Joey Wahler (Host): It's a great treatment option for heart patients. So, we're discussing Transcatheter Aortic Valve Replacement, also known as TAVR. Our guests, both from Beebe Healthcare, Dr. Steven Marra, he's Cardiac Surgery Medical Director, and he is with Anne Villalobos, who's Structural Heart Coordinator. This is the Beebe Healthcare Podcast.

Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Marra and Anne. Welcome.

Steven W. Marra, MD: Hi. Thank you. Nice to be here.

Host: Great to have you both aboard. So first for you, Doctor, what are the basic principles simply put behind TAVR and how does it differ from traditional aortic valve replacement surgery?

Steven W. Marra, MD: Well, thanks for the question. It's an excellent question for our listening audience to uh hear because traditionally when you suffer from aortic valve stenosis, those patients would basically get progressive shortness of breath, chest pain, frequent hospitalizations for congestive heart failure, which is essentially the heart grows weak, trying to pump against a small area and outflow tract, which is your aortic valve.

So traditionally, all we could do for those patients was open heart surgery, which required general anesthesia, opening the chest, and then replacing the valve directly. Now, there are certain patients, particularly elder patients, patients with high risk factor profiles, that weren't candidates for surgery, and unfortunately there was no treatment options for progressive aortic stenosis. So those patients just were literally left for medical management with worsening symptoms till the clock ran out on them essentially. So what TAVR offers, if you're familiar with cardiac catheterization and those things that are done not in the operating room but in the cardiac cath lab. Example would be patients to get stenting of their coronary arteries.

So this involves, not necessarily needing general anesthesia. It can be done under local anesthesia.

It involves the same exposure in the groin arteries, and veins that are traditionally done in the cardiac cath lab. And through those access points, we're able to use dilators and sheaths, and basically, put a valve in non surgically. So there's several platforms. And one valve type, basically you put the valve in and it's crimped. And then what we do is we put a balloon passed through the middle of it and we blow the balloon up and the valve is deployed in the area where your normal valve would be. The other one uses nitinol, which is a metal that when it's warm, it will go back to its original conformation. So when it's cooled, you can crimp it down, but then when you release it in a warm environment, nitinol, the metal will go back to the original form.

So that's a self deploying valve. So we use both platforms here. And again, each particular patient has its own necessary reasons why we do the individual valve. So the introduction of TAVR allowing us to offer this therapy to patients that otherwise would be too sick or judged to be not good candidates for surgery; really has provided such a great opportunity for the patients in our community, especially the elderly patients that are moving here to get this care locally. Annie, did I pretty much answer that question?

Anne L. Villalobos, MSN: I think so.

Host: And speaking of candidates, which you just mentioned, Anne, for you, what are the key patient criteria or the risk factors that determine whether someone is a good candidate for TAVR?

Anne L. Villalobos, MSN: So, again, if you have somebody that's a higher surgical risk profile, TAVR can be a really good option for them, especially for the initial recovery period after your long term recovery period should be, up to standard with a surgical valve replacement. It's just that initial period of time is a little bit easier since you're not going through open heart surgery.

Typically our patient profile, if you're above the age of 70, typically TAVR is going to be a nicer option for you. At times there are particular physical reasons that you may not want to proceed with TAVR and surgical may be a better option. If you need to get another surgery that would require open heart, like if you needed bypass surgery, or if you needed uh, repair or replacement of your thoracic aorta, then really it wouldn't make a lot of sense to do transcatheter.

But typically if there's no other issue going on, you only really have to replace the aortic valve above the age of 70. It's a nicer option.

Steven W. Marra, MD: Yeah, and I will chime in a little bit to say that people, you can't underestimate, at least I don't as a heart surgeon and most of my colleagues that are heart surgeons, the ability to rehab yourself in recovery. So, many patients have complex COPD or chronic obstructive lung disease, end stage renal disease, they're on dialysis.

Some people have bilateral hips and knees and they're mostly in a wheelchair. For those patients, the recovery with a full blown open heart operation is rather difficult, and this offers a very easy, simple solution, that most of our patients go home the next day, and the recovery is very minimal for them.

