Transcatheter aortic valve replacement (TAVR) for patients with severe aortic stenosis has been widely available since 2011, but it was only recently approved for patients at the Rocky Mountain Regional VA Medical Center, a clinical partner of the University of Colorado School of Medicine.
That’s thanks to the efforts of Muhammad Aftab, MD, associate professor of cardiothoracic surgery at the University of Colorado Department of Surgery and surgical director of structural heart disease and chief of cardiac surgery at VA Eastern Colorado Health Care, and Neel Butala, MD, assistant professor of cardiology in the CU Department of Medicine and medical director of structural heart disease at VA Eastern Colorado, who worked with the VA to approve the minimally invasive procedure that allows patients to return home the next day.
“We brought this technology to the VA because veterans deserve the best care possible, the same way we take care of our patients at the University of Colorado Hospital,” Aftab says. “It was a huge process to set up a program, prepare the team and send them to University Hospital for training. They observed it first, then we did several mock procedures where we did the entire procedure as a pretend procedure in the hospital.”
Aortic stenosis is a life-threatening heart condition in which the aorta, the artery that carries blood from the heart, becomes so narrow that blood can barely pass through. Symptoms include dizziness or lightheadedness when going from sitting to standing, fluid backing up into the legs or lungs, causing swelling and difficulty breathing, respectively, and pressure or pain in the chest.
“It’s a fixable problem, and fixing it completely changes people's lives,” Aftab says. “But if you don't fix the problem, the patient will die. When they start passing out, they start having heart failure, they are dead within two to five years if you don't treat them.”
While the treatment for arterial stenosis has historically involved open surgery, the TAVR treatment is a minimally invasive option in which a compressed artificial valve is threaded through the blood vessels, starting in the leg, and expanded once in place.
“It essentially replaces the valve,” Butala says. “And most people go home the next day, compared to open heart surgery, where people are in the hospital for a week and are still recovering a few months down the line.”
Most gratifying for those performing the procedure, many patients notice an immediate improvement afterward.
“After the procedure, they'll say, ‘I can breathe better, I feel better, I have more energy,’” Butala says. “TAVR is one of the most gratifying cardiovascular procedures, because you’re treating an illness that can kill people. You're reducing the likelihood of someone dying, but you’re also making them feel better. People often notice a difference.”
Aftab and Butala both completed fellowships in the TAVR procedure — Aftab at the Cleveland Clinic and Butala at Mass General Hospital in Boston — and they work together to perform the procedure at the VA.
“We started in April, and we have done 14 procedures so far with outstanding success, no mortality, and the patients are doing great,” Aftab says. “Aortic stenosis is a disease of aging, and you can't stop aging. In the past, some of these patients who are in a good health would be candidates for open surgery when they are elderly, whereas a very large number of patients who are frail and have multiple medical problems like severe COPD, chronic kidney disease, and advanced age — the concern has been that they would not tolerate open surgery, and they have been turned down. We are able to treat those patients with TAVR.”
Aftab says veterans are coming from across Colorado and surrounding states such as Wyoming and Montana to get the procedure — previously if they wanted TAVR, he says, they would have to go to a community hospital and find a surgeon and cardiologist trained in the procedure.
Aftab says that developing a TAVR program required multidisciplinary teamwork, involving not only a close collaboration between the cardiothoracic surgery and cardiology teams, but also with the cardiac imaging, cardiac anesthesia, ICU team, OR, and cath lab staff. “All work together as a ‘Heart Team’ approach,” he says. “Other team members instrumental with the TAVR program include Dr. Bilal Aijaz, from interventional cardiology, Dr. Tessa Genders, from cardiac imaging, and Dr. Michael Cain, from cardiothoracic surgery.”
Aftab says it takes a village to care for complex cardiac patients and develop advanced cardiac programs.
“We are grateful for the support of the leadership of Rocky Mountain Regional VAMC and our partnership with the TAVR program at the University of Colorado Hospital, especially the support of Dr. Joseph Cleveland and Dr. John Messenger in cross-training the OR and cath lab teams at the VA hospital,” he says. “Not every patient is a candidate for TAVR — some come in with more complex disease, and we have to do open-heart surgery — but everyone gets the state-of-the-art care. That's the goal.”
Featured image: From left, Muhammad Aftab, MD, Neel Butala, MD, and Bilal Aijaz, MD, members of the "Heart Team," after performing the TAVR procedure at the Eastern Colorado VA in Aurora.