Transcatheter Aortic Valve Replacement (TAVR)

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Find out whether your valve needs treating now

Timing is the decision most patients get wrong, in both directions. Send the echocardiogram with its moving images and its full report, any cardiac CT or angiogram, your ECG, recent blood results and a list of what you take. A heart team reads the file and tells you how severe the narrowing really is, whether it should be treated now or watched, and which treatment fits your anatomy and your age. No fee, no obligation, and a coordinator replies in your own language.

Reading your echocardiogram

Three measurements on the report decide almost everything that follows, and a patient who understands them arrives at the consultation as a participant instead of a passenger. Find them on your own report before you read any further.

Valve area

The size of the opening the blood has to squeeze through, given in square centimeters. A healthy aortic valve opens to around three or four. Severe stenosis is conventionally called below one, and some reports also give an indexed figure that adjusts for your body size, which matters if you are small. This number is the one patients grasp most easily and the one most affected by how carefully the scan was done.

Mean gradient

The average pressure difference the heart has to generate to push blood past the valve, in millimeters of mercury. Forty or above is the usual threshold for severe. It rises as the valve tightens, and it also falls when the heart muscle weakens, which is the trap. A failing ventricle cannot generate a high gradient even through a very tight valve, so a low number in a weak heart can hide severe disease instead of ruling it out.

Peak velocity

Blood speed as it leaves the valve, in meters per second, with four or above marking severe. This is the measurement that tends to be most reproducible between scans, so it is often the one used to track a valve over time. If you are being watched rather than treated, ask what your velocity was at each scan and write the numbers down in one place, because the rate at which it climbs matters as much as where it currently sits.

Where those three disagree with each other, or with how you feel, the answer is more testing. A stress echocardiogram, a CT measuring calcium in the valve, or a scan repeated in a few months will usually settle it.

Severe is not stable

Patients hear the word severe and assume it describes a condition that has arrived and will now sit still. It does not. A calcifying aortic valve is a progressive disease that speeds up as it goes, because calcium deposited on a leaflet changes the mechanics in a way that encourages more calcium, and the heart muscle thickens in response to the extra work it is being asked to do. That thickening is the part patients are rarely told about, and it explains why timing matters so much. A ventricle working against a tight valve for years develops fibrous scarring inside the muscle. Some of that scarring reverses once the obstruction is relieved. Some of it does not. A valve replaced before the muscle has been damaged gives back close to a normal heart, while a valve replaced after years of strain gives back a heart that is better than it was and permanently less than it should have been. So the useful mental model is not a switch that flips when you become symptomatic. It is a slope you are already on, at a speed that can be measured, with an endpoint that is easier to influence early than late.

Valves nobody treats

A group of researchers went through 1,669,536 echocardiogram reports from 24 hospitals in the United States, covering more than a million patients, and asked a blunt question. What happened to the people whose valves were never treated, sorted by how bad the valve was.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Read that carefully, because it is easy to overread. These patients went untreated partly because they were old or frail or had other illnesses, so the deaths reflect those things as well as the valve, and the study cannot tell you how long a person survives from the moment symptoms begin. What it does show is a clean gradient. Mortality climbs with every step of severity, and even after adjustment every degree of narrowing carried increased risk, including the moderate grades that patients are routinely told not to worry about. That last point deserves emphasis, because a report saying moderate is often heard as a report saying fine, and the two are not the same thing at all. The other number in that table is the one clinicians find uncomfortable. Four in ten patients with a severe valve had nothing done to it within four years. Some of those were properly assessed and correctly left alone. Many were not assessed at all.

Symptoms that decide timing

1. Breathlessness on exertion. The commonest and the most easily explained away. Patients attribute it to age, to weight, to a chest that was always weak, and the giveaway is that it has changed. Stairs that were fine last year, a hill you now stop on, a bag you no longer carry the whole way.
2. Chest tightness when you push yourself. A tight valve limits blood reaching the heart's own arteries at exactly the moment the thickened muscle demands more, so it can produce classic angina with perfectly clean coronary arteries.
3. Blacking out, or nearly, during exertion. The most serious of the three, and the one that should produce an appointment this week rather than next month. It happens because the narrowed valve cannot increase output when the body demands it.
4. Swelling and fatigue that creep up. Later, and less specific, and often the sign that the heart muscle has begun to give ground. Ankles by evening, a weight that climbs without eating more, a tiredness that sleep does not touch.
5. Nothing at all, in somebody who has stopped doing things. This is the hardest category. A person who has quietly reduced what they attempt over two years may report no symptoms and have plenty, which is what a supervised exercise test is for.

