2/4/2019. Nursing Perspective of TAVR. Disclosure. Learning Outcomes

Transcription

1 Nursing Perspective of TAVR Tara Whitmire, DNP, APRN-NP, NP-C, CHFN Nebraska Methodist Hospital Cardiothoracic Surgery Nurse Practitioner Danelle Homeyer, RN Methodist 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. 1

2 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 Healthy Aortic Valve 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 Closed Open Diseased Aortic Valve Closed Open Edwards Lifesciences (2018). 2

3 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 3

4 DIAGNOSIS AND TREATMENT Multiple Ways to Diagnose Severe Valvular Disease Auscultation Transthoracic Echo (TTE) Cardiac Cath. Chest X-ray Transesopha g. echo (TEE) 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 4

5 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 openheart surgery, TAVR may be an alternative Both TAVR valves now have indication for intermediate risk patients (STS > 4%) 5

6 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 Severe, symptomatic native valve disease Old age Frailty History of stroke/cva History of syncope Reduced EF Heavily calcified aorta Prior CABG Prior chest radiation History of AFib History of CAD Prior open chest surgery History of COPD Fatigue, slow gait History of renal insufficiency Peripheral vascular disease Diabetes and hypertension Edwards Lifesciences,

7 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.,

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9 PROCEDURES Edwards Sapien Valve 9

10 Medtronic CoreValve 10

11 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 1 st 6 months-then Aspirin 81 mg daily SBE prophylaxis for dental procedures Perform echo 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 11

12 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 doi: 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: /s Arora, S., Misenheimer, J. A., & Ramaraj, R. (2017). Transcatheter aortic valve replacement: comprehensive review and present status. Texas Heart Institute Journal, 44, 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, Medtronic. (2018). TAVR heart valve. Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Fleisher, L. A., Thompson, A. (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, doi: /j.jacc Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, Guyton, R. A., Thomas, J.D. (2014) AHA/ACC guideline for the management of patients with valvular heart disease. Journal of the American College of Cardiology, 63, e57-e185, doi: /j.jacc 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 STS/ACC TVT Registry. (2018). TAVR data up to September Questions? 12