Patient information

Find out what to expect from your first appointment with our structural heart intervention service, which offers TAVI procedure, balloon aortic valvuloplasty and other interventions for structural heart disease.

Before your appointment

You are likely to be referred to our structural service by a local specialist who has found your problem.

If you have been referred for a TAVI procedure, then the aortic valve will need to be narrowed. Our specialist nurse will contact you to arrange your appointment and tell you which member of the TAVI team you will see first.

We actively encourage family members, friends or carers to attend the appointments.

You will receive a lot of information on the day of your appointment. If English is not your first language, please bring a relative or friend who is able understand English well enough to help you understand this information and organise your visit.

When you come to your initial appointment please bring a list of all medications you are currently taking and any additional information other hospitals have given you.

Please also remember to check your appointment letter for anything specific you have been asked to take with you. In addition, it would be helpful if you could bring the following:

• your full address and phone number(s)
• your appointment card and appointment letter
• your GP's name and address
• money to pay for any prescriptions, or an exemption card
• a list of questions you may want to ask your consultant

At your appointment

When you arrive, please bring your appointment letter to the main outpatients department in B block on the ground floor at Hammersmith Hospital. Take your appointment letter to desk C to check in.

Please note that we are a teaching hospital, so medical students may be present for some appointments. If you do not wish to have them in the room please let the nurse or doctor know and the students will be asked to step outside.

Please be aware your appointment may last a few hours as you will be seen by multiple members of the team. This will include a consultant cardiologist and possibly a medicine for the elderly consultant who will review you and may carry out a cognitive assessment.

After your appointment

Following your appointment, you may receive letters inviting you for further investigations, including angiogram, CT scan, echocardiogram, lung function test, carotid duplex and invasive angiogram. Typically, these appointments will happen within the following month and, where possible, they will be booked on the same day to minimise the number of visits you’ll make to hospital.

Treatments we offer

TAVI

The principal part of the service is the transcatheter aortic valve implantation (TAVI) programme. TAVI is a novel minimally invasive procedure that involves replacing a narrowed aortic valve (aortic stenosis) through a small tube (catheter) passed into an artery and channelled to the heart.

The TAVI service is offered to patients with medical conditions that could put them at increased risk if open heart surgery is performed. TAVI typically uses less anaesthesia and is far less invasive than conventional open heart surgery. For some patients, it is the option that carries the lowest risk.

Our team provide a rapid assessment to identify patients in need of an aortic valve treatment before making decisions on what would be the most suitable procedure. We arrange a variety of investigations, usually on the day of the visit.

If you are coming to hospital for a rapid assessment, you should plan for at least a four-hour stay in outpatients. In that time you will have:

• consultant assessment
• ECG
• echocardiography
• blood tests to check blood count and kidney function
• CT of the whole aorta to assess the access route for a TAVI
• lung function tests

Following your visit, we will discuss your case at our TAVI multidisciplinary team meeting (MDT). The options routinely discussed are:

• medical therapy – this helps relieve some of the symptoms but does not take away the problem
• balloon aortic valvuloplasty (BAV) – we offer this to patients for whom TAVI is considered too high risk, or if the outcome is uncertain
• TAVI
• aortic valve replacement (AVR) – we offer this instead of TAVI to patients we consider robust enough for this surgery

Please see our leaflet for more information.

TAVI video from the British Heart Foundation

Watch this video to find out what to expect from your TAVI procedure.

 

Rarer indications for TAVI

TAVI can be performed for failing surgical valves if they are made of tissue and not metal. This can be done in the aortic valve (valve-in-valve aortic TAVI) or mitral valve (valve-in-valve mitral TAVI). This can often be safer than performing surgery. TAVI can also be performed in leaking aortic valves (aortic regurgitation).

Balloon aortic valvuloplasty (BAV)

This procedure is also performed through passing a small tube (catheter) into the groin artery and channelling a balloon through the catheter up to the aortic valve to stretch it open. Our team will decide whether this procedure is suitable for you following a thorough assessment. It does not provide a permanent fix but may help you get through a critical illness when you are too sick for TAVI. 

Patent foramen ovale (PFO) closure

All humans are born with a PFO. It allows blood to channel from the right side of the heart to the left via a small flap between the two atria (collecting chambers), and not go through the lungs when the lungs are full of fluid in the womb. With the first breath, the flap closes. But in 25 to 30 per cent of people, it does not fully stick. If they cough or sneeze, it can briefly open again.

Not all people with PFO will require treatment. However, in people who have had cryptogenic stroke – a stroke for no obvious reason – the PFO is seen as a risk factor. Several large trials have shown that closing the PFO with a small device can reduce the risk of recurrent stroke from 1 per cent per year to 0.5 per cent per year, using a small operation.

Under general anaesthesia, a wire and catheter are passed to the flap to push it open. A “double-umbrella” device is inserted to pull the two sides of the flap together, as a button holds a shirt. The device is on a cable, but is released when in the correct position, and stays in place, closing the flap. The patient goes home the same day.

All referrals with cryptogenic stroke will have been assessed by the stroke team before referral to the PFO closure team, who assess the patients in clinic and discuss them at the structural MDT.

Atrial septal defect (ASD) closure

Some patients are born with a hole connecting the two collecting chambers of the heart (the atria). Not all ASDs need to be closed, but the indications are:

• dilation of the right heart (suggesting strain from abnormal flow)
• paradoxical embolism (when a clot has moved across the hole and caused a heart attack or stroke)

For a significant proportion of these patients, a minimally invasive approach is preferable to open heart surgery. If the defect is too large, surgery is the best option.

A tube (catheter) is channelled via a vein in the groin and a “double umbrella” plug (device) is passed through this to close the hole between the atria.

Imperial College Healthcare offers comprehensive assessment and is linked to The Royal Brompton Hospital adult congenital heart disease (ACHD) service to provide treatment.

Paravalvular leak closure

Some patients with previous heart valve replacement surgery develop a leak on the replacement valve over time. If the leak is through the valve leaflets, then TAVI may be the best option. However, if the leak is on the outside of the valve (due to failing stitches) then this may need to be treated. Indications for treatment are:

• haemolysis – the blood cells being damaged going through the leak, leading to anaemia
• heart failure – the heart feeling the strain of the leak, leading to breathlessness and fluid in the lining of the lungs

Performing surgery again can be too high risk or unsuitable in a proportion of patients. Here, a minimally invasive approach can be taken in some cases by placing a plug over the site of the leak. This procedure again involves passing a tube (catheter) typically via a vessel in the groin and a plug (device) is passed to the leaky heart valve to reduce the leak.

Mitral interventions

Although the mitral valve is a more complex valve than the aortic, the MitraClip procedure is available to treat leaking native mitral valves. Surgery remains the gold standard but in patients for whom surgery is not suitable, the MitraClip can be placed from a small puncture in the groin vein, and reduce the leak. Imperial College Healthcare was one of the first centres in the UK to offer this procedure and the team has extensive experience with this procedure. All cases are discussed at the mitral MDT to ensure surgical and catheter options are discussed.

For the rare patient with rheumatic mitral valve stenosis, balloon mitral valvuloplasty is offered to avoid the need for open heart surgery.

Left atrial appendage closure

In close liaison with our world class electrophysiology team, our service offers left atrial appendage closure to patients that cannot take warfarin therapy, or the newer oral anticoagulants (DOACs) due to bleeding risks. All cases are discussed at the electrophysiology MDT. This service is lead by Professor Prapa Kanagaratnam.