Westchester Medical Center Now Provides Innovative, Minimally Invasive Aortic Valve Replacement
Transcatheter aortic valve replacement (TAVR) is a groundbreaking solution for patients with severe symptomatic aortic stenosis who cannot endure traditional open aortic valve replacement procedures. Since 2012, Westchester Medical Center has offered patients of the Lower Hudson Valley this potentially transformative treatment option.
Symptomatic severe aortic stenosis, characterized by an aortic valve that does not fully open due to excess calcification, results in reduced volumes of blood flowing from the heart, according to the National Institutes of Health (NIH). It is a disease that typically affects the elderly, whose advanced age often shrouds the disease’s symptomatology in that of common age-related comorbid conditions.
Although symptoms vary from patient to patient, Gilbert Tang, MD, MS, MBA, cardiothoracic surgeon at Westchester Medical Center and Assistant Professor of Surgery at New York Medical College, says many patients’ symptoms fall into three broad categories:
- chest pain associated with angina;
- syncope, or lightheadedness resulting from insufficient blood flow through the stenosed aortic valve to the brain as the disease worsens; and
- congestive heart failure, which can greatly debilitate patients, causing them to have trouble breathing — especially at night when lying flat on a bed. Congestive heart failure can also cause swelling around the ankles, according to Dr. Tang.
“TAVR is a relatively new approach to replace the aortic valve in a less invasive way without open-heart surgery. It’s made the possibility of aortic valve replacement available to patients who would benefit from the operation but were too old, frail or sick to undergo open-heart surgery.”
— Steven Lansman, MD, PhD, Chief of the Section of Cardiothoracic Surgery at Westchester Medical Center
Initially, patients may present with increased fatigue or breathlessness, which can make symptomatic severe aortic stenosis difficult to identify in elderly patients, who may have comorbid conditions, such as lung disease and arthritis, that increase fatigue and decrease activity levels. Dr. Tang says physicians whose patients complain of not being able to keep up with activities they used to enjoy should consider all the potential causes before attributing these symptoms to the aging process.
“Looking for these symptoms can help physicians catch the disease early,” he says. “As people age, their aortic valves progressively narrow due to calcium deposits, and the leaflets that open and close within the valve become stiff. These two processes result in insufficient blood supply to the organs and the rest of their bodies. Symptoms may seem innocuous, but when physicians see them, aortic stenosis should be in the back of their minds because the final stage of the disease can result in sudden death.”
Gilbert Tang, MD, cardiothoracic surgeon, preparing for surgery in Westchester Medical Center’s hybrid operating room
Two Paths to Go By
Dr. Tang explains that patients with symptomatic severe aortic stenosis can be completely cured by only open-heart AVR, as no medications that reverse the condition currently exist. For patients who are high- or prohibitive-risk for open-heart surgery, TAVR may be utilized to replace the stenosed valve, thereby restoring normal blood flow and improving patients’ lives.
Steven Lansman, MD, PhD, Chief of the Section of Cardiothoracic Surgery at Westchester Medical Center, says the introduction of TAVR to the Lower Hudson Valley gives hope to people who once had little.
“News about this procedure is spreading,” Dr. Lansman says, “and those patients who previously would have been given medications and told there was nothing else to be done now have a proven method for enhancing their quality of life.”
Based on CT scans that determine whether the leg arteries are wide enough to accommodate the catheter or if patients have vascular diseases that would preclude passage of a catheter from the leg to the heart, the transcatheter heart team at Westchester — consisting of cardiothoracic surgeons, interventional cardiologists, an echocardiologist, a cardiac radiologist and a nurse practitioner — decides between a transfemoral or transapical approach to TAVR.
The transfemoral approach is similar to cardiac catheterization, according to Dr. Lansman. Through a small hole at the groin, physicians access the femoral artery with a needle and then, guided by fluoroscopy, snake the catheter carrying the artificial valve to the aortic valve.
“The valve is tightly compressed onto a balloon on the catheter,” Dr. Lansman explains. “When the balloon blows up, it expands the valve, and the radial force anchors it in the correct position right inside the old valve.”
If patients have significant vascular disease or their leg arteries aren’t big enough to accommodate the catheter, a transapical approach may be necessary.
“The transapical approach involves reaching the aortic valve through a small incision in the chest near the tip of the heart,” Dr. Lansman says. “After exposing the heart, we introduce the catheter through the tip — or the apex — of the heart. Using fluoroscopy, we guide the catheter into the appropriate position and deploy the valve.”
