TAVI/TAVR Procedure

The TAVI or TAVR procedure can be done through very small openings that leave all the chest bones in place. Transcatheter Aortic Valve Implantation (TAVI) also known as Transcatheter Aortic Valve Replacement (TAVR) is advised to the patient to take up this procedure when the adult is fragile to take the trauma of an open-heart surgery. A person’s experience with a TAVR procedure can be rated similar to a coronary angiogram in terms of recovery. Post the procedure it is likely spend less time in the hospital after TAVR as compared to a surgical valve replacement. Risk levels may be the same but the recovery is quicker because it is less invasive as compared to open heart surgery.

TAVI as the name suggests is a process wherein through the catheter an aortic valve is implanted or replaced. Doctors use a catheter (a long, flexible tube that doctors use to reach parts of the body that are usually hard to access, like blood vessels or the heart) to go through a blood vessel, often in the leg or groin, to reach the heart and insert a new valve.

To explain the procedure simply, imagine your heart is like a high-traffic highway with an old, worn-out toll booth (the aortic valve) that cars (blood) have to pass through. Over time, the toll booth gets rusted and stuck & slow moving, making it harder for cars to get through, which causes a traffic jam (poor blood flow). Instead of closing down the whole highway to replace the toll booth (which would be like open-heart surgery), you use a clever method to add a brand new, fully functional toll booth right over the old one.

A team of workers (doctors) bring in a long, flexible arm (the catheter), which slides through the roadways (your blood vessels) to place the new booth in position. Once it’s set up, the new toll booth opens smoothly, letting the cars flow freely again, and the traffic jam clears up — all without any major construction or shutting down the highway.

The TAVR Procedure is Performed using Two Approaches

Transfemoral Approach: This is an approach of entering into the body without requiring a surgical incision in the chest. The invasion is done through the femoral artery which is a large artery in the groin.

Transapical Approach: With this approach, doctor enters into the body with a small incision in the chest through either a large artery in the chest or through the tip of the left ventricle which is also called as the apex.

Step By Step Procedure

1) The procedure begins with a small incision in the groin (in case of femoral approach).

2) After creating an opening in a blood vessel called the femoral artery doctor inserts a flexible tube, called an introducer sheath.

3) Doctor then inserts a flexible guidewire into the femoral artery (most preferred) through the sheath.

4) The guidewire is then passed through the femoral artery up to aorta and is pushed through the opening in the aortic valve into the left ventricle.

5) Doctor uses the guidewire to pass a catheter through the aortic valve. Then a balloon on the tip of the catheter is inflated to widen the opening in the valve. This is done to push the valve leaflets to the sides.

6) The replacement valve is compressed and placed on the tip of another catheter. This catheter is inserted through the aortic valve.

7) Once the catheter reaches the opening in aortic valve, a balloon is inflated underneath the replacement valve to expand it and the stent.

8) Post the placement of the new aortic valve, the doctor deflates the balloon.

9) In expectation that the stent will support and secure the replacement valve in place, the catheter and guidewire is removed.

10) At the end, the introducer sheath in the groin is removed and the skin incision is closed.

Note: There will be another incision on the other side of the groin through which instruments are inserted to monitor the heart during the procedure. This skin incision is also closed after the procedure. Insertion of the flexible tube catheter is well guided using advanced imaging technology like ultrasound or x-ray to carefully reach the aortic valve and deliver the new valve over the old.

Different types of valves used in TAVI:

Balloon Expandable Valve

Self-Expanding Valve

Balloon-expandable valves: Balloon inflation is necessary to deploy and secure these valves, which are attached to a balloon catheter. The stent frame is expanded and the valve is released by clamping the valve onto a balloon, which is then inflated inside the native valve annulus.

Self-expanding valves: the stent frame of these valves is made of nitinol, a shape-memory alloy, which expands without the use of a balloon. The valve is put in a collapsed form into a catheter. When it reaches its destination, it is released, and the stent’s self-expanding characteristics enable it to open and secure itself inside the aortic annulus.

Key Differences Between Balloon-Expandable and Self-Expanding Valves

Feature	Balloon-Expandable Valves	Self-Expanding Valves
Stent Frame Material	Stainless steel or cobalt-chromium	Nitinol (shape-memory alloy)
Deployment Method	Balloon inflation	Self-expands upon release
Precision of Placement	High (due to balloon control)	Adjustable/repositionable
Radial Force	Higher initial force	More gradual, gentle force
Anatomical Suitability	Best for calcified or small annuli	Better for larger or irregular annuli
Risk of Annular Rupture	Higher due to balloon force	Lower due to gradual expansion

Who should opt for TAVI?

The ideal candidate for TAVI is someone whose body cannot withstand the trauma of open-heart surgery. In addition, a patient with severe aortic stenosis who is weak or has additional health conditions that make surgery more perilous, such as diabetes or hypertension. Because TAVI employs a replacement valve, candidates will not require anticoagulants for more than a few weeks following surgery. However, for the rest of one’s life, one may have to take blood thinners such as aspirin or clopidogrel.

Symptoms:

Aortic valve stenosis is hard to detect because the symptoms start to usually show when the condition gets severe with the heart valve getting narrower. It is important to consult a doctor when one notices the following frequently

Shortness of breath
Chest pain, discomfort or angina
Dizziness or fainting
Swelling in the legs and or abdomen
Tiredness when you are increasing your activity level
Heart palpitations (rapid, fluttering heartbeat)
Congestive heart failure

It should be noted that the symptoms may be outcome of any other underlying condition hence the patient should consider complete evaluation from a cardiologist to ensure correct diagnosis.

