Transcript TAVR - SCACVPR

Aortic Stenosis and
TAVR
Kristen Davis, MSN, RN, CCRN
Heart Valve Program Coordinator
Lexington Medical Center
Disclosures
NONE
Objectives
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Identify blood flow through the heart
Recognize normal heart valve function
Differentiate between a normal and diseased aortic valve
Define aortic stenosis (AS)
Identify the various treatments for patients with AS
Define Transcatheter Aortic Valve Replacement (TAVR)
Define post-operative care of the TAVR patient
Identify complications of TAVR
Normal Heart Valves
• The heart has 4 valves (pulmonary, aortic, tricuspid, mitral)
that separate the 4 chambers (left/right atria & left/right
ventricles).
• Each valve opens fully and closes completely in response to
pressure changes in the heart during systole and diastole
• The increase in forward pressure across a valve forces the
valves open
• The increase in backward pressure across a valve forces the
valves closed
• The valves are stabilized by a sheet like fibrous connective
tissue ring called an annulus, which anchors the valves to the
heart
Aortic Valve
• Separates the aorta & left
ventricle
• Opens easily in systole and
closes fully in diastole to
prevent blood from backing into
the left ventricle
• Has 3 leaflets equally sized and
an annulus
Aortic Valve
• There are three sinuses of valsalva that are located behind
each leaflet of the aorta
• The right sinus of valsalva provides an origin for the right
coronary artery
• The left sinus of valsalva provides an origin for the left
coronary artery
Bicuspid Aortic Valve
• Some people are born with an aortic valve that has only 2
leaflets
• The bicuspid aortic valve gets stenotic more quickly as there
are only 2 cusps to absorb the shearing stress of blood
exiting the left ventricle
Aortic Root
Common Problems with Valves
Stenosis: When your valve is narrowed and does not completely open
because of things like build-up of calcium, high cholesterol, age, or
genetics.
Regurgitation: When your valve does not fully close and allows
blood to leak backward through the valve.
Contributing factors of Aortic
Stenosis
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Calcium deposits that accompany aging
Infections
Rheumatic fever as an adult
Congenital abnormalities (bicuspid valve)
Risk factors for the
development of aortic stenosis
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Being a male
HTN
Smoking
Elevation of Lipoprotein A
Increased LDL
Aortic Stenosis
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Narrowing of aortic valve because of a build up of calcium
Obstructs blood flow from heart to body
Causes increased pressure in the heart on the left side
Increases risk of heart failure
Without treatment, half of the people feeling symptoms die
within an average of 2 years
• Signs and symptoms include shortness of breath, low energy
level, weakness, and chest pain
Aortic Stenosis (continued)
When calcium nodules within the layers of the leaflets protrude outwardly toward the aorta, there is
restricted leaflet motion, which results in obstruction of left ventricular outflow that occurs during
systole
Early Clinical Manifestations
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Auscultation of systolic murmur
Exercise intolerance
Shortness of breath with exertion
Exertional dizziness
Lightheadedness
Late Clinical Manifestations
• Angina from decreased blood flow and decreased myocardial
oxygen demand
• Syncope related to decreased cerebral perfusion
• Heart Failure
• Palpitations or Atrial fibrillation
Diagnosing Aortic Stenosis
• Gold Standard is the noninvasive 2-D Echocardiography
• Cardiac catheterization to determine if the coronary arteries
are also affected by the calcification and to determine aortic
pressures
• 12 Lead EKG
• Chest Radiography
• BNP (beta naturetic peptide) is a hormone excreted from the
ventricles in response to increased ventricular pressure
Medical Management of
Asymptomatic Aortic Stenosis
• Reduction of cardiovascular risk factors, such as hypertension,
diabetes, smoking, elevated cholesterol, excess weight, and
being sedentary
• Periodic Echocardiography
• Patients ability to identify signs/symptoms of worsening
disease
• Statins
• Antibiotics prophylactically prior to dental procedures for
patients with rheumatic aortic stenosis
• Regular dental care and optimal oral hygiene
• Blood pressure control under expert care, such as with
vasodilators & ACE inhibitors
• Beta Blockers are used with caution due to depressing
myocardial function and causing left ventricular failure
Aortic Regurgitation
• The aortic leaflets are inefficient and allow blood to backflow
& reenter the left ventricle
• Secondarily, volume overload occurs
• The retrograde flow occurs during diastole while the left
