Finally an alternative to open surgery for patients with high surgery associated risks

  If your aortic valve is severely diseased, you may require replacement of your valve. However you could be advised that an open heart surgery carries too high a risk for you. In this case, you may be eligible to receive an alternative treatment called TAVI (Transcatheter aortic valve implantation). With this novel approach introduced in the UK in 2007, it is possible to replace your aortic valve without requiring a full open heart surgery.

Who can have a TAVI?

  According to the NICE Interventional Procedure guidance (March 2012) TAVI can be offered routinely as a treatment option to patients with aortic stenosis who cannot have open heart surgery because of poor health or technical difficulties, provided that doctors are sure that:

• the patient understands what is involved and agrees to the treatment, and
• the results of the procedure are monitored.

Guidelines issued in August 2012 by the European Association of Cardio Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC) state the following:

“TAVI is recommended in patients with severe symptomatic AS who are, according to the ‘heart team’, considered unsuitable for conventional surgery because of severe comorbidities.”

“Among high-risk patients who are still candidates for surgery, the decision should be individualized. TAVI should be considered as an alternative to surgery in those patients for whom the ‘heart team’ favours TAVI, taking into consideration the respective advantages/disadvantages of both techniques.”

What is involved with the procedure?

  TAVI is an alternative to open heart surgery and is considered as a minimally invasive approach. This heart surgery can be performed using echocardiographic and fluoroscopic guidance for visualization during implantation.
  During the procedure a valve (Figure 1: a balloon expandable stent combined with a bovine pericardial bioprosthetic tissue valve) is reduced to size and placed on a delivery catheter (Figure 2).

  The delivery catheter can then be inserted in the femoral artery through a small incision at the top of the leg (transfemoral approach) or between the ribs (transapical and transaortic approaches).
  Once in the heart, the valve is positioned and deployed across the patient’s diseased aortic valve.

What happens after the operation?

  After a short hospital length of stay, it is possible to be discharged home with a prescription of clopidogrel (for 3 months) and aspirin (for life).

Who can perform TAVI in the UK?

  Only selected accredited centres with trained multidisciplinary heart teams can perform this procedure.
A list of hospitals is available to you here.

Where can I find more information?

Is TAVI available on the NHS? Please refer to the following links:
For England: Clinical Commissioning Policy: TAVI For Aortic Stenosis
For Scotland: First TAVI ops success
For Wales: Specialised Services Policy: CP58

Published experience with TAVI: Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery
Martin B. Leon, M.D., Craig R. Smith, M.D., Michael Mack, M.D., D. Craig Miller, M.D., Jeffrey W. Moses, M.D., Lars G. Svensson, M.D., Ph.D., E. Murat Tuzcu, M.D., John G. Webb, M.D., Gregory P. Fontana, M.D., Raj R. Makkar, M.D., David L. Brown, M.D., Peter C. Block, M.D., Robert A. Guyton, M.D., Augusto D. Pichard, M.D., Joseph E. Bavaria, M.D., Howard C. Herrmann, M.D., Pamela S. Douglas, M.D., John L. Petersen, M.D., Jodi J. Akin, M.S., William N. Anderson, Ph.D., Duolao Wang, Ph.D., and Stuart Pocock, Ph.D. for the PARTNER Trial Investigators. N Engl J Med 2010; 363:1597-1607. October 21, 2010
http://www.nejm.org/doi/full/10.1056/NEJMoa1008232

Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients
Craig R. Smith, M.D., Martin B. Leon, M.D., Michael J. Mack, M.D., D. Craig Miller, M.D., Jeffrey W. Moses, M.D., Lars G. Svensson, M.D., Ph.D., E. Murat Tuzcu, M.D., John G. Webb, M.D., Gregory P. Fontana, M.D., Raj R. Makkar, M.D., Mathew Williams, M.D., Todd Dewey, M.D., Samir Kapadia, M.D., Vasilis Babaliaros, M.D., Vinod H. Thourani, M.D., Paul Corso, M.D., Augusto D. Pichard, M.D., Joseph E. Bavaria, M.D., Howard C. Herrmann, M.D., Jodi J. Akin, M.S., William N. Anderson, Ph.D., Duolao Wang, Ph.D., and Stuart J. Pocock, Ph.D. for the PARTNER Trial Investigators. N Engl J Med 2011; 364:2187-2198. June 9, 2011
http://www.nejm.org/doi/full/10.1056/NEJMoa1103510

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis
Raj R. Makkar, M.D., Gregory P. Fontana, M.D., Hasan Jilaihawi, M.D., Samir Kapadia, M.D., Augusto D. Pichard, M.D., Pamela S. Douglas, M.D., Vinod H. Thourani, M.D., Vasilis C. Babaliaros, M.D., John G. Webb, M.D., Howard C. Herrmann, M.D., Joseph E. Bavaria, M.D., Susheel Kodali, M.D., David L. Brown, M.D., Bruce Bowers, M.D., Todd M. Dewey, M.D., Lars G. Svensson, M.D., Ph.D., Murat Tuzcu, M.D., Jeffrey W. Moses, M.D., Matthew R. Williams, M.D., Robert J. Siegel, M.D., Jodi J. Akin, M.S., William N. Anderson, Ph.D., Stuart Pocock, Ph.D., Craig R. Smith, M.D., and Martin B. Leon, M.D. for the PARTNER Trial Investigators. N Engl J Med 2012; 366:1696-1704. May 3, 2012
http://www.nejm.org/doi/full/10.1056/NEJMoa1202277

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement
Susheel K. Kodali, M.D., Mathew R. Williams, M.D., Craig R. Smith, M.D., Lars G. Svensson, M.D., Ph.D., John G. Webb, M.D., Raj R. Makkar, M.D., Gregory P. Fontana, M.D., Todd M. Dewey, M.D., Vinod H. Thourani, M.D., Augusto D. Pichard, M.D., Michael Fischbein, M.D., Ph.D., Wilson Y. Szeto, M.D., Scott Lim, M.D., Kevin L. Greason, M.D., Paul S. Teirstein, M.D., S. Chris Malaisrie, M.D., Pamela S. Douglas, M.D., Rebecca T. Hahn, M.D., Brian Whisenant, M.D., Alan Zajarias, M.D., Duolao Wang, Ph.D., Jodi J. Akin, M.S., William N. Anderson, Ph.D., and Martin B. Leon, M.D. for the PARTNER Trial Investigators. N Engl J Med 2012; 366:1686-1695. May 3, 2012
http://www.nejm.org/doi/full/10.1056/NEJMoa1200384

TAVI Guideline from the National Institute for Health and Care Excellence for England and Wales:
http://www.nice.org.uk/nicemedia/live/11914/58647/58647.pdf

European guidelines on TAVI from the European Association of Cardio Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC).Vahanian A, Alfieri OR, Andreotti F, Antunes MJ, Gonzalo Baron-Esquivias G, Baumgartner H, et al. Valvular Heart Disease (Management of); August 2012 (pages 17.19):
http://www.escardio.org/Guidelines_Valvular_Heart_Dis_FT.pdf