he says this shouldn’t keep from an open surgery.
I am under consideration for TAVR this fall since the porcine valve I received 8 years ago is failing. Have been reading that there is a possibility of stroke through the procedure but that it can be reduced by the sentinel cerebral protection system or CPS . What is your opinion on this addition to the surgery? My Interventional Cardiologist says they do not use this in his facility and that the rate of stokes I have read about being close to 9 and 1/2 percent and being reduced to less than 4% with CPS is old info. and strokes do not occur at this rate anymore. Can you please elaborate on this. Thank you so much.
It is true that there is a risk of stroke with TAVR however the rate of clinically significant stroke in contemporary TAVR use is much lower than 9 1/2 so i would agree that data is not accurate. I use the sentinel device, in cases i feel are high risk due to the presence of certain anatomical features. I certainly done use it in every case. I feel that in the future, ongoing trials will make it much more clear regarding how to proceed however my personal practice at the time being is to evaluate very case and consider it on a case by case basis.
you can follow my twitter at @MustafaAhmedMD
My husband is 71 years old he suffered from heart attack in 2011 two stents were inserted and he was doing fine but lately he had symtoms of breathless ness and his echo cardiogram report shows severe aortic stenosis and has been advised open heart surgery but he has multiple problems so we would prefer tavr on him with 2 stents can he tavr be performed on him please advice
Yes, TAVR can likely be performed if he qualifies as a candidate after an evaluation.
you can follow my twitter at @MustafaAhmedMD
My mother had her valve replaced and the old valve is crushing her new valve. Have you heard of this ? Will a balloon help this? Also, if she has a leak can that be fixed?
Do you have more specific reports? Has she had a TAVR already?
This is a wonderful article thank you
My 92 year old mum had TAVI 2 weeks ago. Unfortunately she had a TIA a week later which hopefully will pass but she is totally exhausted with no energy and little appetite
Should this improve ?
Also she comments that she can hear her heart beat unlike before the op. She is very thin I’m body-type
Thanks
In general there should be an improvement after the procedure both in terms of energy and other symptoms. If this is not the case it should certainly be paid attention to. The heart beat is not known to be more prominent after the procedure and its not likely related to the valve itself and not a cause for concern.
you can follow my twitter at @MustafaAhmedMD
Dr Ahmed,
Thank you very much for an informative article! I am a male, 53, 135 lb, non drinker or smoker, BP 110/70, no diabetes and my cholesterol is normal. Three years ago, it was found that I was born bicuspid and I had modest aortic stenosis (peak gradient 50 mm Hg, valve area (VTI) 1.09 cm(2)). Due to chest pain after even minor exercise, I did an angiogram yesterday and I was told I need a by-pass surgery as my LAD artery is totally blocked and LC artery 70% blocked (a huge shock to me as you could imagine). Doctors recommend replacing my aortic valve at the same time.
Now I am facing a choice between bioprosthetic valve and mechanic valve. The original plan was to do a BV followed by TAVR when BV degenerates. Now I have to do a by-pass, will I still be eligible to do TAVR down the road in 10 or 15 years?
Given my family history, I will be happy if I could live to 75 years old. Thus this requires BV+TAVR to support me for at least 22 years. I totally believe technologies will advance so TAVR will have a longer life time down the road but I am concerned about BV’s 10-15 life time. This is a pretty wide range and it could make it make or miss in my situations. Any thoughts will be appreciated.
Thank you very much!
John
This is an excellent question. What we have learned with the procedure is that technology continues to improve and so do the boundaries of what we are able to do. Currently at your age with the need for a bypass operation and if you are low risk for surgery the surgical procedure would be recommended. We are finding ourselves in the situation where we are shifting from often recommending mechanical valve to patients we may recommend a tissue valve to a patient simply because we are thinking down the road in terms of a procedure. With a tissue valve the possibility of a valve in valve procedure is available. We now commonly perform these and degenerative tissue valve. There is no reason whatsoever why in the future a valve cannot be placed within this one using a transcatheter method.Historically for people that are 50 years old it would have been reasonable to place a mechanical valve. It’s important to realize that this is often a lifestyle and not a medical decision. Many patients despite being younger out for a tissue valve simply as they do not want to take blood thinner for a lifelong. Of time. The whole availability of the transcatheter valve has made the situation more interesting and also changes the conversations that we have with patience and I see many switching towards the tissue valve with this in mind.
you can follow my twitter at @MustafaAhmedMD
Dr Ahmed,
Thank you very much for the informative article! I am a male, 53, 135 lb, non drinker, non smoker, BP 110/70, no diabetes and my cholesterol is normal. Three years ago, it was found that I was born bicuspid and I had modest aortic stenosis (peak gradient 50 mm Hg, valve area (VTI) 1.09 cm(2)). Due to chest pain after even minor exercise, I did an angiogram yesterday and I was told I need a by-pass surgery as my LAD artery is totally blocked and LC artery 70% blocked (a huge shock to me as you could imagine). Doctors recommend replacing my aortic valve at the same time.
Now I am facing a choice between bioprosthetic valve and mechanic valve. The original plan was to do a BV followed by TAVR when BV degenerates. Now I have to do a by-pass, will I still be eligible to do TAVR down the road in 10 or 15 years?
