EFFECTIVE, RELIABLE, COMFORTABLE METHOD IN THE ELDERLY PATIENTS WITH AORTIC stenosis: TAVI

EFFECTIVE, RELIABLE, COMFORTABLE METHOD IN THE ELDERLY PATIENTS WITH AORTIC stenosis: TAVI

With the prolongation of the life expectancy of societies, the incidence of diseases seen in elderly individuals has increased. Treatments are more difficult in this group of patients due to advanced age and accompanying additional health problems. This is a bigger problem, especially in patients who require surgical intervention. It is clear that the most common diseases are cardiovascular diseases. Many patients and their relatives who need surgical or interventional treatment due to these diseases refuse the treatment due to the risks of the operations and the difficulties they may experience during the recovery process after the treatment. Today, with the technological developments, many cardiovascular diseases The disease is treated with less risk and closed methods by using appropriate medical devices without the need for open surgery. From this point of view, aortic stenosis is one of the prominent diseases.

Aortic Valve;Left ventricle of the heart that pumps blood throughout the body (left ventricle)main artery originating from the heart (aorta)In the aortic valve located between the heart that pumps blood to the body and the main artery aorta, aortic valve stenosis occurs due to stenosis in the valve due to deterioration and calcification in advancing ages, and a decrease in valve movements. In healthy individuals, the aortic valve area is between 3-4 square centimeters Aortic stenosis begins to show clinical symptoms when it falls below 1 square centimeter. In the presence of a congenital, structural disorder or rheumatic heart disease, aortic stenosis can be seen at young ages. In general, the incidence of the disease increases in the 70s and above. 30%There are various degrees of aortic valve stenosis in . (left ventricle) It is exposed to high pressure and also the amount of blood pumped to the body decreases. Exposure of the left heart to high pressure and less blood pumping to the body do not cause any distress to the patient to some extent. When the aortic valve narrows severely, the patient’s complaints begin to appear.

In this disease, there are no complaints for a long period of time, when the symptoms occur, the clinical course deteriorates rapidly and almost all of the patients die within 3-5 years. Depending on the degree of stenosis, chest pain, fainting, shortness of breath and even sudden death can be seen in the person. These patients should be followed closely in terms of complaints, intervened in patients with complaints, and corrected the stenosis. Echocardiography in the diagnosis of the disease (heart ultrasound) It is the gold standard. The severity of the disease and the operation time can be determined by evaluating the valve area, valve pressures and the structure-contraction functions of the heart with echocardiography. Since aortic valve stenosis is a mechanical obstacle, it is not possible to cure the disease with any drug therapy. In these patients, the drug treatment given is effective in reducing the complaints related to the disease rather than curing the disease. Drug treatment does not reduce the progression of the disease and the risks it brings.

Treatment in diagnosed aortic valve diseases; It is performed by removing the aortic valve with impaired function and placing a mechanical or bioprosthetic valve with open heart surgery. The main problems of this method are the need for general anesthesia, the cutting of the breastbone during the operation, the risk of infection and the prolongation of the patient’s full recovery period after the operation. Apart from these, the patients’ advanced age have additional health problems (lung-liver problems, movement restrictions, previous open heart surgery, cancer, etc.)When such risks are added, it makes the operation very risky. For all these reasons, patients with aortic stenosis requiring surgical intervention 30-40%At this point, the TAVI method is an effective and safe treatment alternative for patients who cannot undergo surgical intervention or who are at high risk. (Transcatheter Aortic Valve ImplantationThis alternative method is used for severe aortic stenosis caused by deterioration and calcification of the heart valve structure due to advanced age. (degenerative aortic stenosis)TAVI method is primarily applied to patients who cannot have open surgery for surgical valve replacement or who have a high risk of open surgery.

Apart from this, this method can also be applied to patients with any disability for open surgery. In this regard, patients who are very elderly, have lung, liver or kidney dysfunction, or patients who have had other open heart surgery before are considered to be at high risk for open surgery. . TAVIIt is known that the method is effective in prolonging the life span and improving the clinical condition of the patients in these patients for whom open surgery is not suitable.

The TAVI method was first applied in 2002. Initially, it was a method performed by directly entering the heart through a hole drilled under the nipple in the anterior chest wall. With the advancement in device technologies over time, it is now performed using the inguinal vein. In patients whose inguinal vein is not suitable for various reasons, alternative intervention areas Heart valves installed during this procedure; They are biological heart valves that are still used in valve replacement surgeries all over the world and in our country and obtained from animals. In the TAVI method, this biological valve is placed in a stent sheath and when the stent is opened, it is firmly attached to the area where the valve is inserted. Today, 2 different valves are used according to the placement technique. One of them is a balloon. while the other is placed with the self-expandable method.

