valvular heart disease · 2019-09-27 · 9/6/2019 2 introduction • valvular heart disease is an...

9/6/2019

1

Valvular Heart Disease

Tara Whitmire, DNP, APRN-NP, NP-C, CHFN

Nebraska Methodist College

Director, BSN-DNP Program

Nebraska Methodist Hospital

Cardiothoracic Surgery Nurse Practitioner

Disclosure

• Nothing to disclose

Outline

• Introduction of valvular heart disease

• Diagnosis

• Patient selection

• Discuss TAVR and Mitraclip Procedures

• Post op care

• Case Study

9/6/2019

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 stenosis

9/6/2019

3

Aortic Valve Disease

Diseased Aortic Valve

Healthy Aortic Valve

Closed Open

OpenClosed

Edwards Lifesciences (2018).

• 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

• Severe AS=velocity >4.0 m/s, mean PG > 40 mmHg and AVA < 1.0 cm2.

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)

9/6/2019

4

HF symptoms

• Exercise intolerance

• Angina

• Syncope

• DOE

Pre-TAVR heart failure

13.3%

62.5%

21.4%

2.9%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

NYHA FC IV

NYHA FC III

NYHA FC II

NYHA FC I

Pre-TAVR

STS/ACC TVT Registry. (2018). TAVR data up to September 2017. Reported February 23, 2018.

Mitral valve disease

9/6/2019

5

Mitral Regurgitation

• Mitral valve sits on the left side of the heart between the atrium and ventricle

• Blood usually flows in one direction-from atrium to ventricle

• Mitral regurgitation is the backflow of blood into the atrium

• Mitral regurgitation can lead to heart failure

Mitral Regurgitation

• Over 9% of patients ≥75 years have significant MR (Alozie, Paranskaya, Westphal, et al., 2017).

• Likely to become a growing clinical problem

• Difficult to know when to refer an elderly patient for mitral valve surgery

• Age, severity of MR and reduced EF are factors to consider

• Benefit of surgery at elderly age hard to gauge

HF Symptoms• Dyspnea and Dyspnea on exertion

• Fatigue

• Decrease in appetite

• Dry, hacking cough

• Fainting

• Weight gain

• Edema-lungs, belly, lower extremities

9/6/2019

6

Pre-Mitraclip heart failure

21.5%

63.8%

13.5%

1.2%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

NYHA FC IV

NYHA FC III

NYHA FC II

NYHA FC I

Pre-Mitraclip


Diagnosis and treatment

Trans-thoracic Echo (TTE)

Chest

X-ray

Trans-esophageal echo (TEE)

Cardiac Cath.

Auscultation

Multiple Ways to Diagnose Severe Valvular Heart Disease

9/6/2019

7

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

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 open-heart surgery, TAVR may be an alternative

• Both TAVR valves now have indication for intermediate risk patients (STS > 4%)

• LOW RISK approved August 2019 (STS <4%)

9/6/2019

8

MR Treatment

• Mitraclip approved by FDA in 2013

• Indications (updated in March 2019)

• Moderate-severe MR

• degenerative & functional MR

• No mention of surgical risk

Patient selection

9/6/2019

9

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/cathlab/OR/Palliative care

Characteristics of a Valve Patient

Edwards Lifesciences, 2018

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 valve disease

Valve Clinic Assessment• Frailty/functional assessment

• 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

9/6/2019

10

Afilalo, Lauck, Kim, et al., 2017

9/6/2019

11

Procedures

9/6/2019

12

Edwards Sapien Valve

Medtronic CoreValve

9/6/2019

13

Abbott, 2018

Mitraclip Procedural Overview

9/6/2019

14

Mitraclip Procedural Overview

Abbott, 2018

Mitraclip Implantation Video

Abbott, 2018

9/6/2019

15

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 1st 6 months-then Aspirin 81 mg daily

