Specialist Care Centre – Cardiothoracics
Your doctors are treating you for a condition called aortic stenosis. This is where the main valve which allows blood to flow from the heart to the rest of the body has become narrowed.
What causes aortic stenosis?
In most cases, aortic stenosis is due to general wear and tear and is more common as we age. In some cases, the valve has been abnormal since birth and has become more narrowed or leaky over time. The valve may also become abnormal due to other conditions such as rheumatic fever.
What are the symptoms of aortic stenosis?
Aortic stenosis may cause symptoms of chest discomfort, breathlessness, or blackouts. As the valve narrowing worsens, this can cause weakening of the heart muscles pumping action (times known as heart failure) and this may become a life-threatening problem with time.
Can aortic stenosis be treated?
If the valve is not severely narrowed, no specific treatment is needed, and you will usually be offered routine check-up appointments to monitor for further deterioration of the valve.
Before determining which treatment will be best for you, several tests will need to be completed.
Routine tests include:
- Blood tests
- An ECG (electrical trace of the heart)
- An echocardiogram (ultrasound scan of the heart)
A detailed CT scan of the heart and main blood vessels
In some cases, additional tests are required. These may include:
- Transoesophageal echocardiogram (TOE). This is a more detailed ultrasound scan of the heart where you are asked to swallow a thin tube which is used to look at the heart through the gullet
- Lung function tests (breathing tests by blowing into a small tube)
- In some patients an angiogram will be required to assess any disease in the coronary arteries.
Treatment options
Trans catheter aortic valve implantation (TAVI)
During this procedure, the patient’s own valve is not removed but pushed aside by a tissue valve which is held in place by a metal frame. In TAVI, the new valve is inserted from the blood vessels in the groin or by a small cut in the chest wall (other access sites can be used, if needed these will be discussed with you). The heart does not need to be stopped and a bypass machine is not routinely used.
The procedure is performed under local anaesthetic – meaning you are awake for the procedure. Mild sedation may be used if you are feeling especially anxious prior to the procedure.
Open heart surgery
During surgery, the narrowed valve was removed and replaced with an artificial valve. To do this, a cut is made through the breastbone to open the chest and reached the heart. The heart is then stopped at artificially to allow the valve operation to take place. During the operation, a bypass machine is used to pump blood around the body. You will have a general anaesthetic meaning you will be asleep for the operation.
Medical treatments
The third option for treatment of aortic stenosis is with medication alone. This is most often with diuretics (water tablets) or other tablets to help the hearts pumping action.
How will I know which treatment is best for me?
All patients are discussed at multidisciplinary team meeting (sometime known as MDT or MDM) where cardiologists, cardiac surgeons, specialist nurses, older people’s medicine doctors and in some cases cardiac anaesthetist will be present. Your case and investigations will be discussed, and treatment options will be recommended.
What happens next
Once your case has been discussed we will recommend treatment plan for you. We will make an appointment either face to face or over the telephone to discuss treatment options with you in more detail. If valve intervention treatment is not recommended, we will inform your local heart doctor.
Where both surgery or TAVI are considered appropriate, you will be invited to meet both surgical and TAVI teams to explain your options.
TAVI
If you are suitable for the TAVI procedure, we will add you to our waiting list. There are telephone numbers at the back of this booklet that should be used if you become unwell before you have your TAVI.
Pre-admission clinic
You will be seen in pre-admission clinic prior to your procedure. This appointment will normally last for up to 2 hours. Where possible we would recommend that you bring a member of your family or close friend to the appointment with you.
During this appointment we will discuss your procedure in more detail and answer any questions you may have. We will review your symptoms, medical history and perform a physical examination. Blood tests and a heart tracing will be taken as final checks before you come into hospital.
How is TAVI performed?
In most cases this will be performed via the groin arteries (referred to as trans-femoral access) or through the arteries under the collarbone (called trans-axillary).
During TAVI, the new valve is held in place by the surrounding tissue, your old valve will not be removed. At the end of the procedure, we will do another echo scan to ensure that your new valve is working properly.
We can use a number of different TAVI valves, the team looking after you will select the preferred valve based on the scans you have already had.
Transfemoral TAVI
Transfemoral TAVI is usually done under local anaesthetic meaning you will be awake and able to talk to the team during the procedure. Small doses of service sedatives or painkillers can be used to minimise discomfort.
A small nick is made in the groin so that we can insert the equipment. We will also often need to use your other leg and at least 1 of the arteries in your arm for other smaller tubes to guide the procedure. A tube will then be passed through the blood vessels with your new valve attached. Once in the correct position your new valve will be deployed.
The small hole is closed at the end of the procedure using internal stitches or other closure devices. The small internal stitches do not need to be removed later.
Trans-axillary TAVI
If the groin arteries are too small or narrowed, the procedure may be done through the arteries running under the collarbone (called trans-axillary). A tube will be inserted which will allow us to pass your new valve to your heart.
The small access hole is closed at the end of the procedure using internal stitches or other closure devices. You will be awake during the procedure and will be able to talk to the team. We will use painkillers and local anaesthetic – sedation can be used if needed.
Other access
Other access site maybe used in some cases. If these are to be used, they will be discussed in detail with you by your doctor and or nurse.
What are the benefits of the procedure?
