San Diego Health: How to Fix Heart Valves With the TAVR Procedure


– Hi I’m Susan Taylor with Scripps Health in San Diego California, please subscribe to our Scripps Health YouTube channel, we’ve got great videos
featuring the latest technology, our stellar doctors, and
inspiring patient stories. Each year roughly 300
thousand people in the US need to have a heart valve replaced because of what’s called stenosis. It’s a narrowing of the aortic valve, which affects blood flow. If left untreated, this
can lead to heart failure. In the past, the only way
to treat this condition was through major open heart surgery, cutting the chest open,
but a lot of patients can’t handle that kind
of open heart surgery. Enter TAVR, trans-catheter
aortic valve replacement. That’s a mouthful. Back in 2007, Scripps was
involved in a nationwide clinical trial testing out a new way to replace that failing aortic valve without cutting the chest open, and the doctor who took
part in that clinical trial joins us, Dr. Paul Teirstein,
chief of cardiology at Scripps Clinic in La Jolla California and medical director of the
Prebys Cardiovascular Institute. Thanks so much for being
with us Dr. Tierstein. – Hello, happy to be here. – Let’s start with the basics, talk about the aortic valve, what is
it and how does it work? – Well when the heart
pumps blood around the body and the heart squeezes, the
blood comes out of the heart, and then the heart relaxes, we don’t want the blood to come back into the heart, so the valve shuts, and
the blood then carries down through the rest of the
body, that’s a really important valve, it’s the main
valve in the heart muscle. – So it allows the blood to keep flowing and not come back this way. – Exactly it makes it go
forward as opposed to come back. – And so what can go wrong with it? – Well it can create a lot of problems. The most common is in elderly patients, usually 70, 80 years old,
occasionally in their 60s, where the valve really
becomes worn out, and becomes calcified, and it no longer
opens well or closes well. Most commonly it doesn’t open all the way, and it slowly starts to become
sort of like a rusty valve, and it opens maybe
halfway, and the patient may feel a little short of breath, but then over time, five, ten years, it’s opening minimally,
and maybe by the time it’s only opening 20%,
imagine a door opening 20% and everyone trying
to get out of the room, it gets very hard for the
blood to leave the heart, the heart gets enlarged, and the patient feels generally very short of breath. – Now is that aortic stenosis that you’re talking about?
– That’s called aortic stenosis. – Okay, and how many
people age, what is it, what’s the average, after age
85, of people getting this? 75, 85?
– Well it starts in the 70s, and 80s, by the time you get to the 80s, in this country almost 10% of
patients have this problem. So it’s really a prevalent problem, it’s a very common problem. – So in the past you’ve treated it with this open heart
surgery where you have to cut the chest open, but
what’s the percentage of people who really can’t handle that? – There is a lot of
patients that have trouble, particularly since it’s a
disease of elderly patients, we have a lot of patients that show up for the first time when they’re 95, obviously that’s gonna be a hard thing for a patient to go through,
but even for a young patient it’s no fun to have your chest opened up, and then the heart
opened, and then a valve sown into it, so what a surgeon
does is open up the heart, and actually take out
the valve, and then put a new valve in and put
about 20 sutures around it to hold it nice and tight, and then put everything back together, obviously that’s a pretty big procedure,
and has a long recovery time. With TAVR, it’s much
simpler, we put the valve in through an artery in the leg generally. If that leg artery’s not big enough we can find alternative ways to get it in but usually it’s an artery in the leg, and we just pass it up
into the functioning valve, or the deteriorating
valve, and we implant it usually either by blowing a balloon up, and the valve is attached to a frame, or by unsheathing a self expanding frame, the new valve goes right
inside the old valve and starts working right away, it pushes the old valve aside. – I was gonna say what
happens to the old valve. – Yeah, that’s a tough one
for people to understand, and it was a tough one for
us to understand initially, but the old valve just gets pushed aside, and the new valve starts
working right away. It’s important to put
it in the right place, but we’re very careful about that. – And how do you maneuver
