Transcatheter Aortic Valve Replacement (TAVI):

Transcatheter aortic valve replacement ( TAVR ) or Transcatheter aortic valve implantation ( TAVI ) is a nonsurgical heart procedure performed by an expert interventional cardiologist at the cardiac cath. Lab. of a heart hospital to either repair a faulty or damaged aortic heart valve or to replace it. At CMCS Health we are associated with the best Interventional cardiologist in India to perform Transcatheter aortic valve repair/replacement ( TAVR ) at top Heart hospitals in India. Ask us about the Transcatheter aortic valve replacement (TAVR) cost in India with the best interventional cardiologists in India.

Etiology of Aortic valve disorder:

The aortic valve stenosis is calcification and damage to the aortic valve in the elderly population. The etiology of aortic valve disorders varies from congenital malformations ( bicuspid or unicuspid ) to calcification, and rheumatic disease. Aortic stenosis causes left ventricular outflow obstruction. The development of aortic valve stenosis can be attributed to the following factors:

Congenital:

Children born with a congenital defect in the aortic valve ( bicuspid or unicuspid ) later develop aortic stenosis due to superimposed calcification.

Acquired factors responsible for aortic stenosis:

• Rheumatic valve disease is the most common cause of aortic stenosis in developing countries
• Calcification of tri-leaflet valve
• A very rare genetic disease Alkaptonuria, also called black urine disease. Ochronosis, a degenerative arthritis due to Alkaptonuria.
• An autoimmune disorder Systemic lupus erythematosus 
• Irradiation is the use of high-energy radiation from X-rays, gamma rays, neutrons, and protons to kill cancer cells or reduce the size of the malignant tumors, and may also be the causative factor for aortic stenosis.
• Electrolyte imbalance as in the case of end-stage renal disease patients
• Metabolic diseases such as Fabry disease
• Hypertrophic cardiomyopathy may cause dynamic subvalvular stenosis

Epidemiology of aortic stenosis:

Prevalence of calcific aortic stenosis is more common in elderly people, it increases with age increase. 29% of people above the age of 65 were found to be suffering from aortic stenosis. Overall prevalence was found to be 9% to 45% in the mean age group of 54 to 81 years, with higher prevalence with increasing age.

Calcific aortic stenosis is more common in North America and Europe whereas rheumatic valve disease was found to be more common in developing countries including the African continent.

Symptoms of aortic valve stenosis:

The symptoms of aortic valve stenosis develop over a period of time. Many aortic valve deformity or aortic valve stenosis patients do not exhibit any symptoms for years. Symptoms of aortic valve stenosis usually appear when the damage to aortic valve is severe. The mortality rate, if not treated in time is as high as 90% within a few years of onset of the symptoms. The symptoms when they are noticed could be:

• Feeling shortness of breath even after small exertion or physical activity
• Feeling heaviness or tightness in the chest area or chest pain
• Dizziness or bouts of falling unconscious ( syncope )
• A feeling that the heart is beating too fast or palpitation
• A heart murmur
• Generalized feelings of tiredness or low energy levels

Complications arising due to aortic valve diseases:

Aortic valve disease is treatable but if not diagnosed and treated in time, it may cause serious life-threatening complications:

• Patients with severe aortic stenosis and who are symptomatic are prone to sudden death and should be referred for Aortic valve replacement promptly. Sudden deaths also occur in patients with severe aortic stenosis but who are asymptomatic
• Heart failure is the most common complication of aortic valve stenosis
• Pulmonary hypertension 
• Infective carditis, especially the patients with bicuspid aortic valve
• Increased risk of gastrointestinal tract ( GI ) bleeding due to acquired von Willebrand Syndrome
• Cerebral or systemic emboli due to calcific emboli from the aortic valve 

Diagnosis of Aortic valve stenosis:

The attending clinician will do a physical examination of the patient, take a detailed medical and family history, and also try to hear any distinct heart murmuring sound with a stethoscope indicative of aortic valve stenosis. Doctors will also recommend the following laboratory and imaging tests:

Echocardiogram:

An echocardiogram or echocardiography creates pictures of the heart by using sound waves. An echocardiogram shows the pattern of blood flow through the heart and heart valves. An echocardiogram can also detect any weak heart muscle and also the extent of aortic valve stenosis. 

