A unique procedure is successfully replacing the heart valves of rheumatic heart disease patients without resorting to open heart surgery.

New Zealand cardiothoracic surgeon Dr El Gamel is successfully using a procedure called transcatheter aortic valve implantation (TAVI) also known as transcatheter aortic valve replacement (TAVR).

Since the 1950’s aortic valve replacement has required open heart surgery, in which the heart is stopped and the chest is surgically open for the procedure. 

However, the TAVI approach delivers a replacement valve without the need for open heart surgery.

World-renowned heart surgeon, Dr El Gamel was one of the first to trial the TAVI procedure at Kings College, London.

RHDAustralia asked Dr El Gamel about this fairly new surgical approach and the implications for rheumatic heart disease patients. 

What leads to someone requiring valve replacement for rheumatic heart disease?

Prophylactic treatment (monthly penicillin injections) can prevent rheumatic valve disease but there are many barriers to success:

It’s not one aspect, its multiple health issues, but it’s all related to the same thing - poverty and the unaffordability of looking after yourself.

Lack of access to primary health care is another reason. Even if you wanted to go to the doctor, in many places people don’t live close by to where good doctors are, so you don’t go anywhere.

Pictured above: Dr El Gamel

Rheumatic heart disease is a chronic problem. When you are feeling well you are not inclined to go to the doctors. One of the real difficulties is that it is a chronic condition. Take dental health as an example, we only go to the dentist when we have pain and that may be too late!  Most people finish the course of antibiotics when they feel better; the motivation is not there to continue treatment even if they need it.

Finally, culture. Many kids from Aboriginal and Maori backgrounds associate hospitals with pain, suffering, and death. They experience family members going to hospital and often not returning. There is a real fear of hospitals and lack of trust of the Western medical system. Different to the Western-raised child who thinks highly of hospital and new technology; they may still think of hospitals as places for sick people. In general, though most trust the healing of science.

What is transcatheter aortic valve implantation (TAVI) and how does it work?

I think transcatheter aortic valve implantation (TAVI) will be the future of valve operations. In time it will replace a lot of conventional open heart surgery operations.

Since the 1950’s surgeons have been able to operate on the aortic valve with open-heart surgery. To do this a large incision is made in the chest and the heart stopped for a time so that the surgeon can repair or replace the valve(s).

A lot has happened in the last 50 years, and technology has improved to make open-heart aortic valve surgery safe and effective in those that require it, but open heart surgery is still a big invasion to the human body. People take anywhere from a few weeks to 3-4 months recover.

Now, with imaging technology and the machinery that we have, newer, less invasive techniques have been developed to replace or repair heart valves.

For example, in the last 20 years, coronary artery surgery has been replaced with percutaneous coronary intervention. The value is that you don’t need to stop the heart, there is no incision in the chest and a shorter recovery time.

Can we do the same for the valves? This is where TAVI has come up.

10 - 15 years ago, the idea came up that if we could collapse the valve and make it small, put it in the tube, pass the tube towards the heart, position the valve where you need it, open it with a balloon and everything is done. The valve is in place. The patient can go home in 2-3 days and all they have is a small puncture in their groin from where the tube insertion was made.

For young people with rheumatic heart disease, that can be life changing.

What are the advantages of transcatheter aortic valve implantation (TAVI) in comparison to the standard valve replacement?

When it’s done well it’s very rewarding. There is no opening up the chest, it’s a quick procedure, no blood transfusion, anesthetic time is short and the patient can recover quite quickly.

With any valve replacement procedure, none of the valves work forever. We mostly get valves from an animal, which have a shorter life span – so they only last 10 years or less.

With transcatheter aortic valve implantation (TAVI), because we haven’t opened the patient's chest already, repeat procedures are possible. With this new technology, it’s less of a problem to do a repeat procedure. When the valve is no longer working we can put another in. You can take the patients to 10, 20 or 30 years without opening up their chests.

People can live until they are much older, before there is a need for an open heart operation. The patient may need open heart surgery at some stage, but it will be later in life.

What is the disadvantage of transcatheter aortic valve implantation (TAVI) in comparison to the standard valve replacement?

Expense.

Normally the valve for standard open heart surgery cost 6,000 euros [approx. 8,860 AUD]. Transcatheter aortic valve implantation (TAVI) is 30,000 euros [approx. 44,309 AUD].

Like everything else (such as computers) as more companies get into the market and produce the valves – the price will go down.

But we also have to think differently – maybe the surgical valve is cheaper with standard valve replacement but the time of the surgeon and the time in hospital is greater. In fact, if we look at the economics in a broader sense, as in the whole journey of the patient, the TAVI procedure is not more expensive.

A patient receiving TAVI doesn’t have to take too long off work, someone doesn’t need to look after them, a nurse doesn’t need to take them home, they stay in hospital for less time and they don’t require someone to treat and prevent infections at the surgical site.

What are the risks for transcatheter aortic valve implantation (TAVI)?

Transcatheter aortic valve implantation (TAVI) has predominantly been conducted on older patients with high-risk factors; hence their risk of death and complication is currently a lot higher. Possible complications include: stroke, kidney failure, valve leakage, vessel damage, and death. 

For TAVI the risk of death is 3-4% and the risk of complication is about 10%.

For open heart surgery the risk of is death 2-3% the risk of complication is the same 10%.

Technology continues to develop to make the procedure as safe as possible.

Who is a good candidate for transcatheter aortic valve implantation (TAVI)?

Older patients who have a lot of risk factors, renal problems, chest problems and cannot withstand open heart surgery are good candidates for this type of valve surgery.  

Currently in New Zealand, under the national health system, patients have to be assessed as to whether that they are a good candidate for the procedure – and this generally means they are older patients who cannot withstand open heart surgery.

TAVI is also available in Australia in selected patients.

How many people have had the transcatheter aortic valve implantation (TAVI) procedure?

Worldwide it’s thousands. I myself have done approximately 300.

I was part of the first trial of the transcatheter aortic valve implantation (TAVI) procedure at Kings College, London. We started doing this on elderly patients: people who have a lot of risk factors.

The valves can be put in somebody who is young. There is a partner trial in the USA currently running on young patients. So in the next five years, we will have better insight into the long-term outcomes of people who undertake this procedure.

How long has this procedure been available in New Zealand and Australia?

Approximately six years.

In 2013 an article published in the International Journal of Cardiology titled “Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: The SOURCE ANZ registry: Outcomes at 30 days and one year,” concluded that the introduction of TAVI in the Australia and New Zealand clinical environment, in a select high-risk cohort of patients, has demonstrated excellent outcomes.

Will this procedure one day replace the standard valve replacement for rheumatic heart disease patients?

I predict in the next 10 years or so standard valve replacements will be something of the past.