TAVR is an innovative option for patients in need of heart valve replacements, but who have comorbidities that make them poor candidates for open-heart surgery. Photo: Edwards Lifesciences.
When NKCH physicians began performing transcatheter aortic valve replacements in 2015, they started with a goal of 20 TAVRs per year. In 2016, they surpassed their mark with 39 TAVRs. In 2020, the year’s total TAVRs were 74. On March 4, 2021, the team performed the hospital’s 300th TAVR.
TAVR is an innovative option for people with severe aortic stenosis. These patients need heart valve replacements, but their comorbidities make them poor candidates for open-heart surgery.
Outcomes
In the six years since the program began, Interventional Cardiologists Zafir Hawa, MD, FACC, FSCAI, and James Mitchell, MD, FACC, have adopted an alternative minimalist approach that does not require general anesthesia, lowers the risk of complications, decreases the average length of stay and improves recovery.
After approval from the Food and Drug Administration, they were able to widen patient selection from patients at high risk for death or complications associated with open-heart surgery to include those at intermediate and low risk. Drs. Hawa and Mitchell, both with Meritas Health Cardiology, collaborate with cardiovascular surgeons to perform TAVRs at NKCH.
As with all procedures, post-operative care is optimized to improve outcomes. Within four hours after the procedure, a patient’s cardiac catheters and lines are removed. In addition to patients ambulating early, they typically are discharged the next day, if they have support at home. The hospital’s inpatient mortality rate from July 1 to September 30, 2020, was 0%, compared to the national mortality rate of 0.8%.
Only one NKCH patient during the same quarter required a permanent pacemaker implantation at 30 days post-TAVR. That translated into 1.5% of NKCH TAVR patients, which was well below the 6.3% national average during that quarter, said Dr. Hawa, medical director of Cardiac Clinical Research.
“Advancements in the valve have enabled us to place the valve higher in the aortic annulus, and that has reduced the need for pacemaker implantations,” added Dr. Mitchell, program director of the NKCH Chest Pain Center and STEMI program.
Another advancement came with the FDA’s approval to expand use as a valve-in-valve treatment.
“These patients used to require open-heart surgery, but now we insert a TAVR in the failing artificial bioprosthetic valve,” Dr. Mitchell said.
Age Not a Factor
Patients who are 90 years or older do not have an increase in mortality or major cardiovascular events compared to younger patients.
“People in their mid-90s can receive a TAVR and have a fulfilling life ahead of them,” Dr. Mitchell said. “If a referring physician feels a patient would benefit from a TAVR, they should send them to us for an evaluation.”
Asymptomatic Symptoms
Because severe aortic stenosis symptoms progress over time, it is imperative physicians not only refer symptomatic but also asymptomatic patients for cardiac intervention.
“Although TAVR is only approved for symptomatic patients, we can follow those without symptoms until symptoms develop.” Dr. Hawa said. “We know asymptomatic patients can suddenly develop serious symptoms, and their survival sharply declines. By monitoring them, we can watch for symptoms, catch them early and fix the problem.”
On the Horizon
Drs. Hawa and Mitchell currently perform TAVRs in the Operating Room. As part of ongoing interventional cardiology suite improvements, a dedicated Cath Lab hybrid OR will be completed in 18 months.
Beyond TAVRs, the Cath Lab hybrid OR will give patients access to new procedures coming down the pike. “Our new hybrid OR will help us stay up to date with cutting-edge technology for structural heart procedures,” Dr. Mitchell said.
Zafir Hawa, MD, FACC, FSCAI
Dr. Hawa earned his medical degree from the University of Bombay. He completed his internal medicine residency at the University of North Dakota Medical Center, critical care fellowship at the University of Pittsburgh Medical Center, and cardiology research, cardiology and interventional cardiology fellowships at Western Pennsylvania Hospital.
James Mitchell, MD, FACC
Dr. Mitchell earned his medical degree from the University of Missouri-Columbia. He completed his internal medicine residency at the University of Wisconsin Hospital and Clinics and cardiology and interventional cardiology fellowships at
St. Luke’s Episcopal Hospital in Houston.