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3/6/2019 TAVR: Criteria, Procedure, Pre & Post Care SARAH JOHNSON, RN, MSN, ACNP- BC

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Page 1: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

3/6/2019

TAVR: Criteria, Procedure, Pre & Post Care SARAH JOHNSON, RN, MSN, ACNP- BC

Page 2: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Occurs when the heart's aortic valve narrows.

The narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and onward to the rest of his/her body.

Usually when aortic valve stenosis becomes severe and symptomatic, per ACC/AHA guidelines, the native valve should be replaced.

Left untreated, aortic valve stenosis may lead to sudden death.

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Aortic Stenosis

Page 3: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Aortic Stenosis

Gross specimen of minimally diseased aortic valve (left) and severely stenotic aortic valve (right)

Images courtesy of Renu Virmani MD at the CVPath Institute 3

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Prevalence of Aortic Stenosis

16.5 Million People in US Over the Age of 652

Percentage Diagnosed with Aortic Stenosis

Aortic stenosis is estimated to be prevalent in up to 7% of the population over the age of 651

It is more likely to affect men than women; 80% of adults with symptomatic aortic stenosis are male3

Page 5: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

What Causes Aortic Stenosis in Adults?

Aortic stenosis in patients over the age of 65 is usually caused by calcific (calcium) deposits associated with aging

Age-Related Calcific Aortic Stenosis

Congenital Abnormality

In some cases adults may develop aortic stenosis resulting from a congenital abnormality

More Common

Less Common

Rheumatic Fever Adults who have had rheumatic fever may also be at risk for aortic stenosis

Infection Aortic stenosis can be caused by various infections

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Page 6: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Independent clinical factors associated with degenerative aortic valve disease include the following:4

Increasing age

Male gender

Hypertension

Smoking

Elevated lipoprotein A

Elevated LDL cholesterol

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Major Risk Factors

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Symptoms of Aortic Stenosis5

What are the symptoms of aortic stenosis? Angina - A sensation of aching, burning, discomfort, fullness, pain, or squeezing in

the chest. It may also be felt in the arms, back, jaw, neck, shoulders and throat

Syncope- A sudden and brief loss of consciousness

Shortness of breath - Feeling winded and tired when walking or lying down

Dizziness (after periods of inactivity)

Rapid or irregular heartbeat

Palpitations – An uncomfortable awareness of the heart beating rapidly or irregularly

Page 8: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Trans-thoracic

Echo (TTE)

Chest X-ray

Electro-cardiogram

Cardiac Cath.

Auscultation

Multiple Modalities May Be Used to Diagnose Severe Aortic Stenosis6

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Page 9: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Survival after onset of symptoms is 50% at 2 years1 and 20% at 5yrs. Surgical intervention for severe aortic stenosis should be performed

promptly once even minor symptoms occur1

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Aortic Stenosis Is Life Threatening and Progresses Rapidly7

Page 10: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

• In the absence of serious comorbid conditions indicated in the majority of symptomatic patients with severe aortic stenosis

• Consultation with or referral to a Heart Valve Center is reasonable when discussing treatment options for: o Asymptomatic patients with severe

valvular heart disease o Patients with multiple comorbidities

for whom valve intervention is considered

• Because of the risk of sudden death, replacing the aortic valve should be performed promptly after the onset of symptoms

• Age is not a contraindication to surgery

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Timely intervention is critical for patients with symptoms6

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Sobering Perspective8

Severe aortic stenosis has a worse prognosis than many metastatic cancers

*Using constant hazard ratio. Data on file, Edwards Lifesciences LLC. Analysis courtesy of Murat Tuczu, MD, Cleveland Clinic

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AHA/ACC guidelines for aortic valve replacement in patients with aortic stenosis

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Options for Aortic Valve Replacement

Low Risk Patients (STS <3%)

Intermediate Risk Patients (STS 3-8%) High Risk Patients (STS >8%)

Surgical Aortic Valve Replacement (SAVR)

Minimal Incision Valve Surgery (MIVS)

PARTNER Research: Continued Access for

Low Risk Enrollment for TAVR

Transcatheter Aortic Valve Replacement (TAVR)

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What is in the STS score?

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TAVR is indicated for intermediate-risk patients

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PARTNER 3 Low Risk Continued Access

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History of Edwards’ transcatheter heart valve technology in the United States

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VIV TAVR & TMVR is an option to treat patients with failed surgical valves in high risk patients

For use in patients with: Symptomatic heart disease due to

either severe native calcific aortic stenosis or failure (stenosed, insufficient, or combined) of surgical bioprosthetic aortic or mitral valves.

