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Home > Services & Specialties > Heart & Vascular Services > Valve & Structural Heart Disease Care > TAVR
If you have severe aortic stenosis that isn’t controlled with medications and traditional surgery isn’t safe for you, you may be a candidate for transcatheter aortic valve replacement (TAVR). Essentia offers this advanced minimally invasive procedure at Essentia Health-St. Mary’s Medical Center in Duluth, MN and at Essentia Health-Fargo in Fargo, ND.
Aortic stenosis is a common heart valve disease. It creates a narrowing of the valve in the large blood vessel branching off of the heart. This narrowing keeps the valve from opening fully, reducing blood flow to the body and making the heart work harder. The heart may weaken, causing chest pain, fatigue, and shortness of breath. In severe cases, surgery can repair or replace the valve.
Transcatheter aortic valve replacement (TAVR) is an advanced minimally invasive procedure used to treat severe aortic stenosis. During a TAVR procedure, a tiny uninflated balloon is placed in an artery near your groin. The balloon is threaded up to your heart on a guide wire through a thin flexible tube called a catheter. Once the balloon reaches your heart it is inflated to widen your narrowed aortic valve. This makes space for a new artificial valve to be placed inside your heart.
TAVR treatment may help you live longer and lessen your symptoms more than medication alone. The TAVR procedure has less risks of complications than traditional valve replacement surgeries.
View video transcript Listen to audio description (MP3)
(DESCRIPTION)Text, The Best Part. A woman sits in front of an oil portrait of a younger version of herself
(SPEECH)LEONORE: My name is Leonore. I never knew until just before I turned 88 that I had a heart problem. I just couldn't get the breath.
(DESCRIPTION)Text, Leonore. Heart patient. Essentia Health. She holds up a small plastic ring
(SPEECH)That's the heart valve that's replacing the natural heart valve. It looks like a little crown.
(DESCRIPTION)In her library, she looks at a photo album with a magnifying glass
(SPEECH)I did have my procedure. The next day they said, well, you can go home. That was absolutely wonderful. I knew I was in the best of hands.
(DESCRIPTION)Text, visit the region's heart experts. Essentia health dot org slash heart. The best part. It's here. Essentia Health. Here with you.
Watch as Essentia Health cardiologist Dr. Jason Schultz performs a Transcatheter Aortic Valve Replacement (TAVR) at Essentia Health-St. Mary's Medical Center in Duluth, Minnesota.
(DESCRIPTION)A city skyline next to a river. A helicopter flies overhead Healthcare professionals care for a patient. The Essentia Health logo, three leaves in a circle, appears 2 men in surgical gowns
(SPEECH)SPEAKER 1: Good afternoon, everybody. Welcome to Essentia Health, St. Mary's Cath Lab. It's a beautiful Tuesday afternoon. We're really happy and excited to bring you this case. We thought everybody would be really interested in what it is we do kind of behind the scenes, and this is a procedure that's kind of taking off right now. And we're really happy to bring you one and show you what we do from start to finish. So I'm going to start by introducing the team. It's a relatively big team.
(DESCRIPTION)Gestures at man standing to his left
(SPEECH)Dr. Atul Singla is one of our fellows, so we actually got pretty good at this over the last five years and thought last year that we were good enough that we could start training people how to do it. So Dr. Singla is spending a year of his life here with us learning how to do these, and he's gotten the case started for us and doing a great job.
(DESCRIPTION)Shot widens and shows the entire surgical staff
(SPEECH)Dr. Denton Stam is to his right. He's one of our great cardiovascular surgeons. We're really lucky to have him here. Sherry is one of our tech extraordinaires. Behind her is Laura, one of our Edward's Life Sciences reps who support all of our cases. Amy and Shelly are somewhere in the background back there, the coordinators of the program who all of our patients get to know really, really well. Faith is one of our great PA students. Caroline is in the back, one of the newest members of our team, is one of our great techs. Jude is hiding back there somewhere, one of our great nurses. And then our excellent cardiac anesthesia team, Dr. Askari is up at the top. Greta is our great perfusionist. She's been with us from the very beginning and really does a fabulous job. So that is our team. With that, I want to introduce you to the patient. So this is a delightful 81-year-old lady who came to us with worsening shortness of breath and was found to have aortic stenosis, which essentially means that the aortic valve, the one between the heart and the rest of the body, was narrowed and not opening appropriately. Part of her medical history is that she's a survivor of breast cancer and as part of that treatment, had radiation therapy to her chest, which makes her extremely high-risk to have a sternotomy or open heart surgery, which in many cases is the treatment for these folks. So we decided that she would be better-served with this procedure called transcatheter aortic valve replacement, which is essentially replacing the heart valve using balloons and catheters. So if you zoom in here on my hands, Dr. Singla has it set up really nicely. So in order to do this procedure, the patients don't need to be put all the way out. Our cardiac anesthesiologists and CRNAs are fabulous here, so Emily is just taking a nice snooze right now. Oftentimes, if we actually need to talk to the patients, we can do that.