Tell the truth in that conversation, including about what you have stopped doing. A great many patients minimize their symptoms to a doctor and then describe them accurately to a relative in the corridor afterwards, and the minimizing changes the recommendation.

Treating before symptoms

For decades the rule was to wait for symptoms. A trial published recently tested that rule directly, and its result is the most useful new piece of information a patient with a severe but silent valve can have. Nine hundred and one patients with severe aortic stenosis and no symptoms were randomly assigned either to have the valve replaced through a catheter straight away or to be watched closely and treated when symptoms appeared. Their average age was 75.8 years and 83.6 percent were at low surgical risk. Over a median follow-up of just under four years, the combined outcome of death, stroke or unplanned cardiovascular hospitalization occurred in 26.8 percent of those treated early and 45.3 percent of those watched, a hazard ratio of 0.50.

Read the components before you read the headline. Death was 8.4 percent against 9.2 percent and stroke was 4.2 percent against 6.7 percent, while hospitalization was 20.9 percent against 41.7 percent. Early treatment kept people out of hospital. It has not been shown to keep them alive longer.

One more figure changes how the whole trial reads. By the end of follow-up, 87 percent of the patients assigned to watchful waiting had gone on to have their valve replaced anyway. The trial was therefore never really a comparison of treatment against no treatment. It compared doing it now against doing it soon, and doing it now meant fewer emergency admissions along the way. That is a reasonable argument for acting early in a fit patient with a genuinely severe valve, and it is not an argument for treating moderate disease or for rushing somebody whose valve is borderline. It is also worth knowing that the trial was funded by a valve manufacturer, which does not make the numbers wrong and does mean the framing you meet elsewhere may be more enthusiastic than the data.

Two kinds of valve

Every transcatheter valve in routine use falls into one of two families, and the choice between them is made from your anatomy instead of from a preference list. A balloon-expandable valve sits on a balloon that is inflated to press it into place, on a short frame. A self-expanding valve is made of a metal that springs open as it is unsheathed, on a taller frame that reaches further up the aorta. A randomized trial compared the two directly in 447 patients, and it was designed to test whether they are equivalent rather than whether one wins. On its combined outcome at thirty days they were equivalent. Read the individual figures below with that design in mind, because a trial powered for a composite cannot prove a difference in any single component, and because an equivalence trial inverts the usual meaning of a small p-value. Here a significant result means the two devices matched, which is the opposite of what the same number would mean in an ordinary trial.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Anatomy usually decides for you. A small annulus, a low-lying coronary artery or a plan to place a second valve inside the first later on all push the choice one way or the other, and a unit that always uses the same device for every patient is telling you something about their supply arrangements and not about your heart.

Which risk group you are in

Every recommendation you will be given rests on a surgical risk score, calculated from your age, kidney function, lung disease, previous operations and a list of other items. The score exists because the evidence for this procedure was built one risk band at a time, starting with the patients nobody could operate on and working downward. Knowing your band tells you how much data actually applies to you.

• High risk and inoperable. Where this treatment began, and where its case has never been argued about. If surgery is genuinely too dangerous for you, the alternative to a catheter valve is medication and a poor outlook, since an operation is off the table by definition.
• Intermediate risk. A trial of 2,032 patients found death or disabling stroke at two years in 19.3 percent after a catheter valve and 21.1 percent after surgery, which met its test for non-inferiority. Among the patients treated through the leg artery, the catheter route did slightly better.
• Intermediate risk, five years on. The same patients at five years showed 47.9 percent against 43.4 percent, a difference that did not reach significance. Leakage beside the valve was far commoner after the catheter route, at 33.3 percent against 6.3 percent, and so were repeat hospitalizations and further valve procedures.
• Low risk. The newest and largest body of evidence, and the one where follow-up is still accumulating. Results have tracked surgery closely for the first five years, with the differences that do emerge showing up later rather than sooner.
• A caution about the older data. The intermediate-risk trial used a device generation that has since been replaced, and a quarter of its patients were treated through the chest instead of the leg. That subgroup did worse than surgery. It is also not how the procedure is done today, which is why the five-year figures above should be read as history rather than as a description of what you would be signing up for.

Ask for your score as a number and ask which band it puts you in. A recommendation that cannot be tied to a band is a recommendation resting on habit.

Younger and bicuspid patients

If you are under about seventy with a bicuspid valve, that unproven signal is one of several reasons a surgical opinion belongs in your file alongside the catheter one. Structural deterioration of the implanted valves in that same trial was comparable at three years, at 4.5 percent against 5.2 percent, so the concern is about the fit and the early result rather than about the tissue wearing out faster.