Evaluated by a Heart Team, including a cardiac surgeon, to be at high or greater risk for open surgical therapy

Ongoing trial for intermediate-low risk MVIV patients

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The PARTNER II Trial: Intermediate-risk cohort

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Mortality rates continue to decline

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Intermediate Risk Patients

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All-cause mortality*

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Disabling Stroke*

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Page 25: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Identifying Potential Candidates for TAVR

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Characteristics of a TAVR Patient17

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 aortic valve stenosis

TAVR patients may present with some of the following:

Page 27: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Cohesive, multi-disciplinary approach embodies Optimal patient centric care Dedication across medical specialties Collaborative treatment decision

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The specialized Heart Team

National coverage determination28

The patient (preoperatively and postoperatively) is under the care of a Heart Team

Interventional cardiologist

Cardiac surgeon

Valve clinic coordinator

Nursing

Anesthesiologist

Referring cardiologist

Imaging specialists Heart

Team

28. National coverage determination (NCD) for transcatheter aortic valve replacement (TAVR). 2012

Page 28: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Qualifying gradients (either by TTE or Cath)

TAVR CT- both Heart/coronaries & Chest/abd/pelvis

Coronary Angiogram

Pulmonary Function Test

2 CV surgery visits

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Complete TAVR Workup Includes:

Page 29: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Following Patient Referral, the TAVR Team will Perform Further Evaluation

Confirm the patient is

diagnosed with severe

symptomatic native aortic

stenosis

Confirm the patient has been evaluated by two

cardiac surgeons and

meets the indication for

TAVR

Evaluate the aortic valvular complex using

echocardio-graphy

Evaluate the aortic valvular complex and

peripheral vasculature

using CT

Evaluate the aortic valvular complex and

peripheral vasculature

using catheterization

Note: The above is a suggested flow for the patient screening process, however, the order in which screening tests are conducted varies depending on the patient’s profile and should be at the discretion of the Heart Team.

4 5 3 1 2

Determine access route

for transcatheter aortic valve replacement

6

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A collaborative treatment decision

Page 31: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

According to the 2008 ACC/AHA guidelines, severe aortic stenosis is defined as: Aortic valve area (AVA) less than 1.0 cm2 or index AVA <0.6cm2/m2

Mean gradient greater than 40 mmHg OR jet velocity greater than 4.0 m/s

Echocardiographic Guidelines are the Gold Standard in Assessing Severe Aortic Stenosis6

*Doppler-Echocardiographic measurements

*

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Page 32: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Dobutamine stress echocardiography can be used to differentiate between true and pseudo severe aortic stenosis

Better define the severity of the aortic stenosis

Accurately assess contractile/pump reserve

Some patients with severe aortic stenosis based on valve area have a lower than expected gradient (e.g. mean gradient < 30 mmHg) despite preserved LV ejection fraction (e.g. EF > 50%)

Up to 35% of patients with severe aortic stenosis present with low flow, low gradient

These low gradients often lead to an underestimation of the severity of the disease, so many of these patients do not undergo surgical aortic valve replacement

Paradoxical Low Flow and/or Low Gradient Severe Aortic Stenosis19

Dobutamine stress in low gradient, low ejection fraction AS Chambers, Heart. 2006 April; 92(4): 554–558

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Page 33: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

While some patients may have low STS scores, certain conditions may preclude them from being suitable candidates for surgery, for example:

Extensively calcified (porcelain) aorta Chest wall deformity Chest radiation Oxygen-dependent respiratory

insufficiency Frailty

Complexities of Measuring Risk19

Example: Porcelain aorta in TAVR candidate

3/6/2019

Page 34: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Frailty is an important parameter in assessing operative risk

Transcatheter aortic valve replacement is a best therapy for intermediate and high risk inoperable patients with severe aortic stenosis

Prevalence of frailty increases with aging; old does not necessarily equal frail

Rehab potential post procedure

Elderly patients achieve measurable benefit from cardiac surgery, particularly in terms of: Quality of life

Increased survival

Prevention of adverse cardiovascular events

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Frailty: An Important Parameter

Page 35: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Vessel diameters must be a minimum of: ≥ 5.5mm for a 20, 23 & 26mm valve (requires a 14F eSheath) ≥ 6.0 mm for a 29mm valve (requires a 16F eSheath)

Assessing Appropriate Vascular Access

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Clinical outcomes improves as therapy evolves

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3mensio CT report

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Page 41: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

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Device Selection

Self expanding (in trial)

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Complete range of valve sizes expands the treatable patient population

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TAVR Conference Presentation

TAVR Committee: CMS requires a multi-disciplinary approach; patients are worked up and presented to our in-house TAVR Committee for approval – committee includes cardiologists, CV surgeons, research staff, Cath lab, OR, CCU/HFICU, HVI administration, etc.; meets weekly Slides include: Patient demographics; pertinent medical history; STS score; diagnostic testing results & anatomical measurements; proposed treatment plan

