Latest / Healthy Vitals / TAVR vs. Surgery: Understanding Your Heart Valve Options

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TAVR vs. Surgery: Understanding Your Heart Valve Options · Healthy Vitals

• 0:04
  Scott Webb (Host): This is Healthy Vitals, a podcast from Summa Health.
• 0:06
  I'm Scott Webb.
• 0:07
  Scott Webb: Many people have heard of TAVR, transcatheter aortic valve
• 0:10
  replacement, and may think it's the only option for valve replacement.
• 0:14
  But my guest today says that while TAVR is a good option for some patients,
• 0:17
  it's not always the best option.
• 0:19
  I'm joined today by Dr.
• 0:20
  James Brockett.
• 0:21
  He's a cardiothoracic surgeon with Summa Health.
• 0:24
  Doctor, it's great to have you here today.
• 0:25
  We're gonna talk, TAVR versus surgery and, uh, uh, rely on you to help us
• 0:30
  to understand our heart valve options.
• 0:32
  So from your perspective, a cardiothoracic surgeon's perspective, when a patient
• 0:36
  needs an aortic valve replacement, what are the main valve and procedure options
• 0:40
  that are available today, and why is it really just not a one-size-fits-all?
• 0:45
  Dr. James Brockett:
• 0:45
  Generally there's two ways to replace an aortic valve.
• 0:48
  First is surgical, , aortic valve replacement, and that's what most
• 0:52
  people think of as like an open heart surgery, uh, where we go
• 0:55
  in, we, remove the diseased valve entirely and we sew in a new one.
• 1:00
  and the second one is TAVR, which is, a more recent development,
• 1:03
  in approach as to fix valve.
• 1:04
  It's a transcatheter approach, where we deliver a new valve
• 1:08
  through a catheter and, and it's usually from an artery in the leg.
• 1:11
  And we expand it inside the old valve without removing,
• 1:14
  , the old valve leaflets.
• 1:16
  so are the two main, ways of, of fixing the valve.
• 1:20
  and then within each of those there are choices about the valve, types
• 1:23
  surgically we can, implant either a mechanical valve or a surgical valve.
• 1:27
  And the mechanical valve, is a good option for, especially for younger
• 1:31
  patients because, they last longer but they require lifelong anticoagulation.
• 1:34
  Um,
• 1:35
  Scott Webb: Okay
• 1:36
  Dr. James Brockett:
• 1:36
  the surgical valves that we implant, that are bioprosthetic or, or tissue
• 1:40
  valves, they don't need anticoagulation but they also don't last forever.
• 1:44
  Each valve is a little different but we say, you know, 10 to 15 years or
• 1:47
  so on the, on the valve life for
• 1:49
  Scott Webb: Yeah
• 1:50
  Dr. James Brockett:
• 1:50
  And there's a couple different types of TAVR valves.
• 1:52
  , Some are, expandable where we have a balloon inside of the valve and we
• 1:55
  expand them, by inflating the balloon.
• 1:58
  And others we, , let sit there and then they kind of self-expand.
• 2:01
  They have a, native shape that they take, once they're
• 2:04
  Scott Webb: Yeah.
• 2:05
  Yeah, as you're saying that there's different, valve designs, right?
• 2:08
  And we're making clear, you know, it's not a one-size-fits-all.
• 2:12
  So then, you know, I'm sure patients have heard about TAVR but may not realize that,
• 2:16
  you know, there are different designs.
• 2:18
  It's not a one-size-fits-all.
• 2:19
  So how do you explain the difference between transcatheter valve options and
• 2:23
  surgically implanted valves, you know, in a way that patients could understand
• 2:27
  or a podcast host can understand?
• 2:30
  Dr. James Brockett:
• 2:30
  surgical valve is kind of like, remodeling a room kind of down to the studs.
• 2:34
  I mean, you replace everything, you take out everything on the inside.
• 2:37
  You leave kind of the, two foundations.
• 2:39
  So the aorta is, where the, valve sits, and we remove the leaflets, when we
• 2:44
  remove it surgically, and then we, , use sutures to implant the new valve.
