Pancakes for breakfast the next day. Your results may vary, but that’s what Bob Santos had for breakfast the very next day after his transcatheter aortic valve replacement surgery (TAVR). Maybe we shouldn’t remind his interventional cardiologist, NCMA’s Dr. Patrick S. Coleman, about that.
If a rich, indulgent breakfast one day later sounds a bit out of the norm for a senior man that just had a major heart intervention, you’re right. But it does help underscore just how different a TAVR procedure can be from the more traditional open-heart (sternotomy) procedure.
Bob, himself, is a bit out of the norm, as far as heart patients go. At the time of his TAVR surgery, Bob was a robust 83 years old and, remarkably, “had never spent a night in the hospital” before. It’s not like Bob was an avoider of healthcare, either. He’s a medical man — a retired pediatric dentist of 40 years.
As Bob says, “I’ve just been so fortunate for so many years.” But that changed in mid-2017. After Bob’s remarkable run of good health, he began 2018 with three significant medical procedures during the span of five months. “I have really had a bit much,” he added.
As significant as Bob’s TAVR surgery was, it was perhaps the least taxing of the three in terms of recovery. He was diagnosed a few years back with aortic stenosis which is a progressive narrowing of his aortic heart valve that eventually would kill him if not corrected. In August of last year, his condition had progressed to the point where he was advised by Dr. Coleman to proceed with a screening process for transcatheter aortic valve replacement surgery.
After a bit of a delay due to the October wildfires, Bob completed his diagnostic scans in December and January. Says Bob: “The workup for the TAVR was really extensive — a lot of scans, a lot of pulmonary tests, and other different kinds of tests.”
“Frailty” was a concern. There was concern that Bob was too healthy — he needed to be deemed “frail enough” to qualify for Medicare to cover the TAVR procedure. As luck would have it, the extensive scans Bob endured in preparation for his TAVR surgery may have saved his life — in an unanticipated way.
“When they did the original … abdominal CT scan on me, they found a small cancerous tumor on my liver.” Bob explains, “That was a surprise for everyone. They were hopeful that it would be a hemangioma, which is a benign entity. They couldn’t verify that with the sonogram. They actually had to do a liver biopsy, which was an incredibly complex procedure. Because they have to go through your lung to get to this puppy.” Unfortunately, the scan revealed it was not a benign entity but a malignant tumor.
Fortunately, the tumor had not metastasized and was localized to about five percent of Bob’s liver. Dr. Brendan C. Visser of Stanford University Medical Center committed to perform a liver resection surgery on Bob. This meant two things: Bob now was “frail” enough to qualify for Medicare to cover the TAVR surgery. And he was about to need another major surgery — but it was going to have to wait. Bob’s narrowed heart valve presented too much of risk for liver surgery. His heart needed to be fixed before his cancer could be addressed. Bob’s liver resection would be the third of the three surgeries he was now facing.
Things kicked into high gear in February. “I had chemoembolization on February 6th. I had the TAVR procedure on February 14th.” That’s fast, but it was necessary to get Bob’s health needs addressed.
“After those two procedures, I could barely put one foot in front of the other. It was mostly the chemo that was really … I can’t speak as much as I would like to be able to about TAVR [alone]. It was complicated by the other procedure. [I was on] Plavix (clopidogrel) for two months. Then in mid-April, I had the resection of the tumor from the liver.”
After Bob’s difficult late-winter and spring, he’s got a new perspective on life. “Really, it’s serendipitous. They came up with the tumor diagnosis. If it had proceeded — particularly with organs like the liver and the pancreas — in 12 to 24 months I’d be toast. I mean talk about a lucky guy. I’m so fortunate. Because I am now cancer-free. I have a new heart valve. I can do so many things that I was not able to do.”
Which is good news for Riley.
Riley, Bob and Julia’s Sheltie of several years, was accustomed to a lot of daily “Bob” time. Before Bob’s aortic stenosis worsened, that usually consisted of morning walks of considerable length. Unfortunately, Bob’s aortic stenosis was cutting into Riley and Bob’s time. The walks got shorter and shorter, until they became too much.
“The significant [issue] with stenosis is being out of breath,” Bob explained. “There is just a demand on the large muscles, particularly in the legs, where they’re not getting enough oxygen.” This also meant Bob’s golfing buddies were about as unhappy as Riley.
Bob’s been an inveterate golfer since the age of 18 back in his days at Stanford University. “That became a limitation too. We went from 18 to playing nine. But when we’d play nine, we would pretty much walk and [carry clubs]. Eventually, we had to get into a cart. But even then, it was just too much demand.”
And after TAVR?
“[Things] changed dramatically, with TAVR. With this valve in place and with the ability for that left ventricle to pump blood into that aorta that gets to the rest of my body — it was just night and day. It’s just a whole different experience. It’s almost immediate, too. It’s not like it takes months for this to come into play. It is a very noticeable difference and change. This buys me some time.”
Bob’s enthusiasm for TAVR might be matched by his appreciation and understanding of the technical aspects of the procedure. He says, “I just can’t say enough about it. The approach is through the femoral arteries — just amazing technology. To go up, and make that curve, and to be able to place that valve, and the sizing of the valves and the placement of the valve are the key issues. … But they’re working with fluoroscopy. They know where they are. There is no guesswork here. It’s on a screen. It’s just absolutely incredible.
“They have two interventional cardiologists because the procedure is so technically demanding. [NCMA cardiologist Dr. Vishal] Patel works together with Dr. Coleman to safely deliver the stent. [NCMA cardiovascular surgeon Dr.] Keith Korver was there, who is the traditional surgeon in the event somehow this didn’t work out and they had to open me up. They have to be in one of these hybrid operatories so they can go from the catheter approach to a traditional surgical approach.”
In addition to making this successful series of three surgical procedures possible for Bob, the ability to recover and experience results quickly is what he values the most. For Bob, the symptoms of his aortic stenosis condition are now history after undergoing transcatheter aortic valve replacement.
“The symptoms pass almost immediately. I spent one night in the ICU. Pat thought perhaps I should spend one more night. We talked about it. … Some of the people that are having this procedure are perhaps even older, or more frail, with other medical situations, like diabetes. I didn’t have any of these other complications.”
Bob went home on the second day. “They stay at least two nights in the hospital to be sure they’re stable. But … I just can’t say enough about the whole combination of things. It has given me a new lease on life, really. I mean this has really bought me some time.
“I’m just a lucky guy — the right place and right time.”
Here’s what you should know when you talk with your doctor about heart valve repair/replacement options: Transcatheter aortic valve replacement explained.