Valve Choice Betting on TAVR in the Future?

[Elgato]

A lot of people seem to choose a tissue valve now betting or hoping that TAVR technology will improve by the time they need a replacement.
Both of my surgeons were very positive about the possibility.

A mechanical is not a TAVR candidate because it must be surgically removed.

Currently are you aware of any specific valves that are designed to accommodate TAVR in the future?

Are both stented and stentless candidates for future TAVR?

Thank You

 

[MarkU]

Not aware of any valves that are specifically designed to accomodate a future TAVR, but obviously it would have to be able to be cut out and removed by the catheter.

My doc specializes in interventional cardiology and his stated goal is to eventually "put all the heart surgeons out of business". Unfortunately when I had my AVR 14 years ago, a mechanical was the best option available to me at the time. No complaints, but there are definitely more options to consider today, and hopefully more in the near future.
Mark

 

[clay_from_nj]

Really, mechanical doesn't enter into the "future TAVR" discussion, since they don't wear out and last a lifetime, which is why it is being discussed regarding tissues valves, as they do wear out, and will need to be replaced.

 

[Paleowoman]

Not aware of any valves that are specifically designed to accomodate a future TAVR, but obviously it would have to be able to be cut out and removed by the catheter.

My cardiac specialist nurse was talking to me about TAVR which has been around since 2009 at a London Hospital (forget which one) for people too ill for OHS. The nurse seemed to think they would very soon be fine for anyone and that the higher mortality is due to the weaker patients, not the valve. He said that the stent part of the TAVR pushes the 'diseased' valve to one side, they don't cut or remove any of it. So, as long as they can place the stent over the tissue valve it might work the same as over a native diseased valve ?

 

[Gail in Ca]

I know a man who had a stent placed to open a clogged artery. He was in great shape and had just found out about this clogged artery. He had road biked 40 miles just a week before the procedure.
Of course, this had nothing to do with his valve, but, after the catheter procedure, he was sent home, and just a couple days later was in the ER, had major bleeding in his chest cavity, and died! He was only 60. Something had gone wrong with the stent placement. Most people think of this procedure as an easy thing to go through.
I guess this doesn't have anything to do with TAVR, but I just wanted to comment, because every procedure carries risks, some of them life threatening.
If you choose redo of any type, you are opening yourself up to those added risks.

 

[river-wear]

Excellent point, Gail.

One of the surgeons I talked to mentioned putting in the "largest tissue valve" that would be suitable for me, thus leaving room for a TAVR valve after it wears out. At my age, it could still probably mean another surgery to remove those two and put in a third. Personally I am skeptical about the longevity of a TAVR valve because it does push aside a native or failed tissue valve. How symmetric and long-lasting will that be? We don't have any data on that yet.

I'm not adventurous (optimistic?) enough to count on those advances when it comes to choosing a valve, even though it does seem to be a very popular choice.

 

[ottagal]

A lot of people seem to choose a tissue valve now betting or hoping that TAVR technology will improve by the time they need a replacement.
Both of my surgeons were very positive about the possibility.

A mechanical is not a TAVR candidate because it must be surgically removed.

Currently are you aware of any specific valves that are designed to accommodate TAVR in the future?

Are both stented and stentless candidates for future TAVR?

Thank You

I am not personally aware of all the valves that are future TAVR candidates, but I do know the CE Edwards Perimount is one (this is the one that I had implanted). However, my surgeon also said that because of my valve size being a 'smaller' size it would be questionable as to whether I would be a candidate for TAVR in future (if it becomes a viable option).

I know LynW is well versed in this area. Hopefully, she will be able to chime in to provide some input.

 

[MarkU]

Really, mechanical doesn't enter into the "future TAVR" discussion, since they don't wear out and last a lifetime, which is why it is being discussed regarding tissues valves, as they do wear out, and will need to be replaced.

Although mechanical valves themselves are extremely durable & reliable, there are occasions when they do need to be replaced, due to infections, calcification or other issues. The problem is getting them out, which is the thing eliminating TAVR as an alternative.

Mark

 

[Bryan B]

The way I understand it is that the old valve is not pushed aside, but that the new valve is placed directly inside of the diseased valve and then secured in place. My surgeon lead the TAVR clinical trials at Duke and strongly believes that within 5 years TAVR will be available for patients with a moderate risk for complications. They have already started clinical trials for this catagory (called Partner IIA for the Edwards valve and SurTAVI for Medtronic valve). I am 53 and I have an Edwards bioprosthetic valve. My next surgery will be my third so I will probably fall into this category. I have had this valve for 3 years so I hope it will last long enough for the TAVR procedure to continue advancing so I will be eligible for it when my time comes. From what I am reading it looks promising.

A catheter is placed in the femoral artery (in the groin) similar to angioplasty, and guided into the chambers of the heart. A compressed tissue heart valve is placed on the balloon catheter and is positioned directly inside the diseased aortic valve. Once in position, the balloon is inflated to secure the valve in place.

http://my.clevelandclinic.org/heart/percutaneous/percutaneousvalve.aspx

Article on moderate risk trials: http://www.tctmd.com/show.aspx?id=122078

 

[river-wear]

Maybe it's semantics, Bryan, but when the TAVR is placed inside the old native (or bioprosthetic) valve, it has to push aside the leaflets of that valve. Essentially, it permanently opens the old valve so the new one can take its place. It sounds like you should be a good candidate when the time comes... in 15-20 years, hopefully.

 

[neo]

I recently read some articles about TAVR using not bovine pericardium, but tissue engineered leaflets attached to a stent to be placed inside worn out heart valves. It is thought that TAVR would work better inside of a perfectly circular existing bioprosthesis vs even a native valve, more chance to seal for lack of a better word. People are working on a valve matrix that can be seeded with the patients own stem cells and transplanted via catheter. Theoretically, these leaflets would regenerate and perhaps last indefinitely.

 

[Agian]

One of the other posters got to visit the Cormatrix establishment.
I sent them an email twice, but got no response.

The other thing I've been reading about are the polymeric valves, being currently researched.

http://www.uclb.com/technologies/novel-percutaneous-heart-valve

So close and yet so far away. Here's hoping.

 

[river-wear]

I had one surgeon say he could use CorMatrix to patch a leaflet in an aortic valve, and another say CorMatrix is great for some applications but can't withstand the movement and pressures in a valve. I couldn't find any research to definitively support either position. It certainly looks promising.

If they can create good scaffolding and grow a new native valve, it would be fantastic - even if old-fashioned open surgery is needed to implant it. At least it would eliminate the trade-offs between current tissue and mechanical valves. Here's an old article, if anyone is interested: http://www.dailymail.co.uk/sciencetech/article-479481/Heart-patients-valves-grown-cells.html