Role of the heart team (cardiologist, cardiac surgeon, anaesthetist) becomes paramount in evaluating patients, diagnosing the actual condition and offer specialised treatment.

Preparing for TAVI

After going through series of tests and getting a confirmation with doctors about Aortic Stenosis and preparing for TAVI procedure one must be cautious of the following:

1) Look after oral (mouth) health:

2) Learn more about the process

Pre-operative evaluations:

Apart from the other tests echocardiogram, CT scan, blood tests, and risk assessment are the most important evaluation tests before the procedure.

1) Echocardiography, commonly referred to as an echo, is a non-invasive imaging technique that uses ultrasound waves to create detailed images of the heart. It is one of the most widely used diagnostic tools in cardiology. Echocardiography is an essential tool for diagnosing, guiding, and monitoring cardiac conditions, particularly useful in interventions like TAVI due to its real-time imaging capabilities and detailed visualization of heart structures. There are two types of echo used in TAVI.

2) A CT scan, or Computed Tomography scan, is a medical imaging technique that uses X-ray beams and computer processing to create detailed cross-sectional images of the body. It provides highly accurate, three-dimensional images, making it a great tool for diagnosing and assessing a wide range of illnesses, especially in cardiology and vascular medicine.

These scans are important for assessing cardiovascular structures with high precision, making them an essential resource for organizing and enhancing results for procedures like TAVI. The scan helps in the pre-evaluation stage of the procedure because it ensures accurate measurement of the aortic valve and annulus for proper valve sizing. It assesses the peripheral vascular system to determine the safest access route and provides a comprehensive 3D view of the heart and its surrounding structures, reducing the risk of complications during the procedure.

Here is a comprehensive list of the tests and their purpose.

Evaluation	Purpose
Clinical Assessment	Assess symptoms, comorbidities, and frailty
Echocardiography (TTE/TEE)	Evaluate aortic valve structure and function
CT Angiography	3D assessment of aortic root, annulus, and access route
Electrocardiogram (ECG)	Identify arrhythmias and conduction issues
Pulmonary Function Tests	Assess lung function and respiratory risk
Blood Tests	Check renal function, coagulation, and overall health
Geriatric and Frailty Assessment	Evaluate functional status in elderly patients
Heart Team Consultation	Multidisciplinary decision-making
Anaesthetic Evaluation	Plan anaesthesia approach and manage risks

Additionally, as a candidate for the surgery one must consult with regards to medications that need to be adjusted or stopped before the procedure. And the date of hospitalisation and the admission process and what to expect on the day of the procedure.

Recovering in hospital after your TAVI

Recovery in the hospital is taken care by the health providers. The nurse checks the patient regularly to make sure he/she is comfortable. The nurse regularly checks incision areas, guides on what to expect as one heals and how to care for these sites. The nurse reminds the patient to keep their legs straight the first 4 hours after the procedure. This is very important to prevent bleeding from the insertion sites in the groin. Also, there may be some intravenous tubes or temporary wires attached. After the first 4 hours, the nurse helps the patient to gradually increase the activity, from sitting up in bed to sitting in a chair to walking short distances. When one is fully awake, the institute provides the patient clear fluids to drink. One can start eating food once one starts drinking well.

What is normal?	What are warning signs?
Slightly red, swollen and tender	Any area of redness or swelling that does not get better
A bit lump or bumpy	A lump that is getting bigger
Occasional clear drainage	Yellow or pink drainage
Pain gets better gradually	Pain does not get better or is severe
Bruising	Fever – a temperature of 38.5 °C(101 °F) or higher
	Bleeding from the puncture site that does not stop

Benefits of TAVI

Risks and Potential Complications

Valve surgery is generally very successful, and it can have many benefits. It can help to relieve symptoms, or get rid of them completely. It could help you live longer and improve your quality of life. But, like any other medical procedure, there are risks:

Patients undergoing TAVI have risk

These depend on various factors like

Age
Current state of health
If one is getting a valve replaced or repaired
The level of patients’ condition
Whether you’re having any other procedure simultaneously
Which valve is affected

While the risk for above adverse events is minimal, a patient should always remember that with development in medical technologies, the benefits of TAVI outweigh the anticipated risks. It is also to be noted that with developing aortic stenosis condition, patient is susceptible to various issues and hence should consult experienced cardiologist team.

Comparison Between TAVI and Surgical Aortic Valve Replacement (SAVR)

Comparison of TAVI vs. traditional open-heart aortic valve replacement can be seen through the following parameters:

Long-term Outcomes of TAVI

What do I need to do after I am discharged from hospital?

Once discharged from the hospital one must be mindful of the things one can and cannot do.

List of Don’ts:

Think clearly. Surgery and pain-management medication can often hamper your thinking skills, so do not make important decisions during this time
Easily sit up from a lying position
Raise your arms overhead for dressing
Prepare a meal
Get your incision wet
Lift a jug of milk
Tie your shoes
Climb the staircase
Run the vacuum
Carry a bag

List of Do’s:

Follow your doctor’s directions
Plan your nutrition
Get rest and accept help
Plan your environment and reread your discharge instructions
Verify all medications. List and track your doses too
Ensure that one has all the important numbers handy