TAVR vs Surgical Valve Replacement by Dr. DeFrain

Hi, my name is Dr. Michael Defrain and I'm one of the cardiothoracic surgeons evolved in our Tavern program, which is comprised of many individuals. I'm the one seeing you today you're here because you've been identified to have aortic stenosis, which is a valvular heart condition which affects the ability of your heart to effectively pump blood to your body all of the blood from your heart passes through the aortic valve and when that valve becomes constricted, it affects the amount and the volume of blood flow that gets distributed to your body. And so we can make you feel very sick when that condition develops. What is the difference between saver and tavr another real common question that I'm asked is what is the difference between saver and Tav or surgically versus transcatheter aortic valve replacement?

They're they're very different operations. They're not comparing Apples to Apples in a surgical aortic valve replacement. We actually open the body use the heart and lung machine to stop the heart open the aorta remove the valve leaflet tissue and then re-implant a new usually animal valve that is sewn into place in the aortic anulous so that it's perfect. with transcatheter aortic valve replacement Almost all that I just described does not take place and that the valve is inserted through the aortic Lumen into the aortic valve and the aortic valve leaflet is known is not removed in a Tavern procedure. It is simply pushed the side and the example that I typically

Tell patients if they're from the Midwest or have ever seen snow is a parking lot covered with snow that is cleared by removing the snow to the external the perimeter of the parking lot and it piles up there.

Generally, that's very well tolerated in the body. And the debris is removed. It's now a wide open parking lot or in this case, you're aortic valve or left ventricular outflow tract the blood can easily be ejected from the heart to your body. And then the new valve sits within the cage, which is holding that tissue out of the out of out of the way. They're very different procedures and they have

Different patient populations for which they are best suited for and here today. We're to decide with you. What makes the most sense for your condition? Why choose one procedure instead of the other you may have been identified to have this condition of aortic stenosis long ago or it may have been diagnosed recently. typical treatments for aortic stenosis do not begin with heart surgery and for which you are here to talk to me about today, but they typically begin with monitoring surveillance and medical therapy and you may have already been through some of those phases of the care.

When the condition progresses to a point where it's no longer safe or we have information indicate that you would benefit from an intervention on the aortic valve. That's when your cardiologist or primary care physician may have asked for our opinion. If this is now the right time in the evolution of this condition for you to consider an intervention interventions on aortic valve primarily consists of either surgical therapy where an incision is made in your body to remove the valve tissue and replace it or there's what's called Taver which stands for transcatheter aortic valve replacement where we don't need to open up the body cavity in order to restore normal aortic valve function. Now that procedure is typically done through a small incision in your groin. It can be introduced the valve can be introduced into your body through other avenues such as an upper arm artery and very rarely a neck artery.

Depending on if there are reasons for us to use alternate approaches, but typically it's done from the groin and allows you to avoid an incision into your body. What other tests will I need in order to prepare you for the transcatheter aortic valve replacement or the tower procedure? We need a detailed CAT scan of your body. And that is only done here at Health Park Hospital in order to maintain quality with the study. In addition to that. You'll need a heart catheterization and an echocardiogram many of those tests may have already been done. But if they have not been then we'll need them and be updated within the last 12 months. What is the multidisciplinary conference as part of the transcatheter aortic valve replacement program? We have a team of Physicians that involve Interventional cardiologists who are part of the tavern implant team who work with a side-by-side in the operating room.

We also have the cardiac anesthesiologist that you'll meet the morning of surgery as well as a host of other cardiologists surgeons and pulmonologists and our nursing staff, which are also part of the procedure all meet once a week and discuss each case. So your case will be discussed at that conference at which time I will present your information which include the CAT scan will review that the echocardiogram to verify that the disease warrants intervention and we'll get everyone's opinion on this process and I think through that process of multiple Physicians evaluating your entire situation we come to the best recommendations for you. If I were a patient in your shoes, that is what I would want from my care and that's how I want decisions made for what procedures I would or would not have so and that's the way we approach your care and we value that tremendously and we hope that you will see value in it as well. Unfortunately it does choir about an extra week in order to accomplish this so we ask for your patients, but the effort is to provide you the safest possible journey through this treatment. How long does it take to get on the or schedule once all of the testing has been completed and I present your information to our heart team conference. 

