Structure

The heart is made up of four chambers, called atria and ventricles-one atrium and one ventricle on the right, which pump blood to the lungs, and one atrium and one ventricle on the left, which pump blood around the rest of the body.

Blood circulation

On each side of the heart, the atrium and ventricle are separated by a valve. Blood is pumped through the right atrium and ventricle and out of the heart through the pulmonary valve, then on to the lungs to be oxygenated. This blood then returns to the left side of the heart. It is then pumped through the aortic valve into the main artery (the aorta) and around the body.

The aortic valve

The essential function of a heart valve is to maintain the flow of blood in the right direction. When the left ventricle has contracted fully and pumped the oxygenated blood into the aorta, the aortic valve closes. It only opens again when the ventricle has refilled blood from the left atrium, ready for the next contraction.

Thus, the role of aortic valve is important in process of blood circulation.

• The most common heart valve diseases are aortic stenosis, mitral regurgitation, and tricuspid regurgitation.
• Aortic stenosis is a narrowing of the aortic valve opening, most commonly occurring in the elderly due to age-related aortic valve calcification. Severe symptomatic aortic stenosis is a life-threatening heart valve disease.
• Mitral or tricuspid regurgitation is a leakage of blood backward through the mitral or tricuspid valve.
• Malfunctioning heart valves alter pressure levels inside heart chambers. If the heart valves are damaged, then less oxygenated blood may reach the tissues, resulting in common symptoms of heart valve disease.

Structure

In a patient with aortic stenosis, the aortic valve no longer opens fully. Its opening is restricted as the leaflets of the valve become stenosed (narrowed)over time. This makes it harder for your heart to pump blood through the valve and around your body. The narrower the valve, the harder the heart has to work and worse the symptoms are likely to be.

As the heart was having to work a lot harder, symptoms include feeling out of breath and dizziness. The symptoms may become worse and eventually develop into heart failure.1 Some people also suffer from fainting and in some cases, it may lead to heart stopping completely. 2,3 However, with proper intervention, there is hope for heart valve patients.

What happens when someone has aortic stenosis?

Over time, the leaflets of your aortic valve become stiff, reducing their ability to fully open and close. When the leaflets don’t fully open. Your heart must work harder to push blood through the aortic valve to your body. Eventually, your heart gets weaker, increasing the risk of heart failure (your heart cannot supply enough blood to your body).

Although not everyone will have symptoms, the condition will get worse over time. The only effective way to treat severe aortic stenosis is to replace the aortic valve. This can be done through TAVR or open heart surgery.

What should I do if I think I have Aortic Stenosis?

You should probably start by first seeing your family doctor or cardiologist who may then refer you to a multidisciplinary Heart team. Before your appointment, check with your family members to find out if any close relatives have been diagnosed with cardiac disease, knowing as mush as possible about your family’s health history will help your doctor make informed decisions.

Severe Aortic Stenosis has a worse Prognosis than many metastatic cancers

5-year survival rate (distant metastasis) of lung cancer, colorectal, breast cancer, ovarian cancer and prostate cancer compared to severe inoperable aortic stenosis.

Timely Intervention Is Critical; Timely Recovery Is Important

Without proper and timely intervention, your patient may die within 2 years.

Significant improvement in quality of life scores, as early as 30 days, may be an important factor to your severe aortic stenosis patients. Thus, the rapid recovery time and return to daily activities seen with TAVR is highlighted.

What are different
treatment options?

What are symptoms, causes & risk factors of heart valve diseases?

Aortic stenosis is one of the most common and serious heart valve disease problems. Treatment depends on how far the disease has progressed. If the aortic stenosis is mild, medication may be prescribed to help control symptoms and lower the chance of having certain complications. However, aortic stenosis is a progressive disease. People simply confuse the symptoms of aortic stenosis with “normal” signs of aging.
Many times people do not know they have symptoms until they discuss their daily activity with a doctor.

Following tests are performed to diagnose Aortic Stenosis

What are the treatment options for aortic stenosis?

