SPRINGFIELD, Ore. — A high-tech heart valve replacement surgery that requires less anesthetic, a smaller incision and faster operation and recovery time has been performed on more than 425 heart patients at PeaceHealth Sacred Heart Medical Center at RiverBend in the past five years.
Now, this transcatheter aortic valve replacement procedure — TAVR for short — is available to an expanded group of heart patients: the younger, stronger ones.
“Initially the only people we could put these valves into were the ones at high-risk for open-heart surgery,” said cardiologist Dennis Gory, one of the surgeons who perform TAVR procedures at RiverBend’s Oregon Heart & Vascular Institute.
TAVR long has been considered the aortic heart valve replacement surgery of last resort for people like Herbert Ball, 89, of Cottage Grove.
A professor emeritus of mechanical and nuclear engineering at Kansas State University in Manhattan, Kansas, Ball likes to take walks. But recently he noticed that he was becoming increasingly breathless and exhausted.
A trip to his cardiologist, Dr. David Duke at RiverBend, diagnosed Ball’s problem as aortic stenosis, a narrowing of the aortic valve opening. That narrowing, caused by an accumulation of calcium, weakens the aorta’s ability to close tightly and pump efficiently.
The aortic valve closes off the lower left chamber of the heart after the heart pumps. That closure prevents oxygen-rich blood from moving back into the heart, and instead ensures that the blood flows through arteries into the body. A defective aortic valve inhibits that crucial flow.
Without replacement, an aortic valve failure eventually leads to heart failure and death. Cardiac disease continues to be the top cause of death in the world for both men and women.
The professional group that sets clinical practice guidelines, the Society of Thoracic Surgeons, traditionally has considered open-heart surgery the appropriate treatment for aortic valve replacement with a mechanical valve. But in the summer of 2016, the group climbed aboard the TAVR train, noting in its newsletter: “TAVR was approved in 2011 for use in patients who are at high risk for conventional surgical aortic valve replacement (SAVR). Recently, trials in intermediate-risk patients have shown that TAVR is equivalent and possibly superior to SAVR. These findings have now opened the door to trials in low-risk patients, who make up about 80 percent of patients with aortic stenosis, according to an analysis of data in the STS Adult Cardiac Surgery Database.”
Now the Society of Thoracic Surgeons is predicting an 80 percent shift from open-heart procedures to transcatheter procedures in the next decade.
The shift already is happening — rapidly — in Oregon. Although RiverBend is the only Eugene-area hospital to offer TAVR, three hospitals in Portland and one in Medford also offer the procedure. Soon they will have competition from hospitals in Salem and Corvallis.
A quick comparison of open-heart surgery with TAVR shows why the rapid change:
Open-heart surgery is done under general anesthesia and involves a six-inch midline chest incision, followed by a three- to four-hour open-heart operation. The patient is on life support while the new artificial valve is put into place. Risks include restarting the heart, and after the surgery the patient must be monitored in the intensive care unit and endure a lengthy recovery.
Although Gory has performed many open heart surgeries in his 35 years as a cardiologist, he said he’s never been more gratified by a surgical result than he is with the TAVR procedure he performs three or four times a week at RiverBend.
His sentiments are echoed by fellow cardiologist Sudeshna Banerjee, who said she’s excited at the prospect of seeing more younger heart patients take advantage of the procedure.
“These patients aren’t guinea pigs,” she said, alluding to the surgery’s proven benefits. “It can be right for younger people who have arterial blockages.”
In the hope of spreading the news about the suitability of the surgery to younger heart patients, RiverBend recently invited members of the media to witness a TAVR procedure.
Retired professor Ball gave his written approval to be a living lesson on the procedure, which was photographed and filmed the morning of Dec. 14.
BEFORE THE SURGERY
“I am looking forward to it,” he said in an interview a few days before the operation.
A large cast of professionals, each with a highly specialized role, surrounded Ball, who was lightly sedated but still conscious.
