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Aorta Valve Replacements (AVR), Transcatheter Aorta Valve Replacements TAVR

and Percutaneous Aortic Valve Replacements


Earl Lofland, Medical Terminology
Delaware Technical Community College (RAD Program)
Human Aortic Valve Replacements dates back to 1960. Over the next several decades,
medical advancements were made. calcific aortic stenosis, (CAS), is an age related
disease to the myocardium, where calcium build up occurs on the leaflets.
A congenital defect known as bicuspid aortic valve, (patients are born with only two
leaflets instead of three leaflets), may require a valve replacement. Dextrodcardia1,
(where a person is born with the heart on the right side of the chest), may have other
disorders, requiring the aortic valves to be replaced. Some of these disorders include:

Atrial Septal Defect 2 (ASD) Typically known as a hole in the atrial portion of
the heart

Ventricular Septal Defect 3 (VSD ) Typically known as a hole in the ventricular


region of the heart

Transposition of the great vessels 4 an abnormal spatial arrangement of any


of the great vessels

U.S. National Library of Medicine Dextrocardia


https://www.nlm.nih.gov
Dextrocardia: A condition in which the heart is pointed toward the right side of the chest. Normally, the heart points to the left.
The condition is present at birth (congenital).
2

U.S. National Library of Medicine Atrial Septal Defect


As a baby develops in the womb, a wall (called the interatrial septum) forms that divides the upper chamber into a left and right
atrium. An abnormal formation of this wall can result in a hole that remains after birth. This is called an atrial septal defect, or
ASD
U.S National Library of Medicine Ventricular septal defect a hole in the wall that separates the right and left ventricles of
the heart. Ventricular septal defect is one of the most common congenital (present from birth) heart defects. It may occur by itself
or with other congenital diseases.
3

Pulmonary Artesia, a deformed pulmonary valve

Patients with both congenital defects, or myocardial diseases, may be a candidate for
one of three procedures

Open

Laparoscopic

Robotic Aortic Valve Replacement surgery.

Usually, an electrocardiogram is prescribed by the cardiologist, to determine the


amount of stenosis. Other x-ray techniques may be used including: Magnetic
Resonance Imaging, Sonographic Imaging, Computed Tomography, or
Fluoroscopic Imaging.

In the late 1970s; aortic porcine (pig) heart valve replacement 5, aortic bovine
heart valve replacement, as well as donated human valve replacements where
performed. These are biological tissue valve replacements id.. Open AVR procedures
are highly invasive, having several long term and short term risks. Open AVRs involve
a patient undergoing a median sternotomy. (midsagittal incision is made) , and
osteoclasis, exposing the pericardium, giving the surgeon access to the heart to
replace the defective valve. It also requires arresting the heart during the operation.

U.S National Library of Medicine Transposition of the great vessels is a heart defect that occurs from birth (congenital). The
two major vessels that carry blood away from the heart -- the aorta and the pulmonary artery -- are switched (transposed).
5
Saint Jude Medical Heart Valve Replacement Tissue valves are made with tissues from porcine (pig) heart
valves or bovine (cow) cardiac tissue because they function like human heart valves. Once the tissue is removed
from the animal, it is chemically treated to preserve the tissue and prevent immulogic reactions once it is placed in a
patient. https://health.sjm.com/heart-valve-answers/treatment-options/heart-valve-replacement

University of South California School of Medicine Cardiothroacic Surgery


http://www.cts.usc.edu/hpg-heartvalvesurgery.html
id.

Biological (tissue) valves are taken from pig, cow, or human donors.

The patient is attached to a Transesophageal electrocardiograph6 (TEE), giving the


cardiologist a clear image of the upper chambers of the heart and the valves. During an
open AVR a patient is also be connected to a Cardiopulmonary bypass (CPB), (a
heart and lung machine).
Less invasive valve replacement procedures are:

Transcatheter Aortic Valve Replacement, (TAVR)

Percutaneous Aortic Valve Replacement (PAVR)

Totally Endoscopic Aortic Valve Replacements (TEAVR) (the most recent


procedure).

Most TAVR procedures are performed in a hybrid operating room7 with a fixed
fluoroscopic imaging system8. A fluoroscope is used to determine a diagnosis from
live display of patient anatomy id,

Annuls of Cardiothroacic Surgery Vol 2, No 1 (January 2013) The role of echocardiography in aortic valve repair

Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement

Susheel K. Kodali, M.D., Mathew R. Williams, M.D., Craig R. Smith, M.D., Lars G. Svensson, M.D., Ph.D., John G. Webb, M.D., Raj R.
Makkar, M.D., Gregory P. Fontana, M.D., Todd M. Dewey, M.D., Vinod H. Thourani, M.D., Augusto D. Pichard, M.D., Michael Fischbein,
M.D., Ph.D., Wilson Y. Szeto, M.D., Scott Lim, M.D., Kevin L. Greason, M.D., Paul S. Teirstein, M.D., S. Chris Malaisrie, M.D., Pamela S.
Douglas, M.D., Rebecca T. Hahn, M.D., Brian Whisenant, M.D., Alan Zajarias, M.D., Duolao Wang, Ph.D., Jodi J. Akin, M.S., William N.
Anderson, Ph.D., and Martin B. Leon, M.D. for the PARTNER Trial Investigators
N Engl J Med 2012; 366:1686-1695May 3, 2012 DOI: 10.1056/NEJMoa1200384
8

Radiologic Society of North America Beth A. Schueler, PhD


From the Department of Diagnostic Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Received January 18, 2000; revision
requested March 28 and received April 11; accepted April 14
id, IMAGING & THERAPEUTIC TECHNOLOGY

The AAPM/RSNA Physics Tutorial for Residents General Overview of Fluoroscopic Imaging

The Procedure
Echocardiograms are used to determine the amount of aortostenosis. Once a patient
is confirmed having a valvular heart disease, such as calcfic aortic stenosis, the
surgeon will determine if he/ she is a candidate for TAVR, or will require an open AVR.
A TAVR does not require a general anesthesia, while the preoperative procedures are
the same, determining whether the patient is a candidate for TAVR. The patient is taken
to the operating room, where an anesthesiologist places the patient under
conscientious sedation using one of a variety of medications on the patient.
Fluoroscopy is used to perform any catheter, wire, sheath, or dilator insertion or
removal. The femoral artery is also measured using the fluoroscope prior to the surgery,
to determine the sheath size used in a TAVR. After Heparin is administered, the
replacement is delivered through an incision into inter costal region, entering the apex of
the heart via the thoracic cavity. The valve may also be delivered via an incision made
to the femoral artery, where the implant sheath is inserted in the artery, and advanced
up the artery into the aorta. The sheath transports a balloon to be expanded inside the
aorta, allowing a shunt, housing the new valve and assists in properly seating the valve.
Once the balloon is inflated, the shunt is placed in the aorta and expanded. A pressure
test is performed on the new valve, insuring no reflux occurs with the new valve. A
contrast is administered to test for proper blood flow, and or that no damage or defects
that may require a revision. Once the valve is in place, the wire and sheath are
extracted, and the incisions sutured.

Risks / Complications

According to a 2013 study from Department of Cardiovascular and Thoracic Surgery,


Albert Einstein College of Medicine, patients undergoing TAVR may experience

Acute kidney injury (AKI)

Myocardial infarction (heart attack)

Stroke, bleeding

Vascular complications, and poor valve performance

The risk of mortality