Valve-in-Valve TAVI: A Minimally Invasive Fix for a Failed Surgical Valve

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.

They should be in touch with us and send their CVs. They should be ready to face a physical interview, maybe online or coming here, and then we appraise them that they're fit to be inducted into our program. There are some local country regulatory bodies that clear their CVs — that part is also done by BLK. There are minimal fees involved, and they have to make their local arrangements for stay, food and clothing — and people have really been benefited by being with us in our lab, and we give them hands-on experience at some stage.

It is a technique where a new TAVI valve is placed directly inside a previous surgical aortic valve that has failed, avoiding the need for a second open heart operation.

It is particularly valuable for older or frailer patients whose previous surgical valve has deteriorated and who would otherwise face a high-risk redo open heart surgery.

Yes, careful CT planning remains just as essential, since the position and condition of the old surgical valve must be mapped precisely before the new valve is deployed inside it.