Transesophageal echocardiogram (TTE) is a special type of echocardiogram that helps in getting a better look at the aortic valve. In TTE an ultrasound probe contained in a flexible tube is guided down through the throat and into the esophagus and placed near the heart.

Electrocardiogram (ECG or EKG):

An ECG or EKG measures and keeps track of the electrical impulses of the heart. An ECG reflects how fast or slow the heart is beating and also the signal patterns indicative of any heart disease and swelling of the heart chambers.

Stress test or dobutamine stress test:

In the stress test, the patient needs to walk on a treadmill or ride a stationary bicycle and the technician will look for any symptoms of physical activity-induced aortic valve disease. If a patient is not able to walk on a treadmill or ride a stationary bicycle, the patient will be injected with dobutamine which gives the same effect of physical exertion.

Chest X-ray:

The attending interventional cardiologist will recommend a chest X-ray to determine the health of the heart and lungs. Chest X-ray will reflect an enlarged heart which could be indicative of aortic valve stenosis. A chest X-ray will also show a swollen aorta and stenosis of aortic valve.

Heart CT-scan:

A heart CT scan takes multiple X-ray images of the heart. These X-ray images provide a detailed cross-sectional view of the heart and help in measuring the size of the aorta and the real-time structure of the aortic valve. 

Heart MRI:

A cardiac MRI may also be recommended by the attending interventional cardiologist. A heart MRI will reflect the size of the aorta and also help in determining the severity of aortic valve stenosis.

Heart Angiogram:

Although a heart angiogram or cardiac catheterization is usually not recommended for diagnosis of aortic valve disease it is useful if other diagnostic tests are not able to provide an accurate insight into the condition of the aortic valve. It also helps in determining if the coronary arteries are also blocked.

After receiving the results of the above investigation the attending cardiologist can confirm the diagnosis of an aortic valve disease. These investigations will also help the cardiologist in determining the stage of the disease. Accurate staging of aortic valve disease will help the treating cardiologist in determining the best-suited and tailor-made treatment plan for aortic valve disease patients.

Stages of Aortic Valve Disease:

Aortic valve disease is broadly classified into four stages.

• Stage 1 is the medical condition where the risk factors of an aortic valve disease are present.
• Stage 2 is the medical condition where the aortic valve disease is mild or moderate but asymptomatic.
• Stage 3 is the medical condition where the heart valve disease is severe but asymptomatic.
• Stage 4 is the medical condition where the heart valve disease is severe and causes symptoms.

Treatments for Aortic Valve Disease:

Heart valve disease can be a chronic disease. It develops over a period of time. Many heart valve disease patients may live a full life with this medical condition, however, some patients' medical conditions may deteriorate gradually with noticeable symptoms. In such patients, immediate medical treatments are a must to avoid life-threatening complications like a heart attack, a stroke, or even heart failure. Depending on the stage of aortic valve disease, the attending cardiologist may recommend the following treatment modalities:

• Lifestyle changes and medical management
• Aortic valve repair or replacement surgery
• Non-surgical ( Transcatheter ) aortic valve repair or replacement procedure

Most of the heart valve diseases are treatable. Lifestyle changes and medical management may relieve the symptoms and delay the disease progression but they do not treat the medical condition. 

The attending cardiologist may recommend either aortic valve repair ( if possible ) or aortic valve replacement surgery. In certain cases, the cardiologists may recommend a nonsurgical procedure Transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation ( TAVI).

The Need for Transcatheter Aortic Valve Replacement (TAVR):

A TAVR or TAVI heart procedure is needed if the aortic valve of the heart is either faulty or damaged due to aortic valve stenosis. In aortic valve stenosis, the heart's aortic valve thickens and becomes stiff and narrow. As a result, the valve can't fully open or close and blood flow to the body is reduced. A TAVR / TAVI procedure improves the blood flow in the heart by replacing an aortic valve that doesn't open fully. Many Patients with aortic valve stenosis have a better quality of life after having TAVR / TAVI and their symptoms, such as chest pain and breathlessness improve. TAVR / TAVI is minimally invasive, which means it uses smaller incisions than open-heart valve surgery. It is an option for patients who can't have open heart surgery to replace the aortic valve. Following aortic valve stenosis patients are advised for TAVR / TAVI procedure:

• Patients who have severe aortic stenosis that causes symptoms such as chest pain and shortness of breath.
• A previous biological tissue aortic valve isn't working well.
• Patients with other health conditions, such as lung or kidney disease make open-heart valve replacement surgery too risky.

