TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)
What is a TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)?
A TAVI is a procedure performed to replace a diseased aortic valve that fails to open and close properly.
The aortic valve is the valve between the main pumping chamber of your heart (left ventricle) and the main artery to your body (aorta). The aortic valve usually opens when blood is pumped from your heart to the rest of your body. Heart valve procedures have routinely been treated by heart surgeons but more and more, keyhole procedures are being introduced, enabling interventional cardiologists to perform these traditionally surgical procedures in the cath lab or hybrid cath/surgery labs.
Peninsula Private Hospital has offered keyhole TAVI procedures since 2015. Peninsula Heart Centre cardiologists, Drs Gregory Szto, Mariusz Wolbinski and Vivek Gupta are accredited TAVI operators who operate with support of their surgical colleagues in a state-of-the-art hybrid cardiac cath lab to enable this less invasive valve replacement procedure. This results in shorter healing times and enables earlier discharge from hospital.
Why do I need to have a TAVI?
TAVI may be recommended if you have aortic stenosis, a condition where the aortic valve cannot open and close properly. This can be managed with regular surveillance via annual echocardiogram until the valve becomes narrowed to the point where it begins to put extra strain on your heart. This can result in symptoms such as breathlessness, chest pain, dizziness, and sometimes, blackouts and heart failure.
You may be considered for a TAVI if you are at high risk for open heart surgery. Previous cardiac surgery, age, frailty, renal impairment, diabetes, hypertension and lung conditions, can place you at higher risk for open heart valve procedures.
What does the procedure involve?
Tavi planning begins with evaluating your latest echocardiogram, your presenting symptoms and your overall suitability for the keyhole procedure.
Obtaining a thorough history and gathering the following information assists us in determining this.
TAVI Workup
To assess your suitability for TAVI, the following tests are performed:
- Blood tests
- Echocardiogram
- Diagnostic coronary angiogram and stenting of the coronary arteries if artery blockages are found.
- CT aortogram to measure the dimensions of your valve, aorta and arteries leading from the groin to your heart to confirm we can pass the valve catheter. This information assists us to decide what arterial access is possible and the type of valve you will need – a balloon expandable valve or a self-expandable valve. (insert pics) This is dependent on your aortic and coronary anatomy as well as prior history.
- An aortic valve calcium score is recorded to confirm the severity of the valve narrowing.
- Carotid artery CT scan to evaluate the neck arteries for the placement of a filter to reduce stroke risk
- A dental scan to check for infection or caries that need dental treatment prior to inserting a new valve.
- If you are frail a Geriatric assessment by a geriatrician is made to confirm you will benefit from the treatment.
- Assessment by a cardiac surgeon to discuss the option of surgery to treat the valve narrowing.
Your medical history and all of the test results will be presented and discussed at a TAVI team conference made up of interventional cardiologists, cardiac surgeons, anaesthetists and specialist doctors to determine your suitability for this mode of treatment.
You will be asked to present to the hospital on the afternoon prior to your procedure. Your anaesthetist, cardiologists and (geriatrician if required) will assess you pre-operatively and order any final blood tests or fluids to optimise you for the procedure.
Can I eat or drink before my procedure?
You will be fasting for at least 6 hours before your procedure.
Do I take my medications on the day of the procedure?
Unless advised by your doctor, you should continue to take your usual medications. Some blood-thinning medications may need to be stopped prior to the procedure.
Where do I go to have the procedure?
TAVI is performed at Peninsula Private Hospital in the cardiac hybrid laboratory (cath lab) which converts to an operating theatre. Present to admissions at the main entrance at the hospital at the time recorded on your hospital paperwork
What do I need to bring?
It is recommended that you bring with you to the hospital:
- Your hospital admission paperwork with a signed consent form, health insurance details and Medicare /DVA card.
- Your current medications in their original containers.
- An overnight bag with your belongings, as you will be required to stay 2-3 days in hospital for monitoring after the procedure.
What happens during the procedure?