• 2:48
  But, for a TAVR valve, could say it's kind of like installing a, pipeline inside
• 2:53
  of an old pipe where you, you leave the old, you know, material there, and then
• 2:56
  you just install something new on the
• 2:58
  Scott Webb: Sure
• 2:59
  Dr. James Brockett:
• 2:59
  you know, each design kind of has its own personality and how it anchors, how it,,
• 3:03
  sits relative to the arteries that come off of the aorta, the coronary arteries.
• 3:08
  Of these options are very, are a very personalized, decision when
• 3:12
  we meet with patients and, and to figure out which one is best.
• 3:15
  Scott Webb: Sure.
• 3:15
  Between you, patients, families, you mentioned age as a factor and
• 3:20
  how long they're gonna probably need these to last and how much upkeep, if
• 3:23
  you will, they want over the years.
• 3:25
  I think, doctor, the, a common myth with TAVR is that it's always better
• 3:29
  or safer, because it's less invasive.
• 3:32
  So from your perspective, how do you help patients understand the
• 3:35
  trade-offs between TAVR and surgery?
• 3:37
  Dr. James Brockett:
• 3:37
  is one of the most common, conversations that we have.
• 3:40
  you know, here at Summa we have, a heart team discussion.
• 3:42
  So we always sit down with patients, and the patients will come in and they'll
• 3:46
  talk with an interventional cardiologist who, you know, does the wires and
• 3:49
  catheter techniques, the TAVRs, and, they also talk to us at the same time.
• 3:53
  So they get two different perspectives,, regarding their valve implantation.
• 3:57
  most people come into our office thinking that, you know, they want a TAVR, but
• 4:01
  after we talk to them a, a lot of times, it might not fit for them specifically.,
• 4:06
  Some of the advantages of TAVR, there's much less recovery.
• 4:10
  So patients are usually in the hospital, overnight.
• 4:12
  They spend overnight in the ICU, and then usually they go home the next day.
• 4:15
  , The recovery time for that is about a week, as opposed to surgery
• 4:18
  where you're in, in the hospital for maybe five to seven days.
• 4:21
  And the recovery time, because typically these are done through a sternotomy,
• 4:25
  you have to let that bone heal.
• 4:27
  It's, you know, four to six weeks at home of, of letting the bone
• 4:30
  heal and, and kind of taking it
• 4:31
  easy.
• 4:32
  When you implant a TAVR, like I mentioned, you don't take the, old leaflets out.
• 4:37
  So a lot of times you can't implant a, larger TAVR in than
• 4:40
  what you have in, in the annulus.
• 4:42
  But if a patient comes to us with a very small annulus or a very
• 4:46
  small opening where that valve is sitting, surgically we can do a, an
• 4:51
  enlargement of the annulus, and we can actually implant a, a larger valve.
• 4:54
  So some of those patients that come and see us that have a
• 4:56
  small annulus, sometimes they're better served with surgery.
• 5:00
  also when you're talking about TAVRs, especially in kind of younger folks
• 5:04
  in their 60s, there's a very high chance that they're gonna have to
• 5:06
  have some kind of procedure down the line, whether it's a repeat TAVR or
• 5:10
  a surgical, removal of the TAVR valve and implantation of a new valve.
• 5:15
  I'll tell you from experience, it's very hard to explant a TAVR valve, so
• 5:19
  we try not to plan for that when we're talking about TAVRs with patients.
• 5:25
  so that's another consideration.
• 5:26
  Usually it's better to do surgery first if you plan on doing
• 5:29
  another valve in the future.
• 5:30
  Most of these surgical valves are, are meant to have a
• 5:34
  TAVR implanted into them now.
• 5:35
  Um, that, that's kind of how they design them.
• 5:38
  patients love, faster recovery and everything, but sometimes it's just
• 5:41
  not the best thing for them in, in terms of, the TAVR valve getting
• 5:45
  implanted, in that initial encounter
• 5:47
  Scott Webb: Right.
• 5:48
  Yeah, it does seem from our conversation today that,
• 5:51
  durability, obviously is a concern.
• 5:53
  So just wa- wondering to get a sense from you, you know, how do you talk with
• 5:56
  patients about valve longevity, especially as the younger, healthier patients are now
• 6:01
  probably coming in wanting TAVR, right, as their first-- as their go-to option?
• 6:06
  Dr. James Brockett:
• 6:06
  Right.
