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Aortic Stenosis and TAVR Kristen Davis, MSN, RN, CCRN Heart Valve Program Coordinator Lexington Medical Center Disclosures NONE Objectives • • • • • • • • 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 • • • • Calcium deposits that accompany aging Infections Rheumatic fever as an adult Congenital abnormalities (bicuspid valve) Risk factors for the development of aortic stenosis • • • • • Being a male HTN Smoking Elevation of Lipoprotein A Increased LDL Aortic Stenosis • • • • • 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 • • • • • 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 • • • • • 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 • • • • 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 • • • • 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 06/13/13 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 28 06/13/13 Dr. Nithin P G Requisites • ‘Heart team’ approach • Specific team leader • Close communication • ‘Preplanning procedure’ • Large catheterization labs/ ‘hybrid’ rooms • • • • • 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 • • • • • • 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 06/13/13 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 33 Transfemoral Procedural Animation http://www.edwards.com/products/transcath etervalve/Pages/THVcategory.aspx 34 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 35 Transapical Procedural Animation http://www.edwards.com/products/transcath etervalve/Pages/THVcategory.aspx 36 06/13/13 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 38 • 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 06/13/13 Post TAVR Complications Post Procedure Care • • • • • • • Monitor patients in ICU for 24 hours Monitor closely for post-op complications Bleeding Late AV Block (ECG monitoring) CHF Renal Dysfunction CVA 06/13/13 • • • • Diminished perfusion IV contrast material Baseline and serial monitoring of Cr and electrolytes Gentle NS hydration 06/13/13 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….. 06/13/13 • MRS • MMSE • NIHSS • Anti-platelet regimen • ASA 81 mg • Clopidogrel loading • Afib +/- stents • • 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 06/13/13 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 06/13/13 Pulmonary Issues Paravalvular AI • Hemolysis • Anemia 06/13/13 • 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 06/13/13 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 06/13/13 Heart Failure • Preoperatively • ‘Tune Up’ overloaded patients • Pleural effusions • Concomitant TR or MR • Postoperatively • Acute fluid management 06/13/13 • • • • • • • Cardiology Surgery Nursing Neurology Pulmonologist Pharmacists Cardiac Rehab • • • • Speech Physical Therapy Case Management Business Office/Finance 06/13/13 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 06/13/13 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.