Putting Innovation into Practice: Expanded Options for Aortic Stenosis

At the AMITA Health Heart & Vascular Institute, the Heart Valve Program offers a coordinated approach and comprehensive assessment, evaluation and treatment for patients with valvular heart diseases such as aortic stenosis, mitral stenosis and insufficiency, degeneration of bio-prosthetic aortic and mitral valves, and perivalvular leaks. Diagnosis and evaluation are supported by our IAC-accredited imaging labs, with leading-edge imaging technologies such as 3D echocardiography, 3D transesophageal echocardiography, 256-slice CT angiography, vascular ultrasound, and cardiac MRI. Our multidisciplinary team — with experts from interventional cardiology, cardiovascular surgery, cardiac imaging, anesthesia and cardiovascular nursing — works together to recommend the best treatment plan for each patient, from medical management to open heart surgery, to minimally invasive interventions such as valvuloplasty, transaortic valve replacement (TAVR) or MitraClip^®.

Advancing the treatment of aortic stenosis

As a progressive disease, aortic stenosis develops over years, and symptoms present late in life, usually after the age of 75. Once symptoms start to appear — including angina, syncope, shortness of breath and fatigue — prognosis is poor, with mortality rates of 50 percent at two years. For patients with severe aortic stenosis, surgical aortic valve replacement (SAVR) can relieve symptoms and prolong survival. However, due to advanced age or co-morbid conditions, many patients with severe aortic stenosis are considered to be too high risk to undergo SAVR. These patients can receive medical treatment to address symptoms and attempt to slow disease progression, but most will experience a decline in function and quality of life, and have a high risk of death from heart failure or sudden cardiac death within one year of diagnosis.

TAVR provides a less-invasive option for patients with severe aortic valve stenosis who would otherwise be considered at moderate or high risk of complications with SAVR or who are simply deemed too sick to undergo surgery. Recent data has shown comparable, and in some cases superior, outcomes with TAVR compared with SAVR. The Heart Valve Program at the AMITA Health Heart & Vascular Institute is excited to offer this life-saving treatment option to patients in Chicago and the northwest suburbs.

What is TAVR?

In TAVR, a replacement valve — composed of three leaflets of bovine or porcine heart tissue sewn onto a metal frame — is placed into the patient’s existing stenotic aortic valve. With fluoroscopic image guidance, a guiding sheath is first inserted percutaneously (generally through the femoral artery) into the aorta. The replacement valve is then moved into position over a wire to the heart. Under close monitoring, once the replacement valve is positioned within the stenotic aortic valve, the valve is deployed and starts to function immediately. After final verifications of normal function are made and any adjustments are performed, the catheter and sheath are removed, and the entry site is closed. Depending on the patient’s anatomy and especially the size of their arteries, access sites other than the femoral artery may be used (e.g., transapical – through a small incision between the ribs, subclavian – through an incision above the collarbone, transaortic – through an incision at the top of the sternum or transaxillary – through a small incision in the armpit). In TAVR with transcaval access, the aorta is accessed from the vena cava via the femoral vein. Patients with limited vascular access may also undergo complementary procedures such as perivascular leak interventions, the Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) procedure, and sentinel cerebral embolic protection to improve outcomes.

The entire TAVR procedure takes between one to two hours and involves a highly coordinated team of interventional cardiologists, cardiac surgeons, anesthesiologist, cardiac nurses and support staff, with involvement of other services as needed. After the procedure, patients can expect to stay in the hospital 3-5 days on average for recovery and monitoring (longer inpatient stays and time in a rehabilitation facility may be required depending on the patient’s health and overall strength going in the procedure).

TAVR at the
AMITA Health Heart & Vascular Institute

Patients referred to the AMITA Health Heart & Vascular Institute with symptoms consistent with moderate to severe aortic stenosis are quickly evaluated by the multidisciplinary Heart Valve Program TAVR team, a group of highly experienced, dedicated clinicians. Patients undergo imaging to confirm the diagnosis and then a series of preoperative tests to assess whether they are candidates for TAVR.

These tests are all done on site and are scheduled around the initial clinic visit. In most cases, tests can be completed in three to five days to two weeks, depending on patient and family availability. This ability to schedule tests and visits at the same time is particularly important for older patients who may be less able to make multiple appointments on separate dates. The TAVR Coordinator provides patients and family members with education and guides them through diagnostic testing and preoperative evaluations, the TAVR procedure itself, post-operative instructions and follow-up care.

In accordance with national guidelines, the multidisciplinary TAVR team meets to discuss all patient cases at a weekly multidisciplinary Heart Valve Conference. A surgeon and an interventional cardiologist review the patient history, imaging results and preoperative test results and agree on the best and safest treatment approach for every patient. While all treatment options are available to patients at the AMITA Health Heart & Vascular Institute, the team will work together — each bringing expertise and their own disciplinary perspective — to determine the best approach for each patient. For some patients, medical treatment may be the best option. This cooperative care approach to TAVR has become a model for other areas of patient-centered cardiac and vascular care at AMITA Health Heart & Vascular Institute.

The TAVR program at the AMITA Health Heart & Vascular Institute started in February 2014, and the team has performed more than 400 procedures as of 2019, with the number of procedures increasing  every year. Although patients undergoing TAVR at the AMITA Health Heart & Vascular Institute tend to be older (80-90 years) and have more severe disease and co-morbid conditions than the national average, the procedural success and survival rate for patients undergoing TAVR at the AMITA Health Heart & Vascular Institute is similar to the national average. Patients report significant improvements in daily function and quality of life, and most have been able to return home rather than needing long-term care in a skilled nursing facility.

“One of the most satisfying moments is to see patients come back six months or a year after the procedure, and tell you, ‘I am feeling better, I am able to do things that I was not able to do before.”

– Andrei Pop, MD, Interventional Cardiologist

From diagnosis through follow-up, the AMITA Health Heart & Vascular Institute TAVR team maintains communication with the referring physician to track patient outcomes and address any issues or complications. You can hear about one patient’s experience with TAVR at the AMITA Health Heart & Vascular Institute by visiting: https://www.amitahealth.org/services/heart-institute

To learn more about the AMITA Health Heart & Vascular Institute Heart Valve Program: Call Lynn Hickman, nurse practitioner, at 847.640.5632.