The procedure is generally performed under a general anaesthetic and guided by a transoesophageal echocardiogram. It may also be performed under heavy sedation. This is always administered by a specialist cardiac anaesthetist. You will have an intravenous line inserted into your arm for IV fluids and drugs and an arterial line for monitoring your blood pressure during the procedure.
A temporary pacemaker wire may be inserted into the neck vein to pace your heart beat very fast to reduce the pressure and movement of the heart during the valve deployment..
Both groin arteries will be prepared and tubes (sheaths) inserted allowing the passage of wires, catheters and the device holding the valve up the main blood vessel of the heart, the aorta, to the aortic root which holds the disease valve.
A special filter, Sentinel device, will be placed in the neck artery via the right wrist artery to help prevent a stroke by capturing plaque debris as the valve is deployed. (Insert pic)
Guided by the transoesophageal images and x-rays, a catheter with a balloon at its tip may be inflated across the diseased valve (balloon aortic valvuloplasty) to dilate the narrowed valve ready for the new valve
The new valve will then be carried within a catheter via the groin artery and carefully and precisely positioned across the diseased aortic valve. When satisfied, the heart rate will be artificially increased via the pacemaker, to allow the new valve to be deployed. X ray and TOE images are taken to check the function of the new valve. If required, another balloon dilation may occur to further improve the function.
The groin puncture sites are closed with a self-dissolving stitch. The filter will be removed from the neck artery and pressure applied to the artery. The TOE probe and breathing tube will be removed and once awake and orientated, you will be transferred to the coronary care unit for overnight observation.
How long does the procedure take?
The procedure takes approximately 1 – 2 hours and you will remain in hospital for 2 – 3 days.
What are the risks?
The risks associated with TAVI are:
- Bleeding from or injury /dissection to the arteries requiring surgical repair
- Abnormal heart rhythms or heart block (which may require a pacemaker in 5 – 10%)
- Obstructed coronary artery (which will be dealt with during the procedure with coronary stenting). The valve selection, size and type helps to reduce this risk.
- Aortic regurgitation or leaking around the valve (which will be dealt with during the procedure with further balloon dilatation)
- Kidney impairment
- Stroke (reduced with a “Sentinel” filter )
- Urgent open heart surgery due to valve migration during deployment.
- Death
Your doctors will explain the risks to you prior to the procedure. You are also encouraged to discuss any questions or concerns with your doctor and your family.
After the procedure
Monitoring
After the TAVI, you will be moved to the coronary care unit. Your heart rate and rhythm, blood pressure and pulses/circulation in the limbs will be checked regularly. Neurological signs will be closely monitored for any changes in conscious state, movement of limbs that could indicate stroke. Report any pain or discomfort in the chest, groin/neck/wrist or throat which can be treated with mild analgesics.
You will be able to sit out of bed in 6 hours and start walking to the bathroom within 12 hours of your valve procedure. An echocardiogram will be performed at days 1 and 30 post procedure to confirm that the new valve is working well. You will need to organise for someone to come and pick you up from the hospital to take you home after the procedure as you have had an anaesthetic
A follow up appointment for your 30 day echocardiogram and review appointment with your cardiologist, will be arranged on discharge.
What will I need to do after I go home?
You can resume most gentle activities with no heavy lifting for 4 weeks and no driving for 2 weeks following the procedure. You will continue taking all of your medication unless instructed otherwise.
After TAVI, a combination blood thinning medication (e.g. Coplavix®) is given for a minimum of 6 months
Antibiotics should be prescribed as a prevention against infection of the valve when having dental or surgical procedures.
Report any fever related illness to your GP and cardiologist and obtain an echocardiogram if indicated to check the valve for endocarditis (valve infection)
If you have any questions or concerns relating to your procedure, or pain or discomfort after discharge, contact our office on 03-9789 0088 and speak to one of the critical care nurses
RESULTS
A copy of your procedural report and echocardiograms will be sent to your referring doctor.
The results of your procedure and echocardiograms will be recorded anonymously on an Australian wide central data base of structural procedures managed by the Health Department
