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Bill Klaproth (Host):  So, one advanced alternative to open heart surgery is transcatheter aortic valve replacement or TAVR, T-A-V-R. The minimally invasive procedure offers many benefits so let’s learn more about it with Dr. Timothy Logan, Chief of Cardiology at McLaren Macomb. This is McLaren’s In Good Health. I’m Bill Klaproth. Dr. Logan, so what is TAVR and can you describe the procedure?

Timothy Logan, DO (Guest):  Yes, hi Bill. Thanks for having me. I appreciate the opportunity. Transaortic valve replacement or TAVR is a minimally invasive way to replace the aortic valve in the heart. So, the aortic valve is basically I tell patients it’s like a door that opens and closes as your heart beats and it lets blood flow through when your heart is pumping and then it closes to prevent blood from leaking backwards. Over time, there’s wear and tear that can occur on the heart valve and it can get calcium deposits on it and fibrosis which is thickening and stiffening of the valve. That obviously leads to less efficiency of the heart pump because you can’t get blood out of your heart. So, patients will often show signs of shortness of breath, they may get chest pain or dizziness and that over time may need to be fixed.

So, traditionally, the way to address that problem has been with a valve replacement done by open heart surgery where you need to make an incision and open up the chest and put a new directly surgically replace the heart valve. So, over the past many years; people have thought would it be a better option if we could come up with a less invasive option than open heart surgery and having to put people on breathing machines and bypass pumps and things like that. So, now we have a less invasive option, and this is done through a catheter based procedure. So, instead of opening up the heart; we use catheters that go in through the blood vessels. So, commonly we go in the blood vessel in the groin and the valve actually is collapsed on a balloon and we are able to put the valve in by inflating a balloon and it expands the valve right at the site. And then we take our catheters out. So, that was a very simplified explanation of what happens.

Host:  So, being minimally invasive, I would imagine everyone would prefer this procedure over traditional open heart surgery methods and I would imagine recovery is a lot shorter as well. Can you describe the recovery process after TAVR?

Dr. Logan:  So, the recovery from open heart surgery usually is abut a week in the hospital for recovery and then four to six weeks after that. There is still a lot of recovery with open heart surgery. Ultimately patients have done well for years that way but most of our patients go home in two days after their procedure and they are up walking and feeling pretty darned good right out of the gates because they don’t have to deal with the surgical recovery of the procedure. So, the recovery time is much shorter, and we’ve had excellent results and sometimes we even send patients home the next day.

Host:  And how soon after can they resume normal activity?

Dr. Logan:  So, from the catheter based procedure, the major limitation is healing of the groin site where we put our catheters in. So, if anyone is familiar with a heart catheterization; it’s similar to that. So, we ask people not to drive for about five to seven days after the procedure, not to do any heavy lifting for a few days after the procedure. But after that, basically you can go back to your normal activities.

Host:  So, is the TAVR procedure common and do all hospitals offer this?

Dr. Logan:  Many hospitals offer it but not all hospitals offer it. So, in the state of Michigan, there are about just over 20 TAVR programs in the state. It’s available – usually at patients where you also have to have an open heart surgery program in order to do it. We were the first hospital in Macomb County to offer this procedure when we started our program a couple of years ago. So, you can’t get it done everywhere. You do need to have a very specialized team that works together to get this done. We have a structural heart team that involves multiple interventional cardiologists, multiple heart surgeons and then we have cardiac imaging specialists, nurses, anesthesiologists. It requires quite a team to coordinate the procedure.

It's limited to a certain number of select hospitals.

Host:  Earlier, you mentioned some symptoms to watch out for. Chest pain, dizziness, shortness of breath. Are there any other symptoms that we all should be on the lookout for which would indicate some sort of a heart problem?

Dr. Logan:  So, aortic stenosis does tend to be a sort of slow gradual process. It’s different than a heart attack which can come on you all of the sudden. Aortic stenosis tends to take more time to develop so, the main things that people will notice again, there’s chest pain, symptoms when you are exerting yourself, you’re walking, you start to get tightness in your chest, you can’t breathe, dizziness, lightheadedness, sometimes people get swelling in the extremities and sometimes it’s just lack of energy, just I can’t do the things I used to do. And as a matter of fact, a lot of times, it comes on so slowly that people don’t even notice it’s happening. Patients will, if they are diagnosed with aortic stenosis; may say well I feel fine and we ask them about their activities and if you ask well what kind of activities did you do a year ago compared to what you do now. And sometimes that’s the question that really triggers it for people because if you just say are you short of breath; people will say no. But the reason people aren’t short of breath is they don’t do things that make them short of breath anymore because they don’t feel good. So, sometimes it’s very subtle.

Host:  So, it’s good to remember those symptoms that you were talking about. So, you mentioned aortic stenosis. Is this procedure for anyone with aortic stenosis?

Dr. Logan:  The procedure is not for everyone. There was some changes in the guidelines over the summer of 2019 which opened the door for a lot more patients. So, when we have new technologies and new procedures; what happens often is we start with the patients that are the highest risk which seems backwards perhaps, but we know that surgical valve replacement was a very good procedure, it still is a very good procedure. So, the first patients to get this catheter-based valve were the patients that did not qualify for surgery. They were too sick to get surgery. So, those were nonoperative patients.