(DESCRIPTION)Gloved hand on prepped patient
(SPEECH)So we just use numbing medication to keep the patients comfortable, and Dr. Singla has a nice big to put in the artery right here-- this is how we'll deliver the heart valve-- and then a couple of tubes over on the other side which help guide how we're going to do this.
(DESCRIPTION)Larger tube pointing to bottom left of screen as it exits the patient and 2 smaller tubes toward the right
(SPEECH)So let's show you how far we've come here. We've got all of these tubes in, which takes a little bit of time, and then we put a pacemaker in the heart because although we never stop the heart to do this-- we need it to go really fast as we're deploying the valves so that it doesn't pop out, and we'll talk about that a little more later. So the first thing that we like to do is take a picture of our best view so that we know exactly where we need to land to valve, and we get kind of a perfect angle. So are we ready to take a picture here, guys?
(DESCRIPTION)Screen splits, showing surgeon on the right and their radiographic view on the left
(SPEECH)OK. And inject, please.
(DESCRIPTION)Dye is shown spreading in the radiograph
(SPEECH)So we're not 100% happy with that. Let's go just a little more cranial here. We want to make sure-- it's very, very important that we have everything lined up appropriately so that we know for sure that when we put the valve in it's going to be a perfect job. SPEAKER 2: Or do we want to try that L E O 9 Product?
(DESCRIPTION)Surgeon adjust catheter
(SPEECH)SPEAKER 1: I think this is probably good. Yep, all right. Ready? Inject, please.
(SPEECH)That is not terrible. So I like to make sure there's consensus whenever we doing anything here. So it's a big team, so to not ask for everybody's help would just be foolish. So I like to get a consensus. Dr. Bijou is somewhere, probably standing right behind me. He's the medical director of our program, very, very important. We do all these cases together, so I like to ask them things as the case goes along. And he's shaking his head that he approves of how things look. So after that, the next step is we actually need to cross this valve in order to fix it, so we'll get a catheter here and cross the valve. We've actually had kind of a number of questions come in that we'd be happy to answer.
(DESCRIPTION)They adjust catheters
(SPEECH)And as we do things here with our hands and there's a little bit of downtime, I'm probably going to kick it to Dr. Bijou to ask a question. And if he stumps me, I'll actually have him answer it. SPEAKER 3: What kind of material are these valves that you're putting in through the leg made from? SPEAKER 1: So here we are a comprehensive valve center, and we offer everything that there is to offer. So we actually right now have two different valve portfolios that we can use.
(DESCRIPTION)Shows prosthetic valve
(SPEECH)The valve that we are going to put in this patient is made from cow tissue or the lining of a cow heart.
(DESCRIPTION)tan-colored tissue surrounded by fine metal mesh
(SPEECH)The other valve is made from the lining of a pig heart, so both valves have their pluses and their minuses. We chose, for this particular patient, this valve, so that's a really good question. So often the question is, do I need to take blood thinners when I have one of these valves put in? And the answer is no. Just go a little more LAO for me here, guys.
