Dr Anoop Agrawal
Mrs. Sharma (name changed) couldn’t taste her food anymore. “Just like my hair, my tastebuds are also aging,” she thought. Mrs. Sharma, at 70 years of age, had been a well-kept lady until the previous year. She had enjoyed a healthy, active lifestyle in her youth and adulthood. With an academic bend of mind, she used to teach until her early 60s. At around 61 years of age, she was diagnosed with a bicuspid aortic valve (BAV) that had led to severe aortic stenosis (AS), and was advised to undergo surgical aortic valve replacement (SAVR). Overwhelmed by the flow of information, Mrs. Sharma ended up refusing surgery at the time. Over the next few years, she continued to function independently and forgot about the deformed valve sitting in her heart.
Last year, she started noticing exertional shortness of breath upon walking a few hundred meters. Over the next few months, she slowed down her life to compensate for her exertional symptoms. Slowly, she started developing dyspnea on walking within her house. She lost interest in her food. Her sleep was interrupted with frequent episodes of breathing difficulty. By the time she touched 70, she had lost almost 9 kg over a period of six months due to early satiety and ageusia. She was restricted to her room due to her inability to walk longer distances. Lately, she also started fainting at home, only to regain her senses after a minute or two. It was so frequent that it almost became routine for her and her family. She did seek medical attention for her progressive illness and came up with unanimous feedback: “She needed SAVR, but the risk was too high.” Not ready to undergo a surgery risking her life, she decided to continue with medicines alone, which obviously weren’t working.
Sometime during this hustle, she was referred to me for further evaluation. What I saw was a thin, frail lady who had to take periodic pauses in between her sentences to catch her breath. Even before taking a look at her medical records, I knew that patients with that degree of cardiac cachexia rarely do well with heart surgery. Her medical records made me concerned. On the top of severe AS, she had developed severe aortic regurgitation, severe mitral regurgitation and severe left ventricular systolic dysfunction. Essentially, the blood in her heart was flowing the wrong way. I voiced my concerns to Mrs. Sharma and her family regarding the gravity of the situation and that there wasn’t an easy way out, with or without surgery. I asked her about her goals in life. “I want to get back to shopping,” she replied without any hesitation. We discussed at length about her options, what we can do without imposing a significant procedural risk on her. We discussed about transcatheter aortic valve replacement (TAVR).
TAVR is a procedure where a bioprosthetic valve is crimped and loaded on to a catheter, inserted through groin in a minimally invasive fashion, and implanted in place of the diseased aortic valve. TAVR is approved for patients with severe AS who are considered higher risk for SAVR. We discussed Mrs. Sharma’s case with cardiothoracic surgeons for her eligibility for surgery. After the surgeons deemed her very high risk for surgery, we opted for TAVR, knowing that TAVR will only address problems related to the aortic valve. This was nonetheless her best chance.
After essential investigations, she underwent successful TAVR without any complications. The procedure was performed in the cardiac catheterization laboratory in a complete sutureless fashion. She was extubated immediately after the procedure, was able to talk and eat food that evening. The major hurdle was over and she recovered in a predictable fashion. She was transferred to the room on the third day, was discharged home on day 4. Her post-procedural events were nothing short of magical. She was able to hold long conversations on the evening of the procedure itself. The ability to talk was a luxury to her and she wanted to talk just about anything. That night she slept lying flat on the bed without gasping for breath, something she couldn’t do for the past one year. Next day, she finished her entire meal for the first time in months. On the third day, she reached out for the television remote and watched a random show for more than 30 minutes. Her son was amazed at her behaviour as previously she would get fatigued at home just by watching television for less than 10 minutes. She climbed the stairs up one floor for the first time in more than three years. On her follow up in the out-patient clinic after a few weeks, she reported that she had gained almost 3 kg weight by virtue of being able to eat. Her taste buds were back, which added pleasure to what she was eating. And yes, she was back shopping.
TAVR is the most disruptive medical innovation that modern medicine has seen in the past decade. Life-changing outcomes, as seen in this case, are not exclusive to Mrs. Sharma. The majority of the patients with severe AS who have high surgical risk can be expected to have a similar outcome. TAVR has evolved into both a bail-out strategy in otherwise extreme surgical risk patients, as well as first-line therapy for patients with intermediate surgical risk profile.