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Setting a Benchmark for Quality of Care

Update on Best Practices in Transcatheter Aortic Valve Replacement Programs
Open AccessPublished:April 28, 2022DOI:https://doi.org/10.1016/j.cnc.2022.02.009

      Keywords

      Key points

      • There is strong evidence to guide the implementation of contemporary best practices to promote safe early discharge after transcatheter aortic valve replacement (TAVR).
      • In the pre-procedure phase, the central role of the valve coordinator, a streamlined assessment pathway, and patient-centred education resources are effective best practice.
      • In the peri-procedure phase, the use of local anaesthesia, and the avoidance of invasive lines and vascular access complications facilitate a safe minimalist approach.
      • In the post-procedure phase, the implementation of a standardized clinical pathway to guide close monitoring, accelerated mobilization and discharge teaching enables safe next-day discharge. Nurses play an essential role in the implementation of best practices to improve outcomes and timely access to care, optimize outcomes, and reduce costs.

      Introduction

      In the first decade of transcatheter aortic valve replacement (TAVR) innovation, clinicians and researchers focused their attention on the development of improved devices, multimodality assessment, case selection, and procedural approaches.
      • Lauck S.B.
      • Wood D.A.
      • Baumbusch J.
      • et al.
      Vancouver transcatheter aortic valve replacement clinical pathway: minimalist approach, standardized care, and discharge criteria to reduce length of stay.
      These collective efforts resulted in TAVR rapidly becoming established as a safe and effective treatment option for people with symptomatic severe aortic stenosis (AS) with surgical profiles ranging from prohibitive to low.
      • Kolkailah A.A.
      • Doukky R.
      • Pelletier M.P.
      • et al.
      Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis in people with low surgical risk.
      Today, TAVR has surpassed surgical aortic valve replacement (SAVR) as the preferred treatment for AS in multiple international jurisdictions.
      • Kundi H.
      • Strom J.B.
      • Valsdottir L.R.
      • et al.
      Trends in isolated surgical aortic valve replacement according to hospital-based transcatheter aortic valve replacement volumes.
      This accelerated success of “how we do TAVR” has now enabled a shift to “how we care for TAVR patients.” This new focus is driven by early clinical experience, and the pressing need to standardize processes of care to consistently achieve excellent outcomes, patient experiences, and program efficiencies.
      • Lauck S.
      • Forman J.
      • Borregaard B.
      • et al.
      Facilitating transcatheter aortic valve implantation in the era of COVID-19: recommendations for programmes.
      In this new clinical context, nurses’ expertise in patient-centered care, development of clinical pathways, and change management creates new opportunities for leadership to advance the care of TAVR patients. Nurses are ideally positioned to promote quality improvement initiatives, leverage current evidence, and help recalibrate practices that were often informed by the early era of innovation and surgical blueprints and are ill-suited to contemporary TAVR.
      To reach this goal and help prepare TAVR programs for the anticipated need for increased capacity and decreased health service resource utilization, continuous quality improvement warrants close scrutiny of all aspects of patients’ journey of care, from referral to follow-up across systems of care. The objective of this review is to outline current evidence that supports the adoption of best TAVR practices and highlight opportunities for nurses to be champions of change to improve the care of patients with valvular heart disease.

      Discussion

      The goal of TAVR care is to enable patients to safely return home after a seamless and uncomplicated hospital admission to derive the survival and quality-of-life benefits of the procedure. From patients’ perspective, transitions from their preprocedure assessment pathway and procedure planning, to their periprocedure experience, and finally to their postprocedure care represent a single journey of care.
      • Santana M.J.
      • Manalili K.
      • Jolley R.J.
      • et al.
      How to practice person-centred care: a conceptual framework.
      As such, the adoption of best TAVR practices must encompass a single clinical pathway inclusive of all time points to improve transitions of care and multidisciplinary collaboration.
      • Lauck S.B.
      • Wood D.A.
      • Baumbusch J.
      • et al.
      Vancouver transcatheter aortic valve replacement clinical pathway: minimalist approach, standardized care, and discharge criteria to reduce length of stay.

