17570 Transcatheter Aortic Valve Replacement Tavr

Overview

TAVR (also called TAVI) is a way to replace a narrowed aortic valve without opening the chest. The aortic valve is the one-way door between your heart and your body's main artery, the aorta. When it becomes stiff and narrow — a problem called aortic stenosis — your heart has to work much harder to push blood through. In TAVR, a doctor guides a new valve through a small tube (called a catheter) placed in a blood vessel, usually in the groin, and moves it up to the heart. The new valve opens out and takes over the job of the old, narrow one. Because the chest is not opened, recovery is often quicker than with traditional heart surgery.

Aortic stenosis is one of the most common heart valve problems in older adults, and TAVR has become a routine procedure in many heart centres around the world. It is one of the most commonly performed valve procedures in people over 70.

TAVR is mostly used for older adults, often in their 70s and 80s, and for people whose age, frailty or other health conditions make open-heart surgery risky. It is also being used more often in younger, lower-risk people as evidence grows. Aortic stenosis itself is more common in men and in people with a history of high blood pressure, kidney disease or chest radiotherapy.

Symptoms

Common symptoms

• Feeling short of breath, especially with activity, or when lying flat in bed
• Chest pain, tightness or pressure, often brought on by exertion
• Unusual tiredness and low energy during normal daily activities
• Dizziness, light-headedness or fainting, particularly with exercise
• A fluttering, pounding or noticeable heartbeat (palpitations)
• Swollen ankles or feet
• A heart murmur that your doctor can hear with a stethoscope

Causes

Main causes

• Age-related wear and calcium build-up. Calcium is a mineral normally in your blood; over time it settles into the valve flaps and makes them stiff. This is the most common cause.
• Being born with a valve that has two flaps instead of three (a bicuspid aortic valve). This can narrow earlier in life.
• Rheumatic heart disease, a long-term effect of an untreated strep throat infection in childhood. It is now rare in many countries.
• Radiotherapy to the chest, or long-standing kidney disease, both of which can damage the valve
• In rare cases, a valve infection that has healed with scarring

Risk factors

• Getting older — the single strongest risk factor
• High blood pressure over many years
• High cholesterol
• Smoking
• Diabetes
• Long-term kidney disease
• A family history of heart valve disease
• Previous radiation treatment to the chest

When to see a doctor

See a doctor urgently if:

• You faint, or nearly faint, especially during activity
• Chest pain or tightness that is new or getting worse
• Breathlessness that is worsening quickly, or you cannot lie flat
• Your ankles or legs swell up and you gain weight quickly

Book a routine appointment if:

• You have been told you have a heart murmur
• You get more tired or breathless than other people your age
• You have a family member with heart valve disease
• You have a procedure planned and want to understand your options
• You have had TAVR and want to talk about recovery, medicines or follow-up

Diagnosis

Your doctor will start by asking about your symptoms and listening to your heart with a stethoscope. If they suspect a valve problem, they will arrange an ultrasound scan of the heart. If the valve turns out to be narrowed, you will usually be referred to a 'heart team' — a group of heart doctors, surgeons and imaging specialists who meet to decide together which treatment is best for you.

Tests that may be done

• Echocardiogram — an ultrasound scan of the heart that shows how narrow the valve is and how well the heart is pumping
• Electrocardiogram (ECG) — a painless tracing of the heart's electrical rhythm
• Chest X-ray
• Blood tests, including kidney function and blood counts
• CT scan of the heart and blood vessels — used to plan the TAVR procedure and check the size of the valve
• Coronary angiogram (cardiac catheterisation) — a dye test to check the arteries around the heart
• Exercise or stress testing, and lung function tests, to see how well you cope with activity
• A general health and frailty assessment, so the team knows what you can safely cope with

What to expect at your appointment

Testing usually happens over a few outpatient visits and does not hurt, although the angiogram involves a small tube being placed in a blood vessel, usually in the wrist or groin. After the tests, the heart team will meet and explain your options face to face, including the benefits and risks of TAVR, open surgery, or medicine-only care. Take your time, bring someone with you, and write down your questions beforehand.

Treatment

Treatment depends on how narrow the valve is, whether you have symptoms, and your general health. The options are usually: careful monitoring if the narrowing is mild and you have no symptoms; medicines to ease symptoms and protect the heart; and valve replacement — either by TAVR or by open-heart surgery. The aim of valve replacement is to fix the underlying problem so your heart no longer has to strain.

