Trans Aortic Valve Replacement (TAVR)

Intro: We're talking wellness at MemorialCare Health System. It's time for Weekly Dose of Wellness. Here's Deborah Howell.

Deborah Howell (Host): And welcome to the show. I am Deborah Howell, and today we'll be talking about an innovative heart valve replacement procedure called TAVR. Our guest today is Dr. Michael J. Gault, a cardiologist and internal medicine specialist at MemorialCare Medical Group at Saddleback Medical Center, Long Beach Medical Center, and South Orange Cardiology Group. Welcome, Dr. Gault.

Michael Gault, MD: Thank you. Thanks for having me.

Deborah Howell (Host): What a pleasure. Let's begin at the beginning. What is TAVR?

Michael Gault, MD: TAVR are initials that stand for transcatheter aortic valve replacement. So this is a procedure for people that have an abnormality in the aortic valve. There's four different heart valves, the aortic, mitral, tricuspid, pulmonic, and people that have aortic valvular stenosis, to where, the most common for people is as we get older, the leaflets of the valve can calcify and get stiff, and that narrows the opening of the valve. Traditionally, this has only been able to have been fixed by open surgical resection of the valve and implantation of a new either pig or cow valve. Now, we have the technology of a valve that we can mount onto a stent and we can insert it through the groin, the transfemoral approach, put it inside the existing valve that's diseased, inflate a balloon, which then has the stent with the valve mounted in it, it pushes the old valve to the side, and the new valve takes over and starts working.

Deborah Howell (Host): That is not only remarkable, it's a remarkable explanation that I think we all understood. Amazing. What causes aortic stenosis then and what are the symptoms of that?

Michael Gault, MD: Well, as I mentioned, the most common is just as we get older, as the valve can calcify, the leaflets get stiff and they fuse together. Another is people that have had rheumatic fever, the valve can be affected by the immune complexes that cause the valve to narrow. There's a congenital condition called a bicuspid valve. Normally, the valve has three cusps on it, but many people are born with just two cusps. And in that situation, that valve can narrow more readily, and usually in their 50s or 60s those people have to have a valve replacement. And then also people that have had radiation therapy to the chest for other reasons can be at risk for the valve narrowing.

Deborah Howell (Host): Now I'm sure there are a lot of people who are in denial about this and, you know, say let's just do nothing. But what are the risks with not having the aortic valve replaced?

Michael Gault, MD: Well, there's really four. Number one is a symptom of what we call congestive heart failure, where people get more short of breath, they get winded, they get breathless. Another is that they get angina symptoms, they get chest pain. Another is that they can have what we call syncope or fainting spells or passing out. And the final is not so good, it's sudden death. So, unfortunately, those are the four presenting symptoms of severe aortic stenosis and they don't come in any particular order. So when we diagnose someone with aortic stenosis, we grade it mild, moderate, severe, critical. Once someone gets into that severe symptomatic aortic stenosis, they then have a 50% risk of passing away in two years due to that aortic valve.

Deborah Howell (Host): Oh my goodness, I'm going with door number three, syncope, then. Right? Wow. Okay. So, who is a good candidate for this procedure?

Michael Gault, MD: You know, most people are. It depends on... There's several tests that we do ahead of time to look at the candidacy. And it's the size of the blood vessels. So even though women are smaller than men and usually have smaller blood vessels, we've been able to get the valve down small enough to where even in most women, they are good candidates for it. The elderly, the people that have had other medical issues, that it's more difficult for them to go through an open surgical procedure, this can be an ideal procedure. But there are certain tests that we do ahead of time to see that the valve is situated in the right way, the calcium is where we want it to be, to where it secures the valve into position, and those tests along with evaluation by our team determine whether they're a candidate for this procedure.

Deborah Howell (Host): Okay, let's talk a little bit about those studies and tests. What are they? What are they needed before TAVR?

Michael Gault, MD: Well, the most common first test is an echocardiogram. That's an ultrasound of the heart and we do that and that's kind of our mainstay just to diagnose aortic stenosis. We then do a CAT scan, where we inject contrast and that tells us the sizing, it shows us the pathway for us to put the valve in through to make sure that there's not too many twists and turns and that the arteries are open and big enough for us to fit it. We then do an angiogram to make sure the coronary arteries, that there aren't blocked arteries that need to be taken care of, and then we look into other things, just making sure their lungs are good, and that's primarily it. So it's not nearly as much as we've had to do in the past.

Deborah Howell (Host): So a patient comes in, they have the procedure, and then what is the recovery like after the procedure?

Michael Gault, MD: Typically, if we're able to go transcutaneous, just sticking and no cutting, those people are usually home on an average of three days after being in the hospital.

Deborah Howell (Host): And traditionally, what was it with open heart surgery?

Michael Gault, MD: Yeah, it's usually more about five days, but then also, you know, more recovery just afterwards in recovering from the surgical wounds, which in this procedure there is no surgical wounds.

Deborah Howell (Host): Incredible. A new heart valve with no surgical wounds. Did you ever think we'd see this day?