They were: an anesthesiologist; anesthesia technician; interventional cardiologist; a cardiothoracic or cardiovascular surgeon; one cardiovascular perfusionist to run the bypass machine if needed; a physician assistant; circulating nurse; scrub nurse; another operating room nurse; three or four cardiovascular technologists; an echo technologist who before, during and after the procedure obtains transthoracic and transesophageal echoes to measure effectiveness; one representative from the valve maker (RiverBend uses both FDA-approved kinds of valve); a valve coordinator nurse who is the keeper of the data, collecting it and assisting with diagnostic questions; and a cardiovascular operating room nurse manager, who circulates around like a stage manager, checking on everything.
Becky Hammerschmith, the program manager of the Valve Center at RiverBend, was the one keeping an eye on the details for Ball the day of his TAVR — as she had since his surgery was scheduled.
The night before, she made sure that he received treatment for an upset stomach and was ready for surgery. She answered his questions and attended to any details.
Finally, everyone was in the operating room or an adjoining viewing area, watching what looked like a well-choreographed stage production.
For Ball’s surgery, a team from the manufacturers of the balloon-expandable Sapien XT aortic valve was on hand. The device is made of bovine — cow or bull — pericaridial tissue that forms a kind of peace symbol shape — the same configuration as the human aortic valve. This bovine vein is custom-fitted onto a glittering cobalt chromium frame that looks like a tiny crown. It’s royally priced as well, costing about $25,000.
This device is crimped impossibly small and threaded onto a catheter for insertion.
Gory cut a small incision in the femoral artery in Ball’s right leg and began threading the catheter toward his heart. But the calcium deposits were so thick, he quickly made an incision in the left femoral artery and began again.
Ball began to say something.
“Not just right now, Mr. Ball,” Hammerschmith said, in a kind but authoritative tone. Ball relaxed. The catheter was making steady progress, visible on the array of computer monitors in the room. It was carrying the tightly furled valve toward its new home. It stopped at Ball’s leaking, calcium-thickened aortic valve. Then, as the dramatic execution of a well-rehearsed act, the new valve was expanded, fusing with the old one. For an instant, the monitors showed Ball’s heart pause, almost as if humming, and then the new valve began to steadily and strongly to take over the job of pumping his blood.
Even the calcium had a role, helping to hold the new valve firmly in place.
The surgery had taken less than an hour.
A RETURN TO WALKING
The day after his surgery, Hammerschmith had Ball walking. He went home on the third day, accompanied by his daughter, Alesia Ball, and was chatting amiably on the fourth day about his experience. Because Gory had to thread the catheter through Ball’s left artery, “I have two groin areas that are tender now,” Ball said, more in observation than complaint. “Too bad I can’t go on display,” referring to bruises on his legs that were turning bright and festive colors.
But less than a week after the TAVR, he could detect other differences.
“My body feels much better now,” he said, much warmer.
He was looking forward to rehab. He said the extra blood circulating through his body made his extremities tingle sometimes, but his energy level was good, except for the cold he’d caught.
More than anything, Ball said, he wanted to return to his walks around the fountain in Bohemia Park in downtown Cottage Grove.
“I want to get outside.” But for now, he and his daughter will have another Christmas together.
NEW SURGERY, SAME PRICE
If there is one way that TAVR still isn’t much different than standard open-heart surgery, it’s costs.
TAVR or standard aortic heart valve replacement surgery ranges from $70,000 to $200,000, depending on its complexity.
For the elderly, Medicare covers most of the expense. Much of the TVAR cost for the surgery, Gory said, is because it still is accepted protocol to have an open-heart team standing by during TAVR procedures.
Gory said that might soon change. He said the open-heart team at RiverBend never has had to spring into action in five years.
But given that most of the TAVR patients to date already have overlapping health issues and advanced years, the mortality rate is about 20 percent. There is a risk of strokes.
However, Gory predicts that as more TAVR programs are established, costs will decline.
TAVR, he said, is a good example of how less is proving to be more.
Information from: The Register-Guard, http://www.registerguard.com