it up through the leg and then put it right in the right place? – So we have X-rays, and the patient is lying on the table, and we can actually look at their heart through the X-rays, and see that the valve
is positioned perfectly, and we have it exactly where we want it, we either inflate a
balloon, or we unsheathe it depending on the valve that we’re using, and deploy it in the correct place. The old valve is just pushed aside, the new one starts working right away, and the whole thing happens very quickly. – How long does the procedure take? – Well the patient takes about
an hour to get on the table and draped and all set,
but then once we start, it’s really about a 45 minute procedure, and of course the
patient doesn’t have any, there’s no incision,
there’s no scalpel used, it’s just a little needle
hole in the artery of the leg, so the recovery is basically zero, the patient stays in the
hospital one night, they wake up right away, we don’t even
put them fully to sleep. Now we don’t usually
put a breathing tube in, they’re not intubated, so they awake pretty much right away,
and they have lunch. The next morning they
get up and walk around, we look at their heart again
with a sonogram, make sure everything’s okay, and
they’re usually out by noon. We even had one patient
go out the same day. So the recovery is very minimal, and that’s really the benefit of it. – And compare this to
traditional open heart surgery to replace that aortic valve. – Well traditional open heart surgery, the main problem is the recovery, because you have to open the chest, saw through the breast bone, so of course recovering from that takes a while, so you’re usually in the
hospital four or five days, and when you get home you’re
not driving for weeks, and you’re not really going
back to work right away, there’s a long recovery
process, of course, at the end of the recovery,
in a couple of months, patients who have open chest surgery do really well generally, so it’s just that recovery period that’s so hard, and TAVR avoids that, and
that’s its big benefit. – Because this is so much
less invasive for the body. – Yeah, much less invasive,
much less time in the hospital, usually one night, much
quicker time to recovery, and walking around, usually
you can walk right away, you can drive the next
day, I’ve met patients out to dinner the next night. – (laughs)
– 94 year old patient of mine got married a couple of months later. So they really resume their life, and one of the things that I’ve noticed is the patients feel about 10
years younger on the average. – You say it really turns the clock back. – Yeah, really is more than
almost anything else I’ve done in medicine in my career,
this is transformative to patients’ lives, they
are for the most part, not all of them, but I would say about 80% are so grateful, because
they can breathe again, and they really get their lives back and they’re the way they
were 10 years earlier. Doesn’t stop all their
medical problems obviously, but it is a big big event in their life. – You were talking about patients, I need to tell you that patients come from all over the world to
be treated by Dr. Tierstein, and we want you to hold this thought ’cause we’re gonna come back to this. In a couple of minutes
we’re gonna tell you about one of Dr. Tierstein’s
very special patients, can you guess who it is? We’ll give you a hint,
her initials are MT. MT, hold that thought, we’ll come back to it in just a little bit. How long does the TAVR
last, Dr. Tierstein, once you put a new one in, is that it for the rest of your life? – Currently we really only have data on a large number of patients out to about five or six years, so
at five or six years, we know it’s doing at least as well as the surgically implanted valve that requires opening the chest, so we assume 10 to 15 years later we’ll have to do it again,
but the really cool thing is that we can do that same thing again, and put a new valve inside
the old valve that we placed. So the procedure is exactly the same, and in some ways it’s even easier to put a second valve in,
so we can really avoid the need for major open heart surgery. – How many TAVR procedures have been performed at Scripps roughly? – We’re just at 2000 now, and it’s become a very common procedure,
we’re doing upwards of 400 a year, and it’s
really actually been a big deal for the hospital,
we’ve had to change a lot of the way we do
things and schedule things because it’s become now one
of our most common procedures. – And talk about the collaborative
specialized TAVR team, I think it underscores Scripps’ approach to this kind of comprehensive
