TAVI gives new hope to older cardiac patients

Posted on 1 Mar 2022

Transcatheter aortic valve implantation (TAVI), a key development in alternative cardiac care for ageing patients, is now available at Mediclinic Pietermaritzburg.

For just over a year, doctors at Mediclinic Pietermaritzburg have been performing TAVI, a non-invasive heart valve implantation procedure, for older people with severe aortic valve stenosis.

One such patient is KZN grandmother Jireh Dovey (80), who fell and broke her wrist recently. This was the result of just one of many mini blackouts she’d been experiencing over the past few years, she says. “I was wondering why I was falling about so often. I kept tripping over fresh air and was acting a bit ‘drunk and disorderly’,” she recalls.

Despite having had two knee replacements in her youth, the irrepressible former schoolteacher has always maintained high energy levels. “I discovered yoga in my 30s – and later Pilates – and have always been very flexible and active,” she says. “I swim lengths, do aqua aerobics, walk regularly and am very active in amateur theatre too.”

For someone who survived breast cancer almost 50 years ago – requiring a double mastectomy and chemotherapy – Jireh has always been grateful for her good health. “When my cardiologist Dr Sanjay Maharaj explained I was falling because there was something wrong with a valve in my heart, I almost had a heart attack!” she quips. “I was told I had aortic stenosis and my heart wasn’t sending enough oxygen to my brain.”

Degenerative calcific aortic stenosis is one of the most common heart disease processes in the ageing population, says Dr James Chen, a cardiothoracic surgeon at JJ&J Specialist Cardiothoracic Surgeons at Mediclinic Pietermaritzburg. It happens when the aortic valve separates the left ventricle (the heart’s main pumping chamber) from the main artery that supplies oxygen-rich blood to the aorta (body). “Due to ageing, our bodies start to deposit calcium in the aortic valve for various reasons, which makes the valve morphology (structure) change,” explains Dr Chen. “If all three leaflets of the aortic valve are opening and closing at same time, it doesn’t require too much work to pump blood through the valve to the rest of body.” However, when the leaflets fuse together to create a narrow orifice, it reduces or blocks blood flow from your heart into the main artery to your aorta as well as your coronary arteries and to the rest of your body.

“It’s a vicious cycle,” Dr Chen adds. “If the aortic valve is narrow, your heart has to pump much harder to generate pressure to provide adequate perfusion (delivery of blood) to the rest of the body, which means your heart then needs more blood, but the underlying critical aortic stenosis may render it insufficient.”

Patients suffering from aortic stenosis usually present with easy fatigue, shortness of breath and atypical chest pains. “Dr Maharaj, who is the cardiologist from the heart team, will perform various examinations and investigations. including an echocardiogram (cardio ultrasound), electrocardiogram (ECG), stress ECG, CT aortogram and coronary angiogram to establish a diagnosis and further work-up and treatment,” says Dr Chen. The cardiac team will then discuss valve replacement options with the patient once the diagnosis has been made.

TAVIs are now being performed at Mediclinic Pietermaritzburg for patients like Jireh – she has a tightly narrowed calcified aortic valve due to degenerative process and isn’t a good candidate for more traditional open heart surgery valve replacements due to a number of comorbidities and her age.

Dr Chen explains that TAVI is less invasive than traditional open heart surgery, which demands an open incision through the sternum into the chest cavity. “With surgical valve replacement, the patient is under general anaesthetic,” he explains. “We have to use a cardiopulmonary bypass (artificial heart and lung support) to provide systemic support, paralyse the heart with cardioplegic solution, make an aortotomy (incision into the aorta), cut out the calcified valve, put in sutures and implant a new valve.”

With the TAVI procedure, a small puncture is made in the femoral artery near the groin, allowing the surgeon to reach the valve with the aid of guide wires and a deployment catheter. It’s performed under sedation in a cardiac catheterisation laboratory.  As Dr Maharaj adds, this has significant benefits for the patient. Bleeding risk, length of hospital stay, and mortality and morbidity are all reduced. “The data is clear,” says Dr Maharaj. “The less invasive TAVI procedure is at the same level as surgical outcomes, even in patients with mild disease.”

Since February 2021, the Mediclinic Pietermaritzburg team has performed TAVI on 10 patients, including Jireh, who’ve all have done well and reported feeling 100% better after the procedure. “Structural heart intervention is the way of the future,” says Dr Maharaj. The full cardiac team at Mediclinic Pietermaritzburg comprises three surgeons, two cardiologists, a perfusionist, a cardiac anaesthetist, radiologists, technologists, a standby vascular surgeon, and access to an ICU team. “Each patient is thoroughly scrutinised to ensure they’re suitable candidates for the procedure,” says Dr Maharaj. “We’re one of only three units in KZN performing the TAVI procedure; we aim to create a centre of excellence and use cutting-edge technology for better patient outcomes.”

He adds that this procedure offers new hope for elderly patients. “It’s a different world for them post-TAVI. “After just a day or two in hospital they can become active members for their community again. With this procedure, there is no reason to have a bad quality of life.”

 



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