An innovative therapeutic approach recently implemented at Rambam, for the first time in Israel, enabled an aortic valve transplant in patients who, in the past, had to undergo repeated open heart surgeries for the same type of procedure. An alternative to open heart surgery, this new technique uses cardiac catheterization in patients at high risk for coronary artery blockage during surgery, a complication that can lead to death.
Dr. Arthur Kerner inserts a catheter. Photography: Ben Yuster
Over the past ten years, transcatheter aortic valve implantation (TAVI) has been used for valve replacement, serving as a welcome alternative to open heart surgery for aortic valve replacement. Among patients who have undergone aortic valve replacement via open heart surgery are those who were implanted with a biological prosthesis (the transplanted valve is composed of biological tissue instead of metal). Over the years, such implants can undergo abrasion and degeneration resulting in impaired function leading to severe recurrence or leakage, and even heart failure.
In the past, these patients had to undergo a repeat procedure, i.e., open heart surgery for a new aortic valve replacement. However, with the introduction of TAVI, open heart surgery can be replaced for most patients. However, among this unique patient group was a subgroup for whom valve replacement from inside the valve was impossible due to the risk of obstruction of the coronary artery at the time of implantation – a situation that can cause a heart attack during the procedure or in the hours thereafter.
The first patient to be treated in Israel, a 75-year-old woman and retired Rambam nurse, underwent aortic valve replacement with a biological prosthesis implant in 2014, an operation that was very complicated from a technical perspective. Over time, the prosthetic valve degenerated and led to a recurrence of severe stenosis. In addition, dysfunction of the patient’s heart valves developed. She showed signs of heart failure and shortness of breath following minimal effort, and was unable to perform basic household tasks.
The doctors' evaluation at Rambam was that undergoing repeat surgery for aortic valve replacement, in addition to performing a mitral and tricuspid valve replacement, was also risky and that the patient's chances of surviving the surgery were low. The procedure to implant a valve within a valve was also potentially life-threatening, and would place the patient at an additionally high risk for developing coronary artery blockage during treatment. Following consultations with the leading TAVI experts abroad, it was decided to use TAVI for this particular case. The procedure was performed successfully and without complications. That same evening, the patient ate dinner and the following day, she walked around the hospital ward, feeling well and reporting a dramatic improvement with regard to her symptoms. She was released from the hospital two days later.
“We aren’t talking about a new product, rather a creative and innovative method,” explains Dr. Arthur Kerner, director of the Interventional Cardiology Unit at Rambam Health Care Campus, who led the groundbreaking surgery. “We used techniques and products off-the-shelf to enable treatment using a catheter in patients who, until now, were unable to undergo such procedures because they were life-threatening. This is another barrier that was broken in the treatment of valve illnesses, by way of a catheter, which allowed additional patients to benefit from a minimally invasive, effective solution and avoid repeated open heart surgery. This is an example of creativity, initiative, determination, and striving for excellence for patients in public medicine.”
