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40 Robert WoodJohnson
and Drug Administration approved TAVR for
commercial use in treating severe aortic stenosis,
more than 50,000 procedures have been performed
However, valve-in-valve (i.e., a new artificial valve inside
a previously placed surgical valve) procedures are quite
uncommon, and use of the transcarotid approach is
extremely rare, Dr. Turi says. Only about 20 transcarotid
procedures have been performed nationally--two of which
were performed by specialists at the medical school and
RWJUH. Until Rossi's surgery in June, none of them had
involved a valve-in-valve procedure.
"People are afraid to use the carotid approach because
of the theoretical risks involved," says Dr. Lee.
"The brain is fed by the carotid artery. If you interfere
with the blood flow in the carotid artery, there is the poten-
tial risk for stroke," Dr. Turi explains.
As a result, the procedure requires highly specialized
expertise and what has been described in cardiac interven-
tions literature as "a truly dedicated TAVR team approach."
The multidisciplinary team at the medical school and
RWJUH involves specialists in cardiothoracic surgery, vascu-
lar surgery, and interventional cardiology, among others.
During Rossi's surgery, for example, approximately 15 indi-
viduals were present in the hybrid operating room, including
cardiologist Hemal Gada, MD, assistant professor of medi-
cine; vascular surgeon Saum A. Rahimi, MD, assistant profes-
sor of surgery; and Dr. Lee and Dr. Turi, as well as cardiac
anesthesiologists, nursing staff from the cardiac catheteriza-
tion lab and operating room, and technicians.
Expanding Availability of Treatment
hile traditional surgery is still the procedure of
choice for relatively healthy individuals in
need of aortic valve replacement, the availabil-
ity of TAVR and the ability to offer patients a transcarotid
option further expands the number of individuals who can
receive lifesaving treatment, says Dr. Lee.
"We can offer the full spectrum of care related to the
aortic valve, including standard surgery, two different
kinds of minimally invasive surgeries, and several different
kinds of TAVR procedures. As a result, we can really tailor
the treatment to the patient's needs and overall medical
condition," he says. "There is almost no circumstance in
which we can't treat a patient now."
"The idea that there's nothing we can do, there
are no options for you, is really an obsolete discus-
sion," Dr. Turi agrees.
Changes in the availability of the TAVR technique and
its technology have come rapidly, Dr. Turi notes. What
once was a procedure exclusively for people who were
absolutely inoperable has now been expanded to include
individuals who are at high risk from surgery.
"We're using it in healthier patients than before, because
the data about outcomes have been compelling," Dr. Turi
Since the first TAVR procedure was performed in 2002,
Dr. Turi has seen the devices used getting smaller and
smaller--about half the size they were originally, he says.
More patients have expanded options, they are ambulated
and out of the hospital in days instead of weeks, and ongo-
ing refinements are taking place in the technology, he adds.
Improving Outcomes
hile the average age of patients undergoing the
procedure at RWJUH is in the late 80s, Dr. Turi
has performed a TAVR procedure on a patient
as young as 42. But because TAVR patients are typically
older and more frail, the ability to have an alternative to
open surgery has a lot of appeal to patients, Dr. Turi says:
it's a shorter procedure, it involves deep sedation instead of
general anesthesia, it avoids having the chest open in inva-
sive surgery, and there's even a chance they will be able to
sit in a chair that same night. TAVR eliminates some of the
fear people have about surgery in general, he says.
As for Rossi, she has been pleased with the outcome.
"At first I was weak and couldn't do much, but now I'm
getting my strength back. There may be times when I get tired,
but I'll sit down for a few minutes and will be fine. Little by
little, I'm getting better all the time," she says. "The last three
years had been an ordeal, but so far, it seems to be successful."
Another positive outcome is the improvement in her
appetite, she says. In the years prior to the surgery, she had
lost more than 50 pounds, bringing her well below the
acceptable weight range for a woman of her height. She
would have a piece of chicken smaller than her palm and
only be able to eat less than half of it, she recalls: "Now I'm
able to eat more, which I'm really happy about. My appetite
is still improving, and I'm hoping to gain more weight to get
into the correct weight range."