Transcatheter Aortic Valve Replacement (TAVR) addresses a narrowed aortic valve, known as aortic stenosis. This minimally invasive procedure replaces a diseased aortic valve with a new, man-made valve without traditional open-heart surgery. A new valve is delivered via a catheter, typically inserted in the leg, and guided to the heart. This approach means smaller incisions and generally quicker recovery times compared to surgical aortic valve replacement (SAVR).
The Need for Re-Intervention
While TAVR valves offer significant benefits, they are not permanent solutions. Like any prosthetic valve, TAVR valves are subject to wear and tear over time, leading to degeneration. This can cause the valve to narrow again (stenosis) or leak (regurgitation). Such dysfunction indicates a need for further medical attention.
Degeneration often stems from calcification of valve leaflets. Other causes include leaflet thrombosis (blood clots) or infective endocarditis (infection). As TAVR procedures become more common, especially in younger patients, the need for re-intervention is expected to increase.
Approaches to Replacing a TAVR Valve
When a TAVR valve fails, primary approaches address the issue. One common method is a “valve-in-valve” TAVR procedure. A new transcatheter valve is deployed directly inside the degenerated TAVR valve. Using a catheter, the new valve expands inside the old one, pushing aside its leaflets to regulate blood flow.
Valve-in-valve TAVR is less invasive and offers quicker recovery than open-heart surgery. Its suitability depends on factors including the original TAVR valve’s type and size, and the patient’s coronary anatomy. Careful pre-procedural planning, often using CT scans, assesses these factors to determine the best approach.
In some cases, traditional surgical aortic valve replacement (SAVR) may be necessary after a TAVR procedure. This is often called “SAVR after TAVR” or TAVR explant. This open-heart surgery removes the failing TAVR valve and implants a new surgical valve. SAVR after TAVR is considered when valve-in-valve TAVR is not feasible due to anatomical complexities, patient-prosthesis mismatch, or complications like infective endocarditis.
SAVR after TAVR is more complex than an initial SAVR, carrying higher risks of complications and mortality. Patients may require longer hospital stays and intensive care. Despite increased risks, it remains a viable option for patients who cannot undergo a second TAVR.
Factors in Deciding on a Second Procedure
Deciding on a second heart valve procedure after initial TAVR is complex, requiring thorough evaluation. Overall health and age play a significant role. Older patients or those with comorbidities (existing medical conditions) may face higher risks with invasive surgery. Conditions like kidney disease, lung disease, or diabetes can influence re-intervention choice.
Heart anatomy and the characteristics of the previously implanted TAVR valve are also considered. Imaging assesses the valve’s current state, heart structure size, and surrounding blood vessel condition. The original TAVR valve’s design, size, and implantation method can affect valve-in-valve feasibility.
A multidisciplinary heart team evaluates each case to determine the best course of action. This team includes interventional cardiologists, cardiac surgeons, and imaging specialists. They discuss the patient’s condition, review diagnostic information, and weigh risks against benefits of each treatment option. This collaborative approach tailors the decision to the patient’s unique circumstances and preferences.