Living with heart valve disease is no picnic. The fatigue, dizziness, swelling and shortness of breath that come with age-related or congenital heart valve issues dramatically affects the quality of life of millions of people in the United States.
But the prospect of open-heart surgery to repair a heart valve can be as daunting as the symptoms people cope with. It conjures memories of scenes from television dramas, with medical teams hovering over an opening in a patient’s chest.
The good news is, minimally invasive heart procedures are giving many patients the opportunity to avoid the extended hospital stays and long recoveries associated with open-heart surgery – and offering some patients new options when they once may have been told the door to a healthier heart had closed for good.
OhioHealth interventional cardiologist and structural heart disease specialist Carlos Sanchez, MD, gets us up-to-date on what minimally invasive heart surgery can offer patients, particularly in his specialty of transcatheter aortic valve replacement, or TAVR. He also explains when open-heart surgery might still be recommended, and how to make the best choice for your heart health.
What are the basics of a TAVR procedure?
“TAVR is a minimally invasive surgical procedure used to implant artificial heart valves in patients living with a structural heart condition called aortic stenosis. This is a problem of the aortic valve which causes heart valves to narrow, slowing or blocking blood flow,” says Sanchez.
He says the TAVR procedure can be performed under conscious sedation, meaning that patients don’t need to be completely unconscious under general anesthesia. “Interventional cardiologists and surgeons insert a small catheter into an artery in your groin, or the subclavian artery under your collarbone – though the majority of procedures rely on arteries in the groin – and move the catheter toward your heart,” says Sanchez. “We use imaging to guide the catheter to the proper place within your heart, and then deploy the artificial valve within the space of your diseased valve.”
How is open-heart surgery different from TAVR?
Sanchez says one big difference with open heart surgery is how surgeons get to your heart. “In open-heart surgery, they do a sternotomy, which means they make an incision at the center of your chest and divide your sternum at the center of your ribcage to access your heart.”
The second big difference is recovery time, he says. “With open-heart surgery, patients spend at least four to five days recovering in the hospital, even if the procedure goes well. And once you go home, there is a significant amount of rehabilitation. With minimally invasive heart procedures like TAVR, the vast majority of patients go home the next day, and you can be active right away,” says Sanchez.
Is open heart surgery still common?
Sanchez says the number of open-heart surgeries has gone down, primarily due to the evolution of minimally invasive technologies and techniques like TAVR.
“When we determine which surgical procedure is the best for each patient, one tool we use is a risk calculator developed by the Society of Thoracic Surgery, which takes several factors about a patient’s health into account to predict the risk of mortality for different procedures,” says Sanchez. He says patients who are classified in intermediate and high-risk groups face higher surgical risks of stroke, new-onset atrial fibrillation and other complications with open heart surgery, so TAVR is more frequently recommended.
Is TAVR good for low-risk patients, too?
Sanchez was excited to share that TAVR was just approved by the FDA for low-risk patients on August 16, 2019. “Newer data from clinical trials came out this year, presented at the American College of Cardiology, where the low-risk patient population was presented and compared head-to-head between transcatheter heart valve replacement and open-heart surgery. TAVR offered a safer overall procedure, with lower risk of hospitalization, lower risk of stroke, lower risk of bleeding, and lower risk of arrhythmias such as atrial fibrillation, with only one trial showing a slightly higher risk of pacemaker implant for TAVR,” says Sanchez. “With the FDA approval of low-risk indication for TAVR, essentially every patient will have the choice between TAVR and open-heart surgery.”
Sanchez says at OhioHealth some low-risk patients had been able to get TAVR as part of these clinical trials. “We have access to cutting edge technology that is under investigational research. That’s one of the benefits of seeking care at heart valve centers of excellence like ours. We have the ability to enroll qualified candidates in clinical trials that give them access to investigational therapies that are unavailable at other health systems.”
Is open heart surgery a better option for some people?
Sanchez says open heart surgery may be preferred if you have other surgical needs in addition to an aortic valve replacement. “For example, if you need a new aortic valve, but you also have an ascending aortic aneurysm that needs repaired with open-heart surgery, then you would do the valve implant at the same time. Open heart surgery may also be preferred for patients who have complex coronary disease, or multiple blockages in the coronary arteries, along with severe aortic valve stenosis. Or, for patients with aortic valve stenosis and mitral valve disease, who would benefit from having all their valves fixed at once with a single operation.”
If I need heart surgery, what should I do?
“I think everyone who is diagnosed with structural heart disease should be asking about minimally invasive options, like TAVR. Many physicians are still not aware of how far minimally invasive therapies have progressed, and are not aware of all the options,” says Sanchez. “I recommend seeking out cardiologists and teams who specialize in transcatheter heart valve therapies. As soon as your physician tells you that you have a heart valve condition, you should be referred to a heart valve center of excellence like OhioHealth.”
What if I’ve been told in the past that I’m not a candidate for surgery?
Sanchez says now there are a lot of minimally invasive procedures available to patients who once may have been told they had few options, but time is of the essence. “To those people I say, ask again and don’t wait. Patients who were not candidates for open-heart surgery may now be candidates for transcatheter valve options, but we want to see them while the treatment window is still open.”
Aren’t heart problems just a part of getting old?
Sanchez says many people believe valve conditions are just part of the aging process, or that they wouldn’t survive surgery at their age, and as a result won’t seek treatment. “Even if they feel fatigue and shortness of breath, they don’t seek any help, but that’s the optimal time to get in and get taken care of. We’ve performed TAVR procedures successfully for patients in their 90s.”
He says many people still believe a valve replacement means major surgery. “They often worry about a big operation, and they think they wouldn’t survive, so they say, ‘Why even bother going in and being evaluated for this?’ But when we have an opportunity to explain the minimally invasive options to them and their family members, they understand that they can not only survive these procedures but dramatically improve their quality of life.”