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>> Aortic valve stenosis is a disease
of the aortic valve, which is one of the two
valves on the left side of the heart
that occurs when calcification deposits
on the leaflets and restricts the ability
of the leaflets to open.
This can occur as a natural process of aging,
the wear and tear on the valve over decades of life,
or it can occur in the setting where there
are only two leaflets of the aortic valve,
something called biscupid aortic valve disease.
In any event, this results in the valve leaflets
being restricted in their motion,
and in order for the heart to pump blood
through that valve, it has to generate extra pressure,
and over time, this causes the heart
eventually to fail.
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Gold standard for decades of dealing with aortic
valve stenosis is surgical aortic valve replacement.
And that involves open-heart surgery,
wherein the surgeon cuts out the old valve
and sews in a new valve, either a mechanical
valve or a bioprosthetic valve.
In the last decade, technology has advanced
to being able to replace the aortic valve
with a catheter technique, and that is what
is called transcatheter aortic valve
replacement, or TAVR, T-A-V-R.
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>> The recent clinical research and trials have shown
that TAVR, it's non-inferior to surgery.
That means that the morbidity and mortality
associated with this procedure is now equivalent
to standard surgical aortic valve replacement.
There is a significant difference between the type
of anesthesia we provided during surgical
aortic valve replacement and the type
of anesthesia the patient who receives TAVR has.
In surgical aortic valve replacement,
the patient needs to receive general anesthesia
for the purpose of undergoing endotracheal
intubation and mechanical ventilation,
and eventually being connected to the heart-lung
machine in order to replace his valve.
It can induce more stress on the patient
heart performance, but overall, it's more difficult
to tolerate for the patient in general.
During TAVR, especial with the most recent
approach we provide to the majority of our patient,
approach known as minimalist, all we need is
monitor conscious sedation, meaning the patient
received only a minimal dose of sedation
remains awake throughout the entire procedure
and he's able to communicate with both
the anesthesiologist and the doctor in charge
for the procedure.
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>> Obviously when we're talking about a catheter
delivery of the valve, it's less invasive,
it does not require general anesthesia,
it does not require going on the heart-lung machine.
So the patients are awake during the procedure,
there's no cutting or incision,
catheters are introduced after local anesthesia
and the valve is then delivered within
the existing valve.
There are currently two types of valves,
a self-expanding valve and a ballon-expandable valve,
and in each case, that valve is then inserted
within the existing valve, pushing the existing
valve to the side.
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>> The comprehensive assessment provided
by the multi-disciplinary team in our valve clinic,
it's critical because it allows to establish
the candidacy the patient for either the surgical
aortic valve replacement or the TAVR procedure.
A patient is a candidate for TAVR only if he
meets specific guidelines that allow us
to define him as either prohibitive risk,
high or intermediate risk for surgical
aortic valve replacement.
This type of assessment can only be performed
when the cardiologist and the surgeon
communicate and assess the patient together.
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The quality of life after aortic valve replacement,
whether that's performed through surgery or TAVR,
it's remarkable.
We all know that patient who has severe aortic
valve stenosis and require the replacement
of his valve has a very elevated morbidity
and mortality within one year of the onset
of his symptoms.
The main difference between the two procedures
is that with surgery, the recovery time
will be longer, but in either case,
the recovery and the quality of life is remarkable.
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At Johns Hopkins, we have an extensive experience
with either surgical aortic valve replacement and TAVR.
The Structural Heart Program that performs
the TAVR procedure has been active since 2011,
and ever since then, we have been doing
nearly 800 cases.
We are one of the busiest program on the East Coast.
From a surgical standpoint, we have an experience
that stems back for several decades
and a very high success rate.
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>> One common approach to reduce leaking of the mitral
valve is to apply a clip on the mitral valve
that reduces the amount of leaking.
We are also studying new catheter techniques
for the tricuspid valve, which is on the right
side of the heart.
So there's very exciting work being done
and in multiple transcatheter technologies
that are applicable to the heart.
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So after their one-night stay in the hospital,
patients are seen at one month and one year
by the valve implanting team.
This is mandated by Medicare.
Patients are discharged on an antiplatelet drug,
either aspirin or another antiplatelet drug.
These valves do not require conventional
oral anticoagulation as do mechanical valves.
After one year, patients then are returned
to their referring cardiologist
and undergo annual echocardiograms
to look at the function of the new valve.
In terms of durability of the valve,
we now have seven to eight year data
with these valves and they seem to be
as durable as a surgical bioprosthetic valve.
Obviously within time, all of these biological
valves wear out and an additional procedure
may be required at some point in the future,
but that may be 10 or 15 years from the time of implant.
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