Howard C. Herrmann, MD, leads Penn's TAVR program with Drs. Joseph Bavaria and Saif Anwaruddin. As participants in the PARTNER trial, Dr. Herrmann and colleagues played a fundamental role in the FDA approval of TAVR for high-risk aortic stenosis patients.
Dr. Herrmann is the Director of the Cardiac Catheterization Laboratories at the Hospital of the University of Pennsylvania and the Health System Director for Interventional Cardiology at Penn Medicine. He remains a leader and champion in the effort to make TAVR the "procedure of choice" for most aortic stenosis patients.
"We are gradually moving into TAVR as the default strategy for the majority of patients with aortic stenosis," Dr. Herrmann said. "The bottom line is we are treating younger patients and healthier patients."
Why TAVR?
Transaortic valve replacement, or TAVR, is a minimally invasive alternative to open heart surgery for patients with aortic stenosis. Through the catheter-based approach, TAVR avoids the most invasive elements of open heart surgery, including sternotomy and the cutting of the aorta.
And recovery takes just days--not months, as common with open heart surgery.
Penn's Instrumental Role in the Evolution of TAVR
Dr. Herrmann first began experimenting with the procedure that would become TAVR in the late 1980s. In 2002, a French interventional cardiologist successfully sewed a valve inside a stent on a balloon and inserted it into the aortic valve, demonstrating the feasibility of a TAVR-like procedure in a patient who was too high-risk for open heart surgery.
"That really ushered in this whole era," Dr. Herrmann explained.
Dr. Herrmann performed the first TAVR procedure at The Hospital of the University of Pennsylvania in 2007. At that time, TAVR was an investigational procedure in the United States, and Dr. Herrmann's work moved Penn to the forefront of TAVR research.
Over the next 12 years, Dr. Herrmann worked to lower the risk profile and widen the range of patients who are eligible for TAVR.
As the procedure improved, so did the devices used to treat aortic stenosis. Initially, most patients recovered in the hospital for five to seven days post-op. Today, the devices are much smaller, and Dr. Herrmann now offers conscious sedation to many TAVR patients rather than general anesthesia. He does not routinely use transesophageal echocardiography, and sends most patients home in just a day or two, where they can quickly resume their normal lives.
With more than 2,500 procedures performed to date, Penn is one of the nation's leading providers of TAVR. Penn cardiologists and cardiac surgeons regularly contribute to academic research and a growing body of literature about the transcatheter procedure. Along with an international group of dedicated researchers and heart surgeons, Penn continues to research new and innovative roles for TAVR, making it a safer and more effective procedure for a growing group of patients.
TAVR for Aortic Stenosis: Better Outcomes for Patients
Until recently, an unanswered concern for TAVR involved its safety versus open heart surgery in younger patients at low risk for complications or surgery-associated mortality. The PARTNER 3 trial, as detailed in the New England Journal of Medicine, was a multi-center trial that tracked patient outcomes to assess a primary endpoint composite of death, stroke, or rehospitalization at one year in patients having TAVR vs. open heart surgery.
The authors concluded that among patients with severe aortic stenosis at low surgical risk, the composite rate of death, stroke, or rehospitalization at one year was significantly lower in those having TAVR than surgery (8.5 percent vs. 15.1 percent).
At one year, the rate of death and disabling stroke was 2.9 percent in the open heart group vs. 1 percent in the TAVR group. All patients were younger (mean age 73 years) and were at a lower risk for open heart surgery than the typical TAVR patient.
The results are so significant that they "shift our thinking from asking who should get TAVR to why should anyone get open heart surgery," Dr. Herrmann told the New York Times, earlier this year.
As the proven safety and efficacy of TAVR continues to make it an appealing option for younger and healthier patients, Dr. Herrmann and his Penn colleagues continue to seek new indications for TAVR. In addition to investigating the use of TAVR in patients with bicuspid aortic valves, clinical trials at Penn Medicine are exploring devices to help prevent stroke, minimize any leaks that occur, and minimize the need for pacemakers afterward.
Dr. Herrmann is also using TAVR to put artificial valves in old and failing surgical prostheses in both the aortic and mitral position. He and his team are using devices for the treatment of mitral regurgitation, such as the MitraClip, and continue to look for new opportunities to build on their experience with TAVR, such as transcatheter mitral valve replacement procedures.
The Future of Valve Procedures
TAVR-like procedures may soon be available for patients with mitral regurgitation. "Mitral regurgitation is a more common problem, and if we had really good solutions for it, I think that would drastically improve the ability to treat patients," Dr. Herrmann said.
There are several trials in the United States for transcatheter mitral valve replacement. Penn is currently participating in an early feasibility trial utilizing the EVOQUE transcatheter mitral valve replacement. Penn has done more of these procedures than any institution in the U.S.
"Mitral regurgitation is a more complicated disease than aortic stenosis, but the hope is that over the next five or ten years, we will reproduce the success of TAVR in the mitral position and even in the tricuspid position," Dr. Herrmann explained.
To learn more about TAVR at Penn, listen to the full ReachMD interview with Dr. Herrmann.
Additional TAVR Resources from Penn