Transcatheter Aortic Valve Replacement (TAVR) is a minimally invasive treatment option for patients with severe aortic stenosis (narrowing of the aortic valve). The Emory TAVR program began in 2007 within the PARTNER I clinical trial and to-date over 2,500 patients have received this groundbreaking therapy at Emory HealthCare.
Kendra Grubb, MD, discusses TAVR, and why you might consider this treatment option.
TAVR: Minimally Invasive Treatment for Aortic Stenosis
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Learn more about Dr. Kendra Grubb
Kendra J. Grubb, MD, MHA
Dr. Kendra Grubb is the surgical director of the Emory Structural Heart and Valve Center. Prior to joining Emory, Dr. Grubb was the director of minimally invasive cardiac surgery and the surgical director of the heart valve program at the University of Louisville. Dr. Grubb is a champion for women's heart disease, and is dedicated to improving the lives of all patients, both male and female, through innovation and by building collaborative teams to promote a patient-centered approach to the treatment of cardiovascular disease.Learn more about Dr. Kendra Grubb
Transcription:
Bill Klaproth: Aortic stenosis is a progressive disease affecting more than 2.5 million people over the age of 75 in the United States. Treatment includes open heart surgery, however, the transcatheter aortic valve replacement, or TAVR procedure, offers hope for high-risk individuals. Here to talk with us about the TAVR procedure is Dr. Kendra J. Grubb, surgical director at Emory Structural Heart and Valve Center at Emory Healthcare.
Thank you for your time. First off, what is aortic stenosis?
Kendra J. Grubb, MD, MHA, FACC: Aortic stenosis is tightening of the main outflow valve of the heart. There are four valves in the heart that divide the various chambers, and the aortic valve is the last valve that has to open for the blood to leave the big pumping chamber on the left side of the heart and go out through the entire. Because of aging or previous disease or sometimes because people are born with an abnormal valve, the valve can become stenotic or tight over time and that’s aortic stenotic.
Bill: How common is this?
Dr. Grubb: It’s more common as we age. It is a disease of the elderly. Often times as mentioned, there are patients who are born with only two leaflets or bicuspids and those patients are going to develop symptoms in their 40s or 50s. The majority of patients are going to be in their 70s or 80s by the time they have aortic stenosis.
Bill: How would someone know if they have this and how do you diagnose it?
Dr. Grubb: The diagnosis often happens in the doctor’s office when you listen to someone’s chest with a stethoscope, you'll hear a murmur and that murmur is the flow disturbance across the stenotic valve. If you can think about if you put your thumb over the end of a garden hose and it shoots the water out and makes a sound, it’s the same concept. The main outflow valve of the heart is supposed to open big and wide, about 2.5 cm, allow the blood to exit and it makes very little sound and as that opening narrows, then there's a sound that comes across that. If a doctor was to hear a murmur, the next step would be to do an ultrasound or echocardiogram and that would then allow us to see the valve itself. In terms of the patient, what would they experience? Often times, patients develop shortness of breath or shortness of air when they try to exert themselves, what we call dyspnea on exertion. A patient tries to climb a flight of stairs, they could do it a few months ago and now they notice that they have to stop. That’s a sign of congestive heart failure, also swelling in the legs is a sign of congestive heart failure and some patients will develop swelling because their heart is not efficient. Other symptoms include pain in the chest or what we call angina and some patients will have dizziness or frank syncope that has passing out spells because there's not enough blood flow coming out of the heart and into the brain.
Bill: You said a lot of times this is picked up in the doctor’s office, so when the doctor is listening to our chest with the stethoscope, that’s generally you're listening for heart function and not only lung function too, is that right?
Dr. Grubb: That's right. Often times, we do listen to the lungs, make sure there are no extra sounds in the lungs such as wheezing or diminished sounds that would suggest there is fluid on the lungs, but certainly with the four valves in the heart, primary care physicians, cardiologists, and many doctors will be listening for a murmur.
Bill: Let's talk about the TAVR procedure. Who is a good candidate for somebody who has aortic stenosis?
Dr. Grubb: TAVR procedure has evolved quite a bit over the last few years. Initially, the TAVR, the transcatheter aortic valve replacement devices, were FDA approved for patients who were too sick and too old for open-heart surgery. They call those patients high risk or inoperable. Those initial trials which were started in 2007 resulted in the devices being FDA approved. While the patients actually responded so well to the therapy, the FDA then allowed for us to look at an intermediate risk group of patients. Now those patients also can receive a commercially available, meaning FDA approved, TAVR valve if they meet criteria. Interestingly, we are just finishing up trials in low-risk patients so that we can answer the question ‘do low-risk patients do as well with open heart surgery or the transcatheter valve?' I certainly foresee a time when any patient that has aortic stenosis could potentially be treated with a transcatheter valve and low-risk patients would probably still have the choice for open heart surgery if they had other pathologies or if there was some other reason a traditional surgical approach would be better for them.