• SBE prophylaxis for dental procedures

• Perform echo 24-48 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

9/6/2019

16

Mitraclip Post-op Care

• Universal bed

• Similar to post-cath care

• Figure 8 stitch removed 4 hours after procedure

• Out of bed to care/walking after bed rest done

• Remove central line/CVP next day

• Echo prior to discharge

• Usual stay is 24-48 hours

• Aspirin/plavix for at least 1 month post-op

Mitraclip Post-op Care

• F/u 72 hours post-discharge

• Cardiac rehab as an outpatient

• 1 month (≥ 23 - ≤ 44 days from procedure date) follow up with echo/frailty assessment (must do walk test)

• 1 year (≥ 305- ≤ 425) follow up with echo/frailty assessment (must do walk test)

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)

9/6/2019

17

TAVR Heart Failure

13.3%

62.5%

21.4%

2.9%

0.9%

8.2%

37.5%

53.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

NYHA FC IV

NYHA FC III

NYHA FC II

NYHA FC I

Heart Failure Classification

30 day Post Pre-TAVR


Mitraclip Heart Failure

0.9%

8.2%

37.5%

53.3%

21.5%

63.8%

13.5%

1.2%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

NYHA FC IV

NYHA FC III

NYHA FC II

NYHA FC I

Pre-Mitraclip 30 day Post


Post-TAVR KCCQ-12 Functionality

80.80%

74.40%

60.30%

51.70%

Minimal-5 pt

At least Mod-10 pt

Lg improvement-20 pt

Improved Score

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%

Minimal-5 pt At least Mod-10 pt Lg improvement-20 pt Improved Score


9/6/2019

18

Post-Mitraclip KCCQ-12 Functionality

13.90%

80.80%

74.40%

60.30%

No change

Min >5 pts

Mod > 10 pts

Lg > 20 pts

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

No change Min >5 pts Mod > 10 pts Lg > 20 pts


Case Study• 87 year old y.o. female

• Severe, degenerative AS

• STS 7.616% -Intermediate Risk

• PMH: Afib (holding eliquis), CKD III, CAD, HTN, DM, gastric uclers (clipped on PPI)

• Pre-op EF=50%, NYHA FC IV, Mean PG- 4.47 mmHg, AVA 0.57 cm2

• Pre-op cath showed non-obstructive CAD distal LAD

• 29 mm Medtronic Evolut R valve placed

• POD #1 echo: ejection fraction is 55-60%.

• There is a 29mm Evolut stented aortic valve.

• The valve is well seated.

• There is no evidence of periprosthetic aortic reguritation.

• There is no aortic regurgitation.

• The aortic valve mean pressure gradient is 6 mmHg

• The aortic valve area is 2.28 cm2

• The aortic peak velocity is 1.55 m/s

• There is no pericardial effusion.

• Creatinine 2.0 pre-op; 1.62 POD #1

• No evidence of heart failure

• Discharged on POD #2

9/6/2019

19

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. 689-700 doi: https://doi.org/10.1016/j.jacc.2017.06.024.

• 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: 10.1186/s12872-017-0523-4

• Arora, S., Misenheimer, J. A., & Ramaraj, R. (2017). Transcatheter aortic valve replacement: comprehensive review and present status. Texas Heart Institute Journal, 44, 29-38.

• 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, 10-15.

• Medtronic. (2018). TAVR heart valve. https://www.medtronic.com/us-en/patients/treatments-therapies/transcatheter-aortic-valve-replacement/about/tavr-heart-valve.html

• Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Fleisher, L. A., …Thompson, A. (2017). 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, 252-289. doi: 10.1016/j.jacc.2017.03.011

• Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, Guyton, R. A., … Thomas, J.D. (2014). 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Journal of the American College of Cardiology, 63, e57-e185, doi: 10.1016/j.jacc.2014.02.536

• 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. 49-56

• STS/ACC TVT Registry. (2018). TAVR data up to September 2017.

•

Questions?

valvular heart disease · 2019-09-27 · 9/6/2019 2 introduction • valvular heart disease is an...

Documents