Page 44: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

TAVR Pre-Procedure Overview

Transcatheter Aortic Valve Replacement (TAVR)

Page 45: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Patients will be admitted to the hospital the day before the procedure or will report to the Cath Lab/OR the morning of the procedure depending on facility

Hibiclens scrub Patient education and discharge expectations Shaving Possibility of a Foley Catheter or Condom Catheter MD Preference MAC vs. General Anesthesia

Pre-Procedure Nursing Implications

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Page 46: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Inpatients should be ready for transport by 7am ♥ Labs drawn, consents obtained, anesthesia assessment done ♥ Consent should read: “Transcatheter aortic valve replacement” Procedural needs: ♥ NPO per anesthesia guidelines ♥ Current type and screen with products available ♥ Blood products are to be available in room during procedure ♥ Pre-procedure hydration to prevent kidney injury ♥ CHG bath completed ♥ Clip hair from neck to knees ♥ Arm/blood bands preferably on left arm (anesthesia uses right wrist for

arterial line)

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Pre-Procedure

Page 47: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

TAVR Procedure Overview

Transcatheter Aortic Valve Replacement (TAVR)

Page 48: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

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The TAVR procedure can be performed through multiple access approaches

Page 49: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Arterial

14Fr/16Fr Sheath for Transcatheter Valve

5Fr/6Fr Sheath Pigtail Catheter (contralateral to THV)

Radial Line

Venous

5Fr/6Fr Sheath Temporary Pacemaker (contralateral to THV)

5Fr/6Fr Sheath Secondary venous access (possible)

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Access Sites

Page 50: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Some patients may not have adequate vascular access to accommodate the sheath used during transfemoral procedures

For these patients, alternative access approaches are available, such as transapical and transaortic

An Alternative Option for Patients Without Vascular Access

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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

During the transaortic approach, the Edwards SAPIEN transcatheter heart valve is delivered through an incision in the front of the chest

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Trans-axillary approach

Page 52: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

♥ Access: Femoral (primary method), trans-aortic, trans-subclavian, trans-apical or trans-axillary

♥ Done under MAC anesthesia or general (if necessary)

♥ Valve is advanced via the aorta (over a delivery catheter) to the aortic valve

♥ Valve is positioned and inflated with a balloon (similar to a coronary stent)

♥ Rapid pacing is performed during balloon inflation ♥ This minimizes cardiac motion and

prevents dislodgement of the valve during deployment

♥ Balloon is deflated and removed ♥ Valve positioning is confirmed using

angiography and echo

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Intra-procedure

Transapical

Transfemoral

Page 53: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Edwards SAPIEN Transcatheter Heart Valve Deployment

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Page 54: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

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Angiogram Images

Page 55: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Post-Operative Care and Length of Stay

Page 56: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Two Post-Op Pathways

Transfemoral

Transapical, Transaortic & Trans-axillary

Post-Op Nursing Implications

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Page 57: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Post-Op Nursing Implications Transfemoral27

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Post-Op Nursing Implications Transfemoral27

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Post-Op Nursing Implications TA and TAo27

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Post-Op Nursing Implications TA and TAo27

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Page 61: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

How to reduce Length of Stay (LOS)

TAVR Nursing Implications 3/6/2019

• Patient evaluation and selection • Set patient and family expectations

• Early discharge Pre-procedure

• Procedural brief • Perioperative Protocols

• Foley, MAC vs. GA, Swan-Ganz Procedure

• Extubation • Ambulation

• Transfemoral and Transaortic: 4 hours • Transapical: 6-8 hours

• Foley removal • Swan-Ganz removal • Discharge Communication to family, MD, NP, Charge Nurse

Post-Procedure

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TVT Registry Info

Page 63: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

♥ Vascular issues – damage to iliac/femoral arteries – sometimes requires surgical repair

♥ Ventricular wall perforation by wire – resulting in tamponade (may be seen after leaving the procedural area)

♥ Valvular complications - annular rupture, malpositioning, leaking around the valve

♥ Arrhythmias – heart block related to AV node disruption – sometimes resolves, sometimes requires permanent pacer insertion ♥ Most patients develop a BBB during deployment – this usually resolves over a few

minutes or hours, however, some remain and ultimately require pacing intervention ♥ Temporary pacers maybe left overnight to monitor

♥ Coronary artery occlusion by TAVR valve resulting in MI ♥ Stroke ♥ Death

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Common Complications

Page 64: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

♥ Observe access site for complications ♥ Observe for signs/symptoms of stroke, MI, chest pain ♥ Observe for conduction disruptions – bradycardia, bundle branch

block, heart block ♥ Monitor hemodynamics – address hyper or hypotension ♥ Remember – these are not surgical patients – early ambulation is

preferred (within 2-4 hours) ♥ Up, out of bed, eating as soon as tolerated ♥ Begin discharge planning immediately post-procedure ♥ Consult social work/ case managment ♥ Goal for length of stay is no more than 1-2 days post-procedure ♥ Cardiac Rehab consult o

