8 | HOSPITAL HEALTHCARE EUROPE | 2022

Rajesh Kharbanda Associate Professor of Cardiovascular Medicine , at the Division of Cardiovascular Medicine , John Radcliffe Hospital , Oxford , shares his experience and thoughts on working with TAVI and its impact

About the institution Professor Kharbanda works at John Radcliffe Hospital in Oxford , which is a university teaching hospital and has been performing TAVI for about ten years . In his department there are three TAVI cardiologists and he mentioned how “ an uncomplicated TAVI procedure takes about an hour to an hour and a half for each case , so that on a routine day , we would do four procedures ”. He added that the hospital performs around 350 TAVI procedures each year and 8 to 10 cases per week , which , in terms of volume and experience , places his hospital , as he says , “ within the top 5 or 10 of the 35 centres in the UK ” with nationally around 4500 – 5000 procedures performed every year .

He feels that the rise in the use of TAVI has been driven by several factors . For instance , the simple fact that the population is generally living longer , which leads to an increased prevalence of aortic stenosis ( it affects around 1 in 8 people over the age of 75 ). Because it is less invasive than surgery , TAVI has become a better option for the treatment of high-risk patients .

Why and when was TAVI introduced at John Radcliffe ? Professor Kharbanda described how aortic stenosis is characterised by a narrowing of the aortic valve and , in the past , the only treatment was valve replacement surgery . Nevertheless , as he explained “ because aortic stenosis is a condition of getting older , operating on elderly patients is more challenging , hence there was always a drive to find less invasive , less intrusive treatments to treat the valve ”. He explained how the technique arose in the late 1980s after a cardiologist , Henning Andersen , decided to utilise the stenting procedure ( used for coronary artery disease ) to insert a replacement valve . The procedure has been refined ever since then and John Radcliffe Hospital has been performing the procedure for about ten years .

The drive to introduce TAVI came from the need to treat those elderly patients deemed too unwell or unsuitable for surgery . Once the department could successfully perform TAVI in this group of patients , the natural progression was to move on to high-risk surgical patients . Using TAVI in these high-risk patients reduced the overall recovery time compared to surgery . As Professor Kharbanda described , “ the recovery is much , much quicker , so when we started , patients might be in hospital for 3 – 4 days ; now patients can go home after a couple of days , usually the next day , if there are no problems with their heart rhythms ”. As he continued , for a high-risk surgical patient “ they might have been in hospital for a long time , two or three nights on the intensive care unit , seven to ten days recovering from their operation and then another while recovering from the surgery at home ”. He added that with TAVI , the recovery is much quicker and regaining normal activities is much , much quicker than after an operation .

Are there any patients who are not suitable for TAVI ? Professor Kharbanda felt that even though the use of TAVI has progressed to the treatment of “ healthy ” older patients , i . e ., those for whom surgery would also represent a low-risk option , decisions over whether to use TAVI or surgery are not always that straightforward . He explained that “ while TAVI is good in low-risk patients , surgery is also a very good treatment , and what we haven ’ t got is the evidence for very long-term outcomes for TAVI because it hasn ’ t been around long enough ”. As he continued , “ for a patient in their early seventies who develops aortic stenosis and is completely well , then there is a discussion to be had as to whether surgery or TAVI is appropriate .” The ultimate decision might well be dependent on other factors , for instance , “ if a patient has other things such as narrowed heart arteries , they might need a bypass at the same time , and surgery might be a better option , but the decision is patient dependent ”.

Despite being a less invasive procedure , TAVI still has some potential complications . But Professor Kharbanda noted how , in his experience , complications are rare , and patients only come back occasionally , and that most valve failures result from the insertion not going as well as hoped and that occurs early on . The long-term outcome of these valves is however very good .

How has TAVI impacted on patient outcomes ? Professor Kharbanda depicted how typically a patient with aortic stenosis experiences exertional breathlessness , fatigue , and chest discomfort . Because aortic stenosis is an agerelated condition , many patients may simply attribute their symptoms to “ just getting old ” although the condition can be easily detected by listening to a patient ’ s chest and the diagnosis confirmed in hospital by echocardiography . TAVI results in an almost immediate resolution of symptoms and while clinical trials often use questionnaires to assess symptom improvements ,