Tavr And Previous Chest Radiation
The patients with severe AS undergoing SAVR and history of mediastinal radiation therapy have significantly worse longer-term survival versus a matched cohort group of patients , as shown in a recent study. In another study, the authors compared the outcomes in post chest radiation patients with matched control patients undergoing TAVR and tried to identify predictive factors of survival. It was demonstrated that 30-day survival was 92% in both groups, but patients in the radiation group displayed lower, albeit not statistically significant survival rates compared to the controls at 5-year follow-up . Moreover, the main cause of death in the radiation group was respiratory failure. Nevertheless, in this population, it was shown a sustained post-procedural improvement in functional results after TAVR.
Risk Of Bias In Included Studies
A summary of the risk of bias assessment is illustrated in . Overall, the majority of included studies were at low risk of bias, aside from two studies in which the risk of bias was moderate due to inadequate adjustment for baseline factors or inadequate reporting on attrition rates. Across all outcomes, no evidence of significant publication bias was detected. GRADE assessment revealed moderate quality of evidence in all outcomes. GRADE assessment results for each outcome are reported in .
Forest plot comparing transcatheter and miAVR . Stroke and paravalvular leakage. miAVR, minimally invasive aortic valve replacement RR, risk ratio TC, transcatheter.
Why Would I Need To Undergo Tavr
Your heart has four valves, and blood flows through each one in sequence. The last of the four is the aortic valve. Your heart pumps blood through that valve and out to the rest of your body. TAVR is a procedure that replaces that valve without major surgery.
The most common reason to undergo TAVR is if you have aortic stenosis, which is narrowing the aortic valve or the area around it. That narrowing is usually due to calcium buildup on the valve and age-related wear and tear . It can also happen because of other health conditions.
Narrowing of the valve limits how much blood flows out to the rest of your body, forcing your heart to pump harder to compensate. That usually leads to long-term damage to your heart muscle and then heart failure.
Many people who need aortic valve replacement are high-risk, either because of the severity of the stenosis or other health conditions. That means they have a greater risk of complications or death from such a major surgery, and TAVR is their only option. In 2019, the FDA also approved TAVR for people who are at low risk for complications from surgery. TAVR also has FDA approval for people who previously had valve replacement surgery.
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Is Open Heart Surgery A Better Option For Some People
Sanchez says open heart surgery may be preferred if you have other surgical needs in addition to an aortic valve replacement. For example, if you need a new aortic valve, but you also have an ascending aortic aneurysm that needs repaired with open-heart surgery, then you would do the valve implant at the same time. Open heart surgery may also be preferred for patients who have complex coronary disease, or multiple blockages in the coronary arteries, along with severe aortic valve stenosis. Or, for patients with aortic valve stenosis and mitral valve disease, who would benefit from having all their valves fixed at once with a single operation.
A Quick Refresher On The Basics
Your heart, as you probably already know, has four chambers. Two of them, called the atria, receive blood coming into the heart, and the other two, the ventricles, pump the blood out of the heart. There are four heart valves to prevent the backflow of blood.
The superior vena cava and the inferior vena cava are the two blood vessels that bring deoxygenated blood to your heart. The aorta takes oxygen-rich blood from your heart to supply the oxygen to heart muscle itself and the rest of the body.
When you have aortic stenosis, the opening of the valve that leads from the left ventricle into the aorta is narrowed. Because the opening is too small, your blood cant flow from your heart to your body as it should thus reducing blood flow and in turn oxygen to the whole body.
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Effectiveness And Safety Of Different Tavr Devices Versus Savr
A network meta-analysis which included four trials evaluated the all-cause mortality in patients underwent TAVR vs. SAVR. Both procedures appeared similar regarding safety and efficacy and each procedure followed the same pattern of complications, as previously described. Within the same study, a comparison between the transcatheter devices demonstrated less strokes with CoreValve, than with transfemoral or transpical Sapien, whereas pacemaker implantation was more common with the Core-Valve.
Tavr Vs Savr In Young Low
- Yerasi C, Rogers T, Forrestal BJ, et al.
- Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-Risk Patients With Severe Aortic Stenosis. JACC Cardiovasc Interv 2021 14:1169-1180.
Transcatheter aortic valve replacement has not been systematically studied as an alternative to surgical aortic valve replacement in young , low-risk patients with severe aortic stenosis and current guidelines recommend shared decision making. Unanswered questions about TAVR in this population include the safety and effectiveness of TAVR among patients with bicuspid aortic valve future coronary access the durability of TAVR considerations for surgical explantation of TAVR management of concomitant conditions including aortopathy, mitral valve disease, and coronary disease and the safety and feasibility of future valve-in-valve TAVR.