Given my family history, I will be happy if I could live to 75 years old. Thus this requires BV+TAVR to support me for at least 22 years. I totally believe technologies will advance so TAVR will have a longer life time down the road but I am concerned about BV’s 10-15 life time. This is a pretty wide range and it could make it make or miss in my situations. Any thoughts will be appreciated.
Thank you very much!
John
This is an excellent question. What we have learned with the procedure is that technology continues to improve and so do the boundaries of what we are able to do. Currently at your age with the need for a bypass operation and if you are low risk for surgery the surgical procedure would be recommended. We are finding ourselves in the situation where we are shifting from often recommending mechanical valve to patients we may recommend a tissue valve to a patient simply because we are thinking down the road in terms of a procedure. With a tissue valve the possibility of a valve in valve procedure is available. We now commonly perform these and degenerative tissue valve. There is no reason whatsoever why in the future a valve cannot be placed within this one using a transcatheter method.Historically for people that are 50 years old it would have been reasonable to place a mechanical valve. It’s important to realize that this is often a lifestyle and not a medical decision. Many patients despite being younger out for a tissue valve simply as they do not want to take blood thinner for a lifelong. Of time. The whole availability of the transcatheter valve has made the situation more interesting and also changes the conversations that we have with patience and I see many switching towards the tissue valve with this in mind.
you can follow my twitter at @MustafaAhmedMD
Thank you Dr. Ahmed!
I came across On-X valve. What are you thoughts of this valve? Has the longevity of the valve proved in clinics?
Best regards,
John
Dr Ahmed,
Thank you very much for a very informative article! I am a male, 53, 135 lb, non drinker or smoker, BP 110/70, no diabetes and my cholesterol is normal. Three years ago, it was found that I was born bicuspid and I had modest aortic stenosis (peak gradient 50 mm Hg, valve area (VTI) 1.09 cm(2)). Due to chest pain after even minor exercise, I did an angiogram yesterday and I was told I need a by-pass surgery as my LAD artery is totally blocked and LC artery 70% blocked (a huge shock to me as you could imagine). Doctors recommend replacing my aortic valve at the same time.
Now I am facing a choice between bioprosthetic valve and mechanic valve. The original plan was to do a BV followed by TAVR when BV degenerates. Now I have to do a by-pass, will I still be eligible to do TAVR down the road in 10 or 15 years?
Given my family history, I will be happy if I could live to 75 years old. Thus this requires BV+TAVR to support me for at least 22 years. I totally believe technologies will advance so TAVR will have a longer life time down the road but I am concerned about BV’s 10-15 life time. This is a pretty wide range and it could make it make or miss in my situations. Any thoughts will be appreciated.
Thank you very much!
John
Sorry for the duplicate posts. The fist two do not show up on my pc even I cleaned histories of internet browser.
Hi Dr. Ahmed,
What is the risk level of a stroke (caused by dislodged calcium/plaque) during a TAVI procedure under conscious sedation? Patient was 74-year-old male with severe aortic stenosis. What is the advised intervention should this occur -medication/surgery to remove blockage? How successful are these interventions, and how soon do they need to be done to prevent further damage/brain stem death. How long should one wait to see if patient could make a recovery, or can CT scans confirm brain stem death. Can you direct me to any resources discussing risks and handling of stroke and coma after TAVI please. Thanks in advance.
Stroke is one of the most devastating complications associated with valve replacement, and in general occurs at a rate between 2-5% depending on the risk profile and native valve. The rate of disabling stroke is likely around 1-2%. Its important to realize that the risk of stroke is there for both TAVR and the surgical replacement, in fact the TAVR route is likely a little safer with regard to stroke risk. The patient population of TAVR involves those with calcific valves and therefore some form of debris dislodgment is expected but this is usually subclinical and unnoticed. The use of conscious sedation itself is not associated to the best of my knowledge with any alteration in stroke risk. Once of the difficulties in the acute management of stroke is that its not often until a patient is awake that this is noticed, therefore it essentially is never picked up in the first few minutes. Once recognized, in hospitals that have a stroke team typically a ‘CODE STROKE’ will be called that involves a multidisciplinary and emergent team approach including a neurologist. An emergent CT scan, often with contrast is performed to identify the possible blockage and rule out bleed. Then if within an alloted time window a decision is made on whether to give clot busting medicines or in some cases where a team is available to proceed to the lab for stroke intervention by a trained specialist, although clearly this is not available at all hospitals in fact maybe a minority. All this of course is within an effective time window. Recovery depends on many different factors such as stroke size, rate of recovery etc and is best discussed with the treating neurologist. The post event handling of stroke / coma after TAVR does not in general differ from general management of any other acute event.
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81 year old Mother had TAVR procedure performed in Akron. They had to stop procedure apparently blood pressure dropped to dangerously low level due to bleeding around the heart. There was a nick somewhere in the heart from one of the wires, physicians could not tell us where.
