Scott Webb (Host): This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Many people have heard of TAVR, transcatheter aortic valve replacement, and may think it's the only option for valve replacement. But my guest today says that while TAVR is a good option for some patients, it's not always the best option. I'm joined today by Dr. James Brockett. He's a cardiothoracic surgeon with Summa Health.

Doctor, it's great to have you here today. We're going to talk TAVR versus surgery and rely on you to help us to understand our heart valve options. So from your perspective, a cardiothoracic surgeon's perspective, when a patient needs an aortic valve replacement, what are the main valve and procedure options that are available today, and why is it really just not a one-size-fits-all?

Dr. James Brockett: Generally, there's two ways to replace an aortic valve. First is surgical aortic valve replacement, and that's what most people think of as like an open heart surgery, where we go in, we remove the diseased valve entirely and we sew in a new one.

And the second one is TAVR, which is a more recent development in approaches to fix the valve. It's a transcatheter approach, where we deliver a new valve through a catheter, and it's usually from an artery in the leg. And we expand it inside the old valve without removing the old valve leaflets.

So, those are the two main ways of fixing the valve. And then, within each of those, there are choices about the valve types. Surgically, we can implant either a mechanical valve or a surgical valve. And the mechanical valve is a good option, especially for younger patients because they last longer, but they require lifelong anticoagulation.

Host: Okay.

Dr. James Brockett: The surgical valves that we implant that are bioprosthetic or tissue valves, they don't need anticoagulation, but they also don't last forever. Each valve is a little different, but we say, you know, 10 to 15 years or so on the valve life for those.

Host: Yeah.

Dr. James Brockett: And there's a couple different types of TAVR valves. Some are expandable where we have a balloon inside of the valve and we expand them by inflating the balloon. And others, we let sit there and then they kind of self-expand. They have a native shape that they take once they're implanted.

Host: Yeah. As you are saying, there are different valve designs, right? And we're making clear, you know, it's not a one-size-fits-all. So then, you know, I'm sure patients have heard about TAVR but may not realize that, you know, there are different designs. It's not a one-size-fits-all. So, how do you explain the difference between transcatheter valve options and surgically implanted valves, you know, in a way that patients could understand or a podcast host can understand?

Dr. James Brockett: Surgical valve is kind of like remodeling a room kind of down to the studs. I mean, you replace everything, you take out everything on the inside. You leave kind of the two foundations. So, the aorta is where the valve sits, and we remove the leaflets when we remove it surgically. And then, we use sutures to implant the new valve. But for a TAVR valve, you could say it's kind of like installing a pipeline inside of an old pipe where you leave the old, you know, material there, and then you just install something new on the inside.

You know, each design kind of has its own personality and how it anchors, how it sits relative to the arteries that come off of the aorta, the coronary arteries. Each of these options are a very personalized decision when we meet with patients and to figure out which one is best.

Host: Sure. Between you, patients, families, you mentioned age as a factor and how long they're going to probably need these to last and how much upkeep, if you will, they want over the years. I think, Doctor, a common myth with TAVR is that it's always better or safer, because it's less invasive. So from your perspective, how do you help patients understand the trade-offs between TAVR and surgery?

Dr. James Brockett: This is one of the most common conversations that we have. You know, here at Summa, we have a heart team discussion. So, we always sit down with patients, and the patients will come in and they'll talk with an interventional cardiologist who, you know, does the wires and catheter techniques, the TAVRs. And they also talk to us at the same time. So, they get two different perspectives regarding their valve implantation.

Most people come into our office thinking that, you know, they want a TAVR. But after we talk to them, a lot of times, it might not fit for them specifically. Some of the advantages of TAVR, there's much less recovery.

So, patients are usually in the hospital overnight. They spend overnight in the ICU. And then, usually, they go home the next day. The recovery time for that is about a week, as opposed to surgery where you're in the hospital for maybe five to seven days. And the recovery time, because typically these are done through a sternotomy, you have to let that bone heal. It's, you know, four to six weeks at home of letting the bone heal and kind of taking it easy.

