There used to be one option for patients needing a heart valve replacement for aortic stenosis: open heart surgery. With recent advancements in medicine, a new, less invasive procedure has gained popularity and provides the added benefit of a faster recovery time. Transcatheter aortic valve replacement (TAVR) is performed by inserting necessary instruments through a small incision in the leg.
While there has long been a need for more clinics performing TAVR in Alaska - with, according to Dr. Jonathan McDonagh, roughly five percent of people requiring valve replacement as they age - there has not been infrastructure available to meet the demand. Often patients would be placed on long wait lists or would have to fly to Seattle for care.
A new valve clinic was scheduled to open at Alaska Regional in March, but was postponed due to COVID-19. The opening was rescheduled, and the first two successful TAVR cases were completed on June 24. Alaskans now have more options for aortic valve replacement, with a multidisciplinary team of doctors dedicated to determining what the best option is for each individual patient.
What’s the fuss?
In everyone’s heart, there are four valves, all important for pumping blood throughout one’s body. The aortic valve consists of three leaflets, which create an opening in the shape of a Mercedes Benz emblem. Over time, calcium builds up on the valve, restricting its function. Like old leather, it gets stiffer as it wears out, limiting the heart’s ability to pump blood to the body.
“It’s a gradual process,” said Kelly Isaacs, the Valve Clinic Coordinator and a registered nurse at Alaska Regional Hospital. “It starts slow and can progress to a critical stage.”
The symptoms most of her patients complain about, the ones that brought them in, are fatigue, shortness of breath, decreased exercise tolerance and, as it worsens, chest pains and fainting. Often what prompts further testing is being told they have a heart murmur by their primary doctor.
“You sort of slow down without realizing it’s happening,” Isaacs explained.
Traditionally, valve replacement would see patients opened up and put on a heart-lung machine. During the surgery, the failing valve is removed and replaced with a new one. TAVR, on the other hand, is done by mounting a replacement valve on a catheter and snaking it up through an artery in the patient’s leg. It’s compressed, but once placed, it expands to the size of the valve. Simply put, it pushes the old valve out of the way, making a perfectly open, new channel for blood flow.
Surgical aortic valve replacement necessitates patients be at the hospital for several days to a week post-surgery for observation. Because of the less invasive nature of TAVR, patients often are able to go home the next day.
“After the procedures, I’ve seen people brighten up almost literally,” Isaacs said. “They say, ‘I didn’t realize I felt that way until I felt better.’ They literally pink up.”
Assembling a squad
As part of a collective of medical professionals that assists each potential TAVR patient, Isaacs is often a patient’s first point of contact. That, she says, is what is the most notable about the TAVR program at Alaska Regional and her favorite part — the team approach and shared decision making.
“It allows us to come together to select the best procedure for each individual patient,” Isaacs said.
Beyond the patient and their support group, the team dedicated to finding the best solution includes: Isaacs, a cardiologist or primary care provider, who spots the condition and makes the referral; the interventional cardiologist and the cardiothoracic surgeon, who each evaluate the patient; a Cardiac Anesthetist, who discusses patient procedural sedation needs; the General Radiologist, who does the CT scan; and finally the Cardiovascular Imaging Specialists, who access for any technical constraints or concerns related to the procedure.
Following the work up, the team gathers to review the data collected. Together, they’ll pour over images and reports to determine what would best serve the patient: a surgical replacement, TAVR, or neither?
“Once we’ve reviewed the case and come to a consensus, we present that to the patient so that they can make their informed treatment decision,” Isaacs said. “You’d think because TAVR is new that it would always be the answer, but it’s really a team conversation and it really depends on the patient.”
However, McDonagh, one of the interventional cardiologists, said patients that are right for TAVR often feel better almost immediately.
“You can expect immediate improvement in symptoms and convincing data saying reduced risk of dying,” McDonagh said.
Though the procedure is new to Alaska Regional, it’s not new to the doctors performing it. The same doctors who have completed more than 450 TAVR procedures in the last four years at other hospitals are implementing the procedures done at Alaska Regional.
“The bottleneck wasn’t the available doctors,” McDonagh said. “It’s the space to perform the procedures. It takes a lot of time and staff and all those resources are competing for other procedures, as well. Having it at Alaska Regional opens up a lot of possibilities.”
This story was produced by the creative services department of the Anchorage Daily News in collaboration with the Sponsor. The ADN newsroom was not involved in its production.