A computer image of a TAVR procedure
Patients receive the same benefits from either approach, and Dr. Tang says advanced imaging capabilities enable the heart team to minimize complications that may arise.
“Vascular complications in the leg, such as tearing of the arteries, can be serious, so we’re careful about choosing and making recommendations to minimize these complications,” he says. “CT scans can be used to help us make this decision by providing us with a detailed 3-D reconstruction of the heart and the leg arteries. Despite the risk for adverse outcomes, we’re happy to report that our patients have had zero complications.”
Westchester Medical Center is also one of the few hospitals in the country, says Dr. Tang, that have the capability of creating specialized 3-D images of the heart from the CT scans. The 3-D images allow the heart team physicians to generate a “virtual flight plan” for the TAVR procedure, minimizing radiation and IV contrast exposure to the patient and maximizing patient safety.
Comprehensive Evaluation with Convenience
Patients referred to Westchester Medical Center for symptomatic severe aortic stenosis go through a comprehensive, two-day evaluation process that has been streamlined to most efficiently schedule necessary tests, procedures and specialist visits.
“Westchester Medical Center’s program stands out because we serve patients from a broad geographical range,” Dr. Tang says. “Often, they travel several hours to receive care, so we’ve streamlined our patient evaluation process so that it takes place in two visits to minimize the number of appointments patients have to make and reduce inconvenience.”
On the first day, patients meet with a cardiothoracic surgeon and valve clinic coordinator and nurse practitioner Andrea Cronin, who conduct an echocardiogram and carotid artery exam to assess the patient’s condition and determine if the patient would be best served with an open AVR or TAVR procedure, Dr. Tang says. If patients qualify for TAVR, then a CT scan performed by cardiac radiologist Amar Shah, MD, utilizing Westchester Medical Center’s leading-edge, 256-slice CT scanner, is employed to illustrate the heart’s anatomy and allow the transcatheter heart team physicians to determine if the patient is a candidate for the transcatheter heart valve.
The heart team at Westchester Medical Center performing a transcatheter aortic valve replacement (TAVR)
The second visit is primarily reserved for planning. All the information needed to determine whether TAVR is the best treatment plan has already been gathered, and cardiothoracic surgeons meet with interventional cardiologists and other team members to make the final decision. The preoperative process concludes by setting a date for the procedure.
After completing the evaluation process, patients arrive at the hospital one day before the operation, during which time they meet with pulmonologists, nephrologists, neurologists or any other specialists they may need to see regarding comorbidities they may have. Once all consultations, paperwork and tests have been completed, patients are ready for the TAVR procedure, which takes place in Westchester Medical Center’s new hybrid operating room, introduced in December 2012.
Hybrid operating rooms combine advanced imaging technologies, such as fluoroscopy, housed within cardiac catheterization laboratories with the sterile environment of operating rooms, enabling cardiothoracic surgeons and interventional cardiologists to perform both open and minimally invasive procedures together within the same operating space.
Martin Cohen, MD, Director of Clinical Outreach for Cardiology at Westchester Medical Center, explains that, because all the technology required for TAVR is located within the hybrid operating room, cardiothoracic surgeons and interventional cardiologists can collaborate much more efficiently.
“The hybrid operating room allows us the advantages of each separate room without having to move our patients,” Dr. Cohen says. “This combination is particularly beneficial when we need to use the transapical approach for TAVR because surgeons can conduct their part of the operation while we insert the catheter in the patient’s legs. Standard operating rooms don’t have adequate fluoroscopy for the procedure, and standard catheterization laboratories don’t have the capabilities of an operating room.”
Dr. Lansman adds that the hybrid operating room isn’t necessary to perform TAVR, but it enhances the standard of care.
“It’s not that you can’t perform TAVR without a hybrid operating room,” he says, “but it greatly improves the heart team’s abilities to more safely and accurately replace the valve and achieve better results.”
Steven Lansman, MD, PhD, Chief of the Section of Cardiothoracic Surgery, performing surgery in Westchester Medical Center’s hybrid operating room
Patient Criteria and the Open Alternative
The U.S. Food and Drug Administration developed indications for TAVR based on risk assessment recommendations set forth by the Society of Thoracic Surgeons (STS). Before patients undergo TAVR, two cardiothoracic surgeons must identify them as being at prohibitive risk for heart surgery, meaning they have more than a 50 percent risk for adverse outcomes following open AVR, Dr. Tang says.