(DESCRIPTION)Radiographic view shifts laterally
(SPEECH)So if I struggle with this part of the procedure, usually I just hand it off to Dr. Singla, who gets it right away. Or a lot of times, when it recognizes I'm getting impatient, it smiles upon me. So Dr. Singla came to us from New Orleans. I've only been there a couple of times, but he was actually wearing like a parka or something when I saw him here in Duluth. And it was-- I think it was like 50 degrees out or something, so I'm a little bit nervous for Dr. Singla once winter actually strikes. So the next step is to get our wire into the pumping chamber of the heart so that we can get this heart valve fixed up for, which we've done here. Sometimes there's a little tickling of the heart. We like to let our anesthesiologist know that, and you'll see we kind of methodically walk things out and put them in. Now might be in a nice timed to grab another question. SPEAKER 3: Are the patients completely put out for the procedure, or do you use a different kind of sedation? SPEAKER 1: When we started doing this about five years ago, it wasn't uncommon for the patients to be completely out, with breathing tubes and everything, and what we found is, number one, most of the time that's not necessary. And number two, it usually just prolongs hospital stays. So these days-- and we've been doing this for a year, maybe a little bit more, Scott. We use what we call a minimalist approach, so the less you do to a patient, the better the outcome is going to be. And we usually just use some medication to make them kind of sleepy and a lot of numbing medication in the arteries in the legs to make sure they're comfortable throughout the whole procedure, but very rarely do we ever need to use breathing tubes. And we find that patients end up going home a lot faster that way and in general just are far more comfortable. It's much easier to wake up from just light sedation than it is from general anesthesia, so really, really good question. So the next step of the procedure is to kind of measure what the pressure differences are between the pumping chamber of the heart and the aorta where all the blood is flowing out, and if you look at the pressure screen here, you can see there's a very significant what we call gradient, meaning there's a big pressure difference between the pumping chamber and the aorta, which is exactly the problem we're here to fix.
(DESCRIPTION)Heart pressure readings
(SPEECH)And having all of this information about what the pressures are really guide what we're going to do as we move along here. So now that we have all the information, now it's kind of game time, so now we're going to get the valve delivered. One thing that's really critical is we want to make sure that the blood is thin enough before we deploy the valve, so I always stop before we put the valve up and ask Greta whether or not we've gotten the blood thin enough in order to do this. And if not--GRETA JOHNSON: ACP is 230.SPEAKER 1: OK. So Greta is telling me that we're just not quite thin enough, so we're going to give a little more medication called heparin, which thins the blood and prevents bad things like strokes happening when we deploy the valve. So why don't we give another 2000 heparin, guys?
(DESCRIPTION)Gloved hands shown adjusting equipment to the right, radiograph to the left showing the catheters' locations
(SPEECH)So the next step in this process is going to be to deliver the valve up, and then we'll show you how we put this together in the body. And Dr. Stam's actually gotten really good at this. It's kind of like doing a puzzle in the body. I tell people that this is a lot like a dance, so one of the-- I always say, one of the single greatest things to ever come from the TAVR technology is the fact that we work as a team. So I think when Dr. Stam started his career, he probably never imagined that he'd be standing next to an interventional cardiologist doing cases. It's really been unbelievably fulfilling for my career to have him and his partners by my side and learn from a lifetime of what it is that they do, so I really enjoy the team-based effort that we have here. It's phenomenal. So let's open that up, guys, and see if we can see down to the tip of the sheath. So this is a relatively big tube, you can appreciate, that we're putting in. We do this very gently and very carefully so that we don't damage any of the blood vessels as we're going in. It's very important that we keep the wire exactly where it is because this is one of those situations that once it goes in, it's not coming out. We have to get it into the right place. Good, perfect.
(DESCRIPTION)Radiograph showing location of catheters
(SPEECH)And then I am going to get this into a place that looks a little bit vertical, and then we'll explain how we put the valve together. So let's mag in on that and go a little bit cranial for me, if you would.
(SPEECH)Good. And let's mag up one on the valve, too. I think it might need to go just a hair more cranial, Sherry.
(DESCRIPTION)radiographic close-up view of valve
(SPEECH)I think that's good. So now you can look at Dr. Stam's hands and maybe the screen as well. So in order to make this tube smaller, we have to put this together in the body, so we have to bring the balloon that deploys the valve to within the valve itself. And that's what Dr. Stam's doing now, so it's like putting a little puzzle together within the body here.
(DESCRIPTION)Radiograph shows the balloon entering the valve
(SPEECH)And yeah, perfect. And then we give it a little burp to get all the tension out of it, and now we're ready to go up and around and deliver this heart valve to where it needs to go. So we're all locked up, yeah? OK. So let's go LAO here to cross.