So, aside from the traditional risks that people would look at, being able to just recover from the operation as you get elderly, I'm sure most of our audience will sympathize with this. It's not like it was when you were 45 years old and you just hop out of bed two days after the flu. It takes its toll. In those particular patients, they really do appreciate having the procedure being offered here locally.

Host: Great distinction that you made there, Doctor. So Anne, how do you educate patients and help them to weigh TAVR as a treatment option so that they know it's for them?

Anne L. Villalobos, MSN: Well, we use a shared decision making process here at Beebe HealthCare, and that is not unusual to us. I mean, it's a requirement for the procedure. The patient takes part in the decision making. Now, there are times, of course, that clinically, we have to look at factors, regarding their case that may prompt them towards surgical versus TAVR or towards TAVR versus surgical.

 But sometimes you have patients where it's kind of even steven. You can make a case for TAVR, you can make a case for surgical, and, you You want to give patient those options and have them understand what those options are. So I take a lot of time in the office when we see patients, educating them about the entire process and that they are a part of that process.

They're a part of our team. Their responsibilities on the team are to get all of their pre procedural testing, to communicate with me as soon as possible if there's any new problems, issues, worsening of symptoms. And then when we sit down, clinically as the clinical team, we review patients on a weekly basis for procedural planning.

Once we've had that meeting and we come up with the clinical recommendations, whether very strong in favor of TAVR or very strong in favor of surgical or somewhere in between; I come back to the patient and have a good long conversation with them about what the team thinks. And what do they think how do they feel about things going forward?

Steven W. Marra, MD: Yeah, I will tell you that we have a structural heart team, which is a multidisciplinary team. So, not just in the arena of transcatheter aortic valve replacement, we provide therapy for chronic AFib for patients who can't take their anticoagulation medicine called left atrial appendage devices or the Watchman.

 There's atrial septal defect closure devices. So this all falls under the heading of structural heart team. So our team is composed of myself, Dr. Stevenson, my partner is a CT surgeon, and then the two cardiologists are Dr. Frey and Dr. Mahand. And then we also have other physicians in the community, other cardiologists that they might have a patient that they've been taking care of for a very long time, and they will come and participate in that meeting.

And that meeting involves literally presenting the patient in a well structured format where we look at complex head to toe CT scans where we measure the vessels and look at the different sizes and look at the anatomy of the heart and figure out really what is the best for this patient, as well as plugging them into national norms and risk stratifiers that help us make those decisions.

Host: And how about common misconceptions people have about the procedure that you find yourself addressing the most?

Anne L. Villalobos, MSN: Well, kind of goes in a, in a few different ways. Some people think, well, it's just a cath procedure, so I'm just going to go in there, they're going to pop it in. And, in a couple of hours I'm leaving, or there's no risk to this. I was told by my cousin that, you know, this is the way to go because it's so much safer than surgery and nothing can happen during this type of procedure.

And so you, you have to give them the reality check of, no, it's, you know, it's a cardiac cath procedure. There's no procedures that don't carry risk. There's always some type of risk. We aren't just popping a valve in, you know, it is procedure and there's more than one access point that we have to make during the procedure.

 We're putting in a temporary pacemaker. We're putting in a line to monitor pressures in the heart. We put in the line for the actual valve itself. We put in a line for embolic protection, for cerebral embolic protection. I think sometimes people come in thinking it's super duper simple, and that it's with zero risk.

So you at least have to let them know that there's some risk there. On the opposite side of the spectrum of that, you have some people that come in that are absolutely scared to death to go through this procedure. It's just this big huge, gigantic procedure that they're, you know, they're, you're replacing my heart valve.

And you just have to let them know, this is a it's a less complex way of making your disease process better. Instead of going through an open heart surgery, you are going to have a more simple recovery. It's kind of talking them off of ledges either way, sometimes as far as the complexity or the lack of surgical complexity that they're going to go through.

