What is transcatheter aortic valve replacement?

Transcatheter aortic valve replacement (TAVR) is a procedure that replaces a diseased aortic valve with a man-made valve. Aortic valve replacement can also be performed with open-heart surgery; this procedure is surgical aortic valve replacement (SAVR).

Your aortic valve controls blood flow from your heart to your body. If your valve becomes stiff, you have a condition called aortic stenosis. Your heart may have to work too hard to pump blood through the small valve opening to the rest of your body. This may lead to increasing heart failure.

The Food and Drug Administration approved TAVR for use in a broad spectrum of patients following multiple research studies comparing TAVR to SAVR. Whether TAVR or SAVR is more appropriate for a given individual depends on multiple factors and is discussed with each patient by both an interventional cardiologist and a cardiac surgeon. During TAVR, your doctor inserts a catheter through a blood vessel in your leg to deliver and implant the artificial valve into your heart. Significant research is exploring how to both advance the use of this technique and improve the devices that are used for TAVR.

Why might I need TAVR or SAVR?

You may need replacement of your aortic valve if you have progressive heart failure due to aortic valve stenosis. Factors making TAVR more likely to be recommended than SAVR include conditions that would increase the risk of traditional open-heart aortic valve replacement surgery such as:

• Older age.
• Frailty.
• Weaker heart.
• Previous heart surgery.
• History of stroke.
• Chronic obstructive lung disease (COPD).
• Liver disease.
• Kidney disease.
• Diabetes.
• Previous radiation treatment to your chest.
• Large calcium deposits in the blood vessel that carries blood away from your heart (ascending aorta), called porcelain aorta.

What are the risks of TAVR?

Johns Hopkins has been performing TAVRs for more than a decade and has performed nearly 2,000 procedures. However, TAVR is still a major procedure that has risks. Most TAVR procedures are performed with sedation without the need for general anesthesia. The most common risks associated with TAVR include:

• Damage to your blood vessels.
• Bleeding.
• Decreased blood supply to your brain, causing a stroke.
• Heart attack.
• Kidney failure.
• Collection of fluid around your heart.
• Leaking of the replacement valve.
• Severe heart failure.
• Death.

There may be other risks, depending on your specific medical condition. Be sure to discuss any concerns with your doctor before the procedure.

How do I prepare for TAVR?

Before surgery, your medical and surgical team will evaluate your overall health. This may include X-rays, CT scans, blood tests and other tests to check the health of your lungs and heart. Your medical team will also give you an echocardiogram to evaluate your aortic valve. This test uses sound waves to create images of your heart. Your medical team may also do a cardiac catheterization to evaluate the arteries that supply blood to your heart. You will also need to:

• Tell your healthcare provider about any drugs you are taking, including over-the-counter medicines.
• Quit smoking if you still smoke, because continuing to smoke increases the risk of a procedure-related problem with your lungs.
• Stop certain medicines if your health care provider instructs you to.
• Stop eating and drinking, usually at midnight before surgery.

What happens during TAVR?

Methods may vary, depending on your condition and your doctor's practices. Talk with your doctor about what to expect. Generally, a TAVR procedure follows this process:

• You will remove any jewelry or other objects that may interfere with the procedure.
• You will remove your clothing and will be given a gown to wear.
• You will empty your bladder prior to the procedure.
• An IV line will be started in your arm or hand. Additional catheters will be inserted in your wrist to help guide the procedure. Alternate sites for the additional catheters may include the neck and the groin.
• You will be positioned on the operating table, lying on your back.
• The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Sedation will be given to make you comfortable. Rarely will general anesthesia be required, but then, once you are sedated, a breathing tube will be inserted into your throat and into your trachea to provide oxygen to your lungs. You will be connected to a ventilator, which will breathe for you during the surgery.
• The skin over the surgical site in your groin will be cleansed with an antiseptic solution.
• The surgeon will place a catheter into the leg artery (femoral artery) and thread it to your heart and through your aorta, to reach your aortic valve.
• Your surgeon will place other catheters in your heart to take measurements and X-ray pictures during the procedure.
• Your surgeon will guide your replacement valve, either a self-expanding valve or a balloon expandable valve, up the femoral artery catheter and through your old aortic valve.
• Once the new valve is properly positioned, your surgeon will implant the new valve to replace the old one.
• Your doctor will take measurements and images to make sure your new valve works properly before removing the catheters.
• Your doctor will close your femoral artery with a suture device that does not require any incision.
• Transthoracic echocardiography is then performed to assess the new valve’s function. 

What happens after TAVR?

You will be moved to the cardiac recovery floor of the hospital, so you can be monitored closely during your recovery. You will soon be able to get up and walk and return to a normal diet. You will stay overnight in the hospital. Most patients go home the next day and are allowed to resume their normal activities.

After your doctors feel you have recovered enough to go home, follow all instructions for medicines, pain control, diet, activity and wound care. Make sure to keep all your follow-up appointments.

Complete recovery from deconditioning caused by the aortic stenosis may take several weeks. Here are some helpful guidelines to follow as you heal:

• Your doctor may give you medication to take for several months after TAVR.
• Walk around as much as possible.
• Gradually resume normal activities, but avoid any heavy lifting.
• Participating in a cardiac rehabilitation program is highly recommended and will be arranged for you by your doctors.
• Ask your doctors when you can resume driving, work and sexual activity.
• Watch your groin for any sign of swelling, redness, bleeding or discharge.
• Let your doctor know if you feel any pain or have fever, bleeding or shortness of breath.
• Eat a heart-healthy diet and maintain a healthy weight.
• Don't smoke.

Next steps

Before you agree to the procedure, make sure you know:

• The name of the procedure.
• The reason you are having the procedure.
• What results to expect and what they mean.
• The risks and benefits of the procedure.
• What the possible side effects or complications are.
• When and where you are to have the procedure.
• Who will do the procedure and what that person's qualifications are.
• What would happen if you did not have the procedure.
• Any alternative procedures to think about.
• Who to call after the procedure if you have questions or problems.
• How much you will pay for the procedure.