(DESCRIPTION)View changes as requested, catheter, balloon, and valve advance
(SPEECH)Ready, Dr. Stam? DENTON STAM: Yep. SPEAKER 1: So what he's doing is kind of guiding me. I say this is a dance because it really takes two people to do this well, so Dr. Stam is turning a knob here to guide me around the big vessel in the body called the aortic arch to reduce the risk of causing strokes or things like that. And then once I get to about right here, which is right above where the heart valve is, I like to take a pause, and stop, and make sure that anesthesia and everybody in the room is ready so that we don't have any mistakes or any miscommunication and everybody's on the same page. So we'll stop here and ask Dr. Askri and Matt if they're doing OK, and they tell me that they're OK. So the next step is for us to cross the valve, which we've done here, and now there's a big pusher there that helped me to push. And Dr. Stam is going to bring that pusher back now so that the only thing left is the heart valve. And then the next step is to deploy this.
(DESCRIPTION)Catheter pulls away, leaving the valve in place
(SPEECH)Perfect. And then you might be able to appreciate that we have a little pigtail catheter in there that guides what we're doing here. Let's mag in and go to our deployment view now. And then we like to do a test. So as I said before, we never stop the heart when we're doing this, but we pace it relatively rapidly as we go so that the blood doesn't eject the valve out as we're going. I like to do a test as our as our final thing so that we make sure that the pacemaker's working and there's not going to be any malfunctions. So Ben has joined us in our case, and we're just going to take a little picture here while we're pacing to make sure that the valve is going to be exactly where we want it before we go. OK, you're ready, Ben? SPEAKER 4: Ready. SPEAKER 1: OK. Let's go pacemaker on, please. SPEAKER 4: Pacemaker on. SPEAKER 1: And the pacemaker rapidly paces the heart. Inject, please. And pacemaker off, please. SPEAKER 4: Pacemaker off. So that's a nice little test run. And then once again, just like I said before, we have a whole roomful of people that have done a lot of these, so we like to have consensus and know what everybody thinks before we make any decisions to go forward.
(DESCRIPTION)Radiograph shows dye spread
(SPEECH)Yeah. So I think what the-- Dr Bijou? SPEAKER 5: I think it looks good. SPEAKER 1: Yeah. So the consensus is it looks good. It's probably not perfect, so we're not perfectly happy with it. We're probably going to move it in just a hair, and I think that that's going to be OK. I'm really neurotic about this, and I like to know exactly where it's going to deploy. So we're going to do one more test run here before we do the real thing. So pacemaker on, please. SPEAKER 4: Pacemaker on. SPEAKER 1: I like to see that there's a really good pressure drop here, which we have. Inject, please. And pacemaker off, please. SPEAKER 4: Pacemaker off. SPEAKER 1: And I'm guessing that everybody's pretty happy here. We have a little bit of leaking, which we're going to take care of here very shortly. So this next one is going to be the real thing. This is very military-like right now, so there's usually one voice at the table calling out what we're going to do. And everybody knows their role, and we just do it. So you guys ready? SPEAKER 6: Ready. SPEAKER 1: OK. Pacemaker on, please. SPEAKER 4: Pacemaker on.
(DESCRIPTION)valve circumference slowly increases
(SPEECH)SPEAKER 1: And start, and take it, and one, two, three. Balloon down, please. Keep pacing. Keep pacing. Keep pacing. Keep pacing. Pacer off, please. SPEAKER 4: Pacer off. SPEAKER 1: Start flow. So at this point, the valve is completely deployed, and we're always very eager to check with our anesthesia colleagues how she tolerated all of this and how her blood pressure looks. She seems to be doing, huh, guys? SPEAKER 7: She's doing great.
