Transcatheter Aortic Valve Replacement (TAVR) Procedure

The TAVR full form is Transcatheter Aortic Valve Replacement. Also referred to as Transcatheter Aortic Valve Implantation (TAVI), TAVR is a less invasive technique utilised for replacing a damaged or malfunctioning aortic valve within the heart.

Unlike traditional open-heart surgery, TAVR does not require a large incision or a heart-lung bypass machine. The procedure can replace the aortic valve from inside the body. 

Originally, TAVR was developed as an alternative to open-heart surgery. It was performed for patients with a high risk or who were not the ideal surgery candidate.
However, the procedure is now used for low-risk patients as well. 

Anatomy and Physiology of the Aorta

The aorta is the largest artery in the human body and plays a crucial role in the cardiovascular system. It originates from the left ventricle of the heart and distributes oxygenated blood to all the organs and tissues in the body. 

Anatomy

The aorta is divided into several segments based on its location within the body. 

1. The widest part of the aorta is an aortic root that attaches to the heart. 

2. The aortic valve is three flaps of tissue that open and shut to let oxygenated blood leave the heart. 

3. Once the aorta leaves the heart, it rises upwards. This segment is called the ascending aorta. It begins at the aortic valve. 

4. It then forms an arch known as the aortic arch before continuing downward as the descending aorta. 

5. The descending aorta divides into the thoracic aorta (passes through the chest) and the abdominal aorta (travels through the abdomen).

6. The aorta is made up of three layers: the tunica intima (innermost layer), tunica media (middle layer), and tunica adventitia (outermost layer). 

Physiology

1. The main function of the aorta is to receive oxygen-rich blood from the left ventricle during systole (when the heart contracts) and distribute it throughout the body during diastole (when the heart relaxes).

2. The aortic valve ensures that blood does not flow back into the heart during diastole.

TAVR serves as an alternative to conventional open-heart surgery for aortic valve replacement. Healthcare providers may recommend this procedure for individuals with the following:

1. Severe aortic stenosis causes signs and symptoms like chest pain or tightness with activity, difficulty breathing, dizziness, etc.  

2. A previously implanted biological tissue aortic valve that does not work properly

3. Other health conditions, like kidney or lung disease, make open-heart valve replacement a high-risk surgery.

Conditions Treated With TAVR

TAVR primarily treats aortic valve disease, specifically aortic stenosis. It is the most common condition treated with this procedure. Aortic stenosis develops due to the narrowing of aortic valve opening.

This results in a blockage that obstructs the blood flow from the heart to the rest of the body. Any of the following typically causes the narrowing:

1. Accumulation of calcium deposits on the valve

2. Wear and tear associated with ageing, particularly in individuals over 70 

3. Other underlying health conditions 

When the aortic valve narrows, it restricts the amount of blood that can flow to an individual’s body. This makes the heart work harder to compensate for a lack of blood supply. Over time, this increased workload can cause significant damage to the heart muscle, leading to heart failure.

Contraindications for Aortic Valve Replacement

TAVR is a beneficial procedure for improving blood flow. However, some individuals may not be suitable for the procedure due to certain conditions or circumstances. These conditions include:

1. Congenital heart defects (defects that a person is born with)

2. Very short space for the new valve

3. Heart attack a month before

4. Recent stroke or transient ischemic attack (lasting only a few minutes)

5. Severe weakening of certain parts of the heart

6. Other heart valve problems like mitral regurgitation (blood leakage due to improper closure of the valve between the left heart chambers)

7. Severe kidney disease

The TAVR procedure replaces a diseased aortic valve with a biological tissue valve (a valve made from cow or pig heart tissue). It takes about two to four hours to complete.
The TAVR procedure step-by-step is as follows:

Step 1: Patient Position

The patient is moved to the OT room. They are made to lie comfortably on their back on the operating table. 

Step 2: IV Line Administration

Before the procedure, the anaesthesiologist inserts an IV line in the patient’s arms or hands for medicines or fluids. 

Step 3: Anaesthesia Administration 

The patient may receive general anaesthesia to make them sleep throughout the procedure. Usually, TAVR surgery is performed under moderate sedation, where the patient is not completely asleep but does not feel pain.

In the case of general anaesthesia, the patient has a tube inserted down their throat connected to a ventilator to help them breathe. 

Step 4: Cleaning the Surgical Site

Someone from the nursing team cleans the surgical site with an antiseptic solution to prevent infections. 

Step 5: Monitoring Vital Signs

The anaesthesiologist monitors the patient's vitals throughout the procedure. These vital signs include heart rate, breathing, blood pressure, etc. 

Step 6: Making an Incision

The cardiac surgeon then makes a small incision to access the blood vessels, usually in the groin or chest area. 

Step 7: Inserting the Catheter 

A catheter (a thin, long, flexible tube) is carefully threaded through the incision and guided through the blood vessels to reach the aorta.
Doctors use imaging tests to place the catheter in the correct position. 

Step 8: Placing the Valve

Once the catheter reaches the aortic valve, a biological valve is passed through the catheter and positioned within the diseased valve. A balloon at the end of the catheter is expanded to press the new valve into place.

