Aortic stenosis is a common heart condition where the aortic valve narrows, restricting the flow of blood from the heart to the rest of the body. This obstruction forces the heart to work harder, leading to symptoms like shortness of breath, chest pain, and fatigue. Without treatment, severe aortic stenosis can be life-threatening. Transcatheter Aortic Valve Replacement (TAVR) is a minimally invasive procedure developed to treat this condition, allowing a replacement valve to be implanted directly into the diseased valve without traditional open-heart surgery.
Patient Eligibility and Indications
The determination of a patient’s suitability for TAVR is made by a multidisciplinary team of heart specialists, considering the severity of the valve disease and the patient’s overall health profile. TAVR is reserved for patients with symptomatic, severe aortic stenosis who have a predicted life expectancy of more than one year. The procedure originally focused on patients at high or prohibitive risk for traditional surgical valve replacement.
The procedure has since expanded to include patients at intermediate and low surgical risk, based on clinical trial data showing favorable outcomes compared to surgery. The transfemoral approach is the preferred and least invasive method. Pre-procedural imaging, such as a CT scan, is performed to ensure the femoral and iliac arteries are large enough to safely accommodate the delivery sheath and are free of excessive calcification or tortuosity. If the vascular access route is unsuitable, alternative access points, like the subclavian or carotid arteries, must be considered, which increases the invasiveness of the procedure.
How the Transfemoral Procedure is Performed
The transfemoral TAVR procedure typically begins with the patient receiving local anesthesia and conscious sedation, though general anesthesia may be used. A small incision is made in the groin to access the common femoral artery, and a delivery catheter is inserted.
The physician guides the catheter using advanced imaging, such as fluoroscopy, up through the arteries until it reaches the diseased aortic valve. A stiff guidewire is navigated across the narrowed valve to provide a stable rail for the delivery system. A balloon aortic valvuloplasty (BAV) may be performed to temporarily expand the native valve leaflets and prepare the landing zone.
The replacement valve, a tissue valve mounted on an expandable frame, is crimped onto the delivery catheter. The system is advanced over the guidewire and positioned within the calcified native aortic valve. Deployment depends on the valve design: balloon-expandable valves require inflation to press them into place, while self-expanding valves unfurl once the outer sheath is retracted.
Once deployed, the new valve pushes the old leaflets aside, restoring proper blood flow. The catheter and delivery system are removed, and successful function is confirmed using angiography and echocardiography. The puncture site in the femoral artery is then closed using specialized closure devices.
TAVR Versus Traditional Valve Replacement
TAVR offers a less invasive alternative to Surgical Aortic Valve Replacement (SAVR), the traditional open-heart method. SAVR requires a sternotomy, a large incision through the breastbone, which results in a longer recovery period and an extended hospital stay.
TAVR uses a small puncture site in the groin, avoiding the need to open the chest cavity. This difference translates to a substantially shorter hospital stay for TAVR patients (typically one to three days) compared to SAVR patients (five to seven days or more). The recovery period at home is also significantly reduced with TAVR, often measured in weeks, while SAVR recovery can take several months.
TAVR can often be performed with local anesthesia and conscious sedation, whereas SAVR nearly always requires general anesthesia. TAVR also results in a higher rate of patients being discharged directly home instead of needing transfer to a skilled nursing facility for rehabilitation.
Recovery and Long-Term Outlook
Following the transfemoral TAVR procedure, the patient is closely monitored to ensure the access site is stable and the new valve is functioning correctly. Patients are encouraged to sit up and begin walking within 24 to 48 hours, reflecting the rapid return to mobility of this minimally invasive approach. Most patients return home within two days.
Short-term recovery involves minor restrictions, such as avoiding heavy lifting or strenuous exercise for about a week. Driving is typically prohibited for a short period until the patient is cleared by their physician. Patients must adhere to a medication regimen, often including a single antiplatelet medication like aspirin indefinitely, to prevent blood clots on the new valve.
In the long term, the success of the TAVR procedure is measured by the durability of the valve. Studies have shown that a high percentage of patients remain free from structural valve deterioration (SVD) at five to eight years post-implantation. Follow-up appointments, including regular echocardiograms, are necessary to monitor the valve’s function.