Michael Smith, MD (Host): Welcome to The Pulse at Tallahassee Memorial Healthcare. I'm your host, Dr. Mike. And today I'm with Dr. Thomas Noel from Tallahassee Memorial Healthcare, and we're going to be exploring the topic of minimally invasive heart valve replacement. Dr. Noel, welcome to the show.

Thomas Noel, MD: Thank you for having me.

Host: Really excited to talk about this topic, because I know it's had a huge impact in what you do in patient care. But before we get into the details of it, can you just describe the procedure that we're talking about today?

Thomas Noel, MD: Yeah. So, TAVR stands for transvenous aortic valve replacement. And essentially, a TAVR is when you go in through the artery of the leg, and you go up through into the old aortic valve and you put a new aortic valve inside of that. And that's a way to actually put a brand new aortic valve inside a patient without doing open heart surgery.

Host: And we're talking about this is the main big artery, right? That's coming from the heart and feeding everything.

Thomas Noel, MD: Yeah, absolutely. So, the aortic valve is one of the most important valves in the heart. It's what feeds all the blood flow from the pump of the heart to the rest of the body, and it's the valve that's most often affected to get worse as we get older. And so, this is why it really impacts an older population.

Host: What are the symptoms of an aortic valve that's not working quite right, or the term out there is stenosis. What does that mean? What does that feel like?

Thomas Noel, MD: Yeah. So as the aortic valve opens less well, so it doesn't open the way it should, we call that stenosis. And as the stenosis progresses, as you get older, you ultimately develop symptoms. And those symptoms are chest tightness, shortness of breath, typically with activity. And then, if you were letting symptoms get too long, you can actually develop a heart failure where the heart's not squeezing, or you can even have recurrent episodes where you pass out.

Host: This condition, is it genetically seen or is this just something that could happen as we age, as the population ages?

Thomas Noel, MD: Both. It's interesting actually. So, most patients are born with three leaflets of a valve. It almost looks like a Mercedes sign, if you will, if you were to look down at it from a surgical view. But some patients are born with just two leaflets, and that's called a bicuspid aortic valve. That's a patient population that is born with an abnormal valve itself. And that group will develop aortic stenosis at a much younger age. So, that population of people typically will present in their 60s, early, early 70s, where if you have what we call degenerative aortic stenosis or aortic stenosis that occurs just related to age, typically that's going to happen to you in your 70s, 80s, and 90s. So, you can have two different groups, one's genetic, one's not genetic.

Host: So, we're talking about TAVR, which is using a catheter, right? Versus open heart surgery. What's the difference there? Like, why is this better than the traditional surgery?

Thomas Noel, MD: I think we have to be really careful because, you know, as I'm not a cardiothoracic surgeon, I'm an interventional cardiologist, so I do the TAVRs, but surgery does work great for many patients. And many times, surgery is the preferred option. The challenge with surgery is it does require truly opening the chest a majority of times, or at least creating an incision to get to the heart. And patients have to go on a bypass machine, a heart-lung machine to function for them, and a valve has to be sutured in. Whereas with TAVR, that's done while the heart's beating. Our patients actually are not under general anesthesia. So, they just get a little medication to help them relax and their new valve is put in. For our side, it doesn't require a patient to be in intensive care unit. It doesn't require for them to be on a respirator. So, you can see the level of intensity to provide that valve change is much, much less with a TAVR than it would be with open heart surgery. And a majority of our patients with TAVR go home the next day. And obviously, with a surgical aortic valve, you know, you can be in the hospital somewhere between three and seven days. And then, there's longer recovery process when you have open heart surgery.

Host: So based on everything you just said, if I were a patient having to make this decision of what's best for me, TAVR sounds like the right choice. So, how do I know if I'm an ideal candidate?

Thomas Noel, MD: What I try to tell patients is, TAVR sounds like the best path, but there's so much more information involved in making the right decision. The first thing I would tell patients is you need to have your valve assessed by a heart team. And one thing that we do is we see patients as an interventional cardiologist and a cardiothoracic surgeon. They see patients at the same time. And so, the cardiothoracic surgeon's going to do the surgery. We're going to do the TAVR, but we're going to come together and try to find the best procedure for that patient, because there are nuances to this. And it's really important to understand that, in this day and age, many patients who are 70 years old, they're going to live until their 90s. And we've got to really think about what's the best way to treat that aortic stenosis, because it may actually require two valves in their lifetime. That's what we call lifetime management. It's really thinking about the risk of the procedure, the risk of the patient, and the long-term recovery for that person and how they're going to do over their lifetime.

Host: Is there research that has looked at the safety and efficacy of TAVR, say, versus surgical replacement? And how does that stack up?

Thomas Noel, MD: What we have to understand is that TAVR's been going on for about 15 years and where surgery's been going on for over 50 years. And so, the way TAVR came about is there is a group of patients that we call high risk or inoperable. They're too old, too frail, too other many medical conditions. And that's really how TAVR came to be a benefit. We could show that TAVR was a lower risk complication than obviously doing nothing, because if you do nothing, and you have severe aortic stenosis, you don't survive that long term.

TAVR basically started out in high risk or patients that couldn't have surgery, and then has slowly marched down into intermediate risk patients and low risk patients. So, talking about the longevity of the valve itself, we currently have five-year published data on these valve replacements in low and intermediate risk patients, the comparator was the surgical valve and the TAVR valve and the valves, they were equal in outcomes. So, there was no difference at five years. But when you bring new technology about, it takes time to show that 10-year outcome. If you could imagine, if you're doing a trial and you're waiting for 10-year outcomes, it takes you about 15 years to collect that data in total.