The assessment

What to ask

• How severe is it, in numbers. Ask for valve area, gradient and velocity, and ask whether the three agree with one another. If they do not, ask what is being done about the disagreement.
• Give me my surgical risk score. A figure, and the band it places you in, so you know which trials describe patients like you.
• Was my case discussed by a heart team, and who was in it. A named cardiac surgeon in that discussion is the single best sign that the recommendation is about you and not about the department making it.
• Do I have two leaflets or three. Your CT answers this, and the answer changes how confident anybody should be about the evidence.
• Which device, and why that one for me. Expect an answer that mentions your annulus size, your coronary heights and your conduction pattern.
• Your unit's own pacemaker rate. Ask for their own figure instead of a published average, and ask what they do to keep it down.
• What would surgery offer me instead. Every patient should hear the surgical answer described properly, including a mechanical valve if you are young enough for that conversation.
• If we wait, what exactly are we waiting for. A number that would trigger action, or a symptom, and a date for the next scan. Watchful waiting without a written trigger is drift.

Reading a quote

No figure appears on this page. Before the assessment above has been done, nobody knows which treatment you need, so nobody can price it, and a clinic that quotes on the strength of a symptom description has skipped the part that protects you.

Check six things in whatever you are sent. Whether the planning CT and the angiogram are inside the number or billed separately, since those two are the expensive part of the assessment and the part a package most often omits. Which device the quote assumes, named. Whether the price changes if the heart team recommends surgery instead, which happens and should not cost you a deposit. What a permanent pacemaker would add to the bill if one becomes necessary, since that is the item most likely to appear after the fact. How many nights are budgeted, and what an extra one costs if your stay runs over. And whether the discharge echocardiogram and the written follow-up plan are inside the number.

Two things move the total more than anything else. Kidney disease lengthens the stay and complicates the contrast dye used during the procedure, sometimes enough to require a night of fluids before and after it. Difficult access is the other, meaning leg arteries too small or too diseased to take a sheath, which pushes the route to the chest wall or the neck and turns a short admission into a longer one with a general anesthetic attached to it. Packages published by Turkish hospitals and medical travel agencies for this treatment generally include the airport transfer, pre-procedure testing, the operator and anesthesia fees, the catheter laboratory, the device, the planned nights, an interpreter and the review before departure. They generally exclude flights, insurance, a pacemaker if one becomes necessary, additional nights, treatment of a complication and hotel stays beyond an agreed number. Compare what arrives against both lists before comparing it against anybody else's number.

Coming to Istanbul

Allow two weeks. The assessment fills the opening days, the procedure occupies an afternoon, one to three nights in hospital follow for a routine case, and the balance is hotel time while the rhythm is watched and the puncture site settles. A patient who needs a pacemaker fitted should add several days to that plan. Send the echocardiogram as moving images instead of as a typed report, because the report gives three numbers and the images let a cardiologist check whether those numbers are right. Add a recent ECG, any CT you already have, your blood results including kidney function, and a note of your age and any previous heart surgery. A CT taken in the last few months covering the aorta and the leg arteries may not need repeating here. That shortens your stay and spares your kidneys a second dose of dye. Your case is discussed by a heart team that includes a cardiac surgeon alongside the interventional cardiologist, and you will be told what that team concluded and why, including where they disagreed. One coordinator holds your file from the first message through to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages arranged on request. Say so in your first message if you would prefer a female physician.

One person can stay overnight with you on the ward, where the rooms have a companion bed. Meals from the hospital kitchen cover halal, vegetarian and diabetic diets and a prayer room is available. The international patients office books accommodation for both of you, arranges the airport transfer and the daily transport, and prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, generally around ten days before travel.

Clearance to fly usually comes within a week of the procedure, once the puncture site is sealed with no swelling that is growing, the rhythm is stable off the monitor and the echocardiogram before discharge is satisfactory. A doctor examines you and writes that date instead of estimating it. Take home a file naming the device with its model and size, the gradient and any leak measured before discharge, the tablets you are to take and for how long, a copy of the ECG, and the date of your first scan at home. Address it to a cardiologist and book that appointment before you leave, because the months once you are back home are when a rhythm change or a leak would first show itself. Your coordinator stays reachable on the same WhatsApp number afterwards, so a question about a bruise or a test result reaches somebody holding your notes. Get in touch about swelling or a lump that pulses in the groin, bleeding, a leg that turns pale or cold, fainting or near-fainting, a pulse that slows or turns irregular, or breathlessness returning after it had improved.

Transcatheter aortic valve replacement FAQ