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TAVR- Transcatheter Aortic Valve Replacement
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Learn more about Jithendra Choudary, MD
Jithendra Choudary, MD
Jithendra Choudary, MD is a Cardiologist.Learn more about Jithendra Choudary, MD
Transcription:
Prakash Chandran (Host): Welcome to Right Beside You, a Reid Health podcast. I'm Prakash Chandran and I invite you to listen as we discuss transcatheter aortic valve replacement or TAVR for short. Joining me is Dr. Jithendra Choudary, a Cardiologist at Reid health. So, first of all, Dr. Choudary, it's great to have you here today. I was hoping you could start by giving us a basic explanation around what TAVR is.
Jithendra Choudary, MD (Guest): TAVR means transaortic valve replacement. That means we replace that aortic valve, which is one of the major routes in the heart, which actually opens to let the heart pump blood to the rest of your body. And when that's not opening as well, we replaced that route. Previously, the only option was to have open heart surgery to have it replaced. Now we can do it percutaneously, which means without open heart surgery, most of the time through your leg, through the femoral artery and replace it that way.
Host: Okay. That makes sense. So, let's now talk more specifically around how it's actually done and how the procedure is different from open-heart surgery.
Dr. Choudary: For the traditional open heart surgery, you would generally go under bypass and they would have to open your chest and then going there open the aorta, cannulate the aorta, replace the valve, put a new valve in and sew it in and then close everything and came out. And it would take several days to recover, obviously, because it's a pretty major surgery. But for the last 17, 18 years, the first one was done in 2002, but more commonly it's been done in the last five to 10 years. We have found a way where it's not as invasive. The analogy I would give is something like open surgery versus laparoscopic surgery, even laparoscopic surgery still has a little bit of a holes and other things that you have to put, but in this case, there are several approaches, but the most common approach is called a transfemoral, where we gain access to the femoral artery, which is an artery in your leg.
And then put some tubes and we have special devices, where else and with newer technology, where we had reconnect, advance it through your leg in to the aorta, which is a major artery, which comes out the heart and get down to the valve and place it appropriately and inflate it with the balloon and that way situate it at the right place. We could do this under general anesthesia or sometimes under conscious sedation. And you wouldn't be having any scars or any of those surgical issues. If everything goes well, a lot of people do go home the next day.
Host: Wow. Just the next day. That is incredible. So, let's talk about who is a good candidate for TAVR.
Dr. Choudary: Initially when we started, anybody with severe aortic stenosis, which means the aortic valve is not opening and is severely stenosed, with symptoms would be a candidate. But initially we had only extremely high risk, prohibit risk patients, which means these patients were generally very high risk for surgery or had prohibitive risk for surgery, where they couldn't even consider doing surgery. Those were the people we were doing in main initial phase and now we have more data for people with intermediate risk and low risk patients. So, everybody would be potentially eligible for TAVR, depending on whether you, if they're suitable for the procedure, which would be assessed by doing a CAT scan, which would give us detailed images of the valve and also the arteries in the legs and the aorta, which we need to be able to know for sure whether we can access it that way or not.
Generally we try not to do very young patients because there is a chance that the TAVR valve could degenerate faster than the regular surgical valve and we don't have data on durability for a long time. And also sometimes if patients sometimes have what we call a bicuspid valve, which means your aortic valve normally have three leaflets instead of that, if it just has two leaflets, or there are some other issues with calcium or a very small aorta and things like that, then we would prefer surgery. But potentially all patients, if they wish, could be a candidate for this procedure at this point in time.
Host: So, let's talk about the success rate of TAVR. And if there are any risks that people should be aware of.
Dr. Choudary: Well, the success rate currently is pretty high about 95%. Again, a lot of this depends on patient selection. That's why we have the heart team approach, which means we have several interventional cardiologists and surgeons on a team along with other staff who assist us with this, and then we get all the necessary CT scans and workup, including pulmonary function tests and other things.
Then the patient will see an interventional cardiologist and a cardiothoracic surgeon, and then we discuss it in a meeting and then we decide what would be the best option for that particular patient. The success rate of the procedure itself is extremely high. It's very rare that they can't get a valve in. Of late, we have been mostly do transfemoral procedures. But there are other accesses if we can't get through the transfemoral, then we can do what we called subclavian, which is the artery around your neck. We can do axillary which is an artery in your shoulder pec. We could do a carotid access, which is in your neck. Or we could go directly through the aorta. So, there are other options, but just doing transfemoral TAVR the success rate is around 95%.