ventricular pressure is low and the aortic pressure is high
• Places extra work on the left ventricle, as it has to pump the
normal blood flow as well as the regurgitated blood, which
can result in left ventricular hypertrophy
Physical Assessment findings
of Aortic Regurgitation
• The murmur of aortic regurgitation is a high-pitched,
decrescendo, occurring early in diastole
• In chronic aortic regurgitation, the point of maximal impulse is
misplaced laterally
• The more severe the aortic regurgitation, the louder and
longer the murmur
Acute Aortic Regurgitation
• Acute aortic regurgitation requires urgent replacement of the
valve as compensatory mechanisms do not have time to
develop
• Causes rapid onset of CHF, tachycardia, and decreased cardiac
output
• Acute aortic regurgitation usually occurs from infective
endocarditis
• Endocarditis is treated with antibiotics for a minimum of 48
hours prior to replacement of the valve with a prosthetic
• May also occur due to aortic dissection or dilation
Aortic Stenosis
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Narrowing of aortic valve because of a build up of calcium
Obstructs blood flow from heart to body
Causes increased pressure in the heart on the left side
Increases risk of heart failure
Without treatment, half of the people feeling symptoms die
within an average of 2 years
• Signs and symptoms include shortness of breath, low energy
level, weakness, and chest pain
Treatment Options for Aortic
Stenosis
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Gold Standard is Surgical Aortic Valve Replacement (SAVR)
Balloon Aortic Valvuloplasty (BAV) `
Transapical Transcatheter Aortic Valve Implantation (TAVR)
Transfemoral Transcatheter Aortic Valve Replacement (TAVR)
BAV
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Temporary means to open the aortic valve
Often done in the Cardiac Catherization lab
Usually lasts 6-12 months
Done as a bridge for SAVR/TAVR
Transcatheter Aortic
Valve Replacement
Anticipating Postoperative Needs
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http://newheartvalve.com/#sthash.Np6WV96
Q.dpbs
What is TAVR?
• For patients with severe aortic
stenosis who are either at high risk or
too sick for open-heart surgery, TAVR
may be an alternative
• This less invasive procedure allows the
aortic valve to be replaced with a new
valve while the heart is still beating
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Dr. Nithin P G
Requisites
• ‘Heart team’ approach
• Specific team leader
• Close communication
• ‘Preplanning procedure’
• Large catheterization labs/
‘hybrid’ rooms
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Fluoroscopic imaging
TEE/TTE capabilities
Cardiopulmonary Bypass
Vascular intervention
Urgent AVR, CABG, Vascular
complications
• Anesthesia
• Conscious sedation/ General
Anesthesia
• CPB facility
• Hemodynamic monitoring
and management
Dr. Nithin P G
Work up
• Evaluated and deemed inoperable by 2 cardiothoracic surgeons
• Imaging and Testing
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CTA for sizing annulus, measuring iliacs, femoral arteries, tortuosity
TEE/TTE for valve area, gradients, severity of stenosis, EF
Cardiac catheterization with LE Angiography
Pulmonary Function Test
Objective Frailty Testing
STS (> 8% initially or >15% for 30 day mortality)
Heart Valve Team
A TAVR Heart Team
Is founded on a
Multidisciplinary
Approach to pt. selection
Interventional
Cardiologist
Cardiothoracic
Surgeon
Extended
Heart Team
Anesthesiologist
Cath lab/OR staff
RNs
Referring MDs
Perfusion
Ancillary staff
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Imaging
Heart Valve
Coordinator
Echo
CT
Radiology
Edwards SAPIEN
Transcatheter Heart Valve
Bovine pericardial tissue
Leaflets matched for thickness
and elasticity
Cobalt Chromium
PET skirt
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Transfemoral Procedural
Animation
http://www.edwards.com/products/transcath
etervalve/Pages/THVcategory.aspx
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An Alternative Option for
Patients Without Vascular
• Some patients may not
have adequate vascular Access
access to accommodate
the sheath used during
transfemoral procedures
• For these patients, the
transapical procedure
may be an option
• During the transapical
approach, the Edwards
SAPIEN transcatheter
heart valve is delivered
through the apex of the
heart by making a small
incision between the
ribs
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Transapical Procedural Animation
http://www.edwards.com/products/transcath
etervalve/Pages/THVcategory.aspx
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Devising a Treatment Plan –
A Collaborative Process
Multiple treatment pathways
are now available to treat
severe aortic stenosis