This state-of-the-art review addresses these questions, and discusses risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe AS. The following are points to remember:
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What Happens During This Procedure
TAVR procedures typically take about an hour from start to finish. At the beginning of the procedure, youll receive either moderate sedation or general anesthesia . While these are similar, there are important differences:
- General anesthesia: This technique involves making you sleep using special medications, monitored by a certified registered nurse anesthetist and/or an anesthesiologist . While youre asleep, you wont feel any pain. Medical staff will also place a tube in your throat that connects to an artificial breathing machine called a ventilator. The ventilator ensures you keep breathing even while under anesthesia, and removing the tube typically happens once the procedure is over.
- Moderate sedation: This technique is similar to anesthesia, making you sleep and preventing you from feeling any pain. However, the effect is not as strong, and you don’t need to be on a ventilator during moderate sedation.
An interventional cardiologist will start the TAVR most commonly by inserting a catheter into the artery at your upper thigh. They will then thread this catheter up to your heart.
Other possible blood vessels to use for entry include:
- Direct aortic approach .
Types of valves
As of Sept. 2021, there are three different manufacturers’ that have FDA approval for TAVR valves. These include:
When Should I See My Healthcare Provider
Your healthcare provider will tell you when you should see them for follow-up care. If you have a heart valve replacement, regular follow-up care is vital to ensuring you have the best possible outcome. Follow-up visits will also sometimes include diagnostic tests to make sure the replacement valve is working as intended. Follow-up care is also important because most people who undergo TAVR will need to take blood-thinning medications for the rest of their life.
A note from Cleveland Clinic
Transcatheter aortic valve replacement is a lifesaving technique that offers a promising alternative to surgery, especially if you are too ill to undergo surgery safely. Ongoing research also shows that this technique can also be better even for those with a low risk of complications from surgery. This technique and the valves used as replacements are undergoing constant refinement and research, which may open the door for future improvements of this technique.
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Symptoms Of Aortic Stenosis
First, its important to understand that you may have aortic stenosis and not have any symptoms at all. However, as the opening keeps narrowing, youre more likely to experience symptoms including:
- Becoming breathless easily
- Feeling tired or unenergetic
Left untreated, aortic stenosis can ultimately lead to heart failure and death. Survival rates of untreated aortic stenosis are ~50% at 1-2 years. Aortic stenosis kills more people than many of the common cancers that have spread to the other parts of the body. Thats why its important to consider your options if youve been diagnosed with aortic stenosis.
How Do I Prepare For Tavr
Before surgery, your medical and surgical team will evaluate your overall health. This may include X-rays, CT scans, blood tests and other tests to check the health of your lungs and heart. Your medical team will also give you an echocardiogram to evaluate your aortic valve. This test uses sound waves to create images of your heart. Your medical team may also do a cardiac catheterization to evaluate the arteries that supply blood to your heart. You will also need to:
- Tell your healthcare provider about any drugs you are taking, including over-the-counter medicines.
- Quit smoking if you still smoke, because continuing to smoke increases the risk of a procedure-related problem with your lungs.
- Stop certain medicines if your health care provider instructs you to.
- Stop eating and drinking, usually at midnight before surgery.
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Tavr In Patients With Or Without Previous Coronary Artery By
The perioperative risk in patients with history of previous coronary artery by-pass graft is increased in SAVR. A recent study, based on data from the FRANCE-2 registry, compared the outcome and the overall survival in patients who underwent TAVR with and without history of CABG in 683 patients. On multivariate analysis, CABG was not associated with greater 1-year post-TAVR mortality. Finally, this study concluded that previous CABG not only does not adversely affect outcome in patients who underwent TAVR, but also it could be an alternative procedure to surgery, especially in high-risk patients with history of CABG.
A meta-analysis based on data from five cohort studies evaluated the relative perioperative and long-term survival of patients with previous CABG who underwent TAVR vs. those who underwent SAVR. It was demonstrated that both procedures were equally safe and effective with 1-year all-cause-mortality of 17.2% vs. 16.4%, thereby making TAVR an alternative therapy to SAVR in CABG patients.
What Is Transcatheter Aortic Valve Replacement
Transcatheter aortic valve replacement is a procedure that replaces a diseased aortic valve with a man-made valve. Aortic valve replacement can also be performed with open-heart surgery this procedure is surgical aortic valve replacement .
Your aortic valve controls blood flow from your heart to your body. If your valve becomes stiff, you have a condition called aortic stenosis. Your heart may have to work too hard to pump blood through the small valve opening to the rest of your body. This may lead to increasing heart failure.
The Food and Drug Administration approved TAVR for use in a broad spectrum of patients following multiple research studies comparing TAVR to SAVR. Whether TAVR or SAVR is more appropriate for a given individual depends on multiple factors and is discussed with each patient by both an interventional cardiologist and a cardiac surgeon. During TAVR, your doctor inserts a catheter through a blood vessel in your leg to deliver and implant the artificial valve into your heart. Significant research is exploring how to both advance the use of this technique and improve the devices that are used for TAVR.
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Arent Heart Problems Just A Part Of Getting Old
Sanchez says many people believe valve conditions are just part of the aging process, or that they wouldnt survive surgery at their age, and as a result wont seek treatment. Even if they feel fatigue and shortness of breath, they dont seek any help, but thats the optimal time to get in and get taken care of. Weve performed TAVR procedures successfully for patients in their 90s.