Bill: The valve that you insert is different for the open-heart procedure and the TAVR procedure. Its two different valves, that’s what it sounds like?
Dr. Grubb: That’s correct. The open heart surgery valve is literally hand sown so the patient’s own valve is excised or cut out and all the calcium where the valve has degenerated is debrided and we remove all of that and we hand sow our valve in place. Of course, that’s an invasive procedure. It requires general anesthesia with the patient on the breathing tube, it requires the heart-lung machine, the heart is stopped during that procedure and the patient spends four or five days in the hospital and has about six weeks of downtime. That's the traditional approach that we've been doing for many years. The TAVR valves are based on the same technology where you take a valve made of animal material either the sack around a pig’s heart or the sack around a cow’s heart, the pericardium, and it’s made into a valve. There are two separate valves that are commercially available. One of them is blown up on a balloon and the other one is made of a memory metal that when you put it in place, once it interacts with warm blood, it expands on its own. Those two valves are available to patients now. The technology behind them is very similar to the open heart surgery valve. The difference is we don’t cut out the patient’s old valves. We put the new valve inside and crush the old valve to the side and the new valve holds on by radial force and friction.
Bill: That is just amazing and I know you said this is fairly new technology as of 2007, but the structural heart and valve program at Emory Healthcare was one of the first in the nation to study and offer the TAVR treatment procedure. That’s quite an achievement.
Dr. Grubb: Emory was very early in the trial. They had a very robust history in valvular heart disease. We talk about structural heart now and we often talk about transcatheter therapies. The structural heart just means any of the valves or walls of the heart that are not including the coronary arteries, the arteries that bring blood flow to the heart muscle. Because of Emory’s rich history and understanding in valvular heart disease and structural heart disease, when it came available to be part of the early trials or devices that could potential offer high risk and inoperable patients an operation to fix their valve that we were otherwise unable to offer and patients who were unable to help, of course, Emory wanted to be on the cutting edge of that technology and we've continued to do so with the newer devices and newer adjunct technologies to go along with TAVR.
Bill: Over 2,500 patients have received this groundbreaking therapy at Emory Healthcare, more than any other provider in the southeast. Again, quite an achievement. If you could wrap this up for us, what else do we need to know about the TAVR procedure?
Dr. Grubb: I think the biggest thing to remember is talking to your doctor about your heart every time you go, asking if you hear a murmur and if you develop symptoms to come to a structural heart and valve center that has the new technology to offer. I think there are many patients out there who aren't being treated and our studies have shown that there's a large portion of the population that really could be helped with this technology and they're never making it to the doctor. They're never making it to a heart center where they can be helped, so talk to your doctor.
Bill: Absolutely great advice. Thank you so much for the great information as always, and if you want to learn more, please visit emoryhealthcare.org/heart. That’s emoryhealthcare.org/heart. You're listening to Advancing Your Health with Emory Healthcare. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth: Aortic stenosis is a progressive disease affecting more than 2.5 million people over the age of 75 in the United States. Treatment includes open heart surgery, however, the transcatheter aortic valve replacement, or TAVR procedure, offers hope for high-risk individuals. Here to talk with us about the TAVR procedure is Dr. Kendra J. Grubb, surgical director at Emory Structural Heart and Valve Center at Emory Healthcare.
Thank you for your time. First off, what is aortic stenosis?
Kendra J. Grubb, MD, MHA, FACC: Aortic stenosis is tightening of the main outflow valve of the heart. There are four valves in the heart that divide the various chambers, and the aortic valve is the last valve that has to open for the blood to leave the big pumping chamber on the left side of the heart and go out through the entire. Because of aging or previous disease or sometimes because people are born with an abnormal valve, the valve can become stenotic or tight over time and that’s aortic stenotic.
Bill: How common is this?
Dr. Grubb: It’s more common as we age. It is a disease of the elderly. Often times as mentioned, there are patients who are born with only two leaflets or bicuspids and those patients are going to develop symptoms in their 40s or 50s. The majority of patients are going to be in their 70s or 80s by the time they have aortic stenosis.
Bill: How would someone know if they have this and how do you diagnose it?
Dr. Grubb: The diagnosis often happens in the doctor’s office when you listen to someone’s chest with a stethoscope, you'll hear a murmur and that murmur is the flow disturbance across the stenotic valve. If you can think about if you put your thumb over the end of a garden hose and it shoots the water out and makes a sound, it’s the same concept. The main outflow valve of the heart is supposed to open big and wide, about 2.5 cm, allow the blood to exit and it makes very little sound and as that opening narrows, then there's a sound that comes across that. If a doctor was to hear a murmur, the next step would be to do an ultrasound or echocardiogram and that would then allow us to see the valve itself. In terms of the patient, what would they experience? Often times, patients develop shortness of breath or shortness of air when they try to exert themselves, what we call dyspnea on exertion. A patient tries to climb a flight of stairs, they could do it a few months ago and now they notice that they have to stop. That’s a sign of congestive heart failure, also swelling in the legs is a sign of congestive heart failure and some patients will develop swelling because their heart is not efficient. Other symptoms include pain in the chest or what we call angina and some patients will have dizziness or frank syncope that has passing out spells because there's not enough blood flow coming out of the heart and into the brain.
