Department of Structural Heart Valve Disease & TAVI

The Structural Heart team at Jaslok Hospital & Research Centre performs a wide range of interventions for patients suffering from a variety of cardiac valve ailments. Each procedure is meticulously planned and discussed first among the heart team and the best options are discussed with the patient and their relatives. This process is what ensures the best outcomes for our patients, old and young, simple and complex, high risk as well as very high risk!

What Differentiates Us?

The Jaslok Structural Heart team:-

• Dr. Nihar Mehta - Associate Director, TAVI & Structural Heart Valve Department
• Dr. A. B. Mehta - Director, Cardiology
• Dr. S. R. Handa - Director, Cardiac Cath Lab
• Dr. Nikesh Jain - Consultant, Cardiology
• Dr. Upendra Bhalerao - Consultant, Cardiothoracic Surgery
• Cardiac Anaesthesia
• ICU & Critical Care Medicine

Key Procedures:

Transcatheter Aortic Valve Replacement (TAVR):

• TAVR in calcified AS
• Bicuspid aortic valve
• Horizontally-placed aorta
• Peripheral vascular disease
• Valve-in-valve TAVR
• Coronary artery disease
• Pure AR
• Low-flow, low-gradient AS
• Cerebral embolic protection devices

Mitral Valve Intervention:

• Balloon Mitral Valvotomy (BMV)
• Transcatheter Mitral Valve Replacement (TMVR)
• MitraClip – Transcatheter edge-to-edge Repair

Tricuspid & Pulmonary Valve Intervention:

• Transcatheter Tricuspid Valve Replacement
• CAVI: Heterotopic Caval Valve Implantation
• Transcatheter Pulmonary Valve Replacement
• Balloon Pulmonary valve dilatation

Our Firsts:

• 1st TAVR in Western India
• 1^st TAVR in patient following a cardiac arrest in Western India
• 1^st Subclavian TAVR in Western India
• 1^st Transcarotid TAVR in Western India
• 1^st three cases of MitraClip in Western India
• 1^st CAVI in carcinoid syndrome causing refractory tricuspid regurgitation in India 

Description of Procedures:

TAVI - Trans catheter Aortic Valve Implementation:-

The aortic valve is a regulatory device controlling the blood flow from the left chamber of the heart into the aorta, the principal artery which supplies oxygenated blood to the whole body. The aortic valve can be affected by a number of conditions which causes it to become narrow and unable to open fully, thus limiting the amount of blood reaching the peripheral organs. This is known as aortic stenosis.

Important symptoms of aortic stenosis include:

• Chest pain, chest tightness
• Breathlessness
• Giddiness
• Loss of consciousness
• Easy fatigability
• Palpitations & irregular heart beat

Aortic stenosis include:

• Calcification
• Degenerative- age related
• Rheumatic heart disease – following a Streptococcal infection in early life
• Congenital- from birth

Pre-operative evaluation in aortic valve disease:

The patient & relatives will be guided through the process to determine the treatment plan. Certain investigations requested by the heart team include:

• Complete blood count
• Renal function tests
• Coagulation profile
• Chest X-ray
• Electrocardiogram
• 2D Echocardiography
• CT Coronary angiogram and Aortogram
• Ultrasound of the carotid arteries and bilateral lower limb Doppler

A detailed clinical evaluation of the patient’s symptoms, lab and radiological investigations will be performed, before deciding the patient’s suitability to undergo aortic valve surgery.

The treatment options include:

• Transcatheter Aortic Valve Implantation (TAVI): The aortic valve is replaced percutaneously (i.e. through a skin incision), without opening the chest
• Surgical Aortic Valve Replacement (SAVR): The aortic valve is replaced by open heart surgery. The heart is temporarily stopped and its function is taken over by a heart-lung machine
• Balloon aortic valvuloplasty: A long tube (catheter) with a small balloon located on its tip is positioned across the native aortic valve and inflated gradually, to increase the size of the aortic valve opening. This is to provide symptomatic relief in very ill patients

The TAVR procedure:

The patient will be admitted the day before the procedure, for cardiac surgery and cardiac anaesthesia evaluation. From midnight, the patient should not have anything to eat or drink- only essential medications will be given by nursing staff, with a small sip of water. The patient will be then transported to the cardiac catheterisation room. The cardiac anaesthesia team will administer sedation or general anaesthesia based on the patient profile. Simultaneous arterial and venous access will be secured.

The procedure is started by passing a small flexible tube (catheter) into the artery, which may be in the leg, neck or in between the ribs. A temporary pacemaker wire may be inserted via the vein into the right side of the heart, as a precautionary measure. The valve is loaded onto a long thin catheter which is passed through the arterial access site, through the aorta, uptothe aortic valve. It is then positioned carefully. The valve is deployed gradually under continuous radiological vision and guidance. At this point, the pacemaker may be activated to stabilise the heart. Several images are taken from multiple directions to confirm the positioning of the valve. The valve delivery system is carefully removed from the body. The arterial access site is closed using special percutaneous plug/suture-based devices. The effects of sedation and anaesthesia are reversed, and the patient is transferred to ICU for monitoring and recovery. Most patients are able to go home within the next 2-3 days following the procedure.

Your cardiologist will ask to see you within the next 2-3 weeks following the procedure, to assess your symptoms, heart rhythm with an ECG, and a 2D Echocardiogram to check for valve function and heart pumping function.

Benefits of TAVR:

• Earlier recovery, mobilisation and discharge
• Earlier improvement in symptoms and heart function
• No chest incisions, scars
• Earlier resumption of daily activities
• Additional problems like coronary artery blockages can be treated at the same time, with angioplasty
• More patient comfort and lesser pain
• Overall, a better quality of life
• Use of the latest technology

Risks of TAVR:

• Bleeding - minor and major
• Damage to peripheral arteries- may require stent
• Abnormal heart rhythms, which may require permanent pacemaker implantation
• Pain
• Stroke
• Cardiac chamber perforation
• Death
• Blood clots
• Valve migration
• Valve leakage

MV Interventions - Mitraclip:

Mitra Clip is the FDA approved device utilised for transcatheter edge-to-edge repair in mitral valve regurgitation. Similarly, to the TAVR procedure, The MitraClip can be performed in more unwell patients with greater burden of medical co-morbidities, and that it is a completely transcatheter procedure, avoiding the risks of sternotomy, cardiopulmonary bypass and prolonged general anaesthesia. Patients can be mobilised and discharged quicker compared to patients who have undergone open surgical mitral valve replacement.