Nolan Alexander (Host): A heart procedure while you're not under general anesthesia and a hospital stay overnight and not a week. It's possible with a transcatheter aortic valve replacement, or known as TAVR. We'll explore the topic with Dr. David Drucker, who is an Interventional Cardiologist and the Director of Capital Health's Structural Heart Program.

I'm Nolan Alexander, and this is the Health Headlines podcast series. Dr. Drucker, how are you today?

David Drucker, MD: I am very well. Thank you for having me.

Host: It's our pleasure. Well, could you start by explaining what the TAVR procedure is and how does it work?

David Drucker, MD: Absolutely transcatheter aortic valve replacement is a procedure that's been around for over a decade now. Initially it was designed to treat people who had problems with a valve called the aortic valve, and that valve separates the heart from the rest of the body. With different disease states, and as we get older, the valve doesn't open very well, and we call that problem aortic stenosis. When it gets to be severe and in particular, when it causes symptoms, it's time for a patient to work with their medical team on replacing that valve to improve their quality of life and their life expectancy. In the past, there had only been surgical options to surgically replace the aortic valve, but over the past 10 to 15 years, there is this procedure we have now called transcatheter aortic valve replacement, which is a minimally invasive procedure done under a twilight, usually without any incisions; where we have a stent that has a brand new heart valve sewn on the inside of it. In certain patients, we can do this procedure with a very low risk. The procedure takes less than an hour, and most people are home in 24 hours.

Host: Very interesting. You mentioned symptoms. What are the most common conditions or symptoms that might lead someone to need TAVR?

David Drucker, MD: So the three most common symptoms and the one we always ask patients, family members, and physicians to look for are chest pressure when you exert yourself, passing out for any reason, or heart failure symptoms like shortness of breath when you're active. Those are the three classic symptoms of aortic valve disease and should have your doctor listen with their stethoscope and then if appropriate, order an echocardiogram.

 There are patients who get atypical symptoms, so there are some people who just feel weak or fatigued. There's even a syndrome called cardiac cachexia where a patient just feels so weak they don't eat and they start to lose weight. Those are some non-specific symptoms that the doctors can look for, but the classic symptoms are those first three I mentioned, and those are the ones to really look for.

Host: So if someone feels like they have those symptoms and they've gone through that process, how do you know if you're a candidate for TAVR versus open heart surgery?

David Drucker, MD: So we've done TAVR procedures for people in their sixties, actually up to patients over the age of a hundred. So there's a broad range of patients and age range that are potentially acceptable. I think the biggest thing to know about TAVR is this is a team approach. The interventional cardiologists, which is what I do, we evaluate the patient in terms of their age, their medical comorbidities, and other clinical factors, and we work with our colleagues, the heart surgeons, and we always review all cases together and outline all options for patients.

There are just some patients who are better candidates for surgery and there are some people who are better candidates for the less invasive approach. Most patients undergo a heart catheterization where we go in through the wrist or the leg artery and make sure there's no heart artery blockages. We do an ultrasound test of the heart called an echocardiogram, not just to look at the valve, but also to see if other valves are involved and to look at the heart muscle strength. Then we do a CAT scan that goes from your shoulders down to your hips, basically. And that allows us to see number one, anatomically if the valve will work well in your body. Also, it lets us know that we can safely get from the femoral artery up to your heart, or do we have to use a different access point to get the new valve in position? So this is a complex, multi-team approach that ends up letting us choose the right procedure for the patient and the safest one for the best long-term outcome.

Host: Yeah, this sure seems like a comprehensive, and as you said, a true team approach. Why do you take that route?

David Drucker, MD: Well, the first thing to remember is that in medicine there's always new and less invasive technologies. But that doesn't mean that the tried and true should be left behind. Surgery for aortic valve disease, whether it's restricted valve called stenosis, a leaky valve called insufficiency, or a combination of the two, has been around for decades and decades.

The surgery itself is very low risk in many patients. In some cases with a surgical risk, less than 3%. The surgeries themselves can be done with a full incision in the chest. But there's now surgeons offering minimally invasive surgery with much smaller incisions and excellent clinical results. So we always look at the patient, their longevity, their comorbidities and their personal preference. Surgery has been shown to improve symptoms and improve longevity for many cardiovascular diseases, and that's why we always make sure to have patients look at the benefits and risks of both options before we all make a final choice.