When you implant a TAVR, like I mentioned, you don't take the old leaflets out. So, a lot of times, you can't implant a larger TAVR in than what you have in the annulus. But if a patient comes to us with a very small annulus or a very small opening where that valve is sitting, surgically, we can do an enlargement of the annulus, and we can actually implant a larger valve.

So, some of those patients that come and see us that have a small annulus, sometimes they're better served with surgery. Also, when you're talking about TAVRs, especially in kind of younger folks in their 60s, there's a very high chance that they're going to have to have some kind of procedure down the line, whether it's a repeat TAVR or a surgical removal of the TAVR valve and implantation of a new valve. I'll tell you from experience, it's very hard to explant a TAVR valve. So, we try not to plan for that when we're talking about TAVRs with patients. So, that's another consideration. Usually, it's better to do surgery first if you plan on doing another valve in the future. Most of these surgical valves are meant to have a TAVR implanted into them now. That's kind of how they design them. Patients love faster recovery and everything, but sometimes it's just not the best thing for them in terms of the TAVR valve getting implanted in that initial encounter.

Host: Right. Yeah, it does seem from our conversation today that durability, obviously, is a concern. So, wondering to get a sense from you, you know, how do you talk with patients about valve longevity, especially as the younger, healthier patients are now probably coming in wanting TAVR, right, as their go-to option?

Dr. James Brockett: Right. The bioprosthetic valves last anywhere in the range of 10 to 20 years. And we have a lot of data going back on surgical valves, but the TAVR valves, they're kind of new in the medical scene. They've only been around for 10, 15 years. So, we don't have as robust data about them and their longevity, but the data that we do have shows, you know, very good results up to this point.

When TAVR was initially developed, it was for patients who were too sick or frail for surgery, and those were the patients that we implanted them in. And a lot of those were 80-year-olds that the lifespan longevity that would allow us to study the valve, you know, a lot of times.

So, as the indications for TAVR expanded to lower-risk patients, now we're getting more data in the longevity. So, that's rolling out, you know, kind of as we speak. More and more studies are looking at that. But as far as we know, they're about equal in terms of longevity to a bioprosthetic surgical valve.

Scott Webb: Okay.

Dr. James Brockett: But if you came in and you were, you know, 55 years old, my first recommendation would not be a TAVR valve. It would probably be a mechanical valve, a mechanical surgical valve, just because of the longevity. And really, if you have no contraindications to Coumadin, which is the blood thinner that we use for those valves, and you're able to take the medication reliably, there really isn't any reason not to get a mechanical valve when you're that young. It's kind of a daunting discussion to have with patients.

Host: I'm sure, yeah

Dr. James Brockett: We'd recommend, you know, a surgical valve replacement. But if you think, you know, long-term down the line, six weeks of recovery is definitely worth 20 to 30 years of longevity on the valve, I kind of when you step back and look at it.

Host: Recently, there's been some media attention, if you will, around early failure of a specific surgical valve. Wondering what's the most important myth to correct so patients don't assume that all surgical valves now are unsafe or outdated?

Dr. James Brockett: I think the valve that you're referencing is probably the Trifecta valve, which has been shown to fail a little earlier than other valves. Honestly, there are so many valves out there that one valve's problem isn't really every valve's problem. You know, that was one specific design issue with that valve.

The valves that we make today that we implant now are much more durable. They've been proven to last a very long time. And like, I said, they're made to have a TAVR implanted into them. So, we put them in. And when I implant a surgical valve, bioprosthetic valve now, my plan is to implant one that can accommodate a TAVR, a good-sized TAVR in the future. I'll make it such that we get a good-sized valve in there. I'm not going to put the smallest-sized bioprosthetic valve in there if I don't have to, because the plan would be, you know, maybe this thing fails in 15 years, and we have to consider a TAVR. So, that wasn't the case with the Trifectas. Those weren't made to accommodate a TAVR necessarily. The annulus and the metal in that valve does not expand or accommodate a TAVR.

So, that was one problem with that, those valves, and the other one was that the leaflets tend to calcify sooner than typical. They have lower life expectancy. So, we don't use those anymore. But we have a slurry of other valve options for us depending on the patient's anatomy.