Host: And speaking of which, Doctor, in a nutshell, what would you say is the most important thing a patient ready to undergo this needs to know about the procedure itself? What's the main message for them?

Steven W. Marra, MD: The main message from my standpoint is that, when this procedure is over, you should feel better. Your quality of life should improve and your longevity should improve. Cause we know from the data that once you develop severe aortic stenosis or critical aortic stenosis, your life expectancy is diminished. Your re interventions required, re admissions into the hospital, your frequency of congestive heart failure all goes up. So, I mean I focus more on it's kind of like the analogy, you're at a point where the plane is kind of burning and I have two parachutes. I'm getting out of it. You don't have to get out of the plane, you know, I mean, if you're too tired, you still want to go through the motions and, you know, you'll just see how long the plane can stay in the air, but most people generally, if you get to a point, you know, not everything that extreme, but pretty much when people get to this point with critical aortic stenosis, they've had it with their quality of life, they understand that something must be done, if they're a candidate for it, they opt for the parachute.

 I've had patients that basically are like, you can stop right there. I'm getting out of the plane, so it doesn't matter. I'm not living like this anymore. So if you think that I've got a shot at getting through this and doing okay, I'm taking it. That's kind of the reality.

I mean, it's nice because, the product, so to speak, that we offer, isn't something that we have to sell, we basically have to make sure that we are capable, competent, and able and willing to provide the service. And we provide the service with the same expectations that they can get from any academic center that I've been a part of throughout my career. If we couldn't do that, we wouldn't offer the procedure here. That's what I have patients focus on and the, the difficult type of patient, whether or not you're comfortable, it's like Annie says, the people that are just afraid, they just need to know that you're very confident, you're gonna be straight with them.

You're gonna tell them what the risks are. But what I always tell people is, you know, every operation I do, I manage the risks. I know how to take care of the complications. As a group, we know how to take care of the complications. So that's reassuring to people to know that, you know, this isn't your first rodeo you've done a lot of it.

And if there are complications, you'll take care of them. And if they trust us, we're going to do right by them.

Host: Absolutely. And by the way, Doc, the parachute analogy, very effective, I must say. A few other things. Anne, Dr. Marra just addressed the long term benefits down the road. How about short term? What's the recovery process like?

Anne L. Villalobos, MSN: Initially coming out from the procedure within the first day, a lot of times people can feel a difference. Like, wow, I'm not as short of breath or wow, that chest pressure is already gone. Now that's not always. Some people get pretty debilitated before they come in for this procedure. So sometimes it's not an immediate feeling of like wow, I really feel different.

 Typically people are going to go home the next day, they have kind of a tired weekend at home. We do all of our procedures midweek, and then I see them in follow up a week later to check in on them, see, how their access points look. So that usually that one week followup, they're like, yeah, no, I was pretty tired over the weekend.

I'm like, all right, I'm going to see you in 30 days. So at their 30 day followup, we have gotten some more imaging of the heart just to kind of check on how the valve is looking, get some lab work. And usually at that appointment I get, the, wow, I really feel so much better and I'm really looking forward to doing cardiac rehab and it's that people feel less short of breath, less fatigued, less weak if, um, they were having issues with chest pressure, it's usually very resolved at that point, and then I see them again in a year later and I mean, sometimes they just look absolutely remarkably even different than they did the year before.

 We have a lot of very good outcomes with these type of procedures. And again, in, in recovery, we always suggest cardiac rehab after valve replacement. It's a nice way of being able to get back into activity, monitored by professionals, nursing staff and, exercise physiologists that communicate directly with the patient's cardiology team and let them know about any changes they may be having in their heart rate and their blood pressure and how are they responding to exercise. So we always highly suggest participating in that program as well.

Steven W. Marra, MD: I will say as an academician, I do think that the rewards, with being in cardiovascular medicine, is immense. And so if we have students out there thinking about choosing a career, like Annie has just mentioned, from nurses to technicians to physicians, it's a great specialty. It's a growing specialty.

By the very nature of you know the questions you're asking and this technology. So, that's my little pitch there if you're in high school or college and you're kind of not sure what you want to do, consider a career in cardiovascular medicine. It's very rewarding.

