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Dr. Miller: You need to have your aortic valve replaced. We're going to talk about that next on Scope Radio. Hi, I'm here with Dr. Jim Fang. He's the chief of the division of cardiology and also the executive medical director for the cardiovascular service line. Jim, when someone has critical aortic stenosis, that is, they're experiencing all of the symptoms you would expect to have when the valve is almost completely blocked, what types of treatment are available to that patient?

Dr. Fang: Currently, there are no medical treatments for aortic stenosis. The only treatments for aortic stenosis are either surgical or what we call percutaneous, which is a word for through the skin without surgery.

Dr. Miller: And that's a newer treatment.

Dr. Fang: Yes. That second treatment we call TAVR, which stands for Transaortic Valve Replacement. Other people call it TAVI, Transaortic Valve Implantation.

Dr. Miller: Talk to us a little bit about that particular procedure, because it's new, it's less invasive, that is, they don't have to open the chest to replace the valve. It sounds like a revolutionary procedure.

Dr. Fang: TAVR is a game-changer. The ability to implant or replace your aortic valve without surgery is a futuristic concept that is here today. The idea that an older patient in their 80s and 90s could undergo this procedure and walk home in a couple of days and go back to their daily lives is a huge change from the days where the patient would be after open-heart bypass surgery in the hospital for a week or two, and then literally take six to eight weeks to feel like it was worth it.

Dr. Miller: It reminds me of the revolution around endoscopy where they now remove gallbladders with an endoscope and your time in the hospital is much less and your complication rate is very much lower. So who would be candidates for this percutaneous valve replacement procedure?

Dr. Fang: Currently it is for those patients who are thought to be at a very high or a prohibitive risk of having a surgical approach, which means to undergo surgery, in patients who are frail, have other medical problems in which the surgery would be even difficult to survive. These are the kind of patients that are probably best suited for this technology.

Dr. Miller: Jim, you just told me that this procedure causes or allows the patient to avoid surgery. Now, why wouldn't everybody want this procedure?

Dr. Fang: Well, things are changing. In America the standard of care for this condition is an operation. It is the gold standard. It has been around for many decades and we have lots of experience, and we have very good people who do it. But for those patients in whom surviving an operation becomes a question, then we have alternatives such as this new procedure call TAVR.

I will tell you it is tricky. It still remains tricky as to trying to decide who is best suited for this procedure, but this is where coming to a large center and getting an opinion from many different kinds of people, both surgeons and non-surgeons, who try to figure out what the best approach is for a given patient, and for some it will be an operation and for some it will be TAVR and for some it will be neither.

Dr. Miller: Now, conversely I would think that there are patients that are maybe not making it to your TAVR program because some of the physicians in the community might think that these patients are too frail to even tolerate an operation when you now have this as an option.

Dr. Fang: From my perspective, I think we can help referring physicians with those decisions, and most importantly not only help the referring physician, but help families and their patients with these decisions, particularly because age should never be a reason not to help somebody. And if somebody is symptomatic and having trouble, just because they're older and appear frail doesn't mean that they can't be helped.

Dr. Miller: Now, we have a focused team around percutaneous valve replacement here at University of Utah. Can you talk a little bit about that?

Dr. Fang: We have a collaboration between cardiologists, heart surgeons, anesthesiologists, and doctors, specifically cardiologists, that are expert at taking pictures of the heart. Moreover, we've included our geriatricians in this because all of these patients are frail, and frailty and weakness are an important part of aging. With the collaboration of our geriatricians and their ability to help us assess frailty, we can decide whether or not surgery, TAVR, or maybe just go home is the best option.

updated: September 8, 2021
originally published: November 25, 2015

Dr. Miller: Your heart murmur turns out to be aortic stenosis. What do you do about that? Hi, I'm here with Dr. Jim Fang. He is the chief of the division of cardiology and also the executive medical director of the cardiovascular service line here at the University of Utah.

Jim let's say that you have a heart murmur or a patient has a heart murmur, and their physician sends them for an echocardiogram, which looks at the way the heart pumps and that report comes back that you have aortic stenosis. What is aortic stenosis and what does that mean to the patient?

Dr. Fang: Aortic stenosis is a condition in which there is a narrowing of the heart valve. So the human heart has four one-way valves, so every time the heart squeezes blood goes forward but doesn't come backwards. A normal aortic valve is about the size of a quarter. A narrowed heart valve is probably the size of a dime or smaller.

Dr. Miller: What would they notice if they were having problems from aortic stenosis? I think most patients with a murmur that are diagnosed as having aortic stenosis don't think that they have any problem.

Dr: Fang: Well, the most important history to obtain from a patient when they have aortic stenosis is whether they're having any functional difficulties. What I mean by that is, are they having trouble with shortness of breath? Are they having discomfort in the chest? Are they getting light-headed and dizzy? Have they passed out? Are they feeling fatigued?

Dr. Miller: Especially if they exercise, I guess, right?

Dr. Fang: Most of these symptoms would be elicited during exertion, correct.

Dr. Miller: In this day and age, are most cases of aortic stenosis diagnosed at a time when patients really don't have symptoms?

Dr. Fang: Great question. So aortic stenosis is in general a condition of older people and as a condition of older people, we do often pick up murmurs in the older age because most of these patients have been seen before. It's relatively unusual to see a patient for the first time in health care at the age of 80.

Dr. Miller: Do patients with aortic stenosis invariably progress to critical aortic stenosis where they need some type of intervention?

Dr. Fang: All patients with aortic stenosis will progress. The only question is at the rate at which it will progress. Some patients progress very slowly, other patients progress very rapidly and this is why we advocate close follow up.

Dr. Miller: Jim, do all patients with aortic stenosis ultimately need surgery to repair or replace the valve?

Dr. Fang: Well, the only definitive way to treat this problem is to either replace it surgically or with the use of catheters. But this is still part of the art of medicine because some patients will not be appropriate candidates for either of these procedures.

updated: June 3, 2020
originally published: October 6, 2015