The artificial valve then takes over the original valve's function, allowing improved blood flow.

Step 9: Removing the Catheter and Closing the Incision

Once the valve is securely in place, the catheter is carefully removed. The incision is then closed with sutures and a dressing.

There are several things that patients must keep in mind to ensure a successful TAVR procedure. The healthcare provider will give instructions to be followed before and on the day of the procedure. 

Before TAVR

The patient can expect the following before the procedure:

1. Pre-Anaesthetic Checkup: The doctor will advise the patient for a pre-anaesthetic checkup. This helps understand the potential side effects of anaesthesia for the patient. 

2. Consultation and Evaluation: The healthcare team will thoroughly evaluate the patient’s overall health, medical history, and the severity of aortic valve disease. The tests for this evaluation may include:

1. Blood tests

2. Echocardiogram

3. Electrocardiogram

4. CT scan and X-rays

5. Cardiac catheterisation (to evaluate the arteries that supply blood to the heart)

3. Medications: Patients must inform their provider about their medications, including over-the-counter, supplements, or herbs. They may need to stop taking certain blood-thinning medications before the procedure. 

4. Lifestyle Adjustments: The healthcare team may advise the patient to make certain lifestyle adjustments in the days leading up to the procedure. This could include quitting smoking, as it can delay recovery. 

5. Fasting: The patient will be informed to stop eating or drinking, usually after midnight the day before the procedure. 

6. Discussion: The doctor will briefly explain the procedure, hospital stay, cost, and insurance formalities. They will also inform the patient about the types of artificial valves.

On the Day of TAVR

The patient can expect the following on the day of the surgery:

1. The patient must sign the consent form, giving permission for the procedure. 

2. They will be asked to change into a hospital gown, remove jewellery, dentures, contact lenses, and nail polish. 

3. The team will shave the excess hair at the patient’s surgical site. 

4. The doctor will record their last meal and give medication to be taken with a small sip of water. 

5. An anaesthesiologist will monitor the patient’s vital signs, such as breathing, blood pressure, etc. 

6. The team will move the patient to the OT room.  

After undergoing a TAVR heart surgery, patients can expect a recovery process that is generally shorter and less intense compared to traditional open-heart surgery.
Complete recovery after the procedure usually takes about six to ten weeks. 

The Recovery Process in the Hospital

After TAVR, patients can expect to stay in the hospital for one to four days. However, most people return home within a couple of days. Patients will spend the first night in the intensive care unit (ICU) for monitoring.

Usually, after 24 hours, they will be moved to a regular room. Here’s what patients can expect during the hospital stay:

1. Close Monitoring by the Medical Team: They will check the patient’s vital signs, assess the functioning of the new valve, and ensure there are no immediate complications.

2. Pain Management: Some discomfort or soreness at the incision site is normal after the procedure. The healthcare team will provide pain management medications to help alleviate any discomfort.

3. Movement: The day after the surgery, patients will be encouraged to get up and move around. 

4. Discharge: Once the patient’s condition stabilises, they will be discharged from the hospital. The healthcare team will provide wound care, medicines, pain control, activity and diet instructions.
   They will also provide follow-up instructions. 

Recovery Process/Expectations After Hospital Discharge

The recovery period can vary from person to person. It depends on factors such as age, overall health, duration of surgery, other health conditions, etc. However, here are some general guidelines and tips for a successful TAVR recovery at home:

1. Diet and Lifestyle: Eat a balanced, heart-healthy diet after TAVR surgery to support recovery. Include fruits, vegetables, lean proteins, whole grains, and limit salt and saturated fats.
   Quit smoking, as it can delay recovery. 

2. Wound Care: Keep the incision area clean and dry. Follow the instructions provided by the healthcare team for wound care.
   Keep a close eye on the incision site for signs of infection, like swelling, redness, or discharge.

3. Cardiac Rehabilitation: It is a workout plan to improve the heart’s strength and endurance.
   The rehabilitation program will begin several days after the TAVR procedure. 

4. Activity and Restrictions: Rest well throughout the first few days of recovery. As directed by the medical provider, avoid vigorous activity, heavy lifting, and intense exercises.

   Increase the exercise levels gradually as directed by the healthcare practitioner. Avoid driving for at least four weeks after TAVR or until the doctor approves. 

5. Work: The doctor will provide information about when patients can return to work. It usually takes about two weeks to return to work, depending on the type of work. 

6. Medication: The doctor may prescribe several medications after TAVR. Take all prescribed medicines as directed. These may include:

1. Painkillers (to manage pain and discomfort)

2. Blood thinners (to prevent blood clots)

3. Antibiotics (to prevent infections)

7. Psychological Support: During the rehabilitation process, emotional support is critical. Patients must share their thoughts and experiences with family, friends, and support groups.

   If they experience symptoms of sadness or anxiety, they must seek advice from a healthcare professional.

First Follow-Up Appointment

The first follow-up appointment will occur about one month after the procedure. Attend all follow-up appointments with the healthcare professional.

These visits are critical for tracking the progress and confirming that the replacement valve works properly. They may perform tests such as:

1. Blood tests

2. Echocardiograms

3. Electrocardiograms

TAVR offers several significant benefits, making it a game-changing procedure in the field of cardiology. Some key advantages of TAVR include:

1. Minimally Invasive Approach: TAVR is less invasive than traditional open-heart surgery.

   It only requires a small incision in the leg or chest, reducing the risks associated with large incisions and the use of a heart-lung bypass machine.

2. Faster Recovery: The less invasive nature of TAVR leads to faster recovery times and shorter hospital stays than open-heart surgery.

   Patients typically suffer less post-operative pain and can resume routine activities sooner.

3. Lower Risk of Stroke: The procedure has a lower stroke and death risk than surgical aortic valve replacement. 

4. Symptom Relief: It effectively relieves the symptoms of severe aortic valve disease, such as chest pain, shortness of breath, dizziness, and fatigue. 

Although TAVR is a highly effective and minimally invasive surgery, it has some risks and potential consequences. Individuals and their healthcare providers must explore these factors before deciding on the optimal treatment option.
The following are some risks and complications linked with TAVR:

1. Bleeding: Some patients may experience excessive bleeding at the catheter insertion site or other areas.

2. Blood Vessel Damage: Inserting the catheter through blood vessels can lead to bleeding, damage, or blockage of the blood vessels. 

3. Problems With the Replacement Valve: Dislodgement or leakage (regurgitation) of the new valve may occur during or after TAVR. This may affect the valve’s proper functioning. 

4. Stroke: During the procedure, there is a slight chance of dislodging plaque or clots. This may cause decreased blood supply to the brain, leading to a stroke.

5. Heart Rhythm Issues: The TAVR technique might produce irregular heartbeats (arrhythmias). This may necessitate intervention to implant a pacemaker. 

6. Heart Attack: The procedure’s impact on the heart and blood vessels can cause a heart attack in rare cases. 

7. Kidney Damage: Acute kidney disease is a common complication in patients undergoing TAVR procedures. 

8. Allergic Reactions: In rare cases, patients may have an allergic reaction to the anaesthesia or other medications used during the procedure.

9. Infection: Although rare, patients may have a risk of infection at the incision site or around the new valve.

10. Mortality Risk: As with any medical procedure, there is a slight risk of mortality associated with TAVR. The most common causes include infection and heart failure. 

When to See a Doctor?

If a patient encounters any troubling symptoms or changes in their health during recovery, they must call their healthcare professional immediately.

Prompt communication with the medical team addresses potential concerns and ensures the best possible outcome following TAVR. Patients should consult a doctor if they experience the following:

1. Dizziness

2. Sudden weight gain

3. Fatigue while performing activities

4. Signs and symptoms of infection (high fever, nausea, vomiting, drainage from the incision site, etc.)

5. Swelling of the ankles

The following symptoms require immediate medical attention:

1. Chest pain or pressure

2. Sudden shortness of breath

3. Fainting

Delaying TAVR can pose various risks for patients suffering from severe aortic valve dysfunction. Some of the risks associated with postponing TAVR include:

1. Disease Progression: Aortic stenosis tends to deteriorate over time. A delay in TAVR can result in the additional narrowing of the valve, increasing strain on the heart.

   It may aggravate symptoms like chest pain, shortness of breath, and fatigue.

2. Increased Complication Risk: As aortic stenosis progresses, the risks of complications like arrhythmias, heart failure, and death may increase. 

The cost of TAVR in India can range from ₹ 1,30,000 to ₹ 3,00,000. The cost can differ based on multiple factors. 

Factors that may affect the cost of the procedure may include:

1. City or Location: The cost of TAVR can differ from one city to another based on the healthcare system, cost of living, etc. 

2. Pre-Operative Tests: The cost of diagnostic tests and imaging may differ at different medical facilities, affecting the overall cost. 

3. Type of Hospital: The choice of hospital can affect the cost of TAVR. Premium medical facilities with cutting-edge technology and expert medical teams may demand a higher fee for the treatment.

4. Patient’s Medical Condition: Those who have pre-existing health conditions may require additional evaluations.

   This may contribute to the overall cost. 

5. Experience of Doctors: TAVR cost can be influenced by the knowledge and expertise of medical professionals.

   Medical experts who are highly trained and specialised may charge higher prices for their services.

6. Duration of Hospital Stay: Longer hospital stays may result in increased costs for accommodation, medical care, and other services.

The TAVR procedure has emerged as a groundbreaking and effective treatment for severe aortic valve disease. With its minimally invasive approach and shorter recovery times, TAVR offers a viable alternative to traditional open-heart surgery.

As medical technology advances, TAVR’s potential to enhance the quality of life for individuals with aortic stenosis remains promising.

Are you looking for a trusted partner on the path to a healthier heart with TAVR? HexaHealth can be your right choice! Our experienced healthcare professionals are dedicated to providing expert guidance.

We are here to provide personalised treatment plans, extensive pre-procedure examinations, and post-operative care.

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