Host: Why not make the pitch, Doc? How about, you mentioned technology, you led me beautifully into this last question for you. How about any recent particular technological advancement in TAVR, and anything in terms of emerging research or innovations for the future that you're most excited about?

Steven W. Marra, MD: It's a very exciting time to be a physician, specifically a cardiac surgeon and cardiologist with all this technology, looking at the mitral valve and looking at the aortic valve. I will tell you that the research is ongoing all over the world, looking at smaller platforms, more easy to deploy platforms.

They're looking at smaller sheaths, alternate access, things like that. Something that is near and dear to my heart is our cardiologists, Dr. Frey and Dr. Goresh, are excellent at deploying a device called a sentinel device, which actually goes through the radial artery and it's positioned up in the aortic arch and it's nets essentially.

So that while we're working on the aortic valve, you can imagine the way that your valve becomes narrow is through the deposition of calcium and it kind of becomes hard plaques. That also occurs in the vessels. And that's one of the main reasons elderly people get strokes, is these plaques tend to flick off and go to the brain.

So, by deploying the Sentinel device and putting these nets in before we begin to do our work on the aortic valve itself and the aortic root, it catches small particulate matter that could go to the brain and cause stroke. And at last I checked with the manufacturers and the company representatives we have, we are the largest center in the state of Delaware that performs the Sentinel device. So for people who are prone, to developing a stroke for whatever, list of complications and prior medical history they bring to us; you've had a prior stroke. We routinely use the Sentinel device in all our patients.

And like I said, um Dr. Frey, Dr. Goresh, they do it very well, and like I said, my understanding is in Delaware, there's no other institution that has the expertise, and the rate of use that we have here at Beebe.

Host: And Doc, I note that you mentioned that all of that is something near and dear to your heart. Pun intended, yes. And finally for you Annne, in summary here, just to kind of pick up on what Dr. Marra mentioned a moment or two ago in terms of how rewarding this work is for you and yours, you've literally got people's lives in your hands oftentimes.

What's that like for you when, as you mentioned, oftentimes you see them a year or so later and you can tell even the way they look is completely different than before. How does that make you feel?

Anne L. Villalobos, MSN: Oh gosh, I mean, wonderful. I'm a Sussex County native, and I love that I can be a part of something that we offer to patients here in Sussex County, where they don't have to go to a big tertiary care center or university level care center to obtain it. It's something that's on the cutting edge that we offer here locally.

And that's so convenient for our community. And I've always been very passionate about being able to provide wonderful services to our local community. And this is a top notch service to be able to provide to people and have them not have to seek care elsewhere. It just, I love it. And then seeing how, how much people improve and you build these relationships. As the coordinator, I speak with patients all the time.

They have every way of getting up with me short of walking up to my house. So, I am in contact with patients all the time, but I love that. That's why I went into nursing. For me, this is like a dream job.

Steven W. Marra, MD: And I will tell you, since I've been here, my patients, I run into them at the Fresh Market, at the Acme, I mean, once you've been here for a few years, I mean, you really do become part of the matrix of Lewis and Rehoboth Beach, and so it's a great support system from the community.

Dr. Tam's done a wonderful job as our President and CEO, basically, building the infrastructure, building the physical properties that are necessary to provide care in Sussex County and, that's a lofty goal, but it's certainly a goal that we're focused on to be the, the primary provider in Sussex County for all your needs.

 So I'm just very pleased and like Annie says, we've got great support. We've got great physicians and clinicians and nursing staff and support staff and administrative staff. I can personally say, that I've got all the support I need to provide the services that I need to provide. Very happy.

Host: Really great to hear. Well folks, we trust you're now more familiar with the TAVR procedure. Dr. Marra, Anne, keep up your great life saving work and thanks so much again.

Steven W. Marra, MD: Thanks everybody. Have a great day.

Host: And for more information, please visit beebehealthcare.org/form/TAVR, T-A-V-R-information. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for being part of the Beebe Healthcare Podcast.