Preparing for TAVR / TAVI:

When the treating cardiologist recommends a TAVR procedure for correction of aortic valve disease after carefully examining all the imaging investigations and laboratory workup of the patient, the TAVR procedure date is given by the interventional cardiologist. The patient is also briefed about the procedure, the outcome, and the possible complications. The intervention cardiologist will brief the patient about the two types of replacement aortic valves ( Mechanical or biological also called tissue valves) and their pros and cons. Usually, a biological or tissue valve is used in the TAVR procedure.

• The patient has to stop any blood thinning or anticoagulation medication seven days before the TAVR procedure unless the doctor advises otherwise.
• Patients may be advised to use mupirocin nasal ointment twice a day, three days before the procedure.
• Patients may also be advised to discontinue Warfarin three days before the TAVR.
• Patients who are taking ACE inhibitors like enalapril or lisinopril or ARB like valsartan or irbesartan will be advised to stop these medications two days before the TAVR procedure.
• Patients will be advised to undergo a pre-anesthesia checkup ( PAC ) with the anesthesia team for general anesthesia clearance.
• Diabetics taking metformin may be advised to take only the morning dose one day before TAVR.
• The long-acting insulin dose will be reduced to half on the night before the TAVR procedure. 
• You will be put on NPO ( not eating after midnight ) before the TAVR procedure.

More useful information while preparing for the TAVR procedure can be downloaded as a PDF published by the University of Washington Medicine Center patient education.

The process of the Transcatheter aortic valve replacement (TAVR) procedure :

Transcatheter aortic valve replacement (TAVR) procedure is a minimally invasive procedure to replace a damaged or faulty aortic valve. A TAVR procedure is performed in a cardiac catheterization laboratory ( Cardiac - cath. lab.) by an experienced intervention cardiologist. At CMCS Health, we are associated with the best interventional cardiologist in India for cost-effective TAVR procedures. 

A TAVR procedure is generally performed under local anesthesia but the intervention cardiologist may decide to do the procedure under general anesthesia as well. Depending on the overall health and condition of the blood vessels of the patient. The interventional cardiologist may perform the TAVR by using different blood vessels. The most common blood vessel used by the interventional cardiologist for the TAVR procedure is the femoral artery in the groin region. The team of doctors involved in performing the TAVR procedure will inject local anesthesia near the access site ( either the wrist or groin region ) so the patient will not feel any pain, and a small catheter will be inserted through the skin and into the artery at the selected site. The intervention cardiology team will monitor the progress of the catheter into the heart through dynamic X-rays transmitted to a monitor screen. A patient does not feel the catheter going through the heart as there are not many nerves in the blood vessels of the heart. Once the catheter head reaches the desired place in the heart an X-ray-sensitive dye ( a contrast media ) is injected through it. Further dynamic X-rays are captured as contrast media follows through the heart blood vessels. The Interventional cardiologist sends a biological (tissue)  valve through the catheter and places it in the area of the aortic valve. A balloon on the catheter tip expands to press the new aortic valve into place. Some of the replacement valves expand without the use of a balloon. At times the intervention cardiologist will place the replacement biological valve into a pre-existing valve that no longer works. Once the new aortic valve is secured in place, and doctors ensure that it is working properly with no leakages or disruption of the heart's electrical signals, the catheter is removed. The opening of the blood vessel through which the catheter was inserted is sealed tightly.

The different approaches for performing a TAVR procedure: 

The intervention cardiologist can approach the aortic valve in the left ventricle of the heart through different blood vessels, depending on the overall health of the patient and the condition of the blood vessel.