A successful procedure relieves the narrowed valve and improves the overall heart function. This will usually improve symptoms of chest pain, breathlessness and blackouts. This may improve your overall quality of life and your life expectancy.
What are the risks of the procedure?
With any procedure there are risks of complications however, there are also risks from leaving the valve untreated. Your doctor will weigh up the risks and benefits carefully with you as the risks we quote can vary according to your medical history and clinical condition.
Major risks (can occur during or after the procedure) include:
- Bleeding or damage to the blood vessels needing further surgery or blood transfusion
- Stroke or mini-stroke (TIA)
- Heart attack
- Emergency open heart surgery
- Kidney failure
Serious risks include:
- Bleeding into the sack around the heart
- Reaction to dye
- Infection
Less serious risks include:
- Abnormal heartbeat
- Non-emergency further surgery on the valve
- Bruising around the wound
- Valve leak
- Permanent pacemaker because of slow heart beat
- Failure to insert new valve
Occasionally patients may become confused or disorientated after the TAVI procedure. This may be related to the procedure itself or the patient’s general health in combination with a stay in hospital. It commonly settles in a day or so but rarely can be more prolonged.
What happens after the procedure?
After the procedure, you will be transferred to the day unit, cardiology ward our coronary care unit. Rarely, patients may need to attend the intensive care unit. On most occasions all the tubes that had been inserted during the procedure will be removed to allow you to move around more freely. This may be done quite quickly afterwards or can take a little more time dependent on your way of recovery – if tubes are left in, we will explain why.
Whilst in hospital, you will have further ECGs and blood tests. The need for any extra test will be determined by your doctor and will depend on your overall speed of recovery, these will be discussed with you.
If your progress is uncomplicated, you may be discharged the same day as your procedure. This is not suitable for every patient and will be discussed with you when you attend the pre-admission clinic. Most patients that have TAVI would be discharged the day following their procedure, the duration of stay in hospital can sometimes be longer if your recovery is slower.
Patient discharge after a TAVI
Most people, when they are ready go home, feel an improvement in their symptoms of chest pain, breathlessness, blackouts. However, recovery continues at home, and you may require additional support in the short term. The rate of recovery can vary from person to person.
You will be seen by the specialist nurse after the procedure and given advice regarding ongoing recovery, things to watch out for and the medication you are taking. You will be referred to the cardiac rehabilitation service, who can assist you in returning to normal activities.
We will arrange for you to have an echo around 6 weeks following your procedure and arrange to speak with you on the telephone after this. If you are recovering well, we will ask your local heart team to continue with routine follow-up. If needed, we will arrange for you to come back to the hospital for face to face review.
If you do not receive an appointment within 12 weeks of discharge from hospital, please contact the TAVI nurse on 01642 854239.
Driving
The DVLA advises that you should not drive for 4 weeks after your procedure. You do not need to inform the DVLA about your procedure, but we do advise you tell your insurance company. If you hold a commercial licence, you will need to inform the DVLA who will advise you further.
Flying
Provided you have not experienced complications, you will be able to fly one week after your TAVI if you have had a cut made in your groin or two weeks after your TAVI if you had a cut made in your chest. Despite this, if you are planning a holiday, it may be better if you wait until your follow-up has been completed.
Please contact the TAVI specialist nurse or GP if:
- You have any worries or questions
- You develop any unusual pain, swelling or bleeding at any of the entry sites
- If you develop a fever
- Notice any new swelling particularly in your legs or ankles
You are feeling very dizzy or light-headed
Important
Please seek urgent 111 or 999 assistance if you:
- Blackout
- Have chest pain lasting longer than 10 minutes
- Have severe shortness of breath
If you need urgent advice out of hours following discharge from hospital, you can speak to a member of staff on the Coronary Care Unit 24 hours a day on 01642 854801.
Taking part in research
New medical or surgical procedures are subject to a great deal of investigation to find out ways of improving them, or to decide which patients they should be offered to. The team at the James Cook University Hospital is involved with clinical research and you may be invited to take part in this.
Your cardiologist or surgeon will discuss any potential studies in detail with you. It is important that you are aware that any research is strictly voluntary and that your care will in no way be affected if you decide not to take part. However, such research is valuable in improving care for patients in the future who may have similar problems to your own
Where can I get more information?
- The National Institute of Clinical Excellence (NICE) website: www.nice.org.uk/guidance/ipg586
- If you do not have access to the internet, your cardiologist can provide a copy of this document
- The South Tees NHS Foundation Trust website: https://www.southtees.nhs.uk/services/transcatheter-aortic-valve-implantation-tavi
- Your cardiologist or cardiac surgeon
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Contact us
If you require further information please contact us on:
- TAVI Nurse – Telephone: 01642 854239
- Coronary Care Unit – Telephone: 01642 854801
- Email: [email protected]
Patient experience
South Tees Hospitals NHS Foundation Trust would like your feedback. If you wish to share your experience about your care and treatment or on behalf of a patient, please contact The Patient Experience Department who will advise you on how best to do this.
This service is based at The James Cook University Hospital but also covers the Friarage Hospital in Northallerton, our community hospitals and community health services.
To ensure we meet your communication needs please inform the Patient Experience Department of any special requirements, for example; braille or large print.
T: 01642 835964
E: [email protected]