Once that process takes place later that day which occurs on Tuesday you'll get a call from our nurse coordinator, which is Francesca, passalacqua. She will call you and tell you the nature of what was discussed in our plan for treatment and typically within a week or two of that conversation. You'll be scheduled and have your operation. What should I expect on the day of surgery when it comes time for your Tavern operation?

You'll come to the hospital in the morning of surgery and be taken from there to our hybrid operating room suite where myself and Interventional cardiologist along with the cardiac anesthesiologist a perfusionist and a host of nursing support staff will be there to take care of you.

You'll be sedated and be mostly asleep during the procedure procedure lasts about 20 to 40 minutes typically. During that time, we'll make an incision in the growing which is typically about the width of my finger that allows us to insert the valve into the artery that ultimately lead to the aortic valve in the heart. And once the valve is in position. We expand it and that pushes the native aortic valve calcified obstructive surfaces to the side of the aorta and then the new valve resides within that valve and is a cage which Provides a wide opening for the blood to easily be ejected from the heart whereas before that was present.

Your native disease tissue was in the way creating an obstruction. What are the complications to consider? When we consider any treatment for heart disease and we're performing intervention on your body. There are complications which can occur now fortunately with Tavern it is very safe. However, there are Issues related to the insertion of the device into your body there can be a vascular injury at the point of entry and as we advance the device through the aorta and into position in the aortic valve where we'll ultimately reside there can be injuries to those blood vessels or there can be debris within the aorta which can be dislodged by the process of advancing this catheter. Now the dislodgment of that material can cause stroke which is one of our most feared complications when we deploy the valve in the heart tissue itself, it can push the calcium and debris that is there out into the surrounding tissues which can cause a delay in the conduction through the heart which could require a pacemaker implantation. There are pacemaker implantation rate ranges anywhere from eight to 16 percent after surgery. When should I return to the office once you've completed your tab or procedure you typically stay in the hospital for about One or two days. It will depend on your heart rhythm after surgery because that is one of our main focuses in order to keep you safe and our interest if you're staying an extra day is to ensure your safety and make sure that a pacemaker is not required.

Once that issue has been resolved most patients are home within 24 to 48 hours of the procedure. Once you are home, you'll see us back in the office and approximately two weeks. And then after that visit you'll be back at the 30 day mark for a repeat echocardiogram.

How common is the procedure and what are the benefits many of my patients who come who have been referred for aortic stenosis and are facing the tavar operation are very scared about the process and that's very natural.

Most patients are the fortunate information I can share with you is that we have a very large program and perform approximately two to three hundred Tavern operations per year. So it makes it one of the more common operations that we do. Our team is also very small and very focused so that they're very Adept and have a lot of experience with this. We're one of the first programs in Florida to perform a Tavern implant and our volume is very high. That is to keep you safe. And I think you can benefit from our experience in that regard. the fear of the procedure also Has to be considered in light of their health at the time we evaluate you and we will talk about that later today.

For most patients the risk of death stroke or other major complications is less than one percent. So you should feel very reassured that the treatment that we can offer you to help you feel better. Has very low risk associated with it.

How long should I expect for recovery? So with transcatheter aortic valve replacement the typical recovery is one or two days in the hospital. And then once your home you feel like yourself with very little physical recovery and recuperation ahead of you. with surgically aortic valve replacement typically in the hospital for four to six days after the procedure and when you go home, you have an incision on your chest that will require some time to recover from typically in the order of one to two weeks before you're feeling like you're self fully but most of those patients after surgery are out and about once your home you're riding in a car going to restaurants helping out with groceries at least going to the store.

But there's a period of time for about two weeks where you're just not quite full strength. Will I feel better? Another question many patients ask is this going to make a big difference in the way? I feel well that depends on how you feel. Now. Some patients are very symptomatic with this condition others are not those that have symptoms like shortness of breath. What leg swelling or a host of other problems? Often feel much better after the procedure and that comes usually within a week or two some immediate some feel it immediately right after they wake up from surgery, but that's not common other times. It takes weeks and you will be enrolled in cardiac rehabilitation in order to help you achieve the full benefit of the operation and that goes on for months after the operations performed other patients who are not symptomatic from their condition and you may be one of them.

Still derive significant benefit. We have data that show patients who have been treated medically with the condition of severe stenosis in comparison to those who have been treated with intervention either surgery or Tavr have significantly different life expectancies.

Once the intervention is taken place. So even in patients who may be like yourself who do not have any problems or just told to have aortic stenosis can still drive significant benefit in their life.