Treatment for aortic stenosis depends on how far your disease has progressed. If your stenosis is mild, medication may be prescribed to help regulate your heartbeat and prevent blood clots. However, if the severity of your stenosis progresses, your doctor may recommend replacing your diseased aortic valve. Severe aortic stenosis cannot be treated with medication. The only effective treatmet is to replace your aortic valve.

Today there are two options to replace your diseased aortic valve:

Transcatheter Aortic Valve Implantation (TAVI)

TAVI may be a better option for people who have been diagnosed with severe aortic stenosis depending on their risk for open-heart surgery. TAVI (sometimes called transcatheter aortic valve replacement or TAVR), is a less-invasive procedure than open-heart surgery. This procedure used a catheter to implant a new valve within your diseased aortic valve. TAVI can be performed through multiple approaches, however the most common approach is the transfemoral approach (through a small incision in the leg). Only professionals who have received extensive training are qualifies to perform the TAVI procedure. A properly trained and dedicated multidisciplinary heart team at a TAVI center will conduct a thorough evaluation to determine the most appropriate treatment option for you.

Open Heart Surgical Aortic Valve Replacement

Aortic valve replacement through open heart surgery is another option for treating severe aortic stenosis. Most open-heart surgeries are performed through an incision across the full length of the breast bone, or sternum. Occasionally open-heart surgeries can be performed through smaller incisions.

Open heart surgeries, including those performed through smaller incisions, both require the use of a heart lung machine which temporarily takes over the function of the heart. During the procedure, the surgeon will completely remove the diseased aortic valve and insert a new valve. There are two different types of surgical valves; mechanical (man-made material) and biological (animal or human tissue).

Aortic valve surgery is performed by heart surgeons to treat most commonly, bicuspid valves, other congenital aortic valve diseases, aortic valve stenosis (where the valve that is narrowed and doesn't open properly. The flaps of a valve may thicken, stiffen or fuse together. As a result, the valve cannot fully open) and aortic valve regurgitation (Aortic regurgitation is leakage of blood through the aortic valve each time the left ventricle relaxes. A leaking (or regurgitant) aortic valve allows blood to flow in two directions. This results in increase in workload for the heart, thus predisposing it to failure).

Aortic valve surgery

There are two types of aortic valve surgery: aortic valve repair and aortic valve replacement.

During aortic valve surgery, including aorta surgery, the aortic valve may be repaired or replaced. The results of your diagnostic tests, the structure of your heart, your age, the presence of other medical conditions and other factors will be considered to determine whether aortic valve repair or replacement is the best treatment approach for you.

Aortic valve surgery can be performed using traditional heart valve surgery or minimally invasive approaches.

Traditional Aortic Valve Surgery

During traditional aortic valve surgery, a surgeon makes a 6- to 8-inch incision down the center of your sternum, and part or all of the sternum (breastbone) is divided to provide direct access to your heart. The surgeon then repairs or replaces your abnormal heart valve or valves.

Minimally Invasive Aortic Valve Surgery

Minimally invasive aortic valve surgery is a type of aortic valve repair surgery performed through smaller, 2- to 4-inch incisions without opening your whole chest. This is typically done with a “J” incision and leaves your chest stable. Minimally invasive surgery reduces blood loss, trauma, length of hospital stay and may accelerate recovery.

Most patients who require isolated aortic valve surgery are candidates for minimally invasive aortic valve surgery, but your surgeon will review your diagnostic tests and determine if you are a candidate for this type of surgery.

Repair of an enlarged aorta

Aortic valve disease is often associated with an enlargement (aneurysm) of the ascending aorta, the initial portion of the aorta (the main blood vessel in the body that originates from the aortic valve).

If the enlargement of the aorta is substantial (usually above 4.5 or 5 cm in diameter), this part of the aorta may need to be replaced. The replacement is done at the time of aortic valve repair or replacement. In patients who have a leaky aortic valve and an enlarged aorta, a special procedure (David procedure) can be performed. The David procedure allows surgeons to repair the aortic valve and simultaneously replace the enlarged ascending aorta.

Aortic valve replacement

If valve repair is not an option, your surgeon may replace the valve. The native (original) valve is removed and a new valve is sewn to the annulus of your native valve. The new valve can either be mechanical or biological.