Bill: You said a lot of times this is picked up in the doctor’s office, so when the doctor is listening to our chest with the stethoscope, that’s generally you're listening for heart function and not only lung function too, is that right?
Dr. Grubb: That's right. Often times, we do listen to the lungs, make sure there are no extra sounds in the lungs such as wheezing or diminished sounds that would suggest there is fluid on the lungs, but certainly with the four valves in the heart, primary care physicians, cardiologists, and many doctors will be listening for a murmur.
Bill: Let's talk about the TAVR procedure. Who is a good candidate for somebody who has aortic stenosis?
Dr. Grubb: TAVR procedure has evolved quite a bit over the last few years. Initially, the TAVR, the transcatheter aortic valve replacement devices, were FDA approved for patients who were too sick and too old for open-heart surgery. They call those patients high risk or inoperable. Those initial trials which were started in 2007 resulted in the devices being FDA approved. While the patients actually responded so well to the therapy, the FDA then allowed for us to look at an intermediate risk group of patients. Now those patients also can receive a commercially available, meaning FDA approved, TAVR valve if they meet criteria. Interestingly, we are just finishing up trials in low-risk patients so that we can answer the question ‘do low-risk patients do as well with open heart surgery or the transcatheter valve?' I certainly foresee a time when any patient that has aortic stenosis could potentially be treated with a transcatheter valve and low-risk patients would probably still have the choice for open heart surgery if they had other pathologies or if there was some other reason a traditional surgical approach would be better for them.
Bill: The valve that you insert is different for the open-heart procedure and the TAVR procedure. Its two different valves, that’s what it sounds like?
Dr. Grubb: That’s correct. The open heart surgery valve is literally hand sown so the patient’s own valve is excised or cut out and all the calcium where the valve has degenerated is debrided and we remove all of that and we hand sow our valve in place. Of course, that’s an invasive procedure. It requires general anesthesia with the patient on the breathing tube, it requires the heart-lung machine, the heart is stopped during that procedure and the patient spends four or five days in the hospital and has about six weeks of downtime. That's the traditional approach that we've been doing for many years. The TAVR valves are based on the same technology where you take a valve made of animal material either the sack around a pig’s heart or the sack around a cow’s heart, the pericardium, and it’s made into a valve. There are two separate valves that are commercially available. One of them is blown up on a balloon and the other one is made of a memory metal that when you put it in place, once it interacts with warm blood, it expands on its own. Those two valves are available to patients now. The technology behind them is very similar to the open heart surgery valve. The difference is we don’t cut out the patient’s old valves. We put the new valve inside and crush the old valve to the side and the new valve holds on by radial force and friction.
Bill: That is just amazing and I know you said this is fairly new technology as of 2007, but the structural heart and valve program at Emory Healthcare was one of the first in the nation to study and offer the TAVR treatment procedure. That’s quite an achievement.
Dr. Grubb: Emory was very early in the trial. They had a very robust history in valvular heart disease. We talk about structural heart now and we often talk about transcatheter therapies. The structural heart just means any of the valves or walls of the heart that are not including the coronary arteries, the arteries that bring blood flow to the heart muscle. Because of Emory’s rich history and understanding in valvular heart disease and structural heart disease, when it came available to be part of the early trials or devices that could potential offer high risk and inoperable patients an operation to fix their valve that we were otherwise unable to offer and patients who were unable to help, of course, Emory wanted to be on the cutting edge of that technology and we've continued to do so with the newer devices and newer adjunct technologies to go along with TAVR.
Bill: Over 2,500 patients have received this groundbreaking therapy at Emory Healthcare, more than any other provider in the southeast. Again, quite an achievement. If you could wrap this up for us, what else do we need to know about the TAVR procedure?
Dr. Grubb: I think the biggest thing to remember is talking to your doctor about your heart every time you go, asking if you hear a murmur and if you develop symptoms to come to a structural heart and valve center that has the new technology to offer. I think there are many patients out there who aren't being treated and our studies have shown that there's a large portion of the population that really could be helped with this technology and they're never making it to the doctor. They're never making it to a heart center where they can be helped, so talk to your doctor.
Bill: Absolutely great advice. Thank you so much for the great information as always, and if you want to learn more, please visit emoryhealthcare.org/heart. That’s emoryhealthcare.org/heart. You're listening to Advancing Your Health with Emory Healthcare. I'm Bill Klaproth. Thanks for listening.