Host: Yeah, that is definitely very high. What about any risks that people should be aware of?
Dr. Choudary: When compared to surgery with TAVR there is an increased chance that you may end up with a pacemaker following the surgery, the chance of having major vascular complications, which means complications with the artery is also higher. Those would be the two main things. And also there is increased the leaking of the aortic valve which is known to give you a worse prognosis than if you didn't have it. So, those would be the major drawbacks of when compared to surgical aortic valve replacement. But overall mortality and death for both procedures is similar.
In the most recent study, maybe at 30 days, it was even superior to surgery. But at two years, everything was equipose. So, everything was equal in terms of overall mortality and death and disability, but the advantages are that you would have less bleeding, less atrial fibrillation, you would have less strokes and less kidney injury.
And on the flip side, you would have an increased need for a pacemaker. You could have increased the incidence of valve leaks. And you could have increased incidence of major vascular complications.
Host: Okay. And just for clarity, one of the other things that you mentioned was that you try not to do this procedure on younger people because the durability of the valves just really isn't known yet. So, can you maybe speak to what you do know around how long these TAVR valves usually last?
Dr. Choudary: At about 10 years, about 40 to 50% of valves so far, from what we know, maybe we don't have the newer ones in that long, have some kind of degeneration, which means either they leak or there is some problem with it. Okay. So they're coming up with new models, which could potentially last a lot longer and could help us with that. But if somebody is less than 60 years than we, you know, we potentially expect them to live into their eighties, at least. And in that case, we may have to redo the procedure, which is put another valve in the valve which exists and potentially we would like to avoid that. Also younger patients, you know, they might need other procedures.
Sometimes when we do the TAVR valves, it's hard to get the arteries which supply blood to the heart. So, that if you are having a problem there, it would be harder for us to do stents and other procedures. That's why preferably we would like to avoid doing this procedure on the younger patients
Host: Understood. So, in theory though, from what you're saying, there's a possibility like every 10 to 15 years you would kind of need to replace that valve. Is that correct?
Dr. Choudary: Yeah, every 10 years in about 50% of the patients. It could last longer, but we do think that the newer ones would last much longer.
Host: Okay.
Dr. Choudary: But we don't know that for a fact, because time hasn't been lapsed yet. Those patients in study, they follow them up every year up to 10 years,
Host: Okay.
Dr. Choudary: And then we will have the data for the latest valves.
Host: So, any other benefits besides the obvious benefits of getting TAVR, you know, you also mentioned the quick recovery time, what other benefits can patients expect after getting TAVR?
Dr. Choudary: So, if they are having symptoms like shortness of breath or heart failure, they can expect their heart function to recover. If they are fatigued, beat, they would have more energy, they would just have more blood flowing and flowing through the rest of their body. So they would be doing a lot better.
That's either with TAVR or with surgical valve replacement. Specifically with TAVR, there is a less incidence of stroke when you compare to the surgery. There is a less chance of developing atrial fibrillation which is an irregular heart rhythm. There is less chance of developing acute kidney injury, which means damage to your kidneys. There's less chance of bleeding. You know, those would be the advantages to the procedure.
Host: So let's say someone is listening to this and they're trying to make a decision on whether or not TAVR is right for them, you know, and they're trying to balance all of the benefits we talked about with the risks that you just mentioned. What's a good framework, or what's a good way for them to think about making this decision for themselves?
Dr. Choudary: I would recommend highly that they see their cardiologist and discuss this in detail. And then once they have all the options, they can then see a surgeon and then we go through the heart team approach and make a recommendation. And that's a recommendation which is done after reviewing all the studies and giving every consideration to all possible risks and benefits.
And I would suggest that patients follow that advise.
Host: And Dr. Chaudhry just before we close, is there anything else that you would like our audience to know about getting TAVR?
Dr. Choudary: Just that it's getting more and more common and it's very safe, and the results are very good. And it would be an excellent option for people who are candidates. And as I said, all patients will be vetted through the heart team approach. And if they are candidates for this procedure, then this would be an excellent option which is not as invasive as surgery, and would give excellent results.
Host: Well, Dr. Chaudhry, I really appreciate your time. Thank you so much for a very informative conversation. That's Dr. Jithendra Choudary, a Cardiologist at Reid Health. Ask your doctor if TAVR is right for you. You can call (765) 962-1337 to schedule your appointment today, or for more information, please visit Reedhealth.org to get connected with one of our providers. That concludes this episode of Right Beside You, a Reid Health podcast.