• The most common site for catheter insertion is the femoral artery near the groin or thigh joint area.
• If the femoral artery is too small or damaged, the catheter is inserted through the blood vessels in the chest. Such an approach is called transapical access.
• If the femoral artery is small or damaged the interventional cardiologist may use blood vessels in the the stomach area for a TAVR procedure. This approach is called the transcaval approach and is very useful for a TAVR procedure in high-risk cases and women. Although it is not a very common TAVR procedure approach, but is well-acknowledged as a standard approach for high-risk patients.
• For patients who had heart surgery before or where the approach through the chest blood vessels is not possible, the interventional cardiologist may perform the TAVR procedure through the blood vessel under the clavicle or collar bone.
• Another not very common but useful approach when the other approaches are not possible is the carotid artery in the neck.
• Although rare at times the interventional cardiologist may perform the TAVR procedure through the Septum, the wall of the tissue that separates the right and left atria of the heart.

The new approaches adopted and perfected by our expert interventional cardiologists have made the TAVR procedure available to many aortic valve stenosis patients.

Post TAVR/ TAVI procedure care:

Once the interventional cardiologist completes the TAVR procedure, the patient is shifted from the cardiac cath. Lab. to the recovery room and subsequently to the cardiac ICU for close observation. The majority of the patients are discharged from the hospital the next day when the team of treating doctors finds everything to be normal and the correct functioning of the newly replaced aortic valve. Some of the patients may stay longer in the hospital to attend to total normalcy and proper functioning of the newly implanted aortic valve. At the time of discharge, the treating doctor's team will advise the patient about wound care and to be careful about any possible infection symptoms.

Certain medications may also be prescribed by the team of treating doctors including:

• Blood thinning or anticoagulant medications 
• Antibiotics for preventing any infection

Most of the heart valve infections come from the bacteria in the mouth. Good oral hygiene including teeth and mouth can help prevent these infections. Patients will also be advised for regular dental checkups. Antibiotics may be prescribed for use before certain dental procedures.

Best TAVR procedure doctors in India:

We are associated with the best interventional cardiology doctors in India for transcatheter aortic valve replacement procedures. Our most experienced, well-trained, and qualified Interventional cardiology doctors perform TAVR procedures at the most affordable cost and par success rates with the best in the world. The best TAVR procedure doctors in India are:

1. Dr Manjinder Sandhu at Fortis Memorial Research Institute, Gurugram, India.
2. Dr. Ashok Seth at Fortis Escorts Heart Institute, New Delhi, India.
3. Dr. T. S. Kler at BLK Max Super Specialty Hospital, New Delhi, India.
4. Dr. K. K. Saxena at Indraprastha Apollo Hospital, New Delhi, India.
5. Dr. Sanjay Tyagi at Indraprastha Apollo Hospital, New Delhi, India.
6. Dr. Rajneesh Kapoor at Medanta - The Medicity Hospital, Gurugram, India.
7. Dr. Kuldeep Arora at Artemis Hospital, Gurugram, India.
8. Dr. Jamshed Dalal at Kokilaben Hospital, Mumbai, India.
9. Dr. Robert Mao at Apollo Hospital, Chennai, India.
10. Dr. Sunil Kumar at Apollo Hospital, Hyderabad, India.

The top TAVR procedure hospitals in India:

We offer cost-effective TAVR procedures with the best interventional cardiologists at top heart hospitals in India. Most of the well-known heart hospitals in India are Joint Commission international and NABH accredited. The Top Indian hospitals for TAVR procedure are:

1. Medanta - The Medicity, Gurugram, India.
2. Fortis Escorts Heart Institute, New Delhi, India.
3. Fortis Memorial Research Institute, Gurugram, India.
4. Artemis Hospital, Gurugram, India.
5. Indraprastha Apollo Hospital, New Delhi, India.
6. BLK Max Super Specialty Hospital, New Delhi, India.
7. Nanavati Max Super Specialty Hospital, New Delhi, India.
8. Apollo Hospital, Chennai, India.
9. Apollo Hospital, Bengaluru, India.
10. MGM Healthcare, Chennai, India.

Transcatheter aortic valve replacement (TAVR) cost in India:

The cost of a TAVR procedure in India depends on many factors that include the hospital setup, expertise of the interventional cardiologist, The approach ( which blood vessel is used ) for the TAVR procedure, the type of replacement valve used overall hospital stay for the patient.