specialized patient care. – You know we always get better outcomes if we work together as a team. Two heads, three heads, four heads are way better than one,
so the way we do these procedures is first when
we look at the patients and evaluate them to make
sure they’re good candidates, we work together, I’m a cardiologist, I work with at least one surgeon, it’s actually a whole team of surgeons, and a whole team of cardiologists, and then we have wonderful
nurse practitioners, nurses, catheterization
laboratory technicians, really phenomenal people, and
we bang our heads together to make sure we’re doing the
right thing for the patient. Then when it comes time
to do the procedure, we work as a team, the
surgeon, the cardiologist like myself, anesthesiologist, an imager and echo cardiographer is often involved, so this is, we call it the hard team, and it’s become a very
essential part to our success. – It’s very complex
and it’s very high tech and it’s a very well choreographed
dance that you all do. – Good way of putting it, is
a dance, and I think we all work really well together,
and it’s happening not just with the aortic
valve, now it’s extending to the mitral valve, to other valves, and other structural,
instead of opening the chest, we’re able to do with catheters a lot of what we had to do
before by opening the chest. – Is there anybody who can’t
have the TAVR procedure? – So I was thinking about that, very few. So for example, the valve
comes in certain sizes. And very rarely, a patient is too big, and needs to go to the big and tall shop for the valve, and they
haven’t built that one yet. That’s very very rarely, more commonly, and it’s still rare,
but a more common reason not to get the valve replaced with a TAVR might be that you have something
else wrong with your heart. Another valve that we can’t help you with with a catheter, and we need
to open up your chest for, or you have an aneurysm of the aorta, a swelling of the aorta
that ought to be replaced at the same time, and so that requires at this point still opening the chest. So there are some patients
we have to turn down, but it’s now becoming increasingly rare. – What about patients who
have bleeding problems or pre-existing kidney disease? – That’s a good question, so
pre-existing kidney disease is always a problem for
any kind of procedure. And we have to use some dye
contrast for these procedures, so that is hard on the kidneys, we’ve gotten very good at limiting the amount of dye we
use, and we’re actually really specialized at that, at Scripps, we could do these procedures
with a very minimal, in fact we’ve done a few with no dye, which puts very little
stress on the kidneys. Open heart surgery puts actually
more stress on the kidneys, that’s a big thing for the
kidneys to go through, so TAVR’s usually better for a patient
with impaired kidneys. Bleeding problems can be a problem for either procedure,
usually bleeding is worse for an open procedure,
obviously there’s a lot more bleeding involved,
need for blood transfusion, bleeding can be a problem for the TAVR, it’s something we watch really closely, and we make sure that we
minimize it as much as possible. – Are there any drawbacks
to the TAVR procedure? – So the risks of the procedure
I usually tell the patients there’s about a 5% chance that something will go badly, about a 1% chance of death, about a 2% chance of major stroke, and that of course is what
everyone is most concerned about. And it’s a really serious
thing when it happens. And about a 3% chance of bleeding. So all in all about 5% of the patients have complications, it’s not perfect, but 95% of the patients
do phenomenally well. – Alright so let’s come back to this, people from all over the world come to be treated by out, but you had one very special patient,
who is someone really that everybody knew, tell us what happened back in 1991 with a woman
who had the initials MT. – So Mother Teresa was
in Mexico, in Tijuana, at one of her missions, and she developed a pneumonia and a heart attack,
and was sent to Scripps, and we got to take care of
– She was secretly whisked in from Tijuana, to here.
– Yeah, yeah, one of my students actually, who went back to Tijuana, came to Tijuana to learn, Dr. Aubanel, saw her in
Tijuana and sent her up. That’s how we came to take care of her. – And this was not a TAVR procedure, what was wrong with her? – So she had a pneumonia,
and so she needed antibiotics and care for her lungs, and she also had a heart attack, so she needed an
angiogram, and we did that, – What’s an angiogram?