He says many people still believe a valve replacement means major surgery. They often worry about a big operation, and they think they wouldnt survive, so they say, Why even bother going in and being evaluated for this? But when we have an opportunity to explain the minimally invasive options to them and their family members, they understand that they can not only survive these procedures but dramatically improve their quality of life.
Characteristics Of The Included Studies
We identified 1666 records of which 1370 remained after duplicates were removed. After initial title/abstract screening, 26 articles remained of which 14 were excluded due to ineligible interventions, lack of separate outcome reporting and studies being only available as abstracts. Finally, we included 11 studies in our qualitative analysis, 7 of which were eligible for meta-analysis . Among the included studies, there were no clinical trials, one unmatched, one matched, three where adjustment was made via a multivariate model and six propensity-matched cohort studies. The included studies comprised a total sample size of 4674 patients, of which 2346 underwent TAVR, while 2328 patients underwent miAVR. The average reported follow-up among the included studies was 26.7 months .
Baseline characteristics of enroled patients in the included studies
Furukawa et al and Hirji et al were the only studies to report STS scores . Six studies used EuroScore II for risk stratification, with propensity-matched cohorts including patients with a low-to-moderate surgical risk . Five of the included studies reported logEuroScore with risks ranging from 38% in Zierer et als cohort to 3.77% in Tokarek et als study.
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Tavr Surgical Procedure: Recovery Process
How to maintain a healthy heart and avoid heart disease is one of those topics thats discussed with you throughout your life. From elementary school onward, youre encouraged to eat your fruits and vegetables, the school system encourages exercise and physical activity, and your annual doctor visits include the dreaded ice-cold stethoscope to check your heart.
Unfortunately, surgical procedures arent always unavoidable, even if youre diligent with taking care of yourself, and the thought of any kind of heart surgery can be scary. Whether youre in an accident, obtain a disease that affects your heart health, or are simply getting older and finding yourself dealing with things not working like they used to, its time to consider non-invasive procedures to repair an ailing heart.
Thankfully, many heart procedures have evolved and adapted to be more successful, less invasive, and easier on the patient in terms of recovery and healing. Heart valve surgery is no exception, with a less invasive alternative to open-heart surgery called transcatheter aortic valve replacement available to patients suffering from aortic stenosis with symptoms of heart failure that require valve replacement surgery.
Minimally Invasive Strategy Versus Conventional Strategy
A retrospective study assessed the safety and efficacy of a minimally invasive strategy versus conventional strategy during transfemoral TAVR cases. MIS is based mostly on local anesthesia and conscious sedation, performed in the cath laboratory without transesophageal echocardiography guidance. They used all commercially available valves. Even though the baseline characteristics were similar and procedural success was comparable , Minimally invasive strategy was associated with notable cost-saving, thanks to shorter postprocedural hospital stay and lower cost. Moreover, both procedures showed similar survival rates at a median follow-up of 230 days.
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Impact Of Anesthesia Type On Outcomes
There is still no wide-ranging consensus concerning the use of general instead of local anesthesia with sedation throughout the TAVR procedure. Data from the multicenter ADVANCE study showed clearly that both types are equally safe without significant differences between them, regarding all-cause mortality , cardiovascular mortality or stroke through 2-year follow-up. As expected, major vascular complications were more likely to happened, in the local anesthesia group, due to inappropriate movements of the patient. Moreover, the total hospital stay was comparable between the two types of anesthesia, concluding that the final decision has to be individualized.
The results of another recent retrospective study confirmed the above data. The authors concluded that there was no significant difference between the two types of anesthesia regarding the mid-term survival. Importantly, considering the access route for TAVR , no significant difference could be found in the mid-term survival.
Brighams Tavr Program Is Growing Rapidly
In 2009, Brigham and Womens performed its first TAVR as part of a landmark, multi-institutional series of clinical trials known as the PARTNER trials. Following approval by the FDA, the procedure moved into clinical service at Brigham and Womens in 2011.
Since TAVR went into commercial practice, the program has grown steadily. In 2018, the TAVR Program celebrated its the 1,000th case, making it the fastest to reach this milestone in New England.
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Tavr In Intermediate Risk Patients
An Italian observational, multicenter, real-world study, in a low-intermediate risk population, revealed comparable mortality, major adverse cardiac and cardiovascular events and rates of rehospitalization between SAVR and TAVR in a propensity-matched population of 1300 patient.
In the PARTNER 2A randomized trial, TAVR was compared with SAVR in 2032 intermediate-risk patients. The primary endpoint of all-cause mortality or disabling stroke at two years was to be similar for both groups . TAVR resulted in higher rate of major vascular complications and more paravalvular regurgitation while surgical replacement resulted in higher rates of acute kidney injury, severe bleeding and new-onset atrial fibrillation.