A minimally invasive technique for aortic valve replacement has emerged as one of the most exciting innovations in heart care in decades.
Transcatheter aortic valve replacement (TAVR) allows doctors to insert a prosthetic valve inside a damaged valve in the cath lab. It’s a lifesaving option for patients with severe aortic stenosis (AS), for whom surgery is considered too risky. But it’s not yet ready for everyone.
“The technique and technology are evolving very rapidly. We are in the process of studying how to apply this technology for younger and healthier patients with AS,” says Samir Kapadia, MD, a Cleveland Clinic interventional cardiologist and catheterization laboratory director.
Surgery is the gold standard
In AS, calcium deposits on the leaflets of the aortic valve prevent the valve from opening fully. This forces the heart to pump harder, causing shortness of breath, fatigue and chest pain.
In lower-risk patients—even those well into their late 80’s—surgical replacement of the aortic valve is safe and effective. But many patients with AS have medical issues that make a surgery risky. TAVR can give these patients a second chance at life.
An emerging option
Just as TAVR has been highly successful in reducing the mortality rate from AS in high-risk patients, cardiologists expect it to do the same in lower-risk patients. But there’s still a lot to learn.
TAVR is technically challenging. Because the new valve must fit perfectly, the doctor must choose the right prosthesis for every individual. The wrong choice could increase the risk of a dangerous complication called paravalvular aortic regurgitation (PAR)—backflow, if you will, caused by a poorly fitting valve.
The best route to take—the one most likely to deliver the valve safely with the lowest risk of PAR and stroke—must also be determined. At this time, the rate of PAR and stroke are higher with TAVR than with valve replacement surgery.
In addition, no one knows how TAVR valves will fare over time.
“We have long-term studies showing how long valve replacements last, but we don’t know how TAVR valves will last,” says Dr. Kapadia.
Developments continue
While new valve designs are solving some of TAVR’s potential complications, doctors must gain experience with each new device and a variety of individuals to know how to perform the procedure safely and effectively.
“Operator and institutional experience are very important to ultimate success,” says Dr. Kapadia.
There is little doubt TAVR will become an option for lower-risk patients, as well as in those with other types of aortic valve diseases. It’s just a matter of time. Already, clinical trials of TAVR in medium-risk patients are underway.
“In the upcoming years, we are bound to see rapid spread of this transformative technology with the excellent results that have been seen in clinical trials,” says Dr. Kapadia. “In fact, as the technology matures and our experience evolves, we could expect even better outcomes in the years ahead.”
source: clevelandclinic.org