      Preprocedure Best Practices

      The central role of the transcatheter aortic valve replacement coordinator

      The complexity of referral processes and the assessment pathway create unique challenges for patients with AS referred for treatment. Similarly, cardiac programs require efficient processes to manage communication with referring and procedure physicians, facilitate multidisciplinary consultations, diagnostic imaging, and treatment recommendations, support patient education and shared decision making (SDM), and ensure early discharge and procedure planning.
      • Hawkey M.C.
      • Lauck S.B.
      • Perpetua E.M.
      • et al.
      Transcatheter aortic valve replacement program development: recommendations for best practice.
      Although titles differ between programs and across international regions, the TAVR Nurse Coordinator has emerged as a pivotal member of the Heart Team to address this issue. Widely endorsed by international guidelines, this role has been integrated unevenly in different regions, with an early adoption in the United States, Canada, United Kingdom, and Australia, and growing or emerging interest in European countries and Asia. Nurses are well suited to excelling in the role, given the requirements for comprehensive and cardiac clinical assessment skillset, patient teaching, leadership, and communication.
      • Hawkey M.
      • Højberg Kirk B.
      The valve program clinician.
      ,
      • Perpetua E.M.
      • Clarke S.E.
      • Guibone K.A.
      • et al.
      Surveying the landscape of structural heart disease coordination: an exploratory study of the coordinator role.
      Although the responsibilities of the TAVR Nurse Coordinator differ across programs, most clinicians focus their work on program leadership and coordination, facilitation of patient-focused processes of care, and fostering effective communication pathways. For patients and their families, the Coordinator acts as a case manager who can individualize communication, planning, and teaching; for programs, benefits span centralized coordination and close collaboration with implanting physicians, diagnostic imaging departments, procedure rooms and in-patient units, research services, and administration. Essential competencies and core responsibilities are summarized in Table 1.
      Table 1Competencies and responsibilities of the transcatheter aortic valve replacement nurse coordinator
      Competencies and Core KnowledgeResponsibilities
      • 1.
        Expertise in cardiovascular care:
        • Cardiovascular nursing
        • Specialized knowledge of valvular heart disease
        • Specialized knowledge of TAVR
      • 2.
        Specialized knowledge of providing care for patients with aortic stenosis:
        • Complex heart disease, multiple comorbidities, and frailty
      • 3.
        Clinical assessment skills:
        • Comprehensive cardiovascular assessment
        • Assessment of frailty and functional status
      • 4.
        Patient and family education:
        • Assessment of learning needs to individualize teaching
        • Patient and family teaching skills
        • Conduct of shared decision making
      • 5.
        Coordination of complex processes of care:
        • Organizational skillset to develop and individualize assessment and procedure planning pathways
      • 6.
        Clinical leadership:
        • Leadership skills to contribute to the Heart Team
        • Administrative leadership to develop program efficiencies
      • 1.
        Program leadership:
        • Serves as essential and central member of the Heart Team
        • Supports and leads TAVR program development
        • Participates in program evaluation and quality improvement to improve outcomes
      • 2.
        Facilitation of patient-focused processes of care:
        • Develops seamless and patient-centered processes and clinical pathways
        • Develops evaluation pathways, including diagnostic testing and functional assessment
        • Conducts clinical triage and wait-list management
        • Case manages urgent in-patients and interhospital referrals
        • Facilitates referrals to subspecialty consultants
        • Facilitates and contributes to multidisciplinary, treatment decision making
        • Coordination of procedure planning, admission, and follow-up
      • 3.
        Development of communication pathways:
        • Conducts patient and family education and promotes shared decision making
        • Leads communication with the Heart Team
        • Facilitates communication with administration for planning purposes

