By Stefano Schena, M.D., Ph.D. on November 26, 2018
Reviewers/Contributors: Matt Chacko, M.D.; Matthew Czarny, M.D.; Rani Hasan, M.D.; Jon Resar, M.D.
Aortic valve stenosis (AS) is one of the most common heart valve diseases in the adult population, with a prevalence of up to 7 percent in individuals over age 65 and is the most common reason for valve replacement.
The treatment of aortic stenosis has greatly evolved over the past decade. Surgical aortic valve replacement (SAVR) has been the gold standard for treatment of severe AS for more than 50 years. However, minimally invasive transcatheter aortic valve replacement (TAVR) has recently become the most common method of aortic valve replacement in the United States.
While initially reserved for patients at high or prohibitive operative risk, TAVR is now also offered to patients at intermediate surgical risk. TAVR continues to expand into “low-risk” patients as part of a national clinical trial that includes The Johns Hopkins Hospital. A “continued-access” multicenter registry study for low-risk patients is ongoing, with The Johns Hopkins Hospital continuing to enroll patients.
Patients undergoing TAVR at Johns Hopkins benefit from our extensive experience performing this procedure, which includes the following features:
- Minimalist percutaneous approach
- Placement of cerebral embolic protection devices
- Utilization of alternative vascular access when needed (i.e., axillary, carotid artery and direct aortic)
- Multidisciplinary “Heart Team” approach to provide optimal individualized care for each patient
The minimalist percutaneous approach is different from traditional TAVR in that it utilizes conscious sedation, rather than general anesthesia, and is performed completely percutaneously. The main advantages of this approach include decreased overall stress for the patient, prompt recovery, and discharge within 24 to 48 hours. Moreover, the patient will be able to resume his or her routine activities within days without limitations and concerns deriving from surgical wound management.
A fluoroscopic image shows the self-expanding TAVR platform.
A fluoroscopic image shows the balloon-expandable TAVR platform.
The incidence of stroke during TAVR has decreased in recent years, largely because of significantly smaller catheter delivery systems and utilization of cerebral embolic protection devices. Patients with severe aortic valve stenosis may also have significant peripheral arterial disease, which can represent an additional challenge, particularly with respect to how the new valve is delivered to the heart.
With technological enhancements and the latest iterations of the available delivery platforms, approximately 95 percent of TAVR procedures are performed through percutaneous femoral artery access. Furthermore, chest incisions to deliver the new valve through the apex of the heart have been nearly completely abandoned in favor of less invasive alternative access, including subclavian and carotid approaches.
At The Johns Hopkins Hospital, our multidisciplinary team has expertise in all routes of alternative peripheral vascular access that may be necessary to complete the procedure safely with a success rate comparable to the standard percutaneous femoral artery approach. Through the active and coordinated involvement of interventional cardiologists, cardiothoracic surgeons, imaging experts, anesthesiologists, and advanced nurse practitioners, hundreds of cases are evaluated and meticulously planned every year. The preoperative evaluation is significantly streamlined and involves one or two pre-procedure visits and additional testing, including an echocardiogram, a CT scan, cardiac catheterization, pulmonary function testing, and a carotid ultrasound.
The structural heart clinic at The Johns Hopkins Hospital has become one of the busiest referral centers in the nation. In addition, three structural heart clinics are now active at Johns Hopkins Health Care & Surgery Center – Green Spring Station, Suburban Hospital, and the Johns Hopkins Bayview Medical Centerto better serve the growing population in need of this cardiac procedure. Suburban Hospital, a member of Johns Hopkins Medicine, has also successfully performed increasing numbers of TAVR procedures during the past two years.
The structural heart disease team at Johns Hopkins also performs mitral valve repair and replacement procedures, including MitraClip, and is actively involved in a major pivotal clinical trial for transcatheter mitral valve replacement (TMVR).
For consultations, or to refer a patient, call 443-99-PULSE (78573).
Published in Cardiovascular Winter 2019