TREATMENTS
IMPLEMENTATION OF A TAVI
Introduction
You have a significant narrowing and/or leakage in the aortic valve or even in an already implanted aortic bioprosthesis. This is the valve that separates the left ventricle (the heart pump) from the aorta, and allows blood to pass from the heart to the rest of the body. This narrowing prevents the blood from flowing normally and is responsible for the symptoms you have (shortness of breath on exertion).
The treatment for this disease consists of either replacing your diseased valve with an artificial valve surgically by opening the chest, or deploying an artificial valve in your diseased valve through the femoral artery in the groin fold after puncture of it (TAVI). In your case, this 2nd approach was considered by the medical-surgical team that assessed your situation as the most favorable.
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This procedure is performed under X-ray control. The X-ray dose used is as low as possible, according to the ALARA precautionary principle, recommended by the Public Health Code.
The details of the doses received are an integral part of the reports that will be given to you.
Description of the bioprosthesis
​This artificial valve is made of pericardium (a thin membrane that surrounds the heart) of animal origin (beef or pig), reproducing the general shape of a normal aortic valve, sewn inside a tubular and expandable metal cage (stent) either by inflating a balloon or by self-expansion by gradually removing the outer sheath. This valve is mounted at the end of a tube (or catheter) and pushed to the heart under radiological supervision, then placed and expanded at the level of the diseased aortic valve.
Once in position, it is held in place by the expansion force of the stent alone. The size is chosen according to the dimensions of the aortic annulus (where the stent will be deployed) evaluated by the CT scan performed at the time of your check-up.
Necessary examinations before implantation
The following additional tests are necessary before considering the implantation of the TAVI valve: electrocardiogram, echocardiogram (ultrasound study of the heart allowing a detailed analysis of the condition of your heart and the aortic valve), coronary angiography (evaluation of the condition of the coronary arteries) and cardiac CT scan. These are examinations carried out daily in cardiology.
Analysis of the aortic stricture and the dimensions of the aortic annulus (the structure to which the aortic valve attaches) and the iliac and femoral arteries will be done to determine if the arterial approach is possible. Only after these examinations have been carried out will it be known whether the artificial valve or TAVI can be implanted. These examinations will allow the choice of the type of valve and its size.
Implementation methods
To introduce the artificial valve to the heart, the right or left femoral arterial pathway is used. A minimum diameter of 5mm is essential. Just before the TAVI implantation, your narrowed aortic valve will possibly be opened using an inflatable balloon, a gesture very regularly practiced in order to facilitate the positioning of the TAVI. The valve is implanted in the correct position by means of angiographic controls by injection of iodinated contrast agent to ensure the accuracy of the positioning.
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Implantation of the TAVI bioprosthesis and hospital follow-up
The femoral artery is accessed by simple puncture and will be closed as far as possible by a percutaneous closure system. After the valve is implanted, you will be admitted to a ward with permanent heart rhythm monitoring, which may be a cardiology intensive care unit. Blood tests will be carried out daily and an echocardiogram will be recorded to check that the TAVI is working properly. Your hospitalization should last between 3 and 5 days in the absence of any unforeseen events.
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Other treatment options
There are four treatment options:
1. Continue the medical treatment you are receiving, but the effects of aortic stenosis will persist and worsen.
2. Perform a balloon aortic dilation (enlargement of the aortic valve opening using an inflatable balloon), a technique that can temporarily improve the functioning of your valve but whose results are not maintained over time.
3. Install the TAVI valve through surgical arterial surgery. In this case, general anesthesia is necessary and the procedure is performed in the operating room. This solution is generally proposed when the condition of the arteries does not allow passage through the groin.
4. Use conventional surgery by opening the chest under extracorporeal circulation
Expected benefits
In the current state of our knowledge, and given your clinical condition, the placement of this valve seems to be the best possible solution to improve your symptoms and reduce the risk of your disease in a more sustainable way. The expected benefits of this procedure are a rapid improvement in your symptoms (shortness of breath, chest pain, malaise), an improvement in contractility and the functioning of your heart and above all an improvement in your quality of life and an increase in your life expectancy. The first case was carried out in March 2002 by Professor Cribier in Rouen and the technique as well as the medical devices have progressed considerably since then, making it possible to propose their use in the majority of cases of valve replacement for narrowing of the aortic valve.
Risks and side effects
The risks of the operation are those related to cardiac catheterization, coronary angiography, possible aortic dilation (an examination that has been practiced for many years), to which are added those related to the implantation of the valve itself. They are classified in order of frequency as follows:
- common (between 5 and 20%): cardiac conduction disorders requiring a pacemaker during hospitalization, minimal leakage around the valve and major bleeding.
- uncommon (<5%): vascular complications at the catheter insertion site (hematoma, perforation or arterial obstruction that may give rise to surgical repair, moderate leakage around the valve.
- rare (<0.5%): myocardial infarction, embolization of valve material or clots, aortic dissection (tear of the aortic wall), perforation of a heart chamber, stroke, kidney failure, endocarditis (infection on the valve), displacement of the valve, significant leakage around the valve, valve dysfunction, bleeding requiring transfusion, need for emergency surgery for coronary artery bypass surgery, pericardial drainage or aortic valve replacement, death.
After discharge from hospital
You will be prescribed a blood-thinning medication to prevent clots from forming on the prosthesis. The nature and duration of this treatment will depend on your situation. In the event of dental work, it will be necessary to inform your dentist of the existence of the aortic prosthesis. He or she will prescribe a short-term antibiotic treatment depending on the care you are considering to avoid infection of the prosthesis. In general, it is essential to systematically warn any practitioner that you have a percutaneous aortic valve.
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