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Summer 2013 - Transcatheter Aortic Valve Replacement (TAVR)

Innovative, life-changing treatment options for specific valve and atrial fibrillation patients

“You need a new heart valve, but you are not a candidate for surgery.“
”Unfortunately, we’re running out of treatment options for your atrial fibrillation.”

For patients, these are difficult messages to hear. For physicians, they are difficult messages to deliver. Two highly advanced procedures bring together state-of-the-art technology and the combined expertise of cardiologists, electrophysiologists and cardiac surgeons to treat patients who have severe aortic valve stenosis but cannot have open-heart surgery and those with atrial fibrillation (AFib) who cannot take protective blood thinners because of bleeding problems.

Transcatheter Aortic Valve Replacement (TAVR)

H2H Summer 2013, TAVR 1

H2H Summer 2013, Dr. Walter Tan

“The Benefits Are Typically Immediate.”
This is a quote from WakeMed cardiologist Dr. Walter Tan, an expert in the use of advanced cardiovascular devices and structural heart repair. Dr. Tan is referring to transcatheter aortic valve replacement (TAVR) for patients who have severe blockage (stenosis) in their aortic valve but are not healthy enough to have surgery.
Approximately 7 percent of Americans age 65 and older have aortic valve disease. It is likely 50 percent of these people will not survive beyond two years after the onset of symptoms, which can include chest pain and/ or tightness, heart palpitations, shortness of breath (especially with exertion) and fatigue. Advanced age, severe aortic valve disease symptoms and symptoms from other health conditions can even completely incapacitate people, eliminating quality of life. These patients are often too sick or too weak to undergo open surgery to replace their diseased valve – the preferred treatment. TAVR can be an option for these types of patients.
At WakeMed, Dr. Tan, an interventional cardiologist, Dr. Bryon Boulton, a cardiothoracic surgeon, and a large team of heart failure specialists, midlevels, nurses, physical therapists, anesthesiologists and radiologists join forces to perform TAVR procedures. Dr. Tan is with WakeMed Physician Practices – Cardiovascular and Dr. Boulton is with WakeMed Physician Practices – Carolina Cardiothoracic Surgical Associates. “At WakeMed, safety is our number one priority,” Dr. Tan emphasized. “We take extra time to study the patient’s problems, to understand their priorities and fears, and to explain the complex options to the patient and their family. We treat them as we would our own.”
During a TAVR procedure, a very small incision is made in the groin to access the femoral artery or the chest (transapical approach). The cardiologist uses catheters and wires to place the balloon-expandable valve across the old diseased native valve, with the heart still beating. Crimped to the balloon device is the collapsed replacement valve. The surgeon then deploys the new valve within the diseased valve by expanding the balloon together with the new valve. He then secures it into place inside the old valve, displacing the old valve out of the way. In addition, the new valve starts to work as a normal valve should as soon as the balloon is deflated. “Most of the time, the patients feel immediately better and start to see improvements in quality of life within several weeks,” noted Dr. Boulton.
“TAVR can be not only life-sustaining but life-changing because of the relief from symptoms patients experience after the procedure,” said Dr. Tan. “Some patients are bedridden before undergoing TAVR, and not long after the procedure, they walk into my office with a large grin on their face.”

Converging Technology & Technique to Treat AFib
There are several treatment options for atrial fibrillation – the most common type of irregular heartbeat. “There is a standard endovascular procedure for patients who failed medication that is effective for most AFib patients who have intermittent arrhythmia and a structurally normal heart,” said Dr. Pavlo Netrebko, an electrophysiologist (a cardiologist who specializes in treating heart rhythm disorders) with Cary Cardiology. “Patients with long-standing atrial fibrillation and associated structural heart changes do not respond to standard treatments as well.”
That option is called a convergent procedure – a convergence of technology and technique to treat AFib. A convergent procedure involves both an electrophysiologist and a cardiothoracic surgeon. “One of us works on the inside of the heart, and the other works on the outside,” said Dr. Boulton.
The surgeon creates a tiny incision in the patient’s abdomen instead of a large chest incision as is the case in open heart surgery That smaller incision means the surgery is minimally invasive, which can result in a shorter stay in the hospital and a faster recovery for the patient. The surgeon then uses radiofrequency ablation (the use of targeted heat to destroy tissue in problem areas of the heart to restore its regular rhythm) to create an area of ablated tissue on the back wall of the left atrium from the outside of the beating heart. The electrophysiologist threads a catheter through to the inside of the heart. Using radiofrequency ablation, the electrophysiologist fills in any remaining gaps from the inside of the heart and tests to confirm that all of its abnormal electrical impulses are eliminated.
“We continue to monitor the patient’s heart rhythm after the procedure to determine if the patient still needs medication,” said Dr. Netrebko.

The TAVR and convergent procedures can improve and actually extend life for heart valve patients who cannot undergo surgery and AFib patients whose conditions are otherwise unresolvable. To find out more about TAVR, call WPP – Cardiovascular & Thoracic Surgery/Vascular at 919-231-6333. For information about the convergent procedure, call WPP – Cary Cardiology at 919-233-0059.

What is Atrial Fibrillation?
Atrial fibrillation is the most common type of arrhythmia, which is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or irregularly. The heart cannot pump blood efficiently out of the heart and pooling of blood in the heart’s ventricle chambers occurs. If left untreated, a person with AFib has an increased risk of stroke or heart failure.

H2H Summer 2013, TAVR 2