Host: Of course. Yeah. And I'm getting a sense from you today that you kind of, especially—and I guess, apparently, I'm in this group, so I appreciate this, in my mid-50s, a younger patient—that you have sort of a lifetime valve plan, right? Not just the first procedure, but the other options and what you might do, you know, 15, 20, however many years down the line, right?

So, surgical valve now, TAVR later. So, maybe just take us through your thought process a little bit and then how you advise patients.

Dr. James Brockett: Yeah, it used to be, you know, because we didn't have the TAVRs, we would think what's the best, you know, valve and procedure for this patient today. You know, what's going to get them through today? But now, we're having to kind of play chess and think three moves ahead, you know? The CAT scans that we use and the caths and all the imaging that we do before we decide on what kind of valve that you're going to ultimately get, all that is this planning that, you know, well, the annulus is this size, so we could implant a surgical valve that's about this size, and that would accommodate a TAVR valve that's, you know, X size down the road if we needed to.

Host: Of course.

Dr. James Brockett: Or if we put a TAVR in, can we put another TAVR in later? Or is that going to prevent if they have some coronary disease? Is that going to prevent us from accessing the coronaries via catheter in the future? So, it's nice that we meet all as a team and go over everything all at once, where the interventional cardiologist kind of puts their input into the patient's history and anatomy in terms of delivering a TAVR valve.

You know, I bring the surgical aspect of things. You know, getting two valves out is going to be much more difficult than putting one in initially, you know, that kind of thing. You know, when you come here to assume that you're going to have a team approach and very personalized care, it's definitely not one-size-fits-all for these kinds of things.

Host: Yeah. Wondering if you could maybe, I don't know, share some examples of patients who were surprised to learn that open heart surgery might still be the best option for them, and maybe why that recommendation is, you know, again, about the long-term picture. Yes, people want smaller scars and faster recovery and all of that.

But when we think about the big picture, the long game, if you will, how do you advise them and sort of help them deal with the initial shock of, "Oh, open heart surgery, that sounds like a lot," you know?

Dr. James Brockett: You know, there are a couple of instances where people are coming into the office and thinking that they're going to get a TAVR, you know, maybe in the next week something and we kind of surprise them and, say, open heart surgery is probably better for them. And one of those young patients, maybe you're in your 50s, everybody thinks, "Well, I'm young, so, you know, the recovery time will be less with the TAVR. So, it has to be better and I can get back to work sooner and everything." But like I said, with the mechanical valve, that would be one reason why we recommend surgery is to implant the mechanical valve, it's just kind of a one-and-done solution for those patients.

Another example would be somebody who comes in after their workup and maybe they had their heart catheterization and they have coronary disease also that needs intervention. Maybe they have significant blockages in a couple vessels. You know, surgery is nice in those situations where if we find something else that we can intervene on at the same time, we can also fix all that at the same.

Host: Yeah, one-stop shopping, right? Yeah.

Dr. James Brockett: Right. And so, we can do a bypass, we can do a valve. Sometimes patients have an aneurysm that needs to be fixed. So, we can do all that stuff at the same time. And that makes surgery much more appealing, despite the recovery time as well.

Sometimes I think I mentioned where we have a patient with a small annulus where a TAVR valve might leave a significant gradient or pressure on either side of the valve that would suggest that the valve was undersized or not big enough for that patient. And at surgery, we can enlarge the annulus and get them a bigger initial valve that makes a bigger TAVR valve down the line possible. So, those three situations we see almost every week.

Host: I'm sure, yeah.

Dr. James Brockett: A little surprised, you know, that they need surgical intervention, but it really is the best thing for them.

Host: Yeah. Let's give folks, Doctor, a single question. If they're facing a valve decision, what's maybe the single most important question in your mind that they should talk to the care team, but ask the care team? We're talking about teams involving cardiologists and surgeons and all of that. Like, what's the one thing they should probably ask in this process?

Dr. James Brockett: Hopefully, the surgeons and the interventional cardiologists are already talking to them about it, but what is the lifetime plan? You know, what is the long-term plan? You know, "When I'm 80 years old, what are my options going to be, and what would that look like? And how long do you think, you know, this valve is going to last? Am I going to have to have another procedure?