• 6:07
  the bioprosthetic valves, last anywhere in the range of 10 to 20 years.
• 6:11
  And we have a lot of data, going back on surgical valves, but the TAVR valves
• 6:15
  they're kind of new in the medical scene.
• 6:17
  They've only been around for 10, 15 years, so, we don't have as robust data about
• 6:21
  them and their longevity, but the, the data that we do have shows, you know,
• 6:25
  very good, , results up to this point.
• 6:27
  when TAVR was initially, developed, it was for patients who, uh, were too sick
• 6:32
  or frail for surgery, a- and those were the patients that we implanted them in,
• 6:35
  and a lot of those were 80-year-olds that the lifespan longevity that, would
• 6:40
  allow us to study the valve over a lot of time, you know, a lot of time.
• 6:42
  So, so as the indications for TAVR expanded to lower-risk patients, now we're
• 6:49
  getting more data in, in the longevity.
• 6:51
  So, so that's rolling out, you know, kind of as we speak.
• 6:54
  more and more studies are looking at that.
• 6:56
  but as far as we know, they're, about equal in terms of longevity
• 6:58
  to a, a bioprosthetic surgical
• 7:01
  Scott Webb: Okay
• 7:02
  Dr. James Brockett:
• 7:02
  But if you came in and you were, you know, 55 years old, I probably-- my first
• 7:06
  recommendation would not be a TAVR valve.
• 7:07
  It would probably be a, mechanical valve, a mechanical surgical valve, just because
• 7:11
  of the longevity and, and really if you have no contraindications to Coumadin,
• 7:16
  which is the blood thinner that we use for those valves, and you're able to
• 7:19
  take the, the medication reliably, there really isn't any reason not to get a
• 7:22
  mechanical valve when you're that young.
• 7:24
  Scott Webb: Right
• 7:25
  Dr. James Brockett:
• 7:25
  it's kind of a daunting discussion to have with patients,
• 7:28
  Scott Webb: sure, yeah
• 7:28
  Dr. James Brockett:
• 7:28
  we'd recommend, you know, a surgical valve replacement.
• 7:31
  But if you think, you know, long-term down the line, six weeks
• 7:35
  of recovery is, is definitely worth, 30 years of longevity on the valve,
• 7:40
  Scott Webb: Yeah, agreed.
• 7:41
  Dr. James Brockett:
• 7:41
  kind of when you step back and look at it, so.
• 7:43
  Scott Webb: Recently there's been some media attention, if you will, around early
• 7:47
  failure of a specific surgical valve.
• 7:50
  Wondering what's the most important myth to correct so patients don't
• 7:53
  assume that all surgical valves now are unsafe or outdated?
• 7:58
  Dr. James Brockett:
• 7:58
  I think the valve that you're referencing is probably the Trifecta valve,
• 8:00
  which has been, um, shown to fail a little earlier than other valves.
• 8:03
  honestly, There are so many valves out there that one valve's problem
• 8:06
  isn't really every valve's problem.
• 8:07
  You know, that, that was one specific design, , issue with that valve.
• 8:11
  the valves that we make today, that we implant now are much more durable.
• 8:15
  They've been, uh, proven to, last a very long time.
• 8:17
  And like I said, they're, made to have a TAVR implanted into them.
• 8:20
  So we, we put them in and, when I implant a, a surgical valve, valve now, my plan
• 8:27
  is to, implant one that, can accommodate a TAVR, a good-sized TAVR in the future.
• 8:32
  I'll make it such that we get a good-sized valve in there.
• 8:35
  I'm not gonna put the smallest-sized bioprosthetic valve in there if, if I
• 8:38
  don't have to, um, because, the plan would be, you know, maybe this thing fails in
• 8:42
  15 years, and we have to consider a TAVR.
• 8:44
  So, that wasn't the case with the Trifectas.
• 8:47
  That-- Those weren't made to accommodate a TAVR necessarily.
• 8:50
  , The annulus and the metal in that valve does not expand or accommodate a TAVR.
• 8:55
  So that was one problem with that, those valves, and the other
• 8:59
  one was that the leaflets tend to calcify sooner than typical.
• 9:02
  They have lower life expectancy.