Thoracic surgeon placed chest tube in the heart sac to drain the blood. The next morning her left leg had no pulse. Ultra sound showed no blood flow in the leg and a blockage near where the initial femoral artery incision was made. Emergency surgery performed by another vascular surgeon who cleared this clot and stitched up the original femoral artery hole. Also incision made on both side of her lower leg and further clots removed. After several days finally started to get a pulse in the top of her foot. After this “second surgery” she had difficulty breathing. Chest x-ray showed fluid building on the outside of her right side and lung. Interventional Cardiologist and Thoracic Surgeon felt fluid was from the initial nick in the heart and the addition of the chest tube. Radiologist placed another drain in her right flank. This did the trick and fluid was bloody in nature and has not returned on the chest x-ray. Other minor events, neurogenic bladder and an urinary tract infection are ongoing. She has been transferred today to the rehab hospital next door. After 12 days in the hospital, we are struggling to get back to where we were prior to the TAVR procedure. Now comes the real test, the Heart Valve team is asking us if we want to try it again!
The leak around the heart is called a pericardial effusion and is likely related to the wires used, many steps can be taken to minimize the risk of this however it can still happen occasionally, in those settings the fluid if felt to be of significance in terms of stability needs to be drained. There are many ways of handling this after, in our center we would typically go ahead and fix the valve anyway since it is severely diseased. The leg issue i’m guessing was a complication of the access site and it sounds like it has been taken care of. Since the valve is still an issue the question is will this be safe to fix. From the fluid around the hear standpoint, if a pericardial window has been placed then this should prevent another collection of fluid around the heart. This is a discussion to have with the heart team treating this case. If the valve is severe and poses significant threat to life and quality of life, and your mother is able to undergo the procedure safely then it may have merit. Of course, there is risks to any strategy taken here and they key is a full understanding of risks and benefits.
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Dr. Ahmed,
My last echo, TEE, in March my AVA was .96, but velocity was 3.4. In a couple days I will have my next echo. I have been having spells of very severe dizziness that hit hard and fast, nearly passing out. They usually pass quickly, or I have milder dizziness that lasts for hours. Yesterday I had severe dizziness that lasted for hours.
I am pretty sure it’s time. My heart disease is very complex, but aortic valve is most severe, So they will start with that. There are differences of opinion on if it should be SAVR, OR TAVR. I am young, but it’s complex and I have other health issues.
I have vasculitis , as a general rule does that need to be treated before heart surgery regardless of type? My doctor told me it would be treated with prednisone and a chemo drug. It has not been treated before as they felt treatment would make me sicker than the disease. I am concerned with suppressing my immune system before surgery.
Dr Ahmed,
My husband had the TARV on Nov 9. He is 86 years old and was doing 100 push-ups and walking 3.5 miles up hill daily before the TAVR procedure. For many years he suffered from afib and hypertension. During the TARV pre testing, the doctors found cholesterol in his arteries and put in a stent and started him on Lipitor 80mg. He was not on any cholesterol meds prior. 6 weeks after the Lipitor, he complained of fatigue. His heart was tested and was told to just take it easy. 8 weeks after the Lipitor, he had increasing muscle pain until he could not stand or walk. We took him to emergency hospital, where they diagnosed toxins from Lipitor, which broke down his muscles and deteriorated his kidney function. The toxins were flushed out of system and is now trying to rebuild his muscles and improve his kidneys. He never suffered from decreased kidney function prior.
While hospitalized, he got a staph infection in his blood which the bacteria attach to the new valve. He is taking antibiotics to fight the infection. So far the blood test are returning negative, indicating it is controlling the bacteria. He is also on Xarelto 15mg and plavix. He has loss of appetite and eats poorly even though he is participating greatly with physical therapy. Remember, he likes exercise. Also at the hospital, he is suffering from bed sores because initially it was extremely painful to move or touch any muscles.
What are the possible complications of the bacteria on the valve? Is it OK to take Xarelto with a valve replacement? What precautions with the bed sores? I am also concerned about his 2 hour daily PT without much nutrition. He is 5’7” and weighed 120 lbs upon entering the hospital. He has loss weight in the hospital. His normal weight before all of this was 137. Any other comments will be greatly appreciated.
The angiogram before the TAVR procedure demonstrated artery blockages that your team felt needed to be fixed before the procedure. In general we fix lesions considered severe and in a concerning location prior to the procedure. It then sounds like he developed a condition known as rhabdomyolysis after the statin medication which is an unfortunate and relatively rare side effect and can be serious if not attended to. Then it seems an infection developed, a lot to go through! This of course seems to have taken his toll on him and its good to hear he is recovering. Its important the bacterial infection is treated so that the valve isn’t affected.
The concern if the infection isn’t treated is that bacteria are seeded to the valve tissue and can cause an infection of the valve. In terms of the xarelto, this is fine with the TAVR valve, in fact there is some thought that use of blood thinners may help the valve last longer and trials under way to test this. Has he seen a dietitian to help with a diet plan, if not that may be helpful. The bed sores do need to be paid close attention to and should be attended to by a wound care specialist. PT and activity are also critical otherwise the debilitation may get worse.
Good luck with his recovery, hang in there.
My dad had a TAVR done two weeks ago I’m noticing his face swelling up. Does anyone know if this is a side affect and what the cause could be. I noticed swelling of hands and and incision can be a sign of stroke but what about the face. Thank you and May the Lord Jesus Christ be with you all.
I would recommend that you bring this to the attention of your TAVR team.
Dr Ahmed,
What are your thoughts on TAVR and being on dialysis? and concerning dialysis treatments during recovery?
