Patient Story: TAVR Procedure

Mary Balzarian
Photo courtesy of Telegram & Gazette

This article ran in the Telegram & Gazette on November 18, 2015

By Geraldine A. Collier

Meet 91-year-old Mary Belazarian.

Mary’s back to her old self now, having undergone a minimally invasive procedure that is helping her and others in their 90s – as well as those youngsters in their 70s and 80s – to add more candles to their birthday cakes.

Mary wasn’t running marathons, but when she was healthy she got out of the house fairly often: grocery shopping with her, daughter Linda Kaufman; showing up every Saturday for her beauty shop appointment at PJ’s Hair Tech; going out to eat with friends or family members, and attending the Armenian Church of Our Saviour.

She also liked visiting her family, which besides her two children, includes four grandchildren and five great grandchildren. And sadly, she made frequent trips to the cemetery to family graves, including that of her sister Rose Der Sahakian, who died at the age of 105 in July, two weeks before Mary had her surgery.

However, last year, Mary gradually started to feel too tired to do any of those things. “I didn’t even have the strength to get out of the car,” said the Worcester woman.Unfortunately, for Mary, her aortic valve – one of four valves in her heart – had worn out, causing her to not only feel weak and fatigued, but making it likely that she wouldn’t be making it to her 92nd birthday.

Made out of little flaps of tissue called leaflets, the aortic valve has to open and close with each beat of the heart in order to keep the blood flowing in one direction, from the heart to the aorta, which then feeds it to the organs, according to Dr. Nikolaos Kakouros, director of structural heart disease at UMass Memorial Medical Center.

(At an average of 70 beats per minute, Mary’s aortic valve has opened and closed some 3.3 billion times over her 91 years, estimated Dr. Kakouros.)

If the valve doesn’t open properly, then the heart has to expend extra effort to squeeze the blood out of the narrowed valve and into the aorta. If the valve doesn’t close properly, then blood backs up or regurgitates into the heart, according to Dr. Kakouros. Either way, the heart has to work much harder than normal, and eventually becomes damaged.

It’s a condition that’s called severe aortic stenosis, or less politely, senile degenerative stenosis. Some estimate that there’s as many as 500,000 Americans whose aortic valve is degenerating. Without treatment, half of those seniors will die of heart failure within a year or two after symptoms develop, depending upon the severity of the symptoms.

Because this is a mechanical problem – not one that can be fixed by medication – open heart surgery has been the only way to replace a deteriorating valve.

“You hook the patient up to a heart-lung machine, stop the heart from beating, open up the chest, cut out the aortic valve and sew in a new one,” said Dr. Divaker Mandapati, director of aortic surgery at UMass Memorial Medical Center.

“It’s a big operation and you have to be pretty healthy to recover well from it. If you are old and frail, you may never leave the hospital or you may go into a rehab place and spend the rest of your life there.

“But, if you can change the valve without doing open heart surgery, the elderly patient can live a quite good quality of life,” said Dr. Mandapati.

That option wasn’t possible in the U.S. until a minimally invasive procedure called Transcatheter Aortic Valve Replacement (TVAR) was approved by the federal Food and Drug Administration in late 2011 and approved for reimbursement by the Centers for Medicare and Medicaid Services in 2012.

Nationwide, 16,000 TAVR procedures were performed last year, and hospitals are expected to perform at least 20,000 procedures in 2015, according to Cassie McNulty, media relations manager for The Society of Thoracic Surgeons, one of two major medical groups that keep a national TVAR registry.

At UMass Memorial, a team led by Dr. Mandapati and Dr. Kakouros, started in the summer of 2014 offering the TVAR procedure, and, as of the end of October, 55 patients have undergone this surgical procedure there.

At St. Vincent Hospital, a TVAR team by led by Dr. Joseph Hannan, director of interventional cardiology, and Dr. Robert Bojar, chief of cardiothoracic surgery, have performed the minimally invasive procedure on 42 patients, as of October.

There are actually four different TVAR procedures, ranging from the least to the most invasive.

The least invasive option involves the use of the femoral arteries – the arteries near the top of your legs, near your groin. A catheter (a small tube) containing a compressed artificial valve is inserted through the femoral artery and moved carefully up into the aorta, the body’s main artery. The tube is then threaded upward until it reaches the degenerative valve where the new valve is carefully expanded, pushing aside the old one.

That procedure, however, depends upon the femoral arteries being large enough to accommodate the catheter. If they are not, the second route to the aortic valve is by way of the axillary artery, the main arteries going into the arm instead of the leg.

Unfortunately for Mary, both her femoral and axillary arteries were too small to accommodate the catheter. However, thankfully for Mary, there’s a third version of the procedure that she could undergo, albeit one more invasive than the first two.

Known as the transaortic option, it involves making a small incision in either the middle or the right side of the chest. That allows entryway to the aorta, about 2.5 inches or so above the aortic valve. That’s the procedure Mary had in July, a procedure without which Mary “would probably have passed away by now,” according to her daughter, Linda. “It saved her life.”

As a last resort, Mary could have undergone a fourth procedure, one that is the most invasive, known as the transapical option. In that procedure, a cut is made in the left side of the chest and the tip of the heart is exposed. The TVAR device is then introduced straight into the heart while the heart is still beating. Not a walk in the park.

According to Dr. Kakouros, there is a new generation of catheters coming on the market that are smaller than the ones originally used in doing the TAVR procedures.

“Consequently, the least invasive, transfemoral route, can now be used in the vast majority of patients,” said Dr Kakouros, benefiting patients who, not only have age working against them, but who also can have chronic lung disease, obstructive pulmonary disease, chronic kidney failure or other health issues.“These are very, very frail people,” said Dr. Mandapati. “”It’s very important to evaluate the arteries, the heart, the valves and which route you are going to take, but it’s equally important to evaluate all the other medical conditions that can pop up in someone who is 90 years old."

“The key to success is careful evaluation of the patient as a whole, every little thing.” 

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for nine years in a row.

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