– That’s when we put a catheter into the
arteries that feed the heart and look at them and see
if there’s any blockages. And so she had cholesterol buildup in all three of her
vessels, and we treated them with what we had then,
which was a balloon, we just stretched them, but one of them, her most important artery
did not come out so well with the balloon, and so
fortunately at the time we were also investigating the stent, which is now the routine
way we treat this, and a stent is a little metal scaffold that you can insert, it’s
wrapped on a balloon, and then inflated into
the area of blockage, and it remains in there,
you deflate the balloon, remove the balloon, the stent stays put, and holds the artery open, so we did that with Mother Teresa’s artery
and it stabilized it fine, and really worked beautifully, so it was in some way related to the TAVR in that it was an
investigational procedure we were lucky to be doing at the time that Mother Teresa came,
and we had access to it, so we used it, just like we treat some of our TAVR patients
with investigational valves. – And it became a sacred stent? – Well she blessed it,
she was in the hospital for a month, and it was really wonderful taking care of her, and I got
to go to Calcutta afterwards, and visit with her, but
she was a really special part of my career, my life, and she did bless the stent, we called
it the sacred stent. – (laughs) And you hold up
just fine under pressure, you are unflappable, which
is exactly what you want when you want someone
operating on your heart, but when you heard that the pope was praying for you during the surgery. – Yeah I mean I knew she was very special, and a special VIP, but
what got my attention was when I went out to
talk to the sisters, and I told everything went well, we had a little problem, but we were able to stabilize it with this
new investigational stent, they told me that the pope had my name and was praying for me
during the procedure, which I thought was, that
really got my attention, yeah. – I would imagine, and she
lived another how many years? – Eight years.
– Eight years, and she was able to continue her humanitarian work. – I visited her in Calcutta and saw what she was doing, it
was pretty amazing, yeah. – It’s phenomenal, but it speaks volumes to what you do and what’s
being done here at Scripps. Let’s go back to the TAVR procedure. Up until recently, this was only available for high risk patients,
those were patients who were too ill to undergo
the open heart surgery. Now it’s being expanded to a much wider population, to low risk patients? – Yeah, so we’ve done
studies, and these are randomized studies,
really where a computer flips a coin, and half the patients get open chest surgery,
and half the patients get the TAVR procedure, and those studies have been completed now, the TAVR outdid the open chest procedure hands down, I mean it was less time in the hospital, much quicker recovery, less stroke, better outcomes, we have data out now to three years, and the
TAVR is doing better in the low risk patients
than the open procedure. I believe it will be the
usual way we treat patients with aortic stenosis in the future. – So when you look down
the road what do you see? – Down the road I see a lot of new incredible medical advances,
we are all really lucky to be living in this era where there are technological improvements,
they are really helping patients, not just with TAVR, but with everything to do with
your heart, and then some. Certainly with respect to the heart, we’re replacing a lot of the
major open chest procedures with procedures we could do
through a little catheter in the leg artery or leg vein. – Which is so great for the patient, because it’s less invasive,
it’s faster healing time, you’re up and moving, back to moving at the speed of your life. – Yeah we’re really lucky,
I think the patients are lucky, and we’re all lucky, ’cause we’ll all be
patients, we’re all living longer partly because of this technology, and these are our tools that will be really helpful to so many patients. – Any final thoughts Dr. Tierstein? – I think we should be
happy to be alive today with so much opportunity for health, both preventative and also secondary treatment when we have problems. And we should be really
happy for the technology, it is really important for our lives. – Thanks so much Dr. Tierstein. Thousands of Scripps
patients have successfully been treated with the
TAVR procedure as we said, and Scripps has repeatedly ranked by US News and World Report as one of the best in the nation for heart care. If you want more information
on the TAVR procedure, just click on the link or
go to Scripps.org/videos. Want more critical
information about your health? We take care of you from head to toe, please subscribe to our
Scripps Health YouTube channel, and follow us on social
media at ScrippsHealth. I’m Susan Taylor, thanks
so much for joining us. It’s our mission at
Scripps to help you heal, enhance, even save your life.

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