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Nursing Perspective of TAVR

Tara Whitmire, DNP, APRN-NP, NP-C, CHFN

Nebraska Methodist Hospital

Cardiothoracic Surgery Nurse Practitioner

Danelle Homeyer, RNMethodist Physicians Clinic

Director, Structural Heart

Disclosure

• Nothing to disclose

Learning Outcomes

• The learner will be able to discuss how heart failure

impacts patients with aortic stenosis.

• The learner will be able to discuss how identification of

valve disease has implications in patient selection for

Transcatheter Aortic Valve Replacement (TAVR).

• The learner will be able to describe current minimally

invasive valve replacement procedures and the nursing

care involved.

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Introduction

• Valvular heart disease is an increasing problem

• Severe valvular disease reduces survival

• Surgery remains the “gold standard”

• However, in current era, up to one-third of eligible

patients do not get surgery. Reasons include old age,

end-stage valve disease, COPD, and Redo surgery.

• Percutaneous treatments are viable options for these

high-risk, underserved patients

Aortic Valve Disease

Diseased Aortic Valve

Healthy Aortic Valve

Closed Open

OpenClosed

Edwards Lifesciences (2018).

• Aortic valve sits on the left

side of the heart between the

left ventricle and the aorta

• Last gateway between the

heart and the rest of the

body

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Aortic Stenosis

• 2-3% of the U.S. population is affected by AS (Haight, 2017)

• Mortality rate worse than any malignancies if left untreated

• 50% in 2 years (Arora, Misenheimer, Ramaraj, 2017)

• Aortic stenosis involves calcification and immobilization of valve

leaflets

• Stiffening and narrowing

• Decreased valve opening and cardiac output

• Possible inflammatory process

• Rheumatic Fever

• Congenital bicuspid valve

Aortic Stenosis Progresses Rapidly

• Survival after onset of symptoms is 50% at 2 years and 20% at 5 years Surgical intervention for severe aortic stenosis should be performed promptly once even minor symptoms occur (Edwards Lifesciences, 2018)

HF symptoms

• Exercise intolerance

• Angina

• Syncope

• DOE

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DIAGNOSIS AND TREATMENT

Trans-thoracic

Echo (TTE)

Chest

X-ray

Transesophag. echo (TEE)

Cardiac Cath.

Auscultation

Multiple Ways to

Diagnose Severe Valvular Disease

AS Treatment

• There has been tremendous interest in TAVR

since the first procedure in Europe in 2002

• First approved in U.S. in 2012

• Since then, patient selection, operator skills,

and technology have improved

• 2 companies with TAVR valves that are FDA

approved

• Edwards Sapien valve

• Medtronic Corevalve

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What is TAVR?

• This less invasive procedure allows the aortic valve to be replaced with a new valve while the heart is still beating

• For patients who are either at high risk (STS > 8%) or too sick for open-heart surgery, TAVR may be an alternative

• Both TAVR valves now have indication for intermediate risk patients (STS > 4%)

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PATIENT SELECTION

Unique challenges of “valve

patients”

• Medical Complexity- Elderly, multiple co

morbidities and multiple medications

• Social- a lot of family members dispersed all

throughout the country

• Goals of care- focus on “quality” is more than

“quantity”

• Extremes of care involved- ICU/cath

lab/OR/Palliative care

Characteristics of a Valve Patient

Edwards Lifesciences, 2018

Old age

Reduced EF

Prior CABG

History of stroke/CVA

History of AFib

Prior chest radiation

Prior open chest surgery

Heavily calcified aorta

History of CAD

History of COPD

History of renal insufficiency

Frailty

History of syncope

Fatigue, slow gait

Peripheral vascular disease Diabetes and hypertension

Severe, symptomatic native valve disease

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Valve Clinic Assessment

• Frailty/functional assessment

• Done pre-operatively (baseline)

• 1 month post mitraclip

• 1 year post mitraclip

• Picture of patient (eye-ball test)

• 5 meter walk test or 6 minute walk test to gauge activity and

endurance

• EFT test

• Living situation

• Mobility aids

• Home support

• # of falls in last 6 months

• KCCQ-12 Heart Failure questionnaire

• Mini mental state exam

• Geriatric depression screening

Afilalo, Lauck, Kim, et al., 2017

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PROCEDURES

Edwards Sapien Valve

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Medtronic CoreValve

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POST-OP CARE

TAVR Post-op Hospital Care

• Universal Bed

• Post-op care similar to AVR/CABG

• IJ present with temporary pacemaker or in opposite groin

site

• Groin with perclose

• Up to side of bed/chair the afternoon of procedure

• Up walking by next morning-if pacemaker dc’d or

permanent pacemaker

• Monitor rhythm for at least 24 hours-determine need for

pacemaker

TAVR Post-op Hospital Care

• Aspirin 81 mg daily/Plavix 75 mg daily for 1st 6

months-then Aspirin 81 mg daily

• SBE prophylaxis for dental procedures

• Perform echo 24-48 post-op while in hospital

• f/u in 72 hours with cardiology, then 1 month

(echo, EKG, BMP, CBC, BNP) and 1 year (echo,

EKG, BMP, CBC, BNP) for TVT registry in valve

clinic

• f/u with primary cardiologist after 1 month

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72 hour visit

• Check for s/s fluid overload

• Assess access site (right or left groin or transaortic

access-chest wall)

• Eating, drinking, bowels

• ASA 81 mg daily, Plavix 75 mg daily

• Cardiac rehab appointment to start

• F/u in 1 month with valve clinic (appointment will be

made before they are discharged)

References

• Afilalo, J., Lauck, S., Kim, D. H., Lefevre, T., Piazza, N., Lachapelle, K., et al. (2017). Frailty in older adults undergoing aortic valve replacement the frailty AVR study. Journal of the American College of Cardiology, 70, 6, p. 689-700 doi: https://doi.org/10.1016/j.jacc.2017.06.024.

• Alozie, A., Paranskaya, L., Westphal, B., Kaminski, A., Sherif, M, Sindt, M., et al. (2017). Clinical outcomes of conventional surgery versus Mitraclip therapy for moderate to severe symptomatic mitral valve regurgitation in the elderly population: an institutional experience. BMC Cardiovascular Disorders, 17, p. 1-9, doi: 10.1186/s12872-017-0523-4

• Arora, S., Misenheimer, J. A., & Ramaraj, R. (2017). Transcatheter aortic valve replacement: comprehensive review and present status. Texas Heart Institute Journal, 44, 29-38.

• Edwards Life Science. (2018). New heart valve.com

• Haight, K. (2017). Understanding medical management of aortic stenosis. How to manage your AS patients who aren’t eligible for surgery. American Nurse Today, 12, 10-15.

• Medtronic. (2018). TAVR heart valve. https://www.medtronic.com/us-en/patients/treatments-therapies/transcatheter-aortic-valve-replacement/about/tavr-heart-valve.html

• Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Fleisher, L. A., …Thompson, A. (2017). 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Journal of the American College of Cardiology, 70, 252-289. doi: 10.1016/j.jacc.2017.03.011

• Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, Guyton, R. A., … Thomas, J.D. (2014). 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Journal of the American College of Cardiology, 63, e57-e185, doi: 10.1016/j.jacc.2014.02.536

• Panos, A. M., & George, E. L. (2017). Transcatheter aortic valve implantation options for treating severe aortic stenosis in the elderly. Dimensions of Critical Care Nursing, 33, p. 49-56

• STS/ACC TVT Registry. (2018). TAVR data up to September 2017.

Questions?