• 9:05
  So we don't use those anymore but we have a slurry of other valves that, options
• 9:09
  for us depending on, patient's anatomy
• 9:10
  Scott Webb: Of course.
• 9:11
  Yeah, and I'm getting a sense from you today that you kind of, especially, and
• 9:15
  I guess apparently I'm in this group, so I appreciate this, in my mid-50s,
• 9:18
  a younger patient, that you have sort of a-- lifetime valve plan, right?
• 9:23
  Not just the first procedure, but the other options and what you
• 9:26
  might do, you know, 15, 20, however many years down the line, right?
• 9:31
  So, surg- surgical valve now, TAVR later.
• 9:34
  So maybe just,, take us through your thought process a little bit
• 9:37
  and then how you advise patients.
• 9:39
  Dr. James Brockett:
• 9:39
  Yeah, it used to be, you know, because we didn't have the TAVRs, we would
• 9:42
  think what's the best, you know, valve, and procedure for this patient today.
• 9:47
  You know, what's gonna get them through today?
• 9:48
  But now we're, we're having to kind of play chess and, and think
• 9:51
  three moves ahead, you know?
• 9:53
  the CAT scans that we use and the, the caths and all the imaging that we do
• 9:57
  before we decide on what kind of valve that you're gonna, you're gonna ultimately
• 10:00
  get, all that is, this planning that, you know, well, the annulus is this size,
• 10:05
  so we could implant a surgical valve that's about this size, and that would
• 10:07
  accommodate a TAVR valve that's, you know, X size down the road if we needed
• 10:12
  Scott Webb: Of course
• 10:13
  Dr. James Brockett:
• 10:13
  Or if we put a TAVR in, can we put another TAVR in later, or is that gonna prevent
• 10:18
  if, if they have some coronary disease, is that gonna prevent us, from accessing
• 10:22
  the coronaries via catheter in the future?
• 10:25
  So, so nice that we meet, all as a team and go over everything all at once,
• 10:31
  where the interventional cardiologist kind of puts their input into the,
• 10:36
  patient's history and, and anatomy in terms of delivering a TAVR valve.
• 10:40
  You know, I bring the surgical, aspect of things.
• 10:43
  You know, getting two valves out is gonna be much more difficult
• 10:46
  than, putting one in initially, you know, that kind of thing.
• 10:49
  you know, when you come here to assume that you're gonna have, a team
• 10:52
  approach, and very personalized care.
• 10:54
  And it, it's definitely not one-size-fits-all for,
• 10:57
  for these kinds of things
• 10:59
  Scott Webb: Yeah.
• 10:59
  Wondering if you could maybe, I don't know, share some examples o- of
• 11:02
  patients who were surprised to learn that open heart surgery might still
• 11:06
  be the best option for them, and maybe why that recommendation is, you know,
• 11:11
  again, about the long-term picture.
• 11:13
  Yes, people want smaller scars and faster recovery and all of that.
• 11:17
  But when we think about the big picture, the long game, if you will,
• 11:20
  how do you advise them and sort of help them deal with the initial
• 11:24
  shock of, "Oh, open heart surgery, that sounds like a lot," you know?
• 11:29
  Dr. James Brockett:
• 11:29
  you know, there are a couple of, of instances where people are, coming into
• 11:32
  the office and thinking that they're gonna get a TAVR, you know, maybe in the
• 11:35
  next week or something and, and we kind of surprise them and, and say open heart
• 11:38
  surgery is probably better for them.
• 11:40
  And, and one of those-- young patients, maybe you're in your 50s, everybody
• 11:44
  thinks, "Well, I'm, young, so, you know, the recovery time will be less with the
• 11:47
  TAVR, so it has to be better and I can get back to work, sooner and everything."
• 11:50
  But, but, like I said, with the mechanical valve, that would be one reason why
• 11:54
  we recommend surgery is, is to implant the mechanical valve, just kind of a
• 11:58
  one-and-done solution for those patients.
• 12:01
  another example would be somebody who comes in, after their workup
• 12:04
  and, maybe they had their heart catheterization and they have coronary
• 12:07
  disease also that needs intervention.
• 12:09
  maybe they have significant blockages in a couple vessels.
