TAVR

What is TAVR?

Transcatheter aortic valve replacement (TAVR) is a catheter-based procedure to treat severe aortic stenosis (narrowing). It’s also called TAVI, for transcatheter aortic valve implantation. It is a minimally invasive procedure that involves placing a new aortic valve without removing the diseased valve. Your doctor may recommend a TAVR if you are not able to undergo traditional open-heart surgery to replace your aortic valve. A TAVR can relieve symptoms of aortic stenosis and improve your quality of life.

Your aortic heart valve keeps blood flowing in one direction out of the heart and into the large blood vessel called the aorta. The aortic valve opens to allow blood to flow forward to the body and closes tightly so blood does not leak backwards into the heart. The aortic valve can become thick and stiff as you age, which narrows the valve’s opening. This condition, called aortic stenosis, prevents blood from flowing forward normally.

A TAVR has serious risks and potential complications. You may have less invasive treatment options. Consider getting a second opinion about all of your treatment choices before having a TAVR.

Why is TAVR performed?

Your doctor may recommend a TAVR to treat symptomatic aortic stenosis if you are not an ideal candidate for surgery. Your doctor may only consider a TAVR for you if other treatment options that involve less risk of complications have been ineffective. Ask your doctor about all of your treatment options before deciding on a TAVR.

Your doctor may recommend a TAVR under the following conditions:

• You have severe aortic valve stenosis and are experiencing symptoms, including chest pain, heart failure, fainting, and irregular heart rhythms (arrhythmias).

• Medications have not improved your symptoms.

• You are at intermediate to high risk of poor surgical outcomes due to age, frailty, or other medical conditions.

Who performs a TAVR?

Cardiac surgeons and interventional cardiologists work together to perform TAVRs. A cardiac surgeon specializes in the surgical treatment of conditions of the heart and its blood vessels. Cardiac surgeons may also be known as cardiothoracic surgeons. An interventional cardiologist specializes in diagnosing and treating conditions and diseases of the heart and blood vessels. They use nonsurgical, catheter-based procedures and specialized imaging techniques.

How is a TAVR performed?

Your doctors will perform your TAVR in a hospital. Your doctor will make an incision in your groin and insert a catheter (a long, thin tube) through a blood vessel in your groin. Your doctor will guide the catheter up and into the heart until it reaches the diseased valve. The catheter tip contains a deflated replacement valve that your surgeon expands once the catheter is in place.

Types of anesthesia

Your surgeon will perform your TAVR using general anesthesia. General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You are unaware of the procedure and do not feel any pain.

What to expect the day of your TAVR

Your surgeon may admit you to the hospital the day before your TAVR. The day of your procedure, you can expect to:

• Talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form.

• Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. The surgical team will give you blankets for modesty and warmth.

• Talk with the anesthesiologist or nurse anesthetist about your medical history.

• A surgical team member will start an IV.

• The anesthesiologist or nurse anesthetist will start your anesthesia.

• A tube may be placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the procedure as they happen.

• The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the procedure and during your recovery until you are alert, breathing effectively, and your vital signs are stable.

What are the risks and potential complications of TAVR?

As with all surgeries, a TAVR involves risks and complications. Complications may become serious and life-threatening in some cases. Complications can develop during surgery or recovery.

General risks of surgery

The general risks of surgery include:

• Anesthesia reaction, such as an allergic reaction and problems with breathing

• Bleeding, which can lead to shock

• Blood clot, in particular, a deep vein thrombosis (DVT) that develops in the leg or pelvis. A DVT can dislodge and move to a lung causing a pulmonary embolism.

• Infection

Potential complications of TAVR

Complications of a TAVR are not common but include:

• Blood clots on the new valve

• Damage to the aorta and other arteries

• Death

• Heart arrhythmias

• Heart attack

• Kidney failure and other organ failures

• Mitral valve injury

• Movement of the new valve

• Stroke

Reducing your risk of complications

You can reduce the risk of certain complications by following your treatment plan including:

• Following activity, dietary and lifestyle restrictions and recommendations before surgery and during recovery. This may include cardiac rehabilitation.