Michael Gault, MD: I, you know, amazingly I didn't. I was a skeptic at the beginning, and it's been a wonderful journey to see that this has benefited and it's benefited so many of our patients, and it's just wonderful to see how well they do and how quickly they recover.

Deborah Howell (Host): And doctor, what medications do these patients need after receiving TAVR?

Michael Gault, MD: Really typically we'll put them on an aspirin, but many people are on different blood thinners, and many times we'll just put them back on whatever they were on before the procedure. But other than that, it's, many times we're able to take away many of their medicines.

Deborah Howell (Host): So not even pain pills after the procedure?

Michael Gault, MD: No, no pain pills are necessary.

Deborah Howell (Host): Wow. And what is the follow-up plan after the patient is discharged?

Michael Gault, MD: After the discharge, they typically come back in a month, and they'll go through and do a follow-up ultrasound to show that the valve is working properly, and they'll go through our cardiac rehab program, which typically goes three days a week for 10 weeks and gets them into a regular routine of activity, and it's just supervised by the nurses of the hospital and that pretty much gets them back to their, you know, even better than they were before.

Deborah Howell (Host): Now that you've taken most of the fear out of this for people, let's go back to the beginning. When does a person maybe have the experience of symptoms of, you know, before a TAVR procedure?

Michael Gault, MD: Well, you know, shortness of breath is a very general symptom. Congestive heart failure is a very generally used term that very widely, anytime anyone has too much fluid in their body, we say they have congestive heart failure. So with those combinations of symptoms, typically we'll look into things with an ultrasound of the heart and then that's where if aortic stenosis were to be part of the issue, that's where this would be a consideration.

Deborah Howell (Host): Okay, so I got the shortness of breath part, but how else would a patient be feeling if they had congestive heart failure?

Michael Gault, MD: Well, those other symptoms of syncope, the fainting spells, the angina symptoms, that is another one.

Deborah Howell (Host): Okay, got it. Alright, we're back to the beginning. How can people find out if TAVR is right for them and who should they reach out to?

Michael Gault, MD: Well, certainly to their primary doctor and then evaluation, you know, by a cardiologist. We have at Saddleback, we have a TAVR team, and that is on the website for Saddleback. We have a program coordinator, Miriam Fathy, who's our nurse practitioner. We have two of our heart surgeons that are very involved in the program, Dr. Montero and Dr. Perkowski. Myself, Dr. Bahadorani, there's Dr. Chen-Ching, and also Dr. Hohai Van.

Deborah Howell (Host): It's wonderful that you have a team and it sounds like you really are all coordinated and do work well together.

Michael Gault, MD: It's been a wonderful experience.

Deborah Howell (Host): How important is that, that the team be fluid and in communication at all times?

Michael Gault, MD: Absolutely, that's what leads to the best patient outcomes and the best patient experience, is that everybody's on the same page and we're making sure we're doing the right thing for each individual patient.

Deborah Howell (Host): I have a final question for you, doctor, since you've been so amazing and answered my questions so thoroughly. The complications for this procedure compared to open heart surgery, can you speak to that?

Michael Gault, MD: Right. Well, the complications mainly are related to either the access, where we go in through the groin, the blood vessels typically, there that's the same thing as when we do an angiogram or an angioplasty, it's an access issue. We use minimal amount of contrast. The risk of stroke is less than 1%, which is it's actually even lower than it is with the valve, the surgical valve replacement procedure. And that's primarily it.

Deborah Howell (Host): Absolutely incredible.

Michael Gault, MD: Some people do need a, there is a risk of potentially needing to have a pacemaker, because the electrical conduction system runs right near where the valve is, so in a little over 10% of the patients they'd need to have a pacemaker with the valve replacement, but that's not the majority.

Deborah Howell (Host): What if a patient already has a pacemaker, is it still possible?

Michael Gault, MD: Then it's, that's good, it's absolutely possible, it actually makes it easier, because then we know for certain that they wouldn't need a pacemaker afterwards. The pacemaker itself doesn't affect performing the procedure.

Deborah Howell (Host): Some people listening might not understand why you go through the leg or the groin.

Michael Gault, MD: We do because it's the big vessel, it's a way to access it that's very compressible, we can control the blood vessel at that site. There are people that do not have good access from the groin, and we either do what's called a transapical or a transaortic approach where we go through the tip of the heart directly or we go through the subclavian artery. So there are alternative access sites that we utilize, but the most favorable is going in from the femoral artery in the groin, and that leads to the best outcomes and the best patient experience.

Deborah Howell (Host): Dr. Gault, I thank you from the bottom of my heart for taking so much time today to be on our show with us and to give us new hope for heart patients, it's exciting.

Michael Gault, MD: It's a good era to be involved in cardiovascular care, the treatments we have available for our patients.

Deborah Howell (Host): It's very, very, very good to be a heart patient in 2018. Thank you, Dr. Gault. For more information or to listen to a podcast of this show, please go to memorialcare.org. That's memorialcare.org. I'm Deborah Howell, that's all for this time, have yourself a terrific day.