Open-heart Surgery Vs TAVI: A New Alternative in India?
What is TAVI
There are numerous cardiac conditions. Among them, heart attack or heart blockage of vessels supplying the heart affecting the heart are commonly known. Conditions like valvular heart disease are less known. When it comes to valvular heart disease, age-related calcification and degeneration of the valves result in a reduction in opening amplitude, which impairs blood outflow. One such valve, the aortic valve, located below the main artery, is referred to as an aortic valve, and any restriction to it is referred to as aortic stenosis (AS).
The only viable therapy option for people with AS, who are 80 and 90 years old, up until recently was open heart surgery. Being elderly increases the danger of undergoing such a debilitating procedure. In addition, concomitant conditions including kidney and lung problems would increase the risk. The transcatheter aortic valve implantation (TAVI) procedure, which replaces the valve without opening the heart, has recently been created to circumvent these limitations of surgery.
The risk factors for AS include family history, increased cholesterol levels and bicuspid aortic valve which is commonly seen in India. It degenerates rapidly compared to a normal valve and presents early due to that. Chest pain, dizziness or blackouts and breathlessness are the cardinal symptoms of AS. As is diagnosed by echocardiogram. It determines the gradient across the valve or the level of stenosis which is quantified and the severity of the condition. A detailed CT scan analysis is done before undergoing the procedure to help determine the size of the valve and leg arteries and to help determine the chances of complications.
Balloon expanding valves (BEV) and self-expanding valves are the two different types of TAVI valve platforms (SEV). In BEV, the damaged valve is placed directly across a balloon that is extracted from the leg arteries. The mounted valve is subsequently opened by the balloon’s inflation, pressing the native, failing valve. When the balloon is inflated, the new valve begins to work. For SEV, the valve is installed on a capsule that blooms out when passed over the damaged valve as the capsule is pushed out by a revolving mechanism by the operator.
The requirement for permanent pacemaker implantation (PPI), which can range from 1 to 5%, is the most frequent complication. With BEV, it’s higher than SEV. Another potential problem is an injury to the leg artery during the procedure, which may need stenting the artery. In some instances, it may be necessary to stop any paravalvular leaks or leaks that occur through the sides of valves. Less than 1% of patients will experience a stroke, which is a much lower likelihood than open surgery.
This is a procedure done under sedation. The ECGs are monitored for complete heart blocks and the requirement for PPI after the surgery. On day two of the treatment, echocardiography is performed to look for any obstruction or valve leakage. Contrary to surgery, the recuperation period following a procedure is extremely brief; in fact, patients are discharged the day after the operation.
What is SAVR?
Thousands of patients with varying degrees of aortic stenosis have undergone this open-heart surgery. However, low-risk patients now undergo the bulk of SAVR procedures. The mortality of SAVR during surgery varies depending on the patient’s health.
Patients with moderate or severe AR need to be watched carefully in case a surgical indication for the aortic valve develops. The mainstay of treatment for symptomatic severe AR or severe silent AR with LV systolic failure is aortic valve surgery (mostly aortic valve replacement). Only symptomatic individuals (or asymptomatic patients with LV systolic failure) who are not candidates for aortic valve surgery can receive pharmacologic therapy for severe chronic AR.
Additionally, to prepare for aortic valve surgery, individuals with significant AR symptoms need pharmacologic therapy. Patients with moderate or severe AR need to be watched carefully in case a surgical indication for the aortic valve develops. An incision is required during a SAVR procedure to gain access to the heart. The damaged aortic valve is then taken out and replaced with a new valve. Before the invention of TAVI, SAVR was the standard of care for people with severe aortic stenosis.
Surgery on the aortic valve is likewise not advised in mild to moderate AR cases. In the presence of less severe AR, symptoms, LV dilation, or a decreased EF should not be taken to mean that the AR is responsible for them.
TAVI across India
TAVI has undergone rigorous clinical trials and has demonstrated that it is just as excellent as or better than surgery in high-risk patients. As a result, the USFDA has authorised TAVI as an alternative to surgery for low to high-risk AS.
Currently, both rheumatic and non-rheumatic AS are overrepresented in India. A ray of optimism exists for the future of rheumatic AS even though TAVI has transformed the treatment of non-rheumatic AS. Due to a dearth of epidemiological research in this group, it is challenging to estimate the true burden of AS in India. Many patients are eligible for TAVI, according to various estimations.
The average Indian patient cannot afford TAVI, which is its only downside. For international valves, the average TAVI surgery would cost upwards of 20 lakhs. India’s TAVI implementation is still moving along quite slowly because of several barriers. Policymakers and healthcare professionals must recognize the advantages of this breakthrough and take the necessary action to facilitate the adoption of TAVI throughout the nation. Excellent valve platforms have now been produced by Indian enterprises, which have reduced the expense of maintaining the quality. Additionally, the overall cost of the treatment may go down over time.
India has recently risen to the top of the list of medical travel destinations. The availability of a large number of doctors who are specialists in many branches of medicine, as well as affordable treatment options, is the key cause of this. The scenario is the same when it comes to TAVI. For operations like TAVI, a lot of patients from around the world travel to India. Additionally, TAVI surgery is carried out in numerous hospitals across India, and patients report an increase in quality of life 30 days after the operation. Thirty or more locations in India currently offer TAVI, with seven centres bearing the lion’s share of the workload.
TAVI is a huge boon for individuals who had no other options than surgery up until this point. Of all the medical breakthroughs that have occurred in the past ten years, TAVI has had the biggest impact on the ability of nonagenarians and octogenarians to live longer.
- What is TAVI? (TAVI) | American Heart Association. Accessed August 12, 2022. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/understanding-your-heart-valve-treatment-options/what-is-TAVI
- Natural history and management of chronic aortic regurgitation in adults – UpToDate. Accessed August 12, 2022. https://www.uptodate.com/contents/natural-history-and-management-of-chronic-aortic-regurgitation-in-adults