My mom is 86, successfully been on dialysis for 5 years, pretty active, good life.
She has aortic stenosis, and slowly starting to show symptoms, getting winded, tired and a little cough.
I haven’t see much info with this type of surgery and being already on dialysis. I’d appreciate your thoughts!
Thank you.
In patients on dialysis, who are felt to be relatively stable otherwise there isn’t a contraindication to the TAVR procedure. We have done many TAVR’s on carefully selected patients on dialysis who have had good outcomes. Careful diligence needs to be paid to calcium in the vessels and aorta and valve as these factors if not considered can add risk to the procedure. The TAVR procedure in general is considered safer than conventional valve replacement in patients on dialysis however it is important to know that in patients on dialysis that outcomes are not great in general, due to many factors and often co-existing conditions.
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My sister had a TAVR procedure done one week ago and is doing great….no complications….feeling very good. She had a very bad knee/leg problem prior to surgery. Today she met with the orthopedic surgeon, and as expected, is in dire need of total knee replacement surgery. She’s in extreme pain and can hardly walk — bone on bone. How soon after the TAVR can she had her knee replaced? They’d like to perform this surgery ASAP so she can walk and get back to better health.
This depends on the urgency, i would recommend bringing up this question with the TAVR team at the 1 month follow up. They are likely to approve.
I am 44 and just received open heart surgery to replace my aortic valve, I was not high risk at all but I was wondering if the Dr.had to open my chest or could I have had the TAVR procedure. I did a little research and most Dr. say that you have to be high risk to avoid invasive treatment. I am still recovering and I would’ve preferred to have the noninvasive procedure compared to the amount of pain I am in and have been in for the last several weeks. I was informed that a metal valve was the best option but given a pig tissue valve instead and my thinking is why did they open my chest if a tissue valve is what received. Please help me understand.
As things stand the treatment you received was appropriate. There is not evidence to perform TAVR on a low risk population. In the future that may change, however not as things stand.
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Dr. Ahmed
I am 44 and recently underwent open heart surgery to repair a calcified aortic valve. Prior to the surgery I was informed that due to my age It would be best If I were to receive a metal valve due to its longevity. Instead I received a tissue valve while under so this leads me to question why was I not considered for TVAR after all I was given a tissue valve. I understand I was not high risk or elderly but I would’ve preferred the non invasive procedure compared to the invasive one. Please help me understand.
I am 65 yrs old, had the tarv operation, I am on Plavix , 81mg aspirin. , and Lasix. Sometimes I get dizzy. Is it the Lasix or the Plavix, causing this? In addition, can I drink alcohol? I get different answers to this.
Plavix should not cause dizziness, lasix may cause this if it makes your blood pressure drop. In general drinking while dizzy isnt a good idea, however drinking has no effect on the TAVR itself.
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Hello Dr Admed,
This site is very useful thankyou. My 84 year old father had the Tavi procedure done in Ireland, and is currently extremely ill. He had 2 stents fitted in the last 12 months. He was in excellent shape all his life, extremely fit and well untill 12 months ago. He went down hill in the last 12 months. He had the TAVI and did brilliant for 2 weeks after it. By the 3rd week he had shortness of breath and it was discovered he had a lung infection. They treated that , he was discharged fine again, then one week later again very weak with shortness of breath. He is currently in hospital where they are now looking at pallative care. They have just told us the Tavi was probably not going to resolve everything, (if this was the case why did they perform it) as he had extra leaking valves. My question is should he have had the TAVI ? it seems to have made him worse, he has been told now his heart function is 15 %. How do I find out if the valve was the wrong size? He has constant fluid on the lungs which they are draining Regards
Specifics about the valve itself will be answered by the performing team and the echocardiogram itself. Regarding the TAVR, one of the most difficult decisions is who is right to treat and in whom it is futile. Foe example, in patients with advanced dementia, no matter how bad the valve i feel its hard to justify TAVR. In some cases however its difficult to know what the underlying factor contributing to the patient decline is. Is it the valve? age? frailty? other conditions? even if many factors are involved, is the valve preventing improvement or treatment of the other conditions. Can addressing the valve potentially improve quality of life. These questions are common. Our approach to such cases is a long discussion with the patient and family discussing these factors, the risks, the unknowns and the likelihood of impacting the quality of life. In many cases the valve is so severe that not to try anything would mean likely death in short order, and in those cases we often feel compelled to try.
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Great information. I am 51 y/o and in the process of having my A/V replaced (Ross Procedure in 2001). Significant regurgitation, LV enlargement. I am very active, extreme sports, etc daily. Firefighter. Started showing signs of Pressure in lungs, slowing down, etc. What is your opinion on TAVR vs SAVR? I am mostly concerned about longevity and quality of life for this moment. Do you think that TAVR is a great option for me at 51? I ask this because this is not the normal.
In general at 51, if the operative risk is low, as things stand SAVR is the standard. As things stand today.
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My grandmother is 91 with symptomatic aortic stenosis: she’s been very active her whole life, very healthy diet and only eyesight and vertigo as any extra health problems. She started to develop breathlessness mid-March and she is hoping to get a TAVI in June (they cannot schedule the procedure sooner due to staff availability). She’s now declining to travel or walk far (she can walk about ten-fifteen metres before she needs to take a break) as she gets so tired. I’m so worried that her muscles will atrophy and that she may die before she gets the replacement. Is there any thing you can suggest (exercises, diet, etc.) to help her quality of life and health while she is waiting?