Host: The data you have now is more focused on the normal risk, low risk, right? Knowing that the high risk surgical patient has to have a TAVR or they can't go into surgery.

Thomas Noel, MD: Right. I mean, you prefer the TAVR. Yeah. So, you're really looking at the low risk and the intermediate risk patients, and trying to give them an idea of what's going to give them the best five, ten, fifteen-year plan. And again though, you're even thinking about, well, what if we have to put a second valve in because there are ways to put a TAVR inside a TAVR. So, we're always thinking about that as we try to decide what's best for the patient when they come in. Because what you said is exactly right, everybody wants the TAVR and they want to go home the next day. But it's our responsibility to find the absolute best treatment for them and help them understand that.

Host: We touched on this earlier. I just want to review it again. Can you first explain what TAVR stands for? And can you give us an average day that a patient is going to go through getting a TAVR?

Thomas Noel, MD: Yeah. TAVR stands for transcatheter aortic valve replacement. Essentially, what you're doing is you're taking a valve that's on a catheter and you're delivering it through the artery. And that goes back up into the heart and that valve is delivered inside your old valve, and it essentially pushes the old valve aside. The process of having that procedure, typically you come into the hospital. Our procedures are done in the cath lab. So, you come downstairs, you see our team, you see the cardiothoracic surgeon, you see the cardiologist again. We do have an anesthesiologist who's part of that team, get them prepped, get them to the cath lab. The procedure takes about an hour. They come back to the recovery area. And then, after about three to four hours, we try to get those patients up into a chair and walking. And then, the next day, they have an echocardiogram and typically they're going home.

Host: Since you started doing the TAVR procedures, has it evolved already? Is there some new technology that you find exciting for the future?

Thomas Noel, MD: Absolutely. Where we started and where we are now are really two different times. The catheter size, which is the tube that you have to deliver it on, has gotten so much smaller. And that has allowed us to take care of patients in a different way. As you can imagine, a smaller tube means a smaller hole, means the complication risk goes down. And it means that patients have less tenderness or even kind of achiness around that access site. So, that has been a big change.

The other thing that's interesting is the way they're making the leaflets themselves. The goal here is to make valves that if you have a valve put in at 65 or 70, that survives the rest of your life. So, they're creating technology on those leaflets to take valves that now last about 10 to 15 years that are going to last hopefully 20 to 25. So, those are the kind of technologies that really excite me for our patients and our community.

Host: If I've decided as a patient that you know, TAVR is what I want, your team, right? You and the surgeon decided, "Yeah, you're a good candidate," what are some crucial pre and post-procedure steps I should be aware of?

Thomas Noel, MD: So if I was going to choose a program, the one thing I would say is I would choose a program that has all the different valve types. I think it's really important because, if you only go to a center that has one valve type, then they try to put that valve for every patient. I think it's really important that you know that there are different varieties for different patient situations, different anatomies of the valves.

And I think it's also important that patients understand how important a CAT scan is. We CT all of these patients and the CT is actually how we measure the right valve for each individual because each individual has a completely different size valve. You have to get it within a millimeter or two millimeters to really get the perfect size for that person. But if you do that, the results are amazing.

Host: So TAVR, for the most part, the recovery is a day or so, correct? They get their echo, they go home. What's the recovery time for traditional surgery?

Thomas Noel, MD: It's definitely longer. Typically, patients are in the hospital for three to five days. There's definitely a higher level of soreness with interacting in the chest and typically requiring a sternotomy. That process typically is a lot longer for those patients to recover and, to really kind of get back to feeling like themselves, probably about 30 days. It's definitely a big difference for the patients. And it's kind of interesting, we've taken care of patients that have had open heart surgery and then come for TAVR later in their life, and they're really quite amazed in how different the recovery process is for them.

Host: Is TAVR type procedures the wave of the future for any type of heart valve repair or replacement?

Thomas Noel, MD: I think it is to a degree. You know, I think the one thing I want patients and our community to understand is that surgery will always have a role in taking care of patients. But what you really want is a wider spectrum of methods to provide solutions for heart disease or valve disease that are just beyond surgery. So, the answer to your question is absolutely, there's treatments for the mitral valve that are percutaneous, don't require surgery, for the tricuspid valve that don't require surgery. So, that's why I think it's so important to really go to or be part of a valve center that has all those different modalities, because you don't want to just go to a place that does one thing. And even if they do it well, you want all your options as a patient.

Host: Is there any last word that you would like the audience to know about what you do with TAVR procedures?

Thomas Noel, MD: Well, I mean, I think there's two things. I think as a physician, it's a true honor to have the trust of patients and families to take care of them and return them back to the life, a better life, than what they had before. I think it's also important for them to understand that making sure they are finding those institutions, programs, physicians that are really dedicated to cutting edge, evidence-based care and partnering with the patient in making the right decision for them.

Host: Fantastic. Dr. Noel, this was great. Thank you so much for your time and the information you shared. Fantastic interview. Great job.

Thomas Noel, MD: Thank you. Thank you very much.

Host: For more information, you can visit tmh.org/heart to explore the expert Heart and Valve services at Tallahassee Memorial Healthcare. If you like this podcast, go ahead and share it on your social channels, and also explore our complete podcast library for topics of interest to you. This is The Pulse at Tallahassee Memorial Healthcare. Thanks for listening.