Biological valve replacement

Biological valves (also called tissue or bioprosthetic valves) are made of tissue, but they may also have some artificial parts to provide additional support and allow the valve to be sewn in place.

Biological valves can be made from porcine tissue, bovine pericardial tissue, or pericardial tissue from other species.

These valves are safe to insert, durable (lasting from 15 to 20 years), and allow patients to avoid lifetime use of anticoagulants (blood thinning medications).

Mechanical valves replacement

Mechanical valves are made completely of mechanical parts, which are non-reactive and tolerated well by the body. The bileaflet valve is used most often.

All patients with mechanical valve prostheses need to take an anticoagulant medication, for the rest of their life to reduce the risk of blood clotting and stroke. This may increases the risk of bleeding. This can be prevented by proper monitoring of a blood parameter called PT/INR.

Risk and Benefits

Aortic valve surgery is usually needed when we have no other option but to address the valve which is diseased and results in cardiac dysfunction and failure.

Surgery should be attempted before the heart decompensates. In these situation the benefits definitely outweigh the risks. As we lose more time, heart failure and cardiomyopathy set in , which increases the risks associated with surgery.

Past history of heart surgery, your age, co-existing organ disease (such as emphysema, kidney disease, past history of stroke or ischaemic heart disease,etc), or other conditions that require surgical treatment will affect individual risk. Your surgeon will explain the surgical risks

TAVI: Transcatheter aortic valve implantation

A less invasive therapy for severe aortic stenosis

You may feel overwhelmed if you have been recently diagnosed with severe aortic stenosis and this can make it harder to take the step toward treatment. But the sooner you seek care, the quicker you will be able to get back to life and all the things you love.
TAVI, also called TAVR (transcatheter aortic valve replacement), is a less invasive treatment option for severe aortic stenosis, that is designed to replace a diseased aortic valve.
This procedure used to only be available for people who were too weak to undergo open heart surgery. But now, TAVI is available to more people depending on their risk for open heart surgery.
A doctor can explain the procedure to you and determine if TAVI is right for you.

What happens during TAVI?

Your doctor will perform the procedure at a hospital. Depending on your health, they will determine what type of anaesthesia is best for you. You may be fully asleep, or you may be awake but given medication to help you relax and block pain. Your heart will continue to beat during the procedure. This is quite different to open heart surgery, in which your heart will be stopped, and you will be placed on a heart and lung blood machine .
TAVI is different from open heart surgery in that it uses a less invasive approach to treat a diseased aortic valve. Your doctor will determine the best approach for replacing your valve, but the most common technique involves a small incision made in the leg. This is called the transfemoral approach.

TAVI procedure(step-by-step):

Step 1: A small incision is made in your upper leg. This is where your doctor will insert a short, hollow tube called a sheath into your femoral artery.

Step 2: The new valve is then placed on the delivery system (or tube). The new valve is compressed to make it small enough to fit through the sheath.

Step 3: The delivery system carrying the valve is pushed up to your aortic valve. Once it reaches your valve, the new valve pushes aside the leaflets of your diseased valve. Your existing valve holds the new valve in pace.

Step 4: The new valve will open and close as a normal aortic valve should. Your doctor will make sure your new valve is working properly before closing the incision in your leg.

Your doctor may decide that a different approach is necessary depending on various factors. Other ways to perform the TAVI procedure include:

• Transapical approach: Through an incision in the chest between the ribs
• Transaortic approach: Through an incision in the upper chest.

For TAVR,

Post TAVI/ TAVR , Patients may not need more rest as compared to other procedures, they may actually spend 1-2 days in the ICU followed by hospital stay in the patient room for another 2-3 days.
Nearly all patients start walking in 1 day and can perform small activities in 2-3 days of the procedure, under doctor surveillance.
Before the Patients leave the hospital, they will be suggested to restrict some physical activities for few more days depending upon the condition and will also be advised when to re- visit the doctor after TAVR procedure.
To monitor the condition after TAVR, the patient should have a TAVR check for every 30 days to 1 year (as per the doctor’s suggestion). In case if they face any health changes and discomfort, make sure a visit to the doctor.