08 May Patient base expands for TAVR
Once in a generation, a groundbreaking technology comes along that dramatically changes the landscape of cardiovascular care. Forty years ago, it was angioplasty. Today, the transformational technology is transcatheter aortic valve replacement (TAVR), says interventional cardiologist
Troy Weirick, MD, Beacon Medical Group Cardiovascular Specialists Riverpointe.
He and cardiothoracic surgeon Walter Halloran, MD, FACS, Beacon Medical Group Cardiothoracic Surgery Riverpointe, recently performed their 100th TAVR procedure at Elkhart General Hospital. Cardiothoracic surgeons Stephen Dickson, MD, and Jay Patel, MD, and interventional cardiologist M. Shakil Aslam, MD, are also part of the TAVR team. Elkhart General established its TAVR program in 2014 and is one of only seven hospitals in the state equipped and trained to perform TAVR.
The payoff of having a program in a community setting is enormous, as people who are not able to have surgery or to travel out of town for TAVR can get life-changing care.
“You’ve got these folks who are sickly,nfrail, short of breath and resigned that this is how their life will be, and we offer this therapy that gives them a new lease on life,” Dr. Weirick says. “To offer this to people 15 to 30 minutes away from their home is literally saving their lives.”
The Evolution of TAVR
TAVR originally received Food and Drug Administration (FDA) approval for only the sickest aortic stenosis patients, considered at high surgical risk. In summer 2016, approval extended to use for intermediatesurgical- risk patients. Dr. Weirick talks about an intermediate-risk patient of his who was short of breath and could no longer care for his frail wife. The TAVR procedure restored his ability to breathe and, consequently,
his energy to take care of his spouse.
“Especially for people who don’t have co-morbid diseases, this has really changed their lives,” Dr. Weirick says. “People can walk 500 feet, go grocery shopping, and attend birthday parties and other social events.”
Dr. Halloran says engineering technology has made TAVR possible, with development of better catheters, sheaths and artificial valves over decades.
“This is a high-intensity, unforgiving, very cool technology that’s being compared to a very successful standard surgical procedure,” Dr. Halloran states. “The engineering behind this is unbelievable. The process has to be as perfect as we can make it.”
During a TAVR procedure, the physician typically makes a small incision in the groin, places a catheter into the femoral artery and guides it through the heart to the aortic valve. He then inflates a balloon on the end of the catheter to stretch the valve open. Next, he guides a new, self-expanding valve over the catheter to replace the old aortic valve. The three calcified leaflets of the diseased aortic valve are pushed
against the aortic wall and help cement and anchor the new valve in place. The procedure typically takes 90 minutes.
Clinical trials throughout the country are now working with TAVR for low-risk surgical patients, as well. Both Drs. Halloran and Weirick agree that the transcatheter technique is safe for implanting aortic valves. What is not yet clear is how the valves will perform 10 to 15 years down
the road. TAVR valves, currently either the Edwards SAPIEN™ Valve or Medtronic CoreValve™, are made of cow and pig tissue, but they are constructed differently than aortic valves that are placed surgically.
Dr. Weirick comments, “We have feasibility and good results, but how will the prosthesis last in a 65-year-old man? I’m interested to see the data.” What’s not in question is that TAVR has been proven to be equal or superior to surgery in outcomes of all-cause mortality or disabling
stroke by one year after the valve procedure.
Additionally, it has several advantages over surgery — even minimally invasive surgery:
- Shorter length of stay, with hospital discharge two to three days after the procedure
- Less blood loss and fewer complications from the procedure, including fewer incidents of atrial fibrillation
- Shorter recovery time, with ability to resume normal activities within a couple of weeks
Patients typically notice immediate improvement in their breathing and a gradual improvement in energy.
It Takes a Village
Both physicians agree that the success of Elkhart General’s program is reliant not only on their efforts but on the support of referring physicians and the work of the entire Elkhart General TAVR team.
Dr. Halloran notes, “This couldn’t be successful without the collaborative trust and faith of physicians from Memorial, St. Joseph, Plymouth, Warsaw and Goshen. We’re doing this because the community supported us.”
In praise of the Elkhart General staff, he notes the thoroughness and efficiency of all involved. “We spend way more time preparing for the procedure than performing it,” he says. “Cardiologists and surgeons already had a great collaborative relationship. Cath lab and operating room teams are very detail-oriented with procedures and protocols. Everyone wants to do this.”
Elkhart General TAVR coordinator Mary Miller, RN, BSN, guides a meticulous work-up and assessment over two to four weeks. Two cardiothoracic surgeons must agree that the patient falls into the surgical categories of inoperable, high risk or intermediate risk. The Society of Thoracic
Surgeons score of 8 percent or greater risk of dying has been lowered to 4 percent to accommodate the intermediate-risk patients.
Every Monday morning, the TAVR team gathers for a conference to discuss details of upcoming cases. Referring cardiologists and primary care physicians are welcome to participate in person or via conference call. On the day of the procedure, team members review critical details before beginning the procedure.
“This is an excellent example of how a program can thrive in a small, community environment,” Dr. Weirick says. “Our preparation early on was great, and we haven’t relaxed our protocols or gotten complacent. The support of our referring physicians is essential. We’ve built trust and good communication.”
During the TAVR evaluation, I ask every patient why they want to have this surgery. They want to breathe and be able to walk around their house. They want to keep driving their car. They want more time with family. We show their response along with their picture to our team at the start of our TAVR conference. Sharing this information has allowed the team to understand the unique, personal aspect of the individual who is receiving the TAVR.
– Mary Miller, RN, BSN, TAVR Coordinator, Elkhart General Hospital
TAVR images courtesy of Edwards Lifesciences
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