Please remember to subscribe, rate and review this podcast and all the other Reid Health podcasts. I'm Prakash Chandran. Thanks so much for listening and we'll talk next time.
Prakash Chandran (Host): Welcome to Right Beside You, a Reid Health podcast. I'm Prakash Chandran and I invite you to listen as we discuss transcatheter aortic valve replacement or TAVR for short. Joining me is Dr. Jithendra Choudary, a Cardiologist at Reid health. So, first of all, Dr. Choudary, it's great to have you here today. I was hoping you could start by giving us a basic explanation around what TAVR is.
Jithendra Choudary, MD (Guest): TAVR means transaortic valve replacement. That means we replace that aortic valve, which is one of the major routes in the heart, which actually opens to let the heart pump blood to the rest of your body. And when that's not opening as well, we replaced that route. Previously, the only option was to have open heart surgery to have it replaced. Now we can do it percutaneously, which means without open heart surgery, most of the time through your leg, through the femoral artery and replace it that way.
Host: Okay. That makes sense. So, let's now talk more specifically around how it's actually done and how the procedure is different from open-heart surgery.
Dr. Choudary: For the traditional open heart surgery, you would generally go under bypass and they would have to open your chest and then going there open the aorta, cannulate the aorta, replace the valve, put a new valve in and sew it in and then close everything and came out. And it would take several days to recover, obviously, because it's a pretty major surgery. But for the last 17, 18 years, the first one was done in 2002, but more commonly it's been done in the last five to 10 years. We have found a way where it's not as invasive. The analogy I would give is something like open surgery versus laparoscopic surgery, even laparoscopic surgery still has a little bit of a holes and other things that you have to put, but in this case, there are several approaches, but the most common approach is called a transfemoral, where we gain access to the femoral artery, which is an artery in your leg.
And then put some tubes and we have special devices, where else and with newer technology, where we had reconnect, advance it through your leg in to the aorta, which is a major artery, which comes out the heart and get down to the valve and place it appropriately and inflate it with the balloon and that way situate it at the right place. We could do this under general anesthesia or sometimes under conscious sedation. And you wouldn't be having any scars or any of those surgical issues. If everything goes well, a lot of people do go home the next day.
Host: Wow. Just the next day. That is incredible. So, let's talk about who is a good candidate for TAVR.
Dr. Choudary: Initially when we started, anybody with severe aortic stenosis, which means the aortic valve is not opening and is severely stenosed, with symptoms would be a candidate. But initially we had only extremely high risk, prohibit risk patients, which means these patients were generally very high risk for surgery or had prohibitive risk for surgery, where they couldn't even consider doing surgery. Those were the people we were doing in main initial phase and now we have more data for people with intermediate risk and low risk patients. So, everybody would be potentially eligible for TAVR, depending on whether you, if they're suitable for the procedure, which would be assessed by doing a CAT scan, which would give us detailed images of the valve and also the arteries in the legs and the aorta, which we need to be able to know for sure whether we can access it that way or not.
Generally we try not to do very young patients because there is a chance that the TAVR valve could degenerate faster than the regular surgical valve and we don't have data on durability for a long time. And also sometimes if patients sometimes have what we call a bicuspid valve, which means your aortic valve normally have three leaflets instead of that, if it just has two leaflets, or there are some other issues with calcium or a very small aorta and things like that, then we would prefer surgery. But potentially all patients, if they wish, could be a candidate for this procedure at this point in time.
Host: So, let's talk about the success rate of TAVR. And if there are any risks that people should be aware of.
Dr. Choudary: Well, the success rate currently is pretty high about 95%. Again, a lot of this depends on patient selection. That's why we have the heart team approach, which means we have several interventional cardiologists and surgeons on a team along with other staff who assist us with this, and then we get all the necessary CT scans and workup, including pulmonary function tests and other things.
Then the patient will see an interventional cardiologist and a cardiothoracic surgeon, and then we discuss it in a meeting and then we decide what would be the best option for that particular patient. The success rate of the procedure itself is extremely high. It's very rare that they can't get a valve in. Of late, we have been mostly do transfemoral procedures. But there are other accesses if we can't get through the transfemoral, then we can do what we called subclavian, which is the artery around your neck. We can do axillary which is an artery in your shoulder pec. We could do a carotid access, which is in your neck. Or we could go directly through the aorta. So, there are other options, but just doing transfemoral TAVR the success rate is around 95%.
Host: Yeah, that is definitely very high. What about any risks that people should be aware of?