(DESCRIPTION)Radiograph shows the successfully placed valve
(SPEECH)SPEAKER 1: And then the next step is going to be to measure what the pressures are. So I told you at the beginning when we measured pressures there was a very significant gradient between the pumping chamber of the heart. I like to call it the engine for people that conceptualize this like a car. So there was a big gradient between the engine of the car and some of the fuel lines, and what we would like to see with this brand-new heart valve is that that gradient has disappeared now. So we'll put a pigtail catheter in here and just measure some more pressures. Preliminarily, we're really happy with it. We'll interrogate this using pressures as well as a picture, but preliminarily, we're very happy with it. Laura is probably standing right behind me, and she'll let me know when she thinks that it's a perfect job. There's a lot of things that go into planning for this procedure. A lot of what you don't see is the stuff that happens behind the scenes before we make it to the table. So when I meet with patients, I tell them that the workup to figure out whether or not you're a candidate and plan this procedure is relatively comprehensive, and it usually takes, from the time we meet patients, about a month until we get them to this point. And the reason for that is we want to know about all the hiccups and all the speed bumps beforehand so that when we reach this point, we're 99% sure we're going to be successful. So the short answer to the question is, once we've put it in and it's in this place, the risk is virtually zero that it's going to go anywhere. It's nicely latched into the annulus of the aorta. It's perfectly sized because the CT scan predicts what the size needs to be, and that's why we're so methodical about making sure we're in the exact right place because the only way that valve can go anywhere that it shouldn't be is if we don't take our time, we don't pay attention, we're not methodical, and we end up going up on the balloon in a place where it's not OK. Good question. Thankfully, we've not had that happen here-- knock on wood-- and I hope that we never do. But it is something that is a potential problem. It happens extremely, extremely rarely. So what we're looking at here is an absolutely beautiful result from a blood pressure standpoint. So all of that gradient that we saw before is essentially gone. The pressures in Emily's heart are absolutely normal, and we're really happy with this result. So the next step is that we take some of these catheters out that we're using to monitor, and then we will take one additional picture to make sure that there's no leaking behind the valve before we call this a success. So are we ready to inject, guys? OK. Inject there, please.
(SPEECH)And this is just absolutely a beautiful result, so now is when I should hear Laura in the background saying "perfect". SPEAKER 8: Perfect. SPEAKER 1: She says perfect, so that's when we know we've done a good job. So at this point, the valve part of the procedure is over. So the last part of the procedure is getting these big tubes that we used to deliver the heart valve out, and we do that using little suture devices right here that Dr. Singla put in before we even started. So we take these little tubes out, and then we cinch down on these little sutures to close that big hole that we put in the artery. And similarly, we could do the same for the little tubes over on the other side. So when Emily wakes up very, very shortly after we're finished, she'll need to lay flat maybe just for a couple of hours, and I always tell our patients that you should be eating lunch or dinner and a chair. And we expect to see her up and at 'em just a couple hours after we're finished. So just to summarize what we've done, Emily was an 81-year-old female who came in with a very narrow heart valve, the aortic valve, who was not a good candidate to have surgery because of previous radiation to her chest, so we decided to perform a transcatheter approach to replacing her heart valve, which we demonstrated here and got an absolutely perfect result. And I just want to thank the team for a lot of good preparation. This isn't something that comes together easily. Everybody was really attentive to Emily, and this was just a fabulous success. So thanks for joining us. We look forward to doing more of this in the future. As I said, we're kind of a comprehensive valve program, so we do a lot more than just this. And maybe that'll be the teaser for future things to come. There's a lot of good stuff out there that we can bring you in and hope you really enjoyed this. So thanks. SPEAKER 9: Dr. Schultz, that was a fantastic case.
(DESCRIPTION)Two men in surgical caps
(SPEECH)Would you be willing to summarize how you think everything went and give a little bit of the history of the program here? JASON SCHULTZ: I thought it was a great case. It was a really good example of somebody that would be fairly high-risk to have surgery, open heart surgery, that's better served with this technology.
(DESCRIPTION)Graphic showing how a sheath is deployed in the left femoral artery
(SPEECH)So our program is about five years old. We've been doing this a long time. Emily's actually our 430th case, so we've grown pretty exponentially over the last five years.
(DESCRIPTION)Animation of a bioprosthetic aortic valve
(SPEECH)I think it's probably important to know that this kind of technology-- while it used to be reserved for people that were really high-risk to have heart surgery, now it's approved for most people that have this problem that need a valve replaced. So what we've seen is exponential growth in the number of patients coming because the therapies have become less invasive, and they're more interested in getting them. So I think Emily was a really nice, instructive patient because she's somebody that may have not had other options, had we not had this technology. But the technology is really not limited just to her.
(DESCRIPTION)Animation showing how the valve works after being deployed
(SPEECH)I think it's going to be applied more globally in the months and years to come, so we're really excited about the growth of the program here. It's already growing really quickly, but I think the sky's kind of the limit.
(DESCRIPTION)Logo rotates and appears, consisting of three leaves in a circle. Text, Essentia Health.
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