No, if she is unstable in terms of her symptoms then she needs to have her condition addressed immediately. Would recommend she is seen elsewhere if you are concerned. In large centers like hours, in emergent situations turn around times can be days only.
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Hi, Mr. Ahmed. Thanks for all the info. I had came across Xeltis, an inovative pulmonary valve that had is in the clinical trial on twelve patients in Europe. I think that they are in the pre-clinical tests on an Aortic also. Are you familiar with it? Do you have any more info about it? The also seek an TAVR solution. Cheers.
I have not heard of it.
Hi, thanks for Allan the info about tavr procedure. Do you know anithing about Xeltis? They are also triyng to develop a hybrid valve. Cheers.
How many times can a tarv value be replaced in ones life time.
Likely 2-3 times if absolutely needed.
Dr Ahmed, this was very informative. I am s/p SAVR with porcine valve 13 years ago. My cardiologist reports some fraying of the leaflets and has touched on the possibility of TAVR. I am 82 with COPD. Otherwise capable of ADL and no sign of dementia. I’m hoping this procedure might be possible for me. Thanks so much for your clear explanation.
TAVR would likely be an excellent option
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I am 59 years old and diagnosed with severe aortic stenosis. I went into the hospital because of symptoms and they were going to replace my valve. Before doing so, they found that my aorta was too small for the metal valve. They said that I would need grafting done. They decided to stop the procedure. Now I am seeing a doctor who does the TAVR. Is it safe to do the TAVR or should it be done open? I understand that there is a lot to consider.
Thank you.
Depends on many factors and would require a complete evaluation. In many cases including similar ones TAVR may be an excellent option.
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I have a BAV with severe stenosis, I am 53 and have had cabgx3 and thoracic aortic aneurysms graft 7 years ago along with 11 stents before and after, my cardiologist is recommending TAVR for my valve, I am worried about longevity of the valve at my young age, will I be able to have multiple TAVR over my lifetime? If I have to have OHS in my later years wouldn’t I be better off now OHS while I am young?
The likelihood is that current TAVR valves have the same longevity as the bioprosthetic surgical valves. Furthermore, there will be valve in valve options for TAVR valves also. At 53, certainly a good question to ask and the risk profile determines this. If significant risk to a surgical procedure TAVR may be a good option, the key is a full heart team approach.
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On June 12, 2018 my mother died during her TAVR operation. Please make sure you ask all the right questions before doing this surgery. It does have risk. A less than 2percent risk of death sounds like good odds, unless you are the person who dies.
So sorry to hear about your loss. The risk is very small but very real and as you have mentioned its critical to discuss these things ahead of time. The procedure, as with any procedure should only be done if a very real benefit is perceived and if the cost of leaving the disease alone would be worse than the small upfront risk of proceeding. In TAVR cases, it is known that leaving severe symptomatic aortic stenosis is dangerous and has high risk of death and poor quality of life that in trials has been shown beneficial. Although for the mainstay safe, as with any heart procedure, the risk is very real.
I am 59 years old (female) and have severe aortic stenosis, plus atrial fibrillation. I have had angiogram and CT scans and arteries in good shape, it’s just the valve. I am obese and am terrified of having open heart surgery.
I have been seen by surgeons and cardiologists and they have said I could have a TAVI, or a SAVR with hemisternotomy. The hospital I use does not do SAVR via thoracotomy, which I would have considered. I have two questions.
Might my AF revert to sinus after valve replacement, and if not could I have an ablation at a later date?
The valve they would use is the Edwards Sapiens 3 I think. If all goes okay with a TAVI, how long will I get out of the valve?
I don’t have any family support network and have two daughters, plus Two disabled sisters for whom I care and the worry of all this means I am struggling with horrendous panic and anxiety.
The decision needs to be made by an experienced heart team. Firstly the indication for any given procedure needs to be clear and then the best evidence based and approved options presented. The option needs to take in to account both short and long term outcomes. The team needs to provide all of these options. The question as things stand is your risk profile. If you are determined to be intermediate or high risk then the TAVR procedure has been proven effective, safe, and appears to be durable. If low risk, we dont know then answer yet and in general surgery advised. The surgical approach i.e sternotomy vs. mini depends on available expertise.
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I am a 47 year old female, caucasian, 4’11” 127lbs. I have a fair amount of health history. Diabetes, congenital disease, congenital heart disease, and recently recurrent kidney infections. I dont feel them until I am extremely I’ll. My last one I was scolded and told i should have had it treated sooner as the infection was so severe kidney failure was expected. I went as soon I felt anything to the ER.
Last week I had another infection that was misdiagnosed as a kidney stone. Labs were wrong. As a result it went untreated for 4 days and i became very, very ill. My GFR is 38, creatinine 1.49. The hope is my kidney function will improve as I recover.
I need an aortic valve replacement in 1 to 2 years. Depending on the doctor, i am or am not a candidate for open heart. Most recommend TAVR, I prefer open. But, of i cannot have an open heart, it’s nice to know TAVR is available. I have been unable to have iv contrast for a CT SCAN of my kidneys due to the low function. My meds have had to be adjusted….