Patient with
severe aortic
stenosis
identified by
referring
physician
• TAVR
– For inoperable and high risk
patients
• Surgical or MIS AVR
– For patients who are suitable
for open-chest aortic valve
replacement
• Medical Management and
BAV
– For patients not suitable for
invasive procedures
Treatment decision
discussed with
referring physician
Ultimate treatment
choice is a
collaborative
decision between
the physicians,
patient, and
patient’s family
Multidisciplinary
review & treatment
decision by TAVR Heart
Team
Patient
referred to
TAVR valve
clinic
Additional testing
completed
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• Paravalvular Aortic
Insufficiency
• CVA
• Rhythm Disturbance
• Pulmonary Issues
• Renal failure
• Fluid Balance Issues
• Infection
• Debilitation
• Other Issues
• Tamponade
• GI Issue
Note: Almost 80% of all patients that are 90 yo + experienced postoperative
complications
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Post TAVR Complications
Post Procedure Care
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Monitor patients in ICU for 24 hours
Monitor closely for post-op complications
Bleeding
Late AV Block (ECG monitoring)
CHF
Renal Dysfunction
CVA
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Diminished perfusion
IV contrast material
Baseline and serial monitoring of Cr and electrolytes
Gentle NS hydration
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Renal Failure
CVA Detection/Prevention
Confirm the diagnosis
• CT or MRI
Assess and classify the severity
• Anticoagulation regimen
• LMW of UF heparin bridging
• Intra-procedural heparin (ACT >250)
• Warfarin/dabigatran post op…..
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• MRS
• MMSE
• NIHSS
• Anti-platelet regimen
• ASA 81 mg
• Clopidogrel loading
• Afib +/- stents
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• Recent stents… continue
• No stents.. Load with 300 mg
Clopidogrel maintenance dose
• If no afib - 6 months
• Afib and not anticoag candidate –
consider clopidogrel
• Life threatening bleeding
• 7 – 26%
• Major bleeding
• 3 – 47%
• Transfusion of 1+ UPRBC
• 6 – 80%
• Compounded by
Anticoagulation and antiplatelet agents
• Current device size
• Learning curve associated
with device
• Anticipate giving blood
products if a complication
arises
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Bleeding
• Goal is to leave the cath
lab/CVOR extubated
• Severe COPD
• Home O2
• Pre-op PFT FEV < 1.5L or
DLCO <50% predicted
• Prolonged Ventilation –
involve CC/Pulm Team early
• Pneumonia
• Atelectasis
• Aspiration
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Pulmonary Issues
Paravalvular AI
• Hemolysis
• Anemia
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• Most concerning when
classified as Mod to
Severe
• TEE – intraprocedural &
serial TTE
• Monitor
• Hgb
• Lactate Dehydrogenase
• Bilirubin level
• Estimated Rate
• ~1%
• Causes
• Leaflet jailing the ostia
• Embolization of calcified
material
• Occlusion of ostial by
stent/frame of valve
• Global ischemia
• Rapid pacing runs
• Hypotension
• Tissue compression by
devices themselves
• Apical trauma
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Peri-procedural MI
Infection
• Does fever always mean infection?--- not really
• Pneumonia
• Aspiration precautions
• UTI
• Pre-op Urinalysis/Urine Culture done on all TAVR patients
• Asymptomatic UTI…. Should you treat them?
• Endocarditis
• Antibiotic prophylaxis is recommended
• Ancef
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Heart Failure
• Preoperatively
• ‘Tune Up’ overloaded patients
• Pleural effusions
• Concomitant TR or MR
• Postoperatively
• Acute fluid management
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Cardiology
Surgery
Nursing
Neurology
Pulmonologist
Pharmacists
Cardiac Rehab
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Speech
Physical Therapy
Case Management
Business Office/Finance
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Interdisciplinary Effort
Conclusion
• Assessment of perioperative risks occurs preoperatively
• The interdisciplinary team is critical for ensuring patient is safely
discharged to an environment that (s)he can continue to do well
• Patient and family education and communication is key from the
beginning
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References
• Cary, T. & Pearce, J. (2013). Aortic stenosis: Pathophysiology,
diagnosis, and medical management of nonsurgical patients.
Critical Care Nurse, 33(2), 58-72.
• Edwards Lifesciences. (2014). Treatment options.
NewHeartValve.com. Retrieved September 24, 2014.
http://newheartvalve.com/treatmentoptions#sthash.XJi0vCXF.dpbs
• Woods, S.L., Froelicher, E.S., & Motzer, S.U. (2000). Cardiac
Nursing (4th ed.). Philadelphia, PA: Lippincott.