Host: I think that's fantastic, Doctor, and you said there's a chance it could be minimally invasive surgery. Is that painful? And what does the recovery process look like after that?

David Drucker, MD: So every patient's recovery process is a little bit different. I do feel when you're in the hospital for any procedure and most patients will tell you this; you feel okay when you come home, but you still have some recovery to do. For every day or two that you're in the hospital, it takes you two or three days to get back to where you were before, and that's even with a minimally invasive procedure.

 When you go through general anesthesia, as you do most of the time for open surgery, even if it's a less invasive approach, usually that requires between two and five days in the hospital, and most patients take around one to four weeks to really start to feel like themselves afterwards. One of the big benefits of the transcatheter aortic valve replacement, is that for most patients, this is done without any incisions at all.

We're able to go in through the skin and really there's no major incision to recover from. Most patients are home in a day, and most patients are feeling much better by one to two weeks afterwards. So especially for people who are a little bit older, people who are frail, patients who have lots of other medical problems, the transcatheter less invasive route is often very attractive.

And the transcatheter route has excellent clinical results. When you compare the transcatheter aortic valve replacement to the surgical aortic valve replacement in many patients subsets, the long-term results show at least equivalence of the two procedures. So you're really talking about two great options for patients to consider.

Host: This seems like a novel surgery. How has TAVR, the procedure evolved over the last decade, and when did Capital Health start offering it?

David Drucker, MD: So TAVR initially was invented like a lot of medical procedures. It was designed for those patients with symptomatic aortic valve disease where the valve was restricted and initially the surgeons felt the patient was too high risk or even inoperable. So there were no other options. The procedure was developed by a multitude of physicians and companies, and there's actually three FDA approved transcatheter valves currently available in the United States.

These procedures have now extrapolated out to include all patient subsets. So now we don't just work on people who are high risk or inoperable, but this is offered to symptomatic patients who are even low risk. Again, this ends up being a bit of a personal choice. The TAVR is very attractive for patients who want to have a very short hospital stay, a short recovery, but it's up to the doctors and the patients to really do their research about this. I think one of the biggest benefits of this disease and these procedures is that it's almost never an emergency. When we meet people, patients can be symptomatic, but the disease process tends to be slowly progressive, so patients have time to meet a structural or interventional cardiologist like myself.

They have time to meet a heart surgeon independently and get their opinion, and then time to get the different tests we talked about to really sit down and look and map out the procedure they want and how they want to be followed. So when I see patients for this medical problem, I really tell them this is a great time to actually have this medical issue because there's two excellent options for treatment that give you really good intermediate to long-term results with very low risk.

Host: What do you see as the future of valve replacement? Will TAVR become the standard for most patients?

David Drucker, MD: So that's a great question. There's actually a few articles in some of our cardiology journals this week talking about that. I think when it comes to medical therapy for valve problems, there's always a push to be less and less invasive. And not just for the aortic valve, but for other valves now. The mitral valve that separates the heart from the lungs, the tricuspid valve, which is on the right side of the heart, there are now minimally invasive procedures that can be done in addition to medical therapy, or instead of a surgical repair or replacement that are becoming popular. For transcatheter valve replacement, really, this has become incredibly popular and one of the more predominant procedures done for the aortic valve. Right now what doctors like myself and the heart surgeons are doing is we're re-looking at all the data and we're thinking about lifetime management of these patients.

So when you have an 80-year-old patient and you put a stent valve in them, that is very likely to last them the rest of their life. Because these valves usually last between oh seven and 15 years. But when you have a 60-year-old patient who might need a valve replacement, we start to think about what would be the first option.

Do you want to put a stent in and then know you'll probably have to put another stent in, in a decade, or is it better to do surgery now and then think about a less invasive procedure 10 or 15 years down the line when the patient's in their, let's say late seventies, mid seventies, or even early eighties.

So one of the emphasis right now is this team approach to look at the lifetime management of aortic valve disease, to make sure we have a path set up so that patients can always have the best chance at a great outcome and the lowest risk.

Host: Certainly a lot for us to think about and we learned a great deal in this podcast today. Doctor, thank you so much for your time and insight.

David Drucker, MD: Thank you.

Host: That was Dr. David Drucker. To learn more about Capital Heart Health and Vascular Institute, visit capitalheartandvascular.org. I'm Nolan Alexander and this is the Health Headlines podcast series. Thanks for listening.