Avoid open chest operation for valve disease

When open chest surgery the was only solution for heart attacks, simple angioplasty has replaced it in at least 60% of the cases in in the last 15 to 20 years. .But unfortunately until now no solution was available for valve diseases recently. The common valve problem that we see today is mitral valve and aortic valve. Aortic valve is the major valve which paves way for the pumped blood from the heart to entire body. Aortic valve constriction and stenosis (narrowing) causes dizziness, breathing difficulty. Faints and in extreme cases sudden death (because blood does not reach entire body).But now we have got a good technology just as angioplasty, aortic stenosis can be treated by stent without opening the chest ,but not in all cases.

This minimally invasive surgical procedure repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI).

Valve-within-valve — How does it work?

Somewhat similar to a stent placed in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter.

Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating

How is TAVR or TAVI different from the standard valve replacement?

This procedure is fairly new and is FDA approved for people with symptomatic aortic stenosis who are considered an intermediate or high risk patient for standard valve replacement surgery. The differences in the two procedures are significant.

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What is involved in a TAVR procedure?

Usually valve replacement requires an open heart procedure with a “sternotomy.”, in which the chest is surgically separated (open) for the procedure. The TAVR or TAVI procedures can be done through very small openings that leave all the chest bones in place.

A TAVR procedure is not without risks, but it provides beneficial treatment options to people who may not have been candidates for them a few years ago while also providing the added bonus of a faster recovery in most cases. A patient’s experience with a TAVR procedure may be comparable to a balloon treatment or even an angiogram in terms of down time and recovery, and will likely require a shorter hospital stay (average 3-5 days).

The TAVR procedure is performed using one of two different approaches, allowing the cardiologist or surgeon to choose which one provides the best and safest way to access the valve:

  • Entering through the femoral artery (large artery in the groin), called the transfemoral approach, which does not require a surgical incision in the chest
    or
  • Using a minimally invasive surgical approach with a small incision in the chest and entering through a large artery in the chest or through the tip of the left ventricle (the apex), which is known as the transapical approach.

Who is a good candidate for this type of valve surgery?

At this time the procedure is reserved for those people for whom an open heart procedure poses intermediate risk. For that reason, most people who have this procedure are in their 70s or 80 and often have other medical conditions that make them a better candidate for this type of surgery.with the promising results now researchers are doing this for LOW RISK patients also.

TAVR can be an effective option to improve quality of life in patients who otherwise have limited choices for repair of their aortic valve.In coming years this will play a major role and big boon to the patients.

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A heart attack occurs when a sudden blockage from a blood clot cuts off the food and oxygen supply to the heart muscle. The Golden Hour is a critical time because the heart muscle starts to die within 80-90 minutes after it stops getting blood, and within six hours, almost all the affected parts of the heart could be irreversibly damaged. Heart is a pump. Like bullet shaped. Once the muscle is damaged bullet shape is not maintained and it can’t pump effectively.
So, the faster normal blood flow is re-established, the lesser would be the damage to the heart. 

Why Within golden hour?

The golden hour is a window of opportunity that impacts patient’s life and death. Or quality of life thereafter.

What is our role in the Golden Hour for a heart attack patient? 

To reduce the damage to the heart, it is important to get to the hospital as soon as possible. (Our patients usually go to clinic, and wait to see doctor and waste lot of time. It is important that they should rush to hospital with cath lab facility if possible) Other than the consequences of a damaged heart muscle, the most common killer in the early period following a heart attack is an abnormal heart rhythm called ventricular tachycardia and ventricular fibrillation where the heart muscles contract at a rapid rate (200 to 400)., but no effective pumping of blood from the heart takes place. 

This is why we must ensure that once the person reaches a medical facility (ambulance or hospital); they are immediately put on an ECG monitor to assess the heart rhythm, so they can be given prompt treatment in case of an abnormal rhythm. 

What is the immediate treatment one can expect in a hospital? 

Once the patient reaches the hospital, the primary goal of treatment would be to dissolve the obstructing clot, and restore blood supply to the affected part of the heart. 

This is done, most commonly, by clot busting drugs. But of late, the preferred modality is mechanical dissolution of the clot by a procedure called as primary angioplasty.


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Even in emergency heart attacks, if the patient reaches the hospital within the golden hours angiogram, angioplasty and stenting can be carried out through hand and can walk after few hours in most cases.

Most of angiograms or balloon angioplasties are carried out using local anesthetic to numb the area where the catheter is going to be inserted. 

The procedure will be carried out by us. A nurse and technician will also be present to assist with the procedure.

An intravenous (IV) line will be inserted into a vein in your arm. It can be used to deliver sedatives or any other medication as required. Electrodes (small, metallic discs) may be placed on your chest to record your heartbeat. A blood pressure monitor may also be attached to your arm.

A small plastic tube called a sheath will be placed into one of your arteries. A catheter (a long, thin flexible tube) is inserted through the sheath and on to the arteries being examined. Depending on the area being examined, the catheter is usually inserted into an artery in your wrist or groin.

X-rays are used to help guide the catheter to the right place. Contrast agent will then be injected through the catheter and a series of X-rays will be taken. This will allow a map of the arteries to be created.

The procedure isn’t painful but you may feel a slightly warm sensation, or a mild burning sensation, as the contrast agent moves through your blood vessels. It can take between 10 to 15 minutes for angiogram.

In some cases, other procedures can be carried at the same time, such as inserting a balloon or a small tube called a stent through the catheter to open a blocked. This is known as angioplasty.

Once the procedure has been completed, the catheter is removed and the incision is closed using manual pressure, or wrist band or with some special device

Afterwards

Following angiogram or angioplasty, you’ll be taken to a recovery ward. You’ll be asked to lie still for a few hours, to prevent bleeding at the site of the incision.

Most people are able to leave hospital on the same day or the next day. You’ll be able to eat and drink as soon as you feel ready to, but it may take eight to 12 hours before you’re well enough to resume normal activities.

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