Do these kidney issues mean I am not a TAVR candidate? I mean, I dont want to put the cart in front of the horse here, I need to figure out what’s up with my kidneys first and see if we can improve those numbers, but does this make me ineligible for TAVR? I prefer open, but if I cant have that, it would be nice to know that TAVR is an option. I am pretty concerned there may be no options available.
I dont see anything that youve mentioned that would make you not eligible for TAVR. Its very likely youll have an option.
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As a Jehovah’s Witness could you tell me if there would be the possibility of having to have a blood transfusion during a tavr operation for a heart valve replacement ?
The team must be be aware that transfusion is not an option. Significant blood loss although rare is possible during the procedure and is a known risk.
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Excellent article! I’m happy to read and understand the process. I have just had my aortic heart valve replaced and now I know what was done to me.
I accessed this article in an effort to find out about questions concerning health issues after the valve replacement. Such as breathing, will breathing become better or will I be wearing oxygen the rest of my life? Weakness, I hope this slowly becomes better, but I am pretty weak after the valve replacement (accomplished three days ago).
Would it be possible to address these and any other recovery concerns? Thank you.
The TAVR may well improve breathing and fatigue. In terms of the oxygen it depends on the reason it is required in the first place. If it is from heart failure it may well improve, if a primary lung issue then it may not affect oxygen use although still can improve symptoms. See how you feel at the 1 month point.
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This is the most helpful site concerning TAVR that I’ve encountered. Thank you! I’m a 77 year old male with a history of peripheral vascular disease, and underwent CABG in 2005. Because of shortness of breath and imbalance, but no chest pain, I underwent a heart catheterization and an echocardiogram two weeks ago. Indications were mild to severe aortic stenosis, and elevated velocity gradient. I’m to see a TAVR specialist later this month for further evaluation, although my regular cardiologist has said that I’m a candidate for TAVR. I assume the local hospital uses the team approach for evaluation.
My question is – I hope – a simple one. Because the heart cath via the right femoral artery went off without a hitch, does that suggest TAVR through that artery could be a safe approach?
Glad you found the site useful.
Firstly i think the heart caths should all be done radial, i dont understand particularly in TAVR patients why people would go femoral. Secondly a angiogram of the leg will be taken prior to using the leg foe the TAVR during the procedure that should confirm its suitability.
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i am an 85 year old male . i suffered a syncope (while talking on the phone) 3/29/18 and entered hospital for diagnosis which indicated severe AVS. prior to the syncope i experienced no symptoms; although i experienced a syncope five years earlier (while sitting and having lunch). i led a normal lifestyle and did 45 minutes of cardio 3x weekly. during my four day hospitalization all tests were performed: echocardiogram resting as well as with stress on a treadmill; cardio catheterization only under mild sedation (results: no arterial problems presented). i was advised by the cardiologist/interventionist to have the TAVR procedure. after discharge i consulted with a generic cardiologist who suggested i not do anything for four months (which will expire in august) and lead a normal lifestyle, which i have done. to date i have been asymptomatic except for some fatigue. i also did a subsequent consultation with another interventional/cardiologist; who after studying the previous tests recommended TAVR. both interventional/cardiologists, as well as the generic cardiologist are affiliated with renowned medical centers in NYC. there is one BIG problem: i have lived with a diagnosis of MDS for eight years and my platelets are now in the mid 20,000 range. i have been under the care of a hematologist/oncologist all this time and to date it has only been “wait and watch.” my hematologist/oncologist has given the go ahead to do the procedure providing i get the appropriate platelet transfusions pre and post TAVR procedure and be closely monitored for several days after the procedure. given my platelet condition how will that be affected should i need, if at all, an extended regimen of blood thinner. also what complications are possible during the procedure as well as after the procedure i.e.: stroke, given my MDS condition. i believe within the near future i will need to begin treatment for the MDS given the low platelet count.
Of course these are complex issues that require management from an experienced valve team. The decision regarding blood thinner afterwards depends on a number of factors including risk and history of bleeding and needs to be discussed between the hematology and cardiology teams.
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THANK YOU FOR YOUR WONDERFUL RESOURCES FOR THE TAVR PROCEDURE. MY MOM IS 90 AND WILL HAVE HER PROCEDURE AS SOON AS WE CLEAR UP A VERY BAD KIDNEY INFECTION.
COULD YOU TELL ME HOW LONG I SHOULD EXPECT HER STAY IN THE HOSPITAL AFTER YOU TAVR IS DONE?
THANK YOU!
Glad you found this useful. In general we discharge patients within 36-48 hours all going well and if the patient stable before hand.
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Hello Dr Ahmed
My 82 year old mother underwent the Tavi procedure nearly 3 weeks ago. She was kept in hospital a few days more than expected due to her heart rhythm not being quite right, the team was considering a pacemaker but decided it was not necessary, thing seemed to settle and so she came home.
She is doing well generally, eating well and has been gradually been moving more, doing some walks. However she continues to have dizzy spells when she gets up, some days are better than others but it doesn’t seem to be going away. Can you please advise any reason for this? Her blood pressure has been a bit low and they are trying to adjust her medication for that. Could that be the cause or is it possible something else is going on?
Thank you for your assistance. What I have observed as my parents get older is that they are not comfortable ‘rocking the boat’ or asking their team for advice if they have concerns, rather just waiting to see if things will resolve on their own.
Kind Regards
Has she been for the 1 week TAVR follow up. I would make sure that the heart rhythm remains stable and the valve assessed. A monitor may be of use. Make sure this is bought up asap with the heart valve team.
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How do you print this article out without all the comments?
save it as a PDF then print only the pages you want.
Dr Ahmed, This is an excellent article. Thank you for publishing it. Is the procedure (particularly placement of the valve) more challenging if the patient has chronic a fib? We’re not sure my father will even qualify for TAVR, but we’re trying to gather as much information as possible. He has moderate aortic stenosis but severe aortic regurgitation with CHF.
The presence of Afib should not make a difference to the technical aspects of the procedure.
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Hi Dr,
Great article, I have a question. Due to compromised immune system from RA I am being evaluated for TAVR at the age of 63.I am a 6 ft tall 225 lb male, my ascending aorta measures 4cm. If it should progress to being more significant(aneurism) can it still be surgically corrected if I have TAVR ? And with severe Aortic Stenosis corrected by a new valve would I be less likely to develop an aneurism?
It depends on the cause of the aneurysm, for example if felt due to post stenotic dilation it may arrest further growth rate although surveillance still recommended. The TAVR itself wouldn’t necessarily prevent further surgery for the aneurysm although decision would need to be made at the time regarding replacement of the valve.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Do you perform many TAVRs on patients with cirrhosis and low platelet count.
We have done several of these cases with appropriate precaution and optimization.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Tremendous issues here. I’m very satisfied
to peer your article. Thanks a lot and I am taking a look forward to contact you.
Will you kindly drop me a e-mail?
Hello Dr. Ahmed,
Thank you so much for this article and the information! My 92-year-old father is being evaluated for TAVR at Scripps in La Jolla. My question: He has a severely distended abdomen that bothers him and causes mobility issues. Any chance that TAVR will alleviate some of this?
What is the cause of the distention?
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Hello Dr. Ahmed,
Thanks so much for this helpful and informative article! My 92-year-old father is currently undergoing evaluation at Scripps Hospital in La Jolla for TAVR. My question: He has a severely distended belly that interferes with his mobility. Is there any chance that some of this might be alleviated with TAVR?
Hi I have a question about a TAVR performed and have a medical record of a critical situation and wanted to know can these results cause death? Can a flat inferior vena cava and three other places of internal bleeding cause you to die if you bleed for 10 hours?
Hi Cindy, sorry to hear of the situation, have you made an appointment to discuss with the performing team?
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I am female, 75 and healthy, and active although obese. I have high blood pressure under control and Clinical Depression. My labs look like I am someone much, much younger. Shortness of breath and increasing fatigue…unexplained…except that it …’is my weight’ or that it is ‘anxiety’…. SOB and fatigue has increased and the discussion now is ‘aortic stenosis’. I was first informed I had a ‘murmur’ when I was 28. I had an stress-echo about 8 yrs. ago and passed…maximum heart rate reached…was told my vessels were ‘clear’….and some aortic stenosis. My renowned cardiologist stated that I did not have a ‘murmur’ but some calcification. I have been confused with that statement ever since and so has my Internist !!
Next week will be a new ECHO, etc.
I have longevity in my line…90’s and 100’s with my GRAND parents and GREAT grandparents. I can find no specific information on the expected life of replacement aortic valves other than 10- 15 yrs. Realizing I am asking for an opinion only, IF that is the case, might I just live as long or longer if I do NOT replace it?
If a valve is placed and degenerates in 10-15 years, it will be fine to place another one within it. We already know the results of this are encouraging.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Dr
I had my TAVR surgery two weeks ago and I’m curious when I will begin to feel better. I am marginally feeling a little better, but still very exhausted. I’m taking Plavix, Aspirin 325mg, Accuretic 20mg, Clopidogrel 75 mg and Pravachol 40 mg. I am not nearly as short winded as before. I am wearing a heart monitor. My BP, and heart rate has been consistent. (Heart rate is elevated somewhat, and was before the procedure.) My weight went up about 2 lbs. I don’t appear to have swelling. (Though my stomach does seem bigger) I am type 1 diabetic. (Last A1C 7.4) Blood test came back normal. I expected to feel better quickly. I’d appreciate your comments.
Jeff Davison
Below are results from Echocariogram post surgery
A 26mm Sapien 3 bioprosthesis was well seated with normal antegrade function.
V2=1.6m/s
Peak and mean gradients were 10 and 5mmhg
There was no paravalvular regurgitation
Left ventricle: Size was normal. Systolic function was normal. Ejection
fraction was estimated in the range of 60 % to 65 %. There were no regional
wall motion abnormalities. Wall thickness was normal. Right ventricle: The size
was normal. Systolic function was normal. Wall thickness was normal.
Left atrium: Size was normal.
Right atrium: Size was normal.
Aortic valve: The valve was trileaflet. Leaflets exhibited markedly increased
thickness, marked calcification, and markedly reduced cuspal separation.
Doppler: There was severe aortic stenosis.
LVOT=2.1cm
V1=0.7m/s
V2=3.1m/s
Peak and mean gradients were 38 and 23mmHg
Calculated aortic valve area=0.78cm2 There was no regurgitation.
