Transcript of video
Dr. Anton Titov, MD. How would you compare the open-heart surgery to replace aortic valve with the more minimally invasive interventional procedures like TAVI / TAVR? Dr. Tsuyoshi Kaneko, MD. Great question! This new technology is called the transcatheter valve. We call it a transcatheter aortic valve replacement, TAVR, in the United States. TAVR is a technique to replace the aortic valve through the groin, typically. It is done under x-ray, without opening your chest. Dr. Tsuyoshi Kaneko, MD. We are not using any heart-lung machine. Then we are able to exchange aortic valve without needing any open cardiac surgery. TAVR / TAVI technique has been used since 2011 commercially in the United States. Recently it got approved for a valve-in-valve procedure. This is a procedure used inside of a tissue aortic valve that deteriorated. Sometimes you had previous aortic valve replacement with a pig valve or a cow [bovine] valve. Dr. Tsuyoshi Kaneko, MD. After 10 years, the pig or bovine aortic valve may not function well. Then there is an option of going through the groin, and changing that aortic valve. You can’t do it in a previous mechanical valve. You can only do it in a tissue aortic valve. We have looked at our repeat aortic valve replacement series a couple of years ago. We compared open surgery versus valve-in-valve transcatheter aortic valve replacement. It showed that the risk of operation was about the same. But the length of stay in the hospital and the recovery was much much faster with TAVR / TAVI [transcatheter aortic valve implantation]. I foresee in the future that most of the degenerated bio-prostheses will be treated with valve-in-valve TAVR. Replacement of previously implanted tissue aortic valves will not be done via open heart surgery. I think that time is coming. Dr. Anton Titov, MD. What are benefits and risks of each type of heart valve surgery? How to choose the correct replacement heart valve? Dr. Tsuyoshi Kaneko, MD. There are many options now available to patients. That is a very very good question. That is a very very difficult question too. To start off, there are two types of replacement heart valves. I think that’ll be the main answer to this question. One type of heart valve is called a mechanical heart valve. This artificial valve is made out of carbon. Another heart valve for replacement is called a tissue valve. Dr. Tsuyoshi Kaneko, MD. Tissue heart valve is made out of either pig valve or a cow pericardial tissue. The benefit of mechanical valves is this. Mechanical heart valves last for a long time after you implant them. There are some situation where you have to exchange the mechanical heart valves. But those situations are very rare. Either the mitral valve thrombosis happens, aortic heart valves get stuck and have to be taken out. Or the replaced aortic valve gets infected. Those are the two cases when mechanical valve will need to be explanted [removed]. But the rates of mechanical heart valve problems are very very low. Dr. Tsuyoshi Kaneko, MD. The downside of mechanical valves are that you have to be on a blood thinner. Typically this medication is called coumadin. You are committed to a lifetime of using coumadin [warfarin]. That is the biggest burden of receiving a mechanical heart valve. Of course, the risk of coumadin is bleeding. We will discuss it later. But it’s important to note that coumadin [warfarin] is not an innocuous medication. No, it’s not. On the other hand the tissue mitral and aortic heart valves eliminate the need for coumadin. These are cow heart valves or pig heart valves. Dr. Tsuyoshi Kaneko, MD. The downside of tissue valve are that it does wear out with time. It really varies on the time period of how long a tissue replacement heart valve takes to wear out. You implant a tissue heart valve at a younger age. Then the aortic or mitral valve opens and closes much more. Because you are young and you are more active. Cow or pig heart valve may not even last ten years. You may be 75 and you live a very sedentary life. Your pig aortic valve valve won’t open that much. Dr. Tsuyoshi Kaneko, MD. Therefore, cow mitral heart valve may last up to 15 years. It really varies how long tissue valve lasts. American Heart Association and American College of Cardiology provides guidelines of what valve to choose. But now the strongest recommendation is patient’s preference. Patients get to choose aortic or mitral valve for replacement based on all the information that they get. Dr. Anton Titov, MD. The physician has to provide the important information for the patient. The patients ultimately get to choose if they want tissue or mechanical heart valve for replacement surgery. Dr. Tsuyoshi Kaneko, MD. I had two similar 90-year-old patients. The first 90-year-old patient who was treated about ten years ago, received open-heart surgery to replace aortic valve. He was a very very healthy 90-year-old. He was very functional. He did very well after the operation. He spent about a week in the hospital. He then admitted back in the hospital in about six weeks. He was still trying to recover, he had some fluid in the chest. We injected a lot of Lasix, a diuretic. Eventually he recovered. But it took him over six months. It took about six to eight months for him to completely regain strength and feel better. This is a 90-year-old patient. So he basically wasted six months of his remaining time. On the other hand, I recently treated another 90-year-old man. He was very healthy. But today we can treat aortic stenosis with TAVR. Dr. Tsuyoshi Kaneko, MD. This very old patient got TAVR. TAVR is the minimally invasive Transcatheter Aortic Valve Replacement. That’s correct. We went through the groin to put a catheter via femoral artery. There was no need for open chest surgery. We did this without general anesthesia. Patient was awake during the whole time of TAVR (Transcatheter Aortic Valve Replacement). After the TAVI procedure he did well. He left the following day, on postoperative day #1. Dr. Tsuyoshi Kaneko, MD. We saw him about a month later in outpatient clinic. He was going to his yard, he was working on his garden, he was doing very well. One year after minimally invasive TAVR heart procedure he is feeling better than ever. I’m not saying that TAVR is completely better than surgical aortic valve replacement. Dr. Anton Titov, MD. But you can see that the recovery is completely different. For a 90-year-old patient fast recovery time after procedure is something that really does not appear in the medical literature. Importance of faster recovery is not discussed. I think that faster recovery after TAVR is very important. Dr. Anton Titov, MD. Patients are spending less time in the hospital, going back to what they liked before. I think that quality of life component is something that is really undervalued in TAVI / TAVR. It’s very hard to measure, but it’s undervalued. Dr. Tsuyoshi Kaneko, MD. I think there is going to be more and more of these minimally invasive procedures in the future. There are multiple transcatheter devices for the mitral valve. Dr. Tsuyoshi Kaneko, MD. I think there is going to be more and more of these minimally invasive procedures in the future. There are multiple transcatheter devices for the mitral valve. There are transcatheter devices for the tricuspid valve. There are transcatheter devices for ascending aortic aneurisms. All those are currently being investigated. I think all these minimally invasive procedures are being developed. We will soon see a dramatic change towards minimally invasive cardiac surgery. Dr. Anton Titov, MD. That is, fortunately or unfortunately, the traditional open-heart surgery will diminish. We still have to know how to do open heart surgery. Dr. Tsuyoshi Kaneko, MD. But I think the traditional method of open-heart surgery will decrease. We have to be prepared. But at the same time that will provide better care for the patients. That is why we are here. I think we are very excited to be in cardiac surgery field now. I’m very very excited for the heart disease patients in the future.