TAVR Offers Less-Invasive Alternative for Open-Heart Surgery
Henry Ford doctor says he believes procedure will become standard for patients older than 65 in the next few years
DR. WILLIAM O’NEILL, MEDICAL DIRECTOR OF THE CENTER FOR STRUCTURAL HEART DISEASE AT HENRY FORD HEALTH SYSTEM
At 32 years old, Andy Smith needed a new heart valve — again.
The Traverse City resident and junior-high English teacher first had his valve replaced when he was just 23 years old. It’s very rare for someone so young to require a new heart valve, but Smith’s had been badly damaged by streptococcus bacteria. He underwent open-heart surgery, the standard method for replacing heart valves, at the Cleveland Clinic, and was told the valve would last 10 years, which is typical.
By 2015, the valve was clearly wearing out. “I started to feel fatigued after very limited activity; it was becoming a problem,” Smith says.
His local cardiologist told him about a less-invasive procedure, transcatheter aortic valve replacement (TAVR), which is designed to replace valves in people with aortic stenosis, which is calcification of the aortic valve. The procedure is typically reserved for patients who can’t undergo open-heart, and no one in Traverse City performed it for young, otherwise healthy patients like Smith. So his doctor referred him to Dr. William O’Neill, medical director of the Center for Structural Heart Disease at Henry Ford Health System.
“In the past, the way the aortic valves were fixed involved opening up the chest, taking the old valve out and sewing the new valve in,” says O’Neill, who performed the first TAVR procedure in the country and remains a leading expert on it. “But old people — those over 80 — are very frail, and having an open-heart operation is a huge deal and it’s very hard for them to heal. And they often develop problems with memory.”
TAVR replaces the heart valve via a catheter, typically inserted through a small opening in the chest. Patients spend one to two nights in the hospital, rather than the four to five nights that are typical for open-heart patients, whose chests must be sawed open.
“In general in the United States, if you have a valve that has a problem — it’s leaky or diseased — the gold standard is to have open-heart surgery,” says Ruth Fisher, Henry Ford’s vice president of heart and vascular services. “There’s been very good luck with that procedure; the mortality is really low. It saves a lot of people’s lives. But over the last 10 years, doctors have gotten good at identifying who is a candidate for a less-invasive procedure.”
Issues with the heart valve are primarily due to genetics. A bicuspid aortic valve is the most common birth defect, occurring in about 2 percent of the population. The aortic valve, the main artery from the heart that distributes blood to the body, has three small flaps or leaflets that open to regulate blood flow, allowing blood to flow from the heart to the aorta and preventing blood from flowing backwards into the heart. When someone has a bicuspid aortic valve, there are only two leaflets. As those individuals get older, the valve is more prone to becoming diseased and damaged. Smoking and high cholesterol can increase the risk as well.
Smith was born with a bicuspid valve, though it was the infection that caused the valve to initially need replacing. After meeting with O’Neill, he opted for TAVR for his recent valve replacement. Despite his relatively young age, his previous open-heart surgery bumped him into the medium-risk category for a repeat. (TAVR is not yet FDA-approved for patients for whom open-heart surgery poses a low level of risk.)
Smith says after open-heart, he needed morphine and prescription pain pills. After his TAVR procedure, he was virtually pain-free. He had his procedure in the morning; by that evening, he was eating and walking around.
“I was ecstatic,” he says. “I left the next day. [Two days later], I was home and coaching a soccer tournament. And our team won the tournament, which was like a roller coaster of emotions for that week.”
Today, Smith works out regularly and plays and coaches soccer.
“I feel healthy,” he says. “I feel way better than I did five years ago.”
Smith was not a typical TAVR candidate; in fact, he is the youngest patient to have undergone TAVR at Henry Ford. A patient is most likely to be an elderly woman.
“There are a lot more women at age 80 and 90 than men,” O’Neill says. “So actually this is kind of a women’s disease. And because their blood vessels are smaller [and] their kidney function is not quite as robust, you have to take extra care getting the valve in and making sure they don’t develop kidney damage.”
Rosemary Bucska, an 86-year-old Wyandotte resident, had been experiencing shortness of breath, lightheadedness, and dizziness when she visited her primary care doctor last year. An echocardiogram revealed blockage in her main aortic valve. Her doctor referred her to O’Neill, who recommended valve replacement. Bucska had to jump through considerable hoops to get approved for TAVR; her insurance provider required three additional surgeons to verify her need for it.
“All of them came to the conclusion that I needed it, but the third doctor said the only way he would OK it, given my age, was they would have to go up through the groin and not through the chest,” Bucska says.
She had the procedure in June, spending two nights in the hospital, and says she quickly noticed the impact of having a new valve.
“I noticed a big difference in my energy level,” Bucska says. “I wasn’t lightheaded anymore; there were no more dizzy spells. Before, if I vacuumed just one room, I’d have to sit down and take a breath. Now I can vacuum my whole house, do my regular everyday chores. I can go up and down the basement stairs without stopping halfway to catch my breath. To me, it’s a modern miracle, these procedures they do.”
As with any medical procedure, TAVR comes with risks. Large catheters in vessels can cause bleeding, so vessels must be measured carefully to avoid damage. Some patients require a pacemaker as a result of pressure from the expanding valves on the heart’s electrical wiring system. And the intravenous dye used to see the valve’s fit and placement can damage the kidneys.
O’Neill says he believes TAVR will become standard for patients older than 65 in the next few years. Henry Ford is the largest provider of the procedure in Michigan, performing more than 200 each year, but it’s helped train other centers, and now 20 hospitals in southeast Michigan perform it, including Beaumont Hospital, Detroit Medical Center, and University of Michigan.
“If you have valvular heart disease, it’s really important to understand that there may be other options than traditional heart surgery,” O’Neill says. “It’s important to be educated and know there are a lot of advances. The big hospitals all offer TAVR, so patients have a lot more options. If a doctor says you need open-heart surgery to replace your valves, it’s worth getting another opinion from one of the four big hospitals.”
Fisher agrees: “Some patients are reluctant to get a second opinion. But now is the time; there are so many innovations. Patients shouldn’t be reluctant or think their physician will resent them. Even physicians you trust and value don’t know everything about all the options.”