A shifting paradigm of care advances in transcatheter heart valve procedures
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A shifting paradigm of care: Advances in transcatheter heart valve procedures. Sandra Lauck MSN, RN, CCN(C) Clinical Nurse Specialist, Arrhythmia Management and Interventional Cardiology. What is available for what valve?. Transcatheter aortic valve implantation Mitral valve repair

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A shifting paradigm of care: Advances in transcatheter heart valve procedures

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A shifting paradigm of care: Advances in transcatheter heart valve procedures

Sandra Lauck MSN, RN, CCN(C)

Clinical Nurse Specialist, Arrhythmia Management and Interventional Cardiology


What is available for what valve?

  • Transcatheter aortic valve implantation

  • Mitral valve repair

  • Pulmonary valve implantation

  • What are the implications for cardiac nurses?


Transcatheter approaches

  • Minimally invasive

  • No cardiac bypass

  • Vascular access:

    • Transfemoral

    • Transvenous

    • Transapical

  • Use of catheters to deliver device or perform repair

  • No valve replacement – Native annulus remains in place

  • Imaging requirements:

    • Fluoroscopy

    • Echocardiography

  • Operators: Interventional cardiologists and cardiac surgeons


Transcatheter aortic valve implantation

Stent valve with bovine pericardial

leaflets

Delivery flexible and steerable catheter

with valvuloplasty balloon

Crimped stent valve on

delivery balloon catheter


TAVI approaches

Transfemoral

Transapical


Transfemoral TAVI

  • Femoral artery puncture

  • Steerable catheter

  • Retrograde approach

    • Common iliac arteries

    • Aorta

    • Aortic root

    • Into native annulus

  • Primary operator: Interventional cardiologist


Transfemoral TAVI


Transapical TAVI

  • Mini-thoracotomy

  • Vascular access sheath inserted into apex of LV

  • Primary operator: Cardiac surgeon


Transapical TAVI


Hybrid Cath Lab/OR

Fluoroscopy

Advanced hemodynamic monitoring


Hybrid Cath Lab/OR

Cardiac surgery bypass capacity

Teaching screen

Cardiac anaesthesia


Evidence supporting TAVI


PARTNER A: Inoperable patients

Symptomatic Severe Aortic Stenosis

ASSESSMENT: High-Risk AVR Candidate

3,105 PatientsScreened

Total = 1,057 patients

High Risk

Inoperable

N = 358

N = 699

2 Parallel Trials

ASSESSMENT: Transfemoral Access

Yes

No

1:1 Randomization

Not In Study

N = 179

N = 179

TF TAVR

Standard

Therapy

VS

Primary Endpoint: All-Cause Mortality

Superiority


PARTNER B: Most patients were over 80

50%

Percent of Patients

22%

20%

7%

2%

Age (years)


Mortality at 30 days and 1 year

P = .41

P = .001

Mortality, %

THV (n = 179) Standard Therapy (n = 179)


Repeat hospitalization

P < 0.0001

%

P = 0.17

TAVI (n=179)

Standard Rx (n=179)


“Balloon-expandable TAVI should be the new standard of care for patients with aortic stenosis who are not suitable candidates for surgery”


PARTNER A

Symptomatic Severe Aortic Stenosis

ASSESSMENT: High-Risk AVR Candidate

3,105 Total Patients Screened

Total = 1,057 patients

Inoperable

High Risk

N = 358

N = 699

2 Parallel Trials: Individually Powered

ASSESSMENT: Transfemoral Access

ASSESSMENT: Transfemoral Access

Yes

No

Transapical (TA)

Transfemoral (TF)

Yes

No

1:1 Randomization

1:1 Randomization

1:1 Randomization

Not In Study

N = 244

N = 248

N = 104

N = 103

N = 179

N = 179

TF TAVR

AVR

TA TAVR

AVR

TF TAVR

Standard

Therapy

VS

VS

VS

Primary Endpoint: All-Cause Mortality Superiority

Primary Endpoint: All-Cause Mortality at 1 yrNon-inferiority


All-cause mortality at 1 year

HR [95% CI] =0.93 [0.71, 1.22]

P (log rank) = 0.62

0.5

TAVR

AVR

0.4

26.8

0.3

24.2

0.2

0.1

0

0

6

12

18

24

No. at Risk

Months

TAVR

AVR


Transfemoral AVR

  • Is superior to medical management in inoperable patients

  • Is equivalent to surgery in selected, high risk patients even if they are “operable”


Improved technology = Improved procedural success


Mitral valve repair

  • Edge to edge repair

  • Coronary sinus annuloplasty

  • Mitral valve implantation


Edge to edge repair


Coronary sinus MV annuloplasty

Coronary sinus


Mitral valve ‘cinching’


Mitral valve implantation


Pulmonary valve implantation


Implications for cardiac nurses

  • ‘Hybrid’ procedures

    • Cath lab nursing

    • OR nursing

    • Cardiology and cardiac surgery recovery areas

  • ‘New’ patient population

    • Low volume and higher risk

    • Decision-making support and unique processes of care

    • Evidence-based inter-disciplinary program development

    • Same-day discharge?


Thank you

[email protected]


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