• 12:12
  you know, surgery is nice in those situations where, , if we find something
• 12:16
  else that we can intervene on at the same time, we can also fix all that at the same
• 12:19
  Scott Webb: Yeah, one-stop shopping, right?
• 12:20
  Yeah.
• 12:21
  Dr. James Brockett:
• 12:21
  Right.
• 12:21
  And so we can do a bypass, we can do a valve.
• 12:23
  Sometimes patients have an aneurysm that need to be fixed.
• 12:26
  so we can do all that stuff at the same time.
• 12:28
  a- and that makes surgery much more appealing, despite the recovery time as
• 12:32
  Scott Webb: Of course
• 12:33
  Dr. James Brockett:
• 12:33
  sometimes I think I mentioned where we have a patient with a small annulus
• 12:35
  where a TAVR valve, might leave a, significant, gradient or, or pressure
• 12:40
  on either side of the valve that would suggest that the valve was undersized
• 12:44
  or not big enough for that patient.
• 12:45
  And, at surgery, we can enlarge the annulus and get them a bigger
• 12:49
  initial valve that makes a, a bigger TAVR valve down the line possible.
• 12:53
  So those three situations we see almost every week,
• 12:56
  Scott Webb: I'm sure,
• 12:57
  yeah
• 12:57
  Dr. James Brockett:
• 12:57
  a little surprised, you know, that they need, surgical intervention, but
• 13:00
  it really is the best thing for them
• 13:03
  Scott Webb: Yeah, let's give folks, doctor, a, single question.
• 13:05
  If they're facing a valve decision, what's maybe the single most important question
• 13:09
  in your mind that they should talk to the care team, but ask the care team?
• 13:14
  We're talking about teams involving cardiologists and
• 13:16
  surgeons and all of that.
• 13:17
  Like, what's the one thing they should probably ask in this process?
• 13:21
  Dr. James Brockett:
• 13:21
  hopefully the surgeons and the interventional cardiologists are
• 13:23
  already talking to them about it, but what is the lifetime plan?
• 13:26
  You know, what, what is the long-term plan?
• 13:28
  You know, when I'm 80 years old,, what are m- my options gonna be,
• 13:32
  and what would that look like?
• 13:33
  and how long do you think, know, this valve is gonna last?
• 13:36
  Am I gonna have to have another procedure?
• 13:37
  And, thinking along the same lines of, playing chess, getting, your pieces all
• 13:41
  in a row where, you can have a plan for this valve for the rest of your life.
• 13:45
  also you want the interventional cardiologists and the surgeons to
• 13:48
  personally review your case and, and look at it, and that's actually mandated now.
• 13:52
  When any program that has a, a TAVR or any hospital that has a TAVR program, you have
• 13:57
  to have evaluation by a heart team, which means an interventional cardiologist and a
• 14:01
  surgeon have to take a look at your case.
• 14:03
  And, it's nice when they're all in the same room with you all at the
• 14:06
  same time because then, then you kind of get all those questions
• 14:08
  answered, you know, in one visit.
• 14:10
  You don't have to bounce back and forth.
• 14:11
  There doesn't, doesn't have to be a lot of communication back and forth between
• 14:13
  the surgeon and, and cardiologist.
• 14:15
  But, anywhere you go, you, have to have both of those opinions.
• 14:19
  I think that's important.
• 14:21
  Scott Webb: Yeah.
• 14:21
  And a- you say, you know, in the hands of the right team, especially at Summa
• 14:24
  Health, they're probably already having these conversations, but good to know
• 14:28
  what we should, you know, maybe jot down as we're facing these valve decisions.
• 14:32
  Doctor, here at the end, this has been good stuff today.
• 14:34
  I just wanna kind of do a little myth-busting, if you will.
• 14:38
  So some quick one-offs.
• 14:40
  TAVR is always better than surgery
• 14:42
  Dr. James Brockett:
• 14:42
  I Would say that's a myth.
• 14:43
  TAVR is a, a great option for the right patient.
• 14:46
  I'll put it that way.
• 14:47
  It isn't-- And less invasive doesn't necessarily mean better.
• 14:51
  They're not really the same word.
• 14:52
  You can interchange those.
• 14:54
  for younger patients with other heart problems to fix or
• 14:57
  certain anatomy, surgery kind of still wins in the long game.
