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1. What is aortic stenosis?

The aortic valve is the heart valve which must open to release blood from the pumping heart into the circulation. When this valve is stiff with the leaflets partially stuck together the heart will in effect have to work harder to eject blood and the diagnosis is caused aortic stenosis. This will generally make patients progressively breathless as this becomes more severe but can also cause chest pain, excessive fatigue or falls & collapses.

2. What happens during a transcatheter aortic valve implantation (TAVI) procedure?

A TAVI is a procedure to replace the faulty aortic valve by deploying a new valve through an artery (normally the one at the top of your leg) which is collapsed into a catheter and opens up when in the correct position either using a balloon or a self-expanding frame. This is an alternative to open heart surgery and means recovery times are much quicker.

When you have a TAVI, you will normally come to one of our hospitals the night before but sometimes the morning of the procedure if this is to take place in the afternoon. You will be brought into our cath lab and have some local anaesthetic to both groins and sometime also to your right wrist. You may also be given some sedative medication to keep you relaxed. Catheters will be passed through your groin arteries and a temporary pacing wire is normally introduced through a vein (unless you have a pacemaker already). Your heart beat will be sped up and the new valve will be released. Once we are happy with the new valve position and function, we will take all of the catheters out and seal up your groin artery with some internal stitches or collagen based plug devices.

After this, you will rest in bed for most of the rest of the day but the following day will be up walking around and ready for discharge home either this day or the next. 

3. What tests are required and how do I get approved for a TAVI?

Prior to being approved for a TAVI you will need to have an echocardiogram (ultrasound of your heart) to look at the moving heart valves, a specialised CT scan to analyse your heart anatomy and a coronary angiogram to check whether the heart’s blood supply is blocked. You will consult and discuss the option for TAVI with one of our TAVI doctors and they will present you at a multidisciplinary (MDT) meeting involving a co-ordinator, a heart surgeon, two cardiologists and other specialists to agree that TAVI is a suitable and safe treatment for your condition.  

4. What time should I expect to wait to have a TAVI?

Times vary depending on the urgency of your condition but the above tests and a MDT are mandated before patients are able to have a TAVI 

5. Who will be in involved in my TAVI procedure?

Our TAVIs are normally performed at Wollongong Private Hospital although some may be performed in Sydney depending on who your cardiologist is. There will normally be an accredited TAVI cardiologist or heart surgeon, a secondary operator (also either a cardiologist or surgeon), a cardiothoracic anaesthetist, a TAVI nurse co-ordinator, a team of cardiac cath lab nurses, a radiographer and a representative from the TAVI valve manufacturer. There might also be a vascular surgeon (specialist who can operate on blood vessels). The nurses who look after patients on the ward afterward will also have special expertise in patients undergoing TAVI. 

6. Are there any costs for my TAVI procedure?

Our TAVI doctors do not charge any fees for performing TAVIs.

Anaesthetic fees may apply.

Patients with a medicare card without private health cover can also currently access TAVI procedures at Wollongong Private Hospital on a discounted self-funded basis where a hospital bed fee will apply.

7. What are the risks of a TAVI?

It is very important that before you go in for a TAVI that you understand that your TAVI team are working extremely hard to keep risks to the absolute minimum. Complications are thankfully very rare with TAVI and Wollongong prides itself in having complication rates well below the national average. Planning is key to minimising complications but your cardiologist will discuss the probabilities of things going wrong with you in detail. Complications include:

(a) Problems with your groin during or after the TAVI

There are risks of bleeding from, tearing or blocking off the groin artery through which the new valve is introduced. In these circumstances there may be some blood loss with a need for a blood transfusion. There might be a need for a stent to stop bleeding from or restore flow to the femoral artery. In extreme circumstances there might be a need for an open surgical repair of the artery by a vascular surgeon. Whilst none of these things are common, there are certain thing such as pre-existing peripheral vascular disease (narrowing of the groin arteries) that might increase the risk.

(b) Acute stroke

Debris from the diseased valve can become dislodged during a TAVI and find its way into the circulation of the brain which might cause an acute stroke (brain

damage from a blocked blood vessel). The risk of stroke from TAVI anywhere in the world is on average 3% and there is yet to be any reliable data which TAVI doctors can use to predict when this might happen or reduce this risk. In some patients, we will use a “cerebral protection device” which “sieves” the blood going into the head in an effort to reduce the risk of disabling stroke.

(c) Electrical conduction block and need for a permanent pacemaker implant

The new TAVI implant lies close to the heart’s own electrical conduction system and stretch of this can result in “block” of the heart’s electric signals resulting in a dangerously slow heart beat. In many cases this will recover over time but where this does not, a permanent pacemaker implant may be required. This is a minor procedure which is normally performed the day after the TAVI procedure (a temporary pacemaker can be left in situ for 24 hrs).

There are certain condition that increase the risk of this happening. For example patients with pre-existing electrical heart disease might be at higher risk of needing a pacemaker after a TAVI.

(d) Migration of the TAVI valve after deployment

Like any medical implant, there is a very small chance that this might move or dislodge after it has been placed. This might mean a second valve is needed to be placed or the TAVI that has dislodged might have to be moved (either using specialised catheters or with open heart surgery). This is very uncommon but

(e) Rupture of the aorta or heart

Punching a hole in the aorta (main artery coming out of the heart) or in the heart itself is extremely rare. This is particularly the case with the main kinds of TAVI valve used in Wollongong. In the event of this happening, emergency heart surgery might be required but most patients don’t survive this extremely serious albeit very rare complication. Your cardiologist will carefully analyse your CT scan to ensure that the risks of something like this are minimal.

8. Do I have to be fasted for a TAVI procedure?

You should not have anything to eat six hours before and not have anything to drink 2 hours before the TAVI procedure. Whilst almost all of our TAVIs are performed under conscious sedation without a need for a general anaesthetic, it is safer to fast for this period of time in case a general anaesthetic might be needed for any reason. 

9. What medications need to be stopped prior to a TAVI?

If you are taking blood thinners such as Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) or Warfarin, you should stop these 72 hours before the procedure.  You can continue taking  aspirin, clopidogrel or ticagrelor without stopping these.

If you are taking diabetic medication dapagliflozin (Forxiga) or empagliflozin (Jardiance or Jardiamet), you should stop taking these 3 days before the TAVI procedure

10. What new medications might there be after a TAVI?

Aspirin and/or clopidogrel (antiplatelet medications that stop clots forming around prosthetic vascular implants) might be started after a TAVI. This is not always the case and you will be informed about this before you leave hospital.

11. How long with you be in hospital for a TAVI?

Most patients stay in hospital for 2 nights after a TAVI procedure. This is sometimes only 1 night or sometimes a little longer depending on your other health issues. 

12. When can I get back to normal activities after a TAVI?

Other than bruising around the groin, you would not expect to have any other issues limiting your physical activity after a TAVI. In general, if the groins are not too swollen or tender, you can get back to normal activities (i.e. what you were doing before you came in) as soon as you leave hospital.

13. When can I drive again after a TAVI?

Current Austroads restrictions for patients after any kind of heart valve replacements stipulate that you must not drive using a private licence for 4 weeks or for 3 months using a commercial licence.

14. Where should I go to if I have any other questions?

You can contact our structural heart email (checked regularly by either our Structural Heart Nurse Co-ordinator or one of our TAVI doctors) at wollongongstructuralheart@gmail.com

Alternatively you can contact The Cardiac Centre at reception@thecardiaccentre.com.au and your question will be passed on to your TAVI doctor.

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