Technological advancements have opened the doors to treatment for symptomatic aortic stenosis patients who previously had no viable therapeutic option.
In 2012, physicians at Hackensack University Medical Center (HackensackUMC) performed the first transcatheter aortic valve replacement (TAVR) procedure in Northern New Jersey. The operation leverages the expertise of cardiac surgeons and interventional cardiologists to provide a minimally invasive valve replacement therapy for patients — typically of advanced age — whose health factors rendered traditional open surgical treatment too dangerous.
“The driving force behind the development of TAVR was that there was, and is, no effective medical therapy for symptomatic aortic stenosis,” says Jock Nash McCullough, MD, Vice Chair of the Heart & Vascular Hospital at HackensackUMC. “Unless patients receive a new valve, the long-term prognosis is terrible — about half expire within two years of developing symptomatic disease. For elderly patients and those whose comorbidities — such as renal or hepatic disease and pulmonary disease — and other mitigating factors make open surgery prohibitively risky, there was no therapeutic option. TAVR has proven to be hugely beneficial in not only relieving the dire heart failure symptoms associated with severe aortic stenosis, but also prolonging life for a population that has had no treatment option.”
Thomas Cocke, MD, attending interventional cardiologist at HackensackUMC, explains that the nature of aortic stenosis inherently handicaps medical intervention.
“We can try to stabilize patients medically with ever-increasing dosages, but that’s a losing battle,” he says. “Aortic stenosis isn’t a condition that can be cured or effectively stabilized by medications. It’s a mechanical problem requiring a mechanical solution.”
Interventional cardiologists and cardiac surgeons at HackensackUMC collaboratively perform the TAVR procedure, but cooperation begins much earlier and includes the skills of cardiologists and a cardiac anesthesiologist who is board-certified in echocardiography.
John Rokosny, CVT, and staff observe a cerebral angiogram performed by Daniel Waltzman, MD, of the Department of Neurosurgery at HackensackUMC.
“Beginning with the initial consult, all members of the heart team are involved in the process leading up to TAVR,” Dr. McCullough says. “We discuss each patient’s candidacy for TAVR, as well as the optimal approach.”
Interventional cardiologists typically introduce catheters to the aortic valve through an access point made by cardiac surgeons in the femoral artery. When the TAVR catheter reaches the aortic valve, Dr. Cocke dilates it by deploying a balloon on the tip of the catheter, creating space for the new valve.
Drs. Pranaychandra Vaidya, Thomas Cocke and Michael Wilderman during the wiring of the native aortic valve prior to placing the Edwards Lifesciences Sapien transcatheter valve
The team uses fluoroscopic imaging to ensure the catheter is in position so the new valve will be precisely centered within the native one. Then, the team introduces a temporary pacemaker to increase the heart rate to 180 beats per minute during a period of “rapid overdrive pacing.” Because the valve is narrowed, the heart can’t pump efficiently, and the blood pressure drops. With systolic blood pressure below 60, the balloon experiences less resistance.
“If the heart were pumping normally, the pressure against the balloon would push it and the new valve out of place,” Dr. Cocke explains. “So, with patients under general anesthesia, we lower the blood pressure to reduce the tension in the system and deploy the device, which can take as long as 15 seconds.”
An aortogram shows the positioning of the Sapien valve at the moment of deployment.
After valve placement and a few minutes to allow the heart to recover from the strenuous rapid overdrive pacing, transesophageal echocardiogram imaging confirms that the valve is secure and performing normally.
Because TAVR procedures are minimally invasive, patients — even though most are elderly and frail — generally recover quickly and only require average hospitalizations of three to five days, according to the American Heart Association. The procedure also significantly improves functionality for patients who, because of shortness of breath, fatigue and chest pain caused by aortic stenosis, had suffered quality-of-life deficits.
“Transcatheter aortic valve replacement has proven to be paradigm-shifting in the management of high-risk and inoperable patients with aortic stenosis, for whom there was previously no other option. It’s a viable option for patients who would otherwise, by definition, be terminally ill.”
— Jock Nash McCullough, MD, Vice Chair of the Heart & Vascular Hospital at Hackensack University Medical Center
A Different Approach
When the transfemoral approach is contraindicated, whether because of significant arterial disease in the legs or other causes making the femoral pathway inaccessible, the operative roles switch, and cardiac surgeons take more prominence.
Members of the TAVR team at the Heart & Vascular Hospital at HackensackUMC. Row 1: (L-R) Therese Palazzo, Director; Josefina Martinez, RN; Andrea Ramos, CVT tech; Edwin Nunez, perfusion tech; Anita Stechow, perfusionist; Larry Abrams, MD, anesthesiologist. Row 2: Maria Jain-Cananero, RN; Brenda DiMeglio, TAVR representative; Elly Delaportas, APN; David Lai, RN; Al Londono, RN; Rose Cambridge, RN; Jeff Hulko, CVT tech; Elly Elmann, MD, surgeon; Jose Alvarado, CVT tech; Thomas Cocke, MD, cardiologist; John Rokosny, CVT tech; Pranaychandra Vaidya, MD, cardiologist; Jock McCullough, MD, surgeon; Bill Monahan, TAVR representative; Emma Babenko, surgical tech; Debby Madden, perfusionist
The mounted Sapien transcatheter aortic valve prosthesis
The team approaches TAVR transapically. Dr. McCullough makes an incision in the chest wall, between the ribs, to access the apex of the heart. He then places the initial vascular sheath, through which Dr. Cocke threads the catheter across the diseased valve, around the aortic arch and into the distal thoracoabdominal aorta. After placement, Dr. McCullough removes the initial sheath and places the delivery sheath through the apex of the heart, and another surgeon inserts the catheter carrying the new valve. The cardiac surgeon then positions and deploys the valve following a process similar to transfemorally approached TAVR.
“The division of labor we employ during the different approaches to TAVR is the most efficient manner with which to perform each procedure,” Dr. Cocke explains. “The transfemoral approach requires a higher degree of catheter manipulation to deploy the valve in place, while the transapical approach relies more heavily on surgical prowess to expose the apex of the heart.”
Early Evaluation for Lifesaving Treatment
TAVR can mean a return to function and possibly longer life for patients who traditionally had no hope for treatment of their aortic stenosis. Because the disease progressively worsens, early referral can make a dramatic difference in the quality of a patient’s golden years.
“Any time patients have hemodynamically meaningful aortic stenosis and symptoms, including shortness of breath, chest pain with any type of exertion, or syncope, they should be referred so we can evaluate them for aortic valve therapy,” Dr. McCullough notes. “We offer all forms of aortic valve replacement to treat the spectrum of patients with aortic stenosis, and the addition of TAVR broadens our treatment parameters even further.”
For more information about the TAVR procedure at HackensackUMC, visit hackensackumc.org.