      Measurement of frailty

      The multimodality assessment to inform patients’ eligibility and suitability for TAVR requires diagnostic imaging (eg, transthoracic echocardiography, cardiac angiography, computed tomography), cardiology and cardiac surgery consultations, and specialized referrals (eg, geriatric medicine, nephrology). Nurses’ expertise in the specialized assessment and management of frailty, functional and/or cognitive decline can significantly strengthen a wholistic approach to multidisciplinary treatment recommendation.
      • Jepma P.
      • Latour C.H.M.
      • ten Barge
      • et al.
      Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study.
      Frailty is a complex health state that differs from aging; it is an age-related, multisystem syndrome that increases health vulnerabilities when exposed to stressors that increase the risk of functional decline and other adverse events.
      • Borregaard B.
      • Dahl J.S.
      • Lauck S.B.
      • et al.
      Association between frailty and self-reported health following heart valve surgery.
      Frailty is associated with mortality, morbidity, and quality of life after TAVR, and with processes such as length of stay and health service utilization.
      • Frantzen A.T.
      • Eide L.S.P.
      • Fridlund B.
      • et al.
      Frailty status and patient-reported outcomes in octogenarians following transcatheter or surgical aortic valve replacement.
      ,
      • Afilalo J.
      • Lauck S.
      • Kim D.H.
      • et al.
      Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study.
      The advanced age of most patients with AS warrants a criteria-driven assessment of frailty and function in higher-risk patients who may not derive the benefits of TAVR, who may require a more in-depth geriatric assessment, and/or when the anticipated procedure planning and recovery trajectory present significant challenges to achieve a good outcome.
      There is no consensus on the standardized measurement of frailty in patients with AS.
      • Forcillo J.
      • Condado J.F.
      • Ko Y.
      • et al.
      Assessment of commonly used frailty markers for high- and extreme-risk patients undergoing transcatheter aortic valve replacement.
      Upward of 20 tools are available and used across programs; the most commonly used instruments in TAVR programs are outlined in Table 2.
      Table 2Commonly used instruments to measure frailty in patients with aortic stenosis
      InstrumentDetails of Measurement
      Fried Scale
      • Fried L.P.
      • Tangen C.M.
      • Walston J.
      • et al.
      Frailty in older adults: evidence for a phenotype.
      • Captures core phenotypic domains:
        • Slowness
        • Weakness
        • Low physical activity
        • Exhaustion
        • Shrinking (unintentional weight loss)
      Short Physical Performance Battery
      • Guralnik J.M.
      • Ferrucci L.
      • Simonsick E.M.
      • et al.
      Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability.
      • Captures slowness, weakness, and balance; measured by timed physical performance tests:
        • Gait speed
        • Chair rises
        • Tandem balance
      Essential Frailty Toolset
      • Afilalo J.
      • Lauck S.
      • Kim D.H.
      • et al.
      Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study.
      • Developed to predict mortality after SAVR/TAVR using phenotypic domains:
        • Chair rises
        • Cognitive status (MiniCog: short-term memory and orientation; clock drawing test)
        • Hemoglobin
        • Albumin
      Clinical Frailty Scale
      • Rockwood K.
      • Song X.
      • MacKnight C.
      • et al.
      A global clinical measure of fitness and frailty in elderly people.
      • Captures clinicians’ assessment of accumulated deficits including:
        • Presence of terminal illness
        • Activities of daily living
        • Instrumental activities of daily living
        • Chronic health conditions
        • Patient-reported health status and activities
      Rotterdam Frailty Index
      • Schoufour J.D.
      • Erler N.S.
      • Jaspers D.-L.
      • et al.
      Design of a frailty index among community living middle-aged and older people: the rotterdam study.
      • Captures clinicians’ assessment of 38 accumulated deficits, including:
        • Functional status
        • Health conditions
        • Cognition
        • Mood

      Patient education

      Most TAVR programs can be classified as “procedure-focused” programs: patients are referred by their cardiologist, internist, or other health care provider for assessment of eligibility; episodic care focuses on the short period of admission and ends at the time of follow-up. To match this mandate, the following outlines some key components of the patient education imperatives for TAVR patients:
      • 1.
        Shared decision-making: SDM is a bidirectional process between patients and clinicians that enables an information exchange, and treatment decisions that consider patients’ informed preferences and allows them to participate in choosing the right treatment option. It is not solely patient education. SDM acknowledges equally important forms of expertise to achieve quality decisions: the clinician’s expertise, based on knowledge of the condition, prognosis, treatment, options, and possible outcomes, and the patient’s expertise, informed by the impact of their health condition on their daily life, values, and preferences for the possible outcomes.
        • Lauck S.B.
        • Lewis K.B.
        • Borregaard B.
        • et al.
        What is the right decision for me?” integrating patient perspectives through shared decision-making for valvular heart disease therapy.
        Increasingly, TAVR programs are embracing SDM to ensure patients can make a high-quality decision, especially in light of the emerging equipoise between SAVR and TAVR.
        • Coylewright M.
        • Palmer R.
        • O'Neill E.S.
        • et al.
        Patient-defined goals for the treatment of severe aortic stenosis: a qualitative analysis.
        Patient decision aids (PDAs) are tools to support SDM; PDAs for AS have been published by American and European agencies to strengthen the adoption of SDM and patient empowerment to participate in their treatment decision.
      • 2.
        Streamlined assessment pathway: Information about the TAVR assessment pathway must include information about the sequence, scheