Transcatheter Aortic Valve Implantation

What is transcatheter aortic valve implantation?

Transcatheter aortic valve implantation (TAVI), also referred to as transcatheter aortic valve replacement (TAVR), is a procedure that replaces your diseased aortic valve with a man-made valve. The TAVI procedure has been recommended to you as an alternative to open heart surgery. The old heart valve is not removed but acts like an anchor for the new heart valve. This procedure is done through small cuts (incisions) using a long, thin tube (catheter), X-rays, and ultrasound.

The aortic valve controls blood flow from the left ventricle of your heart to the rest of your body. The valve can become scarred and stiff and not open correctly. This condition is called aortic stenosis. This means the left ventricle of the heart has to work harder to push the blood through the valve. Your heart may have to work too hard to pump blood through this small valve opening to the rest of your body. In some cases, this extra work will make the muscle of the ventricle get thicker. In time, the extra work can tire the heart and cause the heart muscle to get weak. This may lead to increasing heart failure.

During the procedure, your healthcare provider inserts a catheter through a blood vessel in your leg to deliver and implant the artificial valve into your heart. Sometimes, the catheter is placed through a small incision in your chest underneath the collarbone. Or it is put through an incision between the ribs. The new valve helps improve blood flow from your heart to the rest of your body.

Why might I need TAVI?

You may need TAVI if you have progressive heart failure from aortic stenosis, but you aren’t a good candidate for traditional open-heart aortic valve replacement surgery. Conditions that would make open-heart surgery dangerous for you include:

• Advanced age

• Weaker heart

• Past heart surgery

• History of stroke

• COPD (chronic obstructive lung disease)

• Kidney disease

• Diabetes

• Past radiation treatment to your chest

• Large calcium deposits in the blood vessel that carries blood away from your heart (ascending aorta), called porcelain aorta

• Being frail or having a physical disability that would make recovery from an open-heart surgery challenging

What are the risks of TAVI?

As more surgeons and surgical centers get more experience with TAVI, the risks are decreasing. But TAVI is still a major procedure that may need general anesthesia (medicine that puts you to sleep and prevents you from feeling pain). Any general anesthesia includes risks for heart or brain injury.

The most common risks associated with TAVI include:

• Damage to your blood vessels or heart

• Bleeding

• Decreased blood supply to your brain, causing a stroke

• Heart attack

• Kidney damage or failure

• Collection of fluid around your heart

• Failure of your replacement valve

• Heart rhythm problems that may need a pacemaker

• Rupture and damage to the old valve

• Severe heart failure

• Death

There may be other risks, depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for TAVI?

Before the procedure, your heart valve team will evaluate your overall health. This may include X-rays, CT scans, blood tests, and other tests to check the health of your lungs and heart. Your medical team will also give you an echocardiogram to evaluate your aortic valve. This test uses sound waves to create images of your heart. Your medical team may also do a cardiac catheterization to evaluate your heart. You will also need to:

• Tell your healthcare provider about any medicines you are taking, including over-the-counter medicines, vitamins, herbs, and other supplements. It also includes any blood thinners, such as warfarin or daily aspirin. You may need to stop taking some or all of them before the procedure.

• If you still smoke, ask your healthcare provider how soon before the procedure you need to quit.

• Stop certain medicines if your healthcare provider instructs you to.

• Follow any directions you are given for not eating or drinking before the procedure.

• Tell your healthcare provider if you’re allergic to any medicines, have had a reaction to anesthesia, or have a bleeding disorder.

• Talk with your healthcare provider about any questions or concerns you have before the procedure.

• Follow all other instructions that you are given.

What happens during TAVI?

Methods may vary, depending on your condition and your healthcare provider's practices. Talk with your provider about what to expect. Generally, a TAVI procedure follows this process:

• You will need to remove any jewelry or other objects that may interfere with the procedure.

• You will need to remove your clothing and will be given a gown to wear.

• You will need to empty your bladder before the procedure.

• An IV (intravenous) line will be started in your arm or hand. Additional catheters may be inserted in your neck and wrist to keep track of the status of your heart and blood pressure, and to take blood samples. Alternate sites for the additional catheters include under the collarbone.

• You will be positioned on the operating table, lying on your back.

• The anesthesiologist will continuously keep track of your heart rate, blood pressure, breathing, and blood oxygen level during the procedure. If general anesthesia is used, a breathing tube will be inserted into your throat and into your trachea (breathing tube) to provide oxygen to your lungs while you are asleep. You will then be connected to a ventilator, which will breathe for you during the procedure.

• A transesophageal echocardiogram (TEE) probe is often inserted into your esophagus to help visualize the valve. General anesthesia is often used if the TEE probe is used.

• The skin over the surgical site in your groin will be cleansed with an antiseptic solution.

• Your surgeon will make an incision in your groin area to locate your femoral artery and vein. The artery carries blood from your heart down into your leg.

• The surgeon will place a catheter into that artery and thread it to your heart and through your aorta to reach your aortic valve.

• A temporary pacing wire is also placed in the vein and into the heart to allow for pacing.

• Your surgeon may also place other catheters in your heart to take measurements and X-ray pictures during the procedure.

• Your surgeon will guide your replacement valve, inside an expandable balloon, up the femoral artery catheter and through your old aortic valve.

• Once the balloon is correctly positioned, your surgeon will expand it and implant the new valve to replace the old one.

• Your surgeon will take measurements and images to make sure your new valve works correctly before removing the catheters.

• Your surgeon will close your femoral artery or vein and the incision in your groin area with stitches or clips.

What happens after TAVI?

You may be moved to the intensive care area of the hospital, so you can be closely kept track of while you recover from the procedure. Your groin area will be watched for bleeding and for normal blood flow to the leg. Your vital signs, such as your heart rhythm, will be kept track of too. You will soon be able to get up and walk and return to a normal diet. You may need to stay in the hospital for 1 to 2 days.

After your healthcare providers feel you have recovered enough to go home, follow all instructions for medicines, pain control, diet, activity, and wound care. Make sure to keep all your follow-up appointments.

Complete recovery may take 1 to 2 weeks. Here are some helpful guidelines to follow as you heal:

• Your healthcare provider may give you blood thinning medicine to prevent blood clots after a TAVI.

• Gradually resume normal activities, but don't do any heavy lifting.

• Ask your provider when you can resume driving, work, and sexual activity.

• Watch your groin for any sign of swelling, redness, bleeding, or discharge.

• Let your provider know if you feel any pain or have fever, bleeding, or shortness of breath.

• Eat a heart-healthy diet and maintain a healthy weight.

• Don't smoke.

Tell all your healthcare providers and dentists you’ve had a valve replacement. You will need to take antibiotics before you have dental work, as prescribed by your healthcare provider. This is to help prevent bacteria from harming your new heart valve.

Next steps

Before you agree to the test or procedure, make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure