Transcatheter Aortic Valve Replacement

Overview

Transcatheter aortic valve replacement (TAVR) is a procedure to replace the heart's aortic valve without open heart surgery. Instead of opening the chest to place a new valve, we guide a synthetic valve to the heart using a very thin tube called a catheter.

The aortic valve regulates the flow of blood pumped from the heart's left ventricle into the aorta, the body's largest blood vessel. The aorta in turn carries blood from the heart to the rest of the body. The aortic valve opens to allow blood to flow into the aorta when the heart pumps and then closes to prevent blood from flowing back into the heart. If the aortic valve malfunctions, blood may pool in the left ventricle, potentially leading to congestive heart failure, blood clots, and other problems.

One type of aortic valve disorder is known as aortic stenosis, or a narrowing of the aortic blood vessel. Another type of aortic valve disorder is aortic regurgitation, which occurs when the valve does not close properly and blood "leaks back" into the heart from the aorta. Up to a point, medications can control the symptoms of these conditions, but ultimately the aortic valve must be replaced. The standard treatment for aortic stenosis and aortic regurgitation is open heart valve replacement surgery. However, in some cases, open heart surgery may not be the preferred option.

There are 2 types of TAVR procedures. The transfemoral access approach involves inserting the catheter with the new valve into the femoral artery in the groin and guiding the catheter to the heart using X-ray imaging. The transapical surgical access approach involves making a small cut on the left side of the chest, so that the catheter can be inserted directly to the tip of the heart.

The TAVR procedure avoids the risks associated with open heart surgery. The advantages include less trauma to the body and a significantly shorter recovery period. TAVR is seen as a promising alternative for individuals with aortic valve disorders who, for one reason or another, are not good candidates for open heart surgery.

The placement of the new heart valve should relieve symptoms of aortic stenosis and aortic regurgitation and improve heart function right away as well as for the future.

We have developed a program to assist your cardiologist to identify appropriate patients for this procedure and have a team of physicians who will perform the procedure.

Before the Procedure

We give every TAVR candidate a number of tests to assess the condition of your heart and determine if TAVR is appropriate for you. These tests may include:

  • Blood tests
  • Chest X-rays
  • Electrocardiogram and echocardiogram
  • Lung function tests
  • Computed tomography (CT) scan and/or magnetic resonance imaging (MRI) of the chest
  • Diagnostic cardiac catheterization
  • Coronary angiogram

If you are taking blood-thinning medication such as aspirin or warfarin (Coumadin), you may be directed to stop taking it for a period of time before the procedure.

Before the procedure begins, the skin at your incision site will be cleaned with special soap. You will also be given sedative medication through an intravenous (IV) line.

How It Is Done

We place you under anesthesia for the duration of the procedure. Depending on your condition and our judgment, you will either be asleep with general anesthesia or given a local anesthetic that will prevent pain but permit you to remain awake. A catheter will be placed into your bladder to drain urine during the procedure. The TAVR procedure normally takes between 1 and 2 hours. As discussed, there are 2 ways to perform the procedure:

Transfemoral access procedure. The surgeon makes a small puncture in the skin to access the femoral artery, near the groin. Then the surgeon inserts a very narrow, flexible hollow tube called a catheter into the artery. Using X-ray imaging, the surgeon guides the catheter through the artery to the heart. The catheter has a small balloon at its tip. When the catheter reaches the aortic valve, this balloon is inflated to stretch the valve open.

The new valve is then delivered to the heart by a second catheter, via the femoral artery. The second catheter deposits the new valve within the old, diseased valve. The balloon on the second catheter is then inflated, expanding the new valve, which should begin working right away.

Next, the catheters are removed, and the surgeon repairs the femoral artery puncture site and applies a bandage. Measurements are taken to ensure that the heart is functioning properly.

Transapical access procedure. The transapical surgical access approach involves making a small cut on the left side of your chest, so that the catheter can be inserted directly onto the apex, or tip, of the heart. A catheter is then placed directly into the heart muscle and guided with X-ray imaging to the aortic valve.

From this point forward, the stages of this procedure are the same as those of the transfemoral access approach.

Pacing wire
In some cases, a special type of wire known as a pacing wire is used to temporarily speed up the heart, thereby lowering blood pressure and reducing the heart's motion, which makes the procedure safer and easier to perform.

The pacing wire is inserted through a vein in the groin and guided to the heart. An electrical impulse is sent through the wire, causing the heart rate to increase for a few seconds. The pacing wire is withdrawn when the procedure is completed.

Risks

It is important to know that when compared to open heart valve replacement surgery, TAVR carries a higher risk of stroke in the year following surgery (though it presents a lower risk of major bleeding). Other possible risks of the procedure include:

  • Infection
  • Internal bleeding
  • Injury to the access artery
  • Allergic reaction to the anesthetic
  • Heart attack 
  • Discharge of blood clots or air bubbles from the old aortic valve (which may cause a stroke)
  • Kidney failure
  • Bruising at the puncture site

After the Procedure

After the procedure, you will be in the intensive care unit for 24 to 72 hours (1 to 3 days). A number of tubes for breathing, fluids, and medications may remain in place during this recovery period. We may also recommend some breathing exercises to help reduce the risk of lung infection. To prevent blood clotting, you may also be given aspirin or other blood-thinning medication. In some cases, you may be directed to continue taking this medication indefinitely, even after you return home. During this time, we will watch you closely and give you follow-up diagnostic tests, which may include:

  • Chest X-ray
  • Urinalysis
  • Electrocardiogram and/or echocardiogram
  • Blood tests

Following the TAVR procedure, you may be able only to drink liquids such as soup, juice, or water. Gradually, you will also be able to eat soft foods such as applesauce or ice cream.

After returning home from the hospital

After you return home, you can take a shower or bath if you are comfortable doing so. You will need to wash the skin around the puncture site carefully. Please notify us if you experience any of the following:

  • Bleeding, swelling, or draining at the incision site
  • Fever or chills
  • Difficulty breathing
  • Dizziness or lightheadedness
  • Uneven or rapid heart beat
  • Chest pain, nausea, or excessive sweating
Diet and exercise

Even after you are ready to eat solid foods again, you will want to stay hydrated and drink at least 6 to 8 cups of liquid each day. In general, you should eat a variety of healthy foods and minimize your intake of salt and fats. If we need you to make other dietary changes, we will discuss these with you.

Exercise can help with recovery, but you should begin slowly and only do a little at a time at first. We will discuss your exercise options with you. 

Follow-up care

We will let you know about scheduling follow-up visits. During these visits, you will probably have further diagnostic tests, such as a chest X-ray or electrocardiogram.


If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following:
(1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.