Types of TAVI Valves: Balloon-Expandable and Self-Expanding Options

It's difficult to comment on this. It could be a vascular lump or some kind of arteriovenous fistula in the palm, but one has to do a thorough CT scan, a contrast CT, or maybe a DSA, and then only one can find out as to what is the reason — and can also fix it by minimally invasive technique, putting in a covered stent or coils accordingly. But one has to first prove what we're dealing with; I can't say on this bare information.

In India, open heart surgeries are cheaper than the West because the logistics of hospital management, bed and other things lasting six to seven days don't cost as much. Surgery is definitely cheaper here, and given that a lot of innovation goes into preparing minimally invasive procedures, those are at a slightly higher cost, or at least at par with the surgical technique. TAVI in India compared to the surgical procedure is about double the cost — in the West it could even be less than the surgical procedure, because their overheads and surgical procedures are much more expensive. In India we could offer this TAVI procedure for as little as $25,000, which could be perhaps the least in the world.

TAVI is all about planning. Doing TAVI is not a great job — it doesn't need very high level skills, but the whole energy should be dedicated to planning before you embark on the procedure. That planning is a thorough CT scan, which could be conducted locally and sent to us, and then we can plan around that CT finding as to which valve is required and what we're going to face in terms of coronary occlusion, groin complications or stroke. Mortality in TAVI can be very high if you are not careful about the groin — you should know pretty well how to manage it. The whole thing is around planning, planning, planning, planning.

SAVR is a very well-established technique for the last 50-plus years, and given a choice in terms of safety it should be the default choice in my opinion. Although I do TAVI quite a lot, I would still prefer a technique that is well proven and very well established — especially if the valve happens to be a bicuspid valve, a small annulus, or the patient is not very elderly. If my surgeon says the surgical risk is very high, then I chip in and accept those patients for TAVI. Though in recent trials TAVI has been established as non-inferior even for intermediate to low-risk populations, the decision should still be individualised on the merit of the patient.

As far as cardiology goes, the basic screening tools would be a thorough echocardiography and ECG, blood tests like lipid profiles, CRP values, and HbA1c for underlying diabetes mellitus, and sometimes even a stress test to dig out coronary artery disease. These are classical tests conducted in most people who have passed the age of 40 or 45, and especially the elderly — a thorough echocardiography usually digs out the necessary information, and then we start acting on the preventive aspect.

A balloon-expandable valve is crimped onto a balloon and inflated into position under rapid pacing, while a self-expanding valve uses a nitinol frame that expands on its own once released, with a fabric skirt to help prevent leakage around the valve.

The Myval is a balloon-expandable TAVI valve manufactured in India by Meril, available at about half the cost of the Edwards Sapien valve from the United States.

Several self-expanding valve iterations are available from international manufacturers including Abbott, Boston Scientific and Medtronic.

The choice between a balloon-expandable and a self-expanding valve depends on the patient's valve anatomy, annulus size and calcium distribution, all assessed on CT scan before the procedure.