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Post Procedure Management

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Post Procedure Management

♥ Access sites: Primary access site is whichever side the valve delivery sheath is inserted – it could be right or left femoral artery depending on vessel size - the valve sheath is usually 14F – for a 29mm valve it is 16F

♥ Smalling/Dhoble/Balan: Valve sheath & 7F venous (for temp pacer) to primary side; 6F arterial & 5F venous to contralateral side (opposite side)

♥ Kar/Jumean/Kumar/Loyalka: Valve sheath to primary side; 5F arterial & 7F venous (for temp pacer) to contralateral side

♥ Valve sheaths & 6F arterial sheaths are closed with Proglide/Prostar – 5F arterial sheaths are closed with Mynx

♥ Venous sheaths are closed with manual pressure ♥ Lines left in place: Radial arterial line and peripheral IV – generally these are the only lines left

in ♥ If there are AV conductions issues (bradycardia, BBB, other heart block) the temporary pacing

wire will be left in place ♥ If carotid protection (Sentinel) was used, there will be a TR band to the associated radial site

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Carotid Protection

Stroke is a concern during TAVR due to calcification of aortic valve – debris can travel to the cerebral arteries during valve deployment causing stroke Cerebral protection devices: (inserted during procedure and removed at end of procedure) • Sentinel – 6F via radial access (FDA approved) • TriGuard – 9F via femoral access (current trial in enrollment)

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Carotid Protection

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AV Conduction Delays

♥ Some patients experience new BBB or AV block due to swelling/irritation or compression around the AV node

♥ Monitor for heart block, BBB or bradycardia in the post-procedure period – this can be a late occurrence ♥ Avoid use of beta-blockers that may potentiate heart block

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Post Procedure Hypertension Management

Patients may experience post TAVR hypertension ♥ Due to the decrease in afterload by relieving LV outflow obstruction

(the heart is used to working hard, but no longer needs to) ♥ For transapical or transaortic access – keep SBP no more than 120

mmHg to prevent suture line tears ♥ Commonly treated with Cardene gtt – Dr. Smalling prefers his MAPs

to be 75-85 for all TAVR patients

Page 70: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

♥ Hyperdynamic ventricle – some patients develop an enlarged LV with diastolic dysfunction due to chronic high afterload

♥ Rapid relief of the obstruction results in severe hypotension/shock – dubbed “suicide ventricle”

♥ Generally have small LV cavity, enlarged septum and high EF (>70%) – “little old ladies” are particularly at risk

♥ LV is unable to fill adequately (preload), decreasing CO; tachycardia decreases LV filling time even more, creating a downward spiral

♥ Use of Dopamine, Epi, Norepi increases contractility & heart rate even more – this makes it worse!

♥ Treatment involves decreasing contractility using beta-blockers and ensuring adequate preload by increasing volume

♥ Beta-blockers & Volume

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Post Procedure Hypotension

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Resources

Page 72: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Resources Available for You and Your Patients

Resources for healthcare providers to access information about aortic stenosis and TAVR

Patients can learn about the disease and locate a local TAVR Center

Symptom checklist to help patients discuss their treatment options with their healthcare provider

3/6/2019 TAVR Nursing Implications

Page 73: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

9,000+ people clicked on the Symptom Checklist & Doctor Discussion Guide

3/6/2019 TAVR Nursing Implications

Page 74: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

NewHeartValve.com Resource Library Severe Aortic Stenosis Brochure Patient Brochure TAVR Patient Screening Fact Sheet Patient Screening Supplement Heart Tablets SAS Kit SAS Poster TF & TA Posters SAS Brochure Stand Rubber Valve Display Stands

3/6/2019 TAVR Nursing Implications

Page 75: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

Edwards Heart Master Apps on iTunes

• Educational Resource that can be used to help educate patients

• Dedicated to AS with 3D immersion in heart anatomy and pathophysiology

• Free iPad and iPhone Apps

3/6/2019 TAVR Nursing Implications

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Questions?

TAVR Nursing Implications 3/6/2019

Page 77: TAVR: Criteria, Procedure, Pre & Post Care · TAVR Nursing Implications • Patient evaluation and selection • Set patient and family expectations • Early discharge Pre-procedure

1. Otto CM. Timing of aortic valve surgery. Heart. 2000;84:211-21.

2. Census.gov – 2010 US Census Report.

3. Ramaraj R, Sorrell VL. Degenerative aortic stenosis. Br Med J 2008;336: 550–5.

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