• Informing your doctor if you are nursing or there is any possibility of pregnancy.

• Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage.

• Taking your medications exactly as directed.

• Telling all members of your care team if you have any allergies.

How do I prepare for my TAVR?

You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome. You can prepare for a TAVR by:

• Answering all questions about your medical history, allergies, and medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.

• Getting preoperative testing as directed. Testing will vary depending on your age, health, and specific procedure. Preoperative testing may include a chest X-ray, EKG (electrocardiogram), echocardiogram (echo), blood tests, and other tests as needed.

• Following dietary guidelines as directed.

• Losing excess weight before the surgery through a healthy diet and exercise plan.

• Not eating or drinking before surgery as directed. Your surgery may be canceled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.

• Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and can help the healing process.

• Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners. Your doctor will give you instructions for taking your medications and supplements.

Questions to ask your doctor

Facing surgery can be stressful. It is common for patients to forget some of their questions during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before surgery and between appointments.

It is also a good idea to bring a list of questions to your preoperative appointments. Questions can include:

• Why do I need a TAVR? Are there any other options for treating my condition? Why is TAVR the best option for me?

• How many TAVR procedures have you performed, and what were the outcomes?

• How long will the surgery take? When can I go home?

• What restrictions will I have after the surgery? When can I return to work and other activities?

• Will I need cardiac rehabilitation and where do I go for it?

• What kind of assistance will I need at home?

• What medications will I need before and after the surgery?

• How will you treat my pain?

• When should I follow up with you?

• How should I contact you? Ask for numbers to call during and after regular hours.

What can I expect after TAVR?

Knowing what to expect can help make your road to recovery after a TAVR as smooth as possible.

How long will it take to recover?

You will stay in the recovery room after surgery until your vital signs are stable. Your care team will then move you to an intensive care unit (ICU). ICUs provide 24-hour specialized monitoring and care.

It may take a few hours until the major effects of anesthesia wear off and you are alert. When you wake up, you may have a breathing tube in your mouth and tubes and wires attached to your body. These allow your team to monitor your vital signs, drain bodily fluids, take blood, and give medications and fluids.

You will not be able to talk if you have a breathing tube. However, the care team usually removes it within 24 hours. You may have a sore throat from the tube. This is usually temporary, but tell your care team if you are uncomfortable.

As you recover, you may move to a hospital room outside the ICU. This room will have equipment to monitor your heart rhythm and vital signs. Typically, hospital stays after a TAVR range from four to seven days.

Recovery after surgery is a gradual process Recovery time varies depending on your general health, your age, and other factors. Your doctor may refer you to a cardiac rehabilitation program to help you recover. Full recovery takes up to six months.

Will I feel pain?

Pain control is important for healing and a smooth recovery. There will be discomfort after your surgery. Your doctor will treat your pain so you are comfortable and can get the rest you need. Call your doctor if your pain gets worse or changes because it may be a sign of a complication.

When should I call my doctor?

It is important to keep your follow-up and cardiac rehabilitation appointments after a TAVR. Call your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:

• Bleeding

• Breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing

• Change in alertness, such as passing out, unresponsiveness, or confusion

• Dizziness

• Chest pain, chest tightness, chest pressure, or palpitations

• Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of surgical infection. However, you should follow your doctor's specific instructions about when to call for a fever.

• Inability to urinate or have a bowel movement

• Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot

• Pain that is not controlled by your pain medication

• Unexpected drainage, pus, redness or swelling of your incision

How might a TAVR affect my daily life?

A TAVR can restore normal blood flow in your heart. It can relieve the debilitating symptoms of aortic stenosis so you can lead a more active, normal life. The TAVR procedure is an emerging technology that researchers are still studying. The longevity of this type of replacement valve has not yet been fully determined.

You will need to take blood-thinning medications for six months after your TAVR. You may also need to take aspirin for the rest of your life. Regular visits with your cardiologist will be an important part of life after your TAVR.