HA Convention 18-19 May 2015 The Impact of TAVI Nurse Coordinator on patient management of Transcatheter Aortic Valve Implantation (TAVI) program in QEH Division of Cardiology Department of Medicine Queen Elizabeth Hospital Kowloon Central Cluster Cecilia MC Chan 1, Michael KY Lee 1, CB Lam 1, C Leung 1, LK Chan 1, KC Chan 1, SF Chui 1, CY Wong 1, KT Chan 1 CS Chiang 1, MY Fan 1, KW Leung 1, HL Cheung 2, V Ng 2, E So 3, D Fok 3, MK Chan 4, W Chan 4, SF Yip 4, A Cheung 4 Department of Medicine 1 Department of Cardiothoracic Surgery 2 Department of Anaesthesiology 3 Department of Diagnostic Radiology & Imaging 4
Introduction Aortic Stenosis most common valvular heart disease in the elderly 4.6% in adults 75 years of age Healthy Aortic Valve Stenosed Aortic Valve
AVR Not performed in Some Patients with severe aortic stenosis if High surgical risk Short life expectancy Co-morbidities hindering GA, e.g. poor lung reserve Advanced age High frailty score Untreated Severe Aortic Stenosis Patients are at a High Risk for Death and a Poor Quality of Life repeated admission for symptom exacerbation
TAVI TAVI emerges as a viable alternative in inoperable or high risk elderly patients with symptomatic AS CoreValve Edwards Sapien Schoenhagen P et al. Eur Heart J 2009;30:2079-2086
CoreValve Transcatheter Procedure Balloon catheter threaded through sheath and into heart CoreValve in place, procedure completed CoreValve placed into position over the diseased aortic valve Experimental Device in the United States and Limited by Federal Law to Investigational Use.
Key to Success Patient Selection - Understand our patients - Meticulous patient assessment Multi-disciplinary TAVI Heart Team - Collaborative effort
Understanding Our Patients Comorbidities Quality of life Frailty Advanced age Disability Expectations Motivations
Consenting for Risks and Benefits Mortality Myocardial Infarction Stroke Bleeding Acute Kidney Injury Vascular Complications Conduction Disturbances Valvular Function
Multi-disciplinary TAVI Heart Team Cardiac Anesthesiolgists Radiologists Interventional Cardiologists Patients with Severe AS TAVI Nurse Coordinator Echo Cardiologist Cardiac surgeons
TAVI Nurse Coordinator s Duties Pre-operative Preparation Patient and family s education Cardiologists assessment Echocardiogram Independent assessment by cardiac surgeon Coronary angiogram + Peripheral angiogram CT aortogram TAVI Heart Team meeting
TAVI Nurse Coordinator s Duties Follow-up & Data collection Arrange FU 1 week, 1 month and then every 3-4 months Drug compliance checking: - Plavix for 3 months, Aspirin for life Echo at 1, 6, 12 months and then yearly 6 min walk test at 1, 6, 12 months SF-12 at 3 & 12 months NYHA functional class assessment Risk factors control
TAVI Nurse Coordinator s Duties Assist Patient s Assessment Diagnostic Work-Up Coordination Patient and Family Education Communicate among Heart Team Members Development of Program Forms Waitlist Management Communication With Referral Base Data Collection HA TAVI Audit Follow-Up Program Support for Research Clinical Coordination & Education Convenor Role General Admin & Data Mx
The Hong Kong Experience First TAVI performed at Queen Elizabeth Hospital on Dec 6 th, 2010 Medtronic CoreValve - 86 Center # of Cases Queen Elizabeth Hospital 49 Prince of Wales Hospital 26 Queen Mary Hospital 15 HK Adventist Hospital 10 Union Hospital 1 TOTAL 101 Edwards Sapien - 15
2-Year All-cause Mortality US CoreValve Pivotal Trial Vs QEH ACC 2015 QEH TAVI 14.3% 14.3% 19
30-Day Stroke Rate 20.0% 15.0% 10.0% 9.6% 5.0% 0.0% 4.5% 4.0% 4.0% 1.9% 2.5% 1.7% 1.8% 0.0% 18 Fr S&E 1 ANZ 2 French 3 Belgian 4 German 5 UK 6 Italian 8 Asia QEH 1. Medtronic. Data on file. COR 2006-02: 18 Fr Safety & Efficacy Study Re-Analysis, August 14, 2009. 2. Meredith. VARC-adjudicated Outcomes in Inoperable and High Risk AS Patients. TCT 2010, Washington, DC. 3. Eltchaninoff. French Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 4. Bosmans. Belgian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 5. Zahn. German Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 6. Ludman. UK Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France. 7. Petronio. Italian Registry, TAVI Facts, Figures and National Registries. EuroPCR 2010, Paris, France.
Mean Gradient & Valve Area 60 2.5 QEH Registry Mean Gradient (mmhg) 50 40 30 20 10 0.7 49.7 2 1.97 1.96 1.87 1.9 MPG AVA 9.5 8.49 8.19 8.2 8.03 2 1.5 1 0.5 AVA (cm 2 ) 0 Baseline 30 days 6 months 1 year 2 years 3 years 0 The PARTNER Trial CoreValve ADVANCE Study
QEH Symptom Status (NYHA Class) 100% NYHA Classification Changes in NYHA Classification 80% 35% 59% 60% 86% 40% 55% Class I Improved 2 Classes 20% 35% Class II Class III Improved 1 Class Maintained 0% 10% 14% 6% Pre-TAVI Post-TAVI 30-day Post-TAVI 6-month Class IV * NYHA: New York Heart Association Functional Classification for Heart Failure Stages (Class I = Best, Class IV = Worst)
6-Minute Walk Test 280 257.6 260 Meters 240 220 215 200 Pre-TAVI Paired-sample t-test: p<0.05 Post-TAVI
Measurement for Quality of Life (SF-12) Physical Component 33.58 50.46 Pre-TAVI Post-TAVI Mental Component 52.63 58.36 30 35 40 45 50 55 60 Score Physical Component Paired-sample t-test: p<0.05 Mental Component Paired-sample t-test: p<0.05
Conclusions Queen Elizabeth Hospital is the first hospital to perform TAVI in Hong Kong and adopt TAVI coordinator TAVI Nurse coordinator enhances the process of care and clinical triage coordination Pivotal role of TAVI Nurse coordinator as the central hub for the smoother logistics of the TAVI program
TAVI 3-Year Celebration