Today, TAVI procedure can be performed with deep sedation and analgesia. In our clinical practice, we perform the procedure under local anesthesia and deep sedation without the need for general anesthesia. We use general anesthesia only in patients who may experience serious respiratory problems during the operation. A plastic pipe system is placed where the needle enters during the procedure and will be removed at the end of the procedure, through which the balloon can be advanced. The placement of this pipe system can be done in two ways. The first way is through the skin, the second way is by surgically opening and viewing the artery. In our current practice, the skin route is preferred. Because with this method, the risk of infection that may occur in the inguinal region and the time required for the patient to be mobilized are significantly reduced compared to the open method. After it is placed in the vein and the process is completed and the materials are removed, it is possible to perform the method in a completely closed manner by combining the stitches in the vein. During the procedure, a temporary pacemaker cable is placed to the heart through the vein from the other groin to be used for rhythm disturbances that may occur during the procedure and after the procedure.

After the preparations for the intervention are made, a guide wire is advanced through the vein towards the heart until it reaches the valve, and is passed through the narrowed aortic valve in the plastic pipe system placed in the artery. .The balloon is inflated during the stimulation phase with this battery, in which the movement of the heart is restricted, so that an opening is provided for the new valve to pass through. After the balloon is removed, the new valve sent over the guide wire is placed in its place. With a temporary pacemaker, it can be operated at 180 speed for periods not exceeding 20 seconds. At the end of the procedure, the guide wire is removed.

Patients who do not develop any complications after the procedure are discharged from the intensive care unit for 2 days, generally in 4-5 days after the procedure. After the discharge, the patients can continue their daily lives normally. The patients take two blood thinners for 3-6 months after the procedure. There is no need for any movement restrictions. Because the cover cannot be moved in any way.

Although the TAVI procedure is a low-risk method, it has some risks. The risk of death and disability in this procedure is higher than other diagnostic and therapeutic methods used in the field of cardiology. The fact that it is larger than cardiovascular devices is the reason for the increased risk. The mortality rate in the procedure and in the 30-day period after it varies between 3-5 percent and is lower than surgical intervention. There may be rupture and bleeding in the vessels where the intervention is made, and surgical intervention and blood transfusion may be required. rupture of the artery (dissection) and fluid collection around the heart are other complications. When such complications develop, open heart surgery may be required under emergency conditions. Again, depending on the procedure, there may be a need for a pacemaker due to paralysis due to particles breaking from the valve during the balloon, valve insufficiency and the effect of the valve on the conduction system of the heart. In addition to the risks brought by the intervention, the general condition of the patient, co-morbidities, and non-interventional factors such as cardiac functions are decisive in the emergence of the operation. If severe aortic stenosis is not treated, it is a clinically high-risk disease. As I mentioned above, surgical intervention brings a high risk in these patients. From these perspectives, TAVI method is performed on patients who cannot be operated or who have a very high risk of surgery, and the existing disease already has a chance to be treated otherwise. It should be noted that there is no

TAVI methodWhile it has been applied to high-risk patients who cannot undergo surgery until today, its effectiveness and safety have also been investigated in surgically moderate-risk patient groups in large-scale scientific studies conducted in recent years. TAVI showed that the method is as effective and reliable as open heart surgery; However, it should not be forgotten that TAVI method offers a more comfortable and convenient treatment option compared to open heart surgery.

The TAVI method We have been using it in our clinical practice since the second half of 2014. At first, we used the surgical method of opening the inguinal artery, but recently we have done it with a completely closed method through the skin. We use both balloon and self-expanding devices as the device selection. We have performed about 80 operations until now. We are among the experienced cardiology clinics in our country in terms of operation. We perform TAVI operations in approximately 30 minutes in our clinic. We perform our operations under local anesthesia and superficial sedation. In general, our clinical results are similar to world standards. We provide benefits. In such patients, we perform the relevant operation in a short period of 5 days, including 2 days for pre-procedure preparation and 3 days for follow-up after the procedure. and there is a significant improvement in their general condition.

TAVI methodoffers an effective, safe and comfortable treatment method for patients who cannot undergo surgery or are at high risk despite severe aortic stenosis due to advanced age calcification. Moreover, it offers these advantages by significantly reducing the risks of surgical intervention.

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