And thinking along the same lines of playing chess, getting your pieces all in a row where you can have a plan for this valve for the rest of your life. Also, you want the interventional cardiologists and the surgeons to personally review your case and look at it, and that's actually mandated now.

When any program that has a TAVR or any hospital that has a TAVR program, you have to have evaluation by a heart team, which means an interventional cardiologist and a surgeon have to take a look at your case. And it's nice when they're all in the same room with you all at the same time, because then you kind of get all those questions answered, you know, in one visit. You don't have to bounce back and forth. There doesn't have to be a lot of communication back and forth between the surgeon and cardiologist.

Host: Yeah.

Dr. James Brockett: But anywhere you go, you have to have both of those opinions. I think that's important.

Host: Yeah. And as you say, you know, in the hands of the right team, especially at Summa Health, they're probably already having these conversations, but good to know what we should, you know, maybe jot down as we're facing these valve decisions.

Doctor, here at the end, this has been good stuff today. I just want to kind of do a little myth-busting, if you will. So, some quick one-offs. TAVR is always better than surgery.

Dr. James Brockett: I Would say that's a myth. TAVR is a great option for the right patient. I'll put it that way. And less invasive doesn't necessarily mean better. They're not really the same word. You can interchange those.

For younger patients with other heart problems to fix or certain anatomy, surgery kind of still wins in the long game. I think, TAVR is a great option for folks who have a lot of medical issues, who are a little later in life, where we think that the TAVR valve is going to last for the rest of their life.

Thankfully with the miracles of modern medicine, both options typically are very low risk for patients. If it's an isolated aortic valve replacement in a healthy patient, you're talking about a mortality risk, usually less than 1%, which is quite good. You know, it wasn't like that 20 years ago. It was much higher.

Host: Of course, yeah.

Dr. James Brockett: You know, technology has advanced to the point where these things are very routine and very safe. And I think a lot of folks come into the office thinking that, you know, they have a 30% risk of dying, you know, on the table or something with surgery, and it's just not the case. So, that's another big myth, I think that, you know, surgery versus TAVR, it's very safe these days.

Host: Yeah, sounds like it. All right, myth or fact, Doctor, surgical valves don't last anymore.

Dr. James Brockett: Well, that's a myth. I think it's almost backwards. Today's TAVI valves have, the longest published track records of any valve option, honestly, with most of them lasting 15 to 20 years. Like you mentioned with one particular valve, problems with one valve doesn't really change the category. It actually shows that we're watching the valves very closely in terms of making changes.

Host: Of course, yeah.

Dr. James Brockett: And so, we've learned from that valve and we've adapted the valves to accommodate TAVRs now. And so, things are constantly changing in the valve world, and we're getting better and better valves as the years goes.

Host: Yeah. Change you for the better, for sure. All right, last one here I've got for you, Doctor. Myth or fact, once you choose a valve, you're stuck with it forever.

Dr. James Brockett: Yeah. Well, that's a myth. I guess, tissue valves can usually be replaced often with a catheter procedure, a TAVR, a valve inside with a new valve. The caveat that makes a good closing point, I guess, is that the first valve choice really determines how good your future options are. You're not stuck, but you have to choose your first move—

Host: Choose wisely.

Dr. James Brockett: That's why we have a heart team approach to all that, just to plan everything out for you so there's no issues down the road with picking another valve if it's needed.

Host: Yeah. As you say, choose wisely, but you won't be choosing wisely by yourself. You'll obviously have maybe family, friends involved, but the great team at Summa Health, as we got rolling here today, we talked about how it's not a one-size-fits-all. There are lots of options. There are lots of factors like age and all of that. So, really good stuff today. Appreciate your time. Thanks so much.

Dr. James Brockett: Thank you. Appreciate it.

Host: And for more information, go to summahealth.org/heart. And if you enjoyed this episode of Healthy Vitals, we'd love it if you'd leave us a review. Your review helps others find our educational content. I'm Scott Webb. Thanks for listening, and we'll talk again next time.