Aorta: The root exhibited normal size.
Mitral valve: Valve structure was normal. Doppler: There was no evidence for
stenosis. There was no regurgitation. Tricuspid valve: The valve structure was
normal. There was normal leaflet separation. Doppler: There was no
regurgitation.
Pulmonary artery: The size was normal.
Pericardium: There was no pericardial effusion. The pericardium was normal in
appearance.
A lot depends on whether there are other coexistent conditions that are associated with your symptoms. It sounds the procedure went well and there was an immediate clinical benefit, also if severe symptomatic aortic stenosis prior then there is now a much reduced risk of death. Hopefully with conditioning your symptoms improve.
Are you enrolled in cardiac rehab?
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
My Grandmother is 80 years old and has an aneurysm behind her heart plus diabetes and might be needing this procedure done for her and the doctors said it will be 50/50 If she was to have this done so I just want to know what the risks could be and how risky do you think it will be and should she get it done?
Hello,
I am scheduled to have an open heart aortic valve replacement on April 15th with a possible aortic root replacement at the same time. I am currently trying to decide on a mechanical or a bovine valve.
I am 63 years old. I had an open heart ascending aorta graft performed in 2014. I am relatively healthy … all organs have been assessed and are in prime shape. I have controlled high blood pressure & am overweight (5′ 2″ and 184lbs). My valve is severe stenosis and I have multiple systems (shortness of breath, chest pain, light-headed, fluttering heartbeat, swelling). My aortic root is 5.2cm.
I am being advised to have the mechanical valve, however have some concerns about the maintenance of Warfrin afterward. Amongst the many, one of those is that I travel out of the country (out of the USA) to remote villages during about 4 months of the year. During those time my diet consists of whatever they eat which could cause quite a fluctuation in the Vit k levels.. I am contemplating having the bovine valve now and then a TAVR when needed (hopefully about 12 to 15 years from now). My question is can a TAVR be performed when there is already a grafted ascending aorta and a grafted aortic root?
Thank you for your time!
Hello,
I am scheduled to have an open heart aortic valve replacement on April 15th with a possible aortic root replacement at the same time. I am currently trying to decide on a mechanical or a bovine valve.
I am 63 years old. I had an open heart ascending aorta graft performed in 2014. I am relatively healthy … all organs have been assessed and are in prime shape. I have controlled high blood pressure & am overweight (5′ 2? and 184lbs). My valve is severe stenosis and I have multiple systems (shortness of breath, chest pain, light-headed, fluttering heartbeat, swelling). My aortic root is 5.2cm.
I am being advised to have the mechanical valve, however have some concerns about the maintenance of Warfrin afterward. Amongst the many, one of those is that I travel out of the country (out of the USA) to remote villages during about 4 months of the year. During those time my diet consists of whatever they eat which could cause quite a fluctuation in the Vit k levels.. I am contemplating having the bovine valve now and then a TAVR when needed (hopefully about 12 to 15 years from now).
My question is can a TAVR be performed when there is already a grafted ascending aorta and a grafted aortic root?
Thank you for your time!
Yes TAVR can be performed after aortic surgery.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
My Dr. wants to do a TAVR when I reach 50%. Yet at 64 I lift weights, squat 225, for 2/3 hours a day nd walk 3-6 miles a day. Why would I exchange a great quality of life for a limited 10-15 years valve replacement ? Shouldn’t I feel ill, weak or need help?
At the age of 64 surgical valve replacement would be likely recommended particularly in a fit and healthy individual. It’s important that a bicuspid valve ruled out and the ascending aorta assessed. The indication for surgery is typically symptoms even if mild symptoms. Rate if progression and other factors may play a role. There are some TAVR trials where early patients may be enrolled but it’s not standard. Discuss your indicators for surgery with your team to seek clarification.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I am a 71 yr. old male in good health overall (well controlled high BP with Metoprolol), am quite active physically and socially, non-smoker and light drinker. I walk 4-5 miles most days and feel great. However, I was advised 6 mos. ago by a cardiologist that I had moderate to severe Aortic Stenosis, leaning toward severe: MG @ 31 and AJV @ 4.0. He would have liked to perform TAVR right away but the hospital went into shutdown for elective procedures due to Covid and the decision was made to evaluate again in May. Subsequent Echo Cardiogram was done 4/21/21 with resulting values: MG @ 45 and AJV @ 4.5. He again advised TAVR be performed ASAP, probably next month. The test results would surely indicate significant progression however I am still experiencing NO symptoms and am able to do all the things I want, including rugged hiking with no shortness of breath or dizziness/light-headedness. He keeps saying that I’ll feel better after the procedure but I feel great now. My question is this: Is TAVR being indicated now for people who aren’t sick and is there a significant benefit to intervention before onset of symptoms? I have concerns about the long list of possible disastrous events that can and do occur, i.e.: death, stroke, bleeding, a-fib, etc. I have read quite a few accounts on here of otherwise healthy patients succumbing after this “safe” procedure, on the other hand, I do want to live for as many more years that I can live well. I anxiously await your reply. Thank you for making this resource available.
Question: Is air travel safe two or more years after having a TAVR placed? What are the risks?
Thanks for sharing this knowledgeable information.