The cost of the TAVR procedure also depends on the cross-consultation of the different specialists like the endocrinologist and nephrologist ( if needed ). The generalized cost of the TAVR procedure in India :

Frequently asked questions about the TAVR procedure:

Why will I need a TAVR procedure?

Any patients who have severe aortic stenosis either symptomatic or asymptomatic and who can not go for an open heart surgery because of higher risk ( due to advanced age, existing kidney or lung disease ) or who already have any cardiac implant like an ICD or pacemaker are good candidates for a TAVR procedure.

Is TAVR a high-risk heart procedure?

Like any complicated cardiac surgery, a TAVR procedure also carries certain risks. But considering that a TAVR procedure is taken up for high-risk patients who are prone to sudden death, your treating interventional cardiologist will discuss all the pros and cons of the procedure with you before recommending a TAVR. Clinical studies have shown that a TAVR procedure is safe and effective. Moreover, our team of interventional cardiologists has the desired qualifications competency, and vast experience in performing a TAVR procedure with a par success rate as compared to the best in the world.

What kind of replacement aortic valve will be used during the TAVR?

In the majority of the TAVR procedure, the biological or tissue valve is used. You can ask your doctors about the benefits of a mechanical valve or a tissue or biological valve. Your treating interventional cardiologist will help you in selecting the best-suited replacement aortic valve by discussing with you, your medical condition and the benefits and disadvantages of both types of valves.

How long will I be staying in the Hospital for the TAVR procedure?

Usually, a patient will stay in the hospital for two to three days post a successful TAVR, but your treating interventional cardiologist and the other expert doctor's team will keep a close observation on your progress and decide about your stay in the hospital. Once they are sure that now you can be safely discharged, they will discharge you with advice for medications, lifestyle changes, and certain dos and don'ts for ensuring the maximum benefit and minimizing the risks.

How Long will I be staying in India after a successful TAVR procedure?

After your discharge from the hospital, you will see your treating doctor's team for follow-up. Usually, you will see your treating doctor at least twice post-discharge to keep track of your progress. Once your treating doctor is confident of the success of your TAVR procedure and feels that it is safer for you to return to your native country, you will be given a fitness to fly certificate to fly back to your native country and home. In general, a patient is advised for at least two to three weeks stay in India post a successful TAVR for cardiac rehabilitation.

How soon can I return to my normal activities post a successful TAVR?

Although a patient will be able to start the core activities within 1 to 2 weeks of the TAVR procedure, the full recovery will be different for every individual patient. Usually after 2 - 6 weeks of the TAVR procedure, you can resume your normal activities.

Do I need to come back to India for a follow-up?

Usually after the Successful TAVR procedure and a full recovery, you do not need to come to India. For follow-up. Your local treating doctor will keep track of your health. In case of any complications or issues, we will help you connect with your TAVR procedure doctor in India with a video consultation.

How CMCS Health will help me in my TAVR procedure?

Once your medical reports and medical advice from your local treating doctors are received by us, we discuss your case with the best TAVR specialist doctors from top TAVR hospitals in India. We asked them about the treatment course, cost of treatment, success, rate, and hospital and India stay required. We compiled all the information and sent it to you with profiles of the best TAVR specialist doctors in India. We empower you to choose the best Indian specialist for your TAVR procedure. Once you decide about your treating doctor and hospital, we will send you a performance invoice and visa assistance letter from the treating hospital for medical visas. We assist you with your medical visa and travel itinerary. We schedule your appointments with your treating doctors before you arrive in India for a prompt start of your medical treatment. Upon receiving your air ticket details, we will make arrangements for your airport pick-up. We also arrange a budget hotel room or a guest house room with a well-furnished kitchen as per your need and budget. We will provide a dedicated patient care executive who is well-versed in your local language and English, to coordinate your medical treatments and India stay. After successful medical treatments, we will arrange your airport drop for your return to your home. We will help you in your medical treatment follow-up once you reach back your home cured and happy.

The latest technology, state-of-the-art infrastructure, and low treatment costs with the highest success rates have made India the preferred destination among Global medical travelers.

We thrive to provide you best services as your Global Healthcare Guardians.