• 15:01
  I think, TAVR is a great option for folks, who have a lot of, medical
• 15:06
  issues, who are a little later in life, where we think that the TAVR valve is
• 15:10
  gonna last, for the rest of their life.
• 15:12
  thankfully with the miracles of modern medicine, both options typically
• 15:17
  are very low risk for patients.
• 15:19
  if it's an isolated aortic valve replacement in a healthy patient, you're
• 15:22
  talking about a mortality risk usually less than 1%, which is, is quite good.
• 15:27
  You know, it wasn't like that 20 years ago.
• 15:29
  It was much higher
• 15:29
  Scott Webb: Of course, yeah
• 15:30
  Dr. James Brockett:
• 15:30
  we are-- You know, technology has advanced, to the point
• 15:33
  where, where these things are very routine and, and very safe.
• 15:36
  And, and I think a lot of folks come into the office thinking that, you
• 15:39
  know, they have a 30% risk of dying, you know, on the table or something with
• 15:43
  surgery, and it's just not the case.
• 15:45
  So that's, that's another big myth, I think that, you know, surgery versus
• 15:49
  TAVR, it's very safe these days.
• 15:51
  Scott Webb: Um, yeah, sounds like it.
• 15:52
  All right, myth or fact, doctor, surgical valves don't last anymore.
• 15:56
  Dr. James Brockett:
• 15:56
  Well, that's a myth.
• 15:56
  I think it's almost backwards.
• 15:57
  Today's TAVI valves have, the longest published track records of
• 16:01
  any valve option, honestly, with, most of them lasting 15 to 20 years.
• 16:06
  like you mentioned with one particular valve, problems with one valve
• 16:09
  doesn't really change the category.
• 16:11
  It actually shows that we're watching the valves very
• 16:14
  Scott Webb: Of course, yeah
• 16:15
  Dr. James Brockett:
• 16:15
  changes.
• 16:16
  And, and so we've learned from that valve and, we've adapted the
• 16:19
  valves to accommodate TAVRs now.
• 16:21
  And, and so things are, constantly changing in the valve world and, and,
• 16:25
  uh, we're, we're getting better and better valves as, as the years goes
• 16:28
  Scott Webb: Yeah.
• 16:29
  Change you for the better, for sure.
• 16:31
  All right, last one here I've got for you, doctor.
• 16:33
  Myth or fact, once you choose a valve, you're stuck with it forever
• 16:37
  Dr. James Brockett:
• 16:37
  yeah.
• 16:37
  Well, that's a myth.
• 16:38
  Um, I, I guess with a caveat though, the, tissue valves can usually be replaced,
• 16:42
  , often with a catheter procedure, a TAVR, a valve inside with a new valve.
• 16:47
  the caveat, that makes a good, closing point, I guess, is that, the
• 16:50
  first valve choice really determines how good your future options are.
• 16:54
  you're not stuck, but, you have to choose your first move
• 16:57
  Scott Webb: wisely.
• 16:58
  Dr. James Brockett:
• 16:58
  that's why we have a heart team approach to all, all that, just to, just to,
• 17:02
  to plan everything out for you so there's no, issues down the road with,
• 17:06
  picking another valve if, if it's
• 17:07
  Scott Webb: Yeah, as you say, uh, choose wisely, but you won't
• 17:10
  be choosing wisely by yourself.
• 17:12
  You'll obviously have ho- maybe family, friends involved, but the
• 17:15
  great team at Summa Health, as we got rolling here today, we talked about
• 17:18
  how it's not a one-size-fits-all.
• 17:21
  There are lots of options.
• 17:22
  There are lots of factors like age and all of that.
• 17:25
  So, uh, really good stuff today.
• 17:27
  Appreciate your time.
• 17:28
  Thanks so much
• 17:29
  Dr. James Brockett:
• 17:29
  Thank you.
• 17:30
  Appreciate it
• 17:30
  Scott Webb: And for more information, go to summahealth.org/heart
• 17:35
  Host: And if you enjoyed this episode of Healthy Vitals, we'd
• 17:37
  love it if you'd leave us a review.
• 17:38
  Your review helps others find our educational content.
• 17:41
  I'm Scott Webb.
• 17:42
  Thanks for listening, and we'll talk again next time.