So, then it worked in that group of patients, so they said all right, lets try high risk patients. You can get surgery but it’s a pretty high risk thing for you to get it. And it worked in that and then intermediate risk patients were approved, and then lower risk patients were just approved last summer. So, basically, any patient with aortic stenosis can be considered to have the catheter-based procedure. So, the majority of patients now will get the catheter-based procedure. There are still some questions that are out there. Some people – part of the process is we need to look at your arteries in your heart to make sure you don’t have blockage. If you have multiple blocked arteries well it might make more sense to get your valve replaced surgically and then do a coronary artery bypass at the same time and just fix it all at once.

The other question we have is younger patients. Because of the newer valves on the catheter-based valves are newer, they haven’t been around as long so if you are going to put a valve in a really young patient, and really young in this population would be say 60 years old. So, if you are going to put a valve in a 60-year-old, how long is it going to last? And we don’t actually know yet. Because patients with - the technology hasn’t been around long enough. So, the expectation is they should last as long as the surgical valves which is ten to fifteen years, but we don’t really know. So, those are the conversations that we need to have with our patients on an individual basis to talk about well what is the best procedure for you based on our team approach and patient preferences.

Host:  Right, those are really good questions and I was going to ask you how long a valve lasts. Speaking of aortic stenosis; how do you diagnose this then? Do you pick this up with a normal EKG, a regular physical; how do you diagnose aortic stenosis?

Dr. Logan:  The most common way it is diagnosed is on physical exam. That’s usually the first place we’ll find it. When you have a thickened aortic valve; you valve if you think about the way blood flows through a heart valve. Normally, is should be nice, smooth flow.

Host:  I’m imagining the door opening and closing smoothly as you described.

Dr. Logan:  Correct. Yup the door opens, blood flows through. But if the door is not opening the blood flow becomes a lot faster and turbulent. So, the analogy that we always use is it’s like putting your thumb over the end of a garden hose.

Host:  Okay, very visual. Got it.

Dr. Logan:  And that’s the way the blood is coming out. So, that makes a sound called a heart murmur. A heart murmur can be picked up on physical exam. So, that is a common way to find it, you have a heart murmur and then we can confirm it with something called an echocardiogram. An echocardiogram is an ultrasound of the heart and we can actually take measurements and look at the valve function. So, it’s not often – there are things that can change on an EKG that we can see as a result of aortic stenosis, but you can’t directly diagnose it with the EKG. It’s usually physical exam and echocardiogram.

Host:  So, during a physical exam when the doctor asks you to take a deep breath and then exhale, now we know one of the things he or she is listening for.

Dr. Logan:  Correct. Which is a good point that we should add. That’s why you should have a routine annual physical at a minimum so that your doctor can pick this up early because earlier, you obviously would like to catch it earlier rather than later.

Host:  So, getting that yearly physical when you hit a certain age gives the doctor a baseline so he or she will have an easier time of discovering this with these subtle changes over the years.

Dr. Logan:  Yes, absolutely.

Host:  So, when you lay it out like that, it’s easy to see how the yearly trip to see the doctor can really help you out and give your physician that really important information he or she needs to monitor your health year to year to potentially discover things like this early. So, let’s turn to the services you offer. So, as you offer Macomb County’s first comprehensive cardiovascular program; what other advanced procedures foes McLaren Macomb offer?

Dr. Logan:  We offer sort of the full range of cardiovascular procedures at our hospital. And we can probably do a separate podcast on each of them. But we pride ourselves on bringing a lot of technologies that are available at some of the larger what we tertiary care hospitals and being the first ones in Macomb to bring those to our community and out patients so you don’t have to travel elsewhere to get them. So, we were the first in Macomb to do the TAVR procedure. We also offer something called a cardiomems device which is an implantable pulmonary artery monitor for heart failure patients. We are the only hospital in the state of Michigan that is the last time I checked that is doing electrical procedures of the heart using ultrasound instead of x-ray. So, we have an electrophysiologist that does that. It saves the patient and the physician from radiation during that procedure. So, we have a full scope. Actually we offer open heart surgery, valve replacements, bypass surgeries. We offer stents, support devices for heart failure patients. We have quite a range of services.

Host:  For lack of a better term it’s a one stop shop.

Dr. Logan:  Absolutely. So, basically what our goal is to provide everything that we can at our institution up to basically heart transplant and some of the more really very, very specialized devices. Those are things that you need to go elsewhere. But everything else we can provide from a cardiovascular standpoint. Our goal is to provide that.

Host:  Well it’s great to know that we have such comprehensive cardiovascular care right here. Dr. Logan, this has been great talking with you. Very informative. Thank you so much for your time.

Dr. Logan:  Yeah, thanks Bill, I appreciate it.

Host:  That’s Dr. Timothy Logan, Chief of Cardiology at McLaren Macomb and to learn more about Dr. Logan or submit a question visit www.mclaren.org/logan, that’s www.mclaren.org/logan. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is McLaren’s In Good Health. I’m Bill Klaproth. Thanks for listening.