Candidates for open AVR who are considered high risk — having a greater than 8 percent risk of death as determined by the STS guidelines — and have comorbidities, such as aortic calcifications, liver disease, cancer, frailty or chest wall deformities, may be elevated to a mortality risk to greater than 15 percent. Dr. Tang explains that in high-risk patients for whom TAVR results in nearly equivalent benefits as open AVR, TAVR is the preferred option for many ill, elderly patients because of a faster recovery and return to normal activities.
TAVR, which takes only about two hours to perform, is much less complicated than traditional open AVR, Dr. Lansman says.
“Ordinarily, for AVR, we’d have to open the chest, expose the heart, put the patient on the cardiopulmonary bypass machine, stop the heart, open the heart, take out the old valve and replace it,” he explains. “It’s a very involved procedure compared with threading a compressed valve through the artery, positioning it with X-ray, expanding the valve with a balloon to make it stay in place and immediately taking over the valve’s function.”
Hasan Ahmad, MD, interventional cardiologist; Dr. Tang; and Martin Cohen, MD, Director of Clinical Outreach for Cardiology and interventional cardiologist, perform a TAVR procedure.
Since TAVR was introduced in 2002, medical literature has examined negative outcomes that can result from TAVR. However, overall patient outcomes have been exceptional at Westchester Medical Center. Dr. Lansman notes that, since the introduction of TAVR, the results have been highly successful, even in patients whose conditions are severe.
“Of course it depends on how ill patients are before TAVR, but the procedure can produce dramatic turnarounds,” Dr. Lansman says.
Dr. Tang adds that for many patients, TAVR quickly improves quality of life.
“Many of our patients who previously were bedbound and suffering from aortic stenosis were able to get out of bed and get around in the days following TAVR,” Dr. Tang reports. “The majority has a voracious appetite where previously they may not have, and we see improved energy levels.”
Drs. Tang and Cohen remember one of the first patients who underwent TAVR at Westchester Medical Center and point to him as an example of the dramatic improvement in quality of life TAVR can produce.
One week following the procedure, the nurse in charge of the patient’s home care called the hospital to report that the patient was nowhere to be found. Later, the patient returned from the grocery store, where he had been shopping for his neighbors. This kind of activity would not be possible following an open-heart procedure, Dr. Cohen says.
Patients whose symptomatic severe aortic stenosis prevents treatment for comorbid conditions can benefit from the improvements TAVR makes in their overall health. Dr. Tang remembers a 91-year-old patient whose symptomatic severe aortic stenosis had caused swelling up to her knees. One month after TAVR, the swelling subsided enough to allow the patient to move around her house and wear the clothing she wanted to wear. Additionally, she had a hernia that was unable to be repaired for years because of her aortic stenosis. TAVR fixed the narrowed aortic valve and allowed surgeons to repair her hernia.
But this kind of recovery isn’t uncommon and has been demonstrated over longer periods of time.
“Even when we see our patients months after the procedure, we can see they’re happy,” Dr. Tang notes. “Their energy and activity levels have improved, and they’re extremely pleased that they can see their families and visit with children and grandchildren in ways that may not have been possible had TAVR not helped them feel better.”
Dr. Lansman and Dr. Tang review images in the hybrid operating room.
Keeping Care Local
Because the evaluation and planning process is so time-consuming, Westchester Medical Center offers patients in the Lower Hudson Valley the opportunity to receive leading-edge care in a state-of-the-art facility without having to travel long distances, navigate congested interstates and city streets, or spend excessive money on travel.
With convenience in mind, Westchester Medical Center provides meal and parking vouchers to patients and family members who accompany them. Dr. Cohen adds that these considerations can be a boon for patients with symptomatic severe aortic stenosis.
“This is a procedure with extensive preoperative evaluation,” he emphasizes. “Patients need CT scans, X-rays, angiograms and pulmonary function tests. Among the many reasons why it’s hard for patients to have the procedure if it’s not performed locally is that candidates for TAVR are frail and often wheelchair-bound, so it’s hard for them to travel, and it’s important they can stay local and be treated closer to home.”
For more information about Westchester Medical Center’s TAVR program, please visit www.westchestermedicalcenter.com.