Dr. Choudary: When compared to surgery with TAVR there is an increased chance that you may end up with a pacemaker following the surgery, the chance of having major vascular complications, which means complications with the artery is also higher. Those would be the two main things. And also there is increased the leaking of the aortic valve which is known to give you a worse prognosis than if you didn't have it. So, those would be the major drawbacks of when compared to surgical aortic valve replacement. But overall mortality and death for both procedures is similar.
In the most recent study, maybe at 30 days, it was even superior to surgery. But at two years, everything was equipose. So, everything was equal in terms of overall mortality and death and disability, but the advantages are that you would have less bleeding, less atrial fibrillation, you would have less strokes and less kidney injury.
And on the flip side, you would have an increased need for a pacemaker. You could have increased the incidence of valve leaks. And you could have increased incidence of major vascular complications.
Host: Okay. And just for clarity, one of the other things that you mentioned was that you try not to do this procedure on younger people because the durability of the valves just really isn't known yet. So, can you maybe speak to what you do know around how long these TAVR valves usually last?
Dr. Choudary: At about 10 years, about 40 to 50% of valves so far, from what we know, maybe we don't have the newer ones in that long, have some kind of degeneration, which means either they leak or there is some problem with it. Okay. So they're coming up with new models, which could potentially last a lot longer and could help us with that. But if somebody is less than 60 years than we, you know, we potentially expect them to live into their eighties, at least. And in that case, we may have to redo the procedure, which is put another valve in the valve which exists and potentially we would like to avoid that. Also younger patients, you know, they might need other procedures.
Sometimes when we do the TAVR valves, it's hard to get the arteries which supply blood to the heart. So, that if you are having a problem there, it would be harder for us to do stents and other procedures. That's why preferably we would like to avoid doing this procedure on the younger patients
Host: Understood. So, in theory though, from what you're saying, there's a possibility like every 10 to 15 years you would kind of need to replace that valve. Is that correct?
Dr. Choudary: Yeah, every 10 years in about 50% of the patients. It could last longer, but we do think that the newer ones would last much longer.
Host: Okay.
Dr. Choudary: But we don't know that for a fact, because time hasn't been lapsed yet. Those patients in study, they follow them up every year up to 10 years,
Host: Okay.
Dr. Choudary: And then we will have the data for the latest valves.
Host: So, any other benefits besides the obvious benefits of getting TAVR, you know, you also mentioned the quick recovery time, what other benefits can patients expect after getting TAVR?
Dr. Choudary: So, if they are having symptoms like shortness of breath or heart failure, they can expect their heart function to recover. If they are fatigued, beat, they would have more energy, they would just have more blood flowing and flowing through the rest of their body. So they would be doing a lot better.
That's either with TAVR or with surgical valve replacement. Specifically with TAVR, there is a less incidence of stroke when you compare to the surgery. There is a less chance of developing atrial fibrillation which is an irregular heart rhythm. There is less chance of developing acute kidney injury, which means damage to your kidneys. There's less chance of bleeding. You know, those would be the advantages to the procedure.
Host: So let's say someone is listening to this and they're trying to make a decision on whether or not TAVR is right for them, you know, and they're trying to balance all of the benefits we talked about with the risks that you just mentioned. What's a good framework, or what's a good way for them to think about making this decision for themselves?
Dr. Choudary: I would recommend highly that they see their cardiologist and discuss this in detail. And then once they have all the options, they can then see a surgeon and then we go through the heart team approach and make a recommendation. And that's a recommendation which is done after reviewing all the studies and giving every consideration to all possible risks and benefits.
And I would suggest that patients follow that advise.
Host: And Dr. Chaudhry just before we close, is there anything else that you would like our audience to know about getting TAVR?
Dr. Choudary: Just that it's getting more and more common and it's very safe, and the results are very good. And it would be an excellent option for people who are candidates. And as I said, all patients will be vetted through the heart team approach. And if they are candidates for this procedure, then this would be an excellent option which is not as invasive as surgery, and would give excellent results.
Host: Well, Dr. Chaudhry, I really appreciate your time. Thank you so much for a very informative conversation. That's Dr. Jithendra Choudary, a Cardiologist at Reid Health. Ask your doctor if TAVR is right for you. You can call (765) 962-1337 to schedule your appointment today, or for more information, please visit Reedhealth.org to get connected with one of our providers. That concludes this episode of Right Beside You, a Reid Health podcast.
Please remember to subscribe, rate and review this podcast and all the other Reid Health podcasts. I'm Prakash Chandran. Thanks so much for listening and we'll talk next time.