Self-care at home

• Stop smoking — ask your doctor or pharmacist for support, as this is the single biggest thing you can do for your heart
• Weigh yourself at the same time each day and note any sudden gain, which can be a sign of fluid build-up
• Keep as active as feels comfortable; ask your team what level of activity is safe for you
• Eat a balanced diet and keep salt moderate to help with fluid and blood pressure
• Take your medicines as prescribed and check with your pharmacist before starting anything new, including over-the-counter remedies
• Keep your dental check-ups up to date — healthy gums help protect the heart valve, especially after a replacement
• Keep your vaccination appointments up to date, as chest infections are harder on a strained heart
• Attend your follow-up scans and appointments, even if you feel well

Medical treatments

No medicine can unblock a narrowed valve. Medicines are used to ease symptoms and protect the heart — for example to lower blood pressure, remove extra fluid, steady the heart rhythm and treat high cholesterol. Your doctor will choose these individually and review them regularly. After a valve replacement you may need blood-thinning or antiplatelet medicine for a period of time, and you should always tell any dentist, surgeon or pharmacist that you have a replacement valve. Never stop or change a heart medicine on your own without speaking to your doctor.

When is surgery considered?

Valve replacement is usually offered once the narrowing is severe and causing symptoms, because without it the heart struggles more over time. TAVR is generally preferred when open-heart surgery would be too risky — for example because of age, frailty, previous chest surgery or other illnesses. Open-heart surgery is often a good option for younger, fitter people, and it can last for many years. Sometimes the heart team will advise waiting and watching if you feel well and the narrowing is not yet severe. These decisions are made with you, not for you.

Living with this condition

Most people go home within a few days of TAVR. Expect to feel tired for a couple of weeks and to build up slowly over four to six weeks. You may have a small wound in the groin, wrist or chest — keep it clean and dry and check it daily. Avoid heavy lifting and strenuous activity for the time your team advises, usually a few weeks. Ask about driving, returning to work and travel at your follow-up appointment.

Lifestyle tips

• Build activity up gradually — short, regular walks are better than occasional long ones
• Join a cardiac rehabilitation programme if one is offered; it helps you recover safely and meet others in the same situation
• Stay smoke-free and avoid smoky places
• Keep alcohol within sensible limits
• Get plenty of sleep and pace yourself on busy days
• Tell any healthcare professional that you have a replacement heart valve
• Carry your procedure details or a valve card with you if you are given one

Diet and exercise

A heart-friendly diet means plenty of vegetables, fruit, wholegrains, beans, fish and lean protein, with less salt, processed food and fried food. You do not need a strict diet — small steady changes work best. For exercise, aim to move most days. Start with gentle walking and build up as you feel able. If you feel chest pain, dizziness or unusual breathlessness, stop and rest, and tell your team about it.

Mental health and emotional wellbeing

It is very normal to feel anxious before the procedure and uncertain afterwards. Some people feel low for a while, or worry about every twinge. This usually settles, but help is available and you do not have to cope alone. If low mood or worry is affecting your sleep, appetite or daily life, tell your doctor — talking therapies and support groups can help a great deal. If you ever have thoughts of harming yourself, contact your local emergency number or a crisis support service straight away.

Prevention

You cannot fully prevent the age-related calcium build-up that causes most aortic narrowing. But you can lower the strain on your heart and reduce your risk of related problems by keeping blood pressure and cholesterol in a healthy range, not smoking, staying active, managing diabetes and kidney disease well, and treating a strep throat infection properly. These steps protect your heart and blood vessels overall, even if they cannot turn back a valve that is already scarred.

Screening programmes

There is no routine screening programme for heart valve disease in most countries. The best 'screening' is having your heart listened to when you see a doctor — if a murmur is heard, an ultrasound scan of the heart is the next step. If you have symptoms or a family history of valve problems, ask your doctor whether a scan is appropriate for you.

Complications

If left untreated

• The heart muscle can become weak and stiff, leading to heart failure — breathlessness, swelling and exhaustion
• Irregular heart rhythms, which can feel like a racing or fluttering heartbeat
• Fainting and falls, which can cause injuries
• Fluid build-up in the lungs
• In severe untreated cases, the strain on the heart can become life-threatening

Long-term outlook

Most people who have TAVR notice real improvements — easier breathing, more energy and a return to things they had given up. Recovery takes weeks rather than days, and some people need a period of rehabilitation. As with any procedure there are risks, which your heart team will explain honestly, and some people need further treatment or monitoring over the years. The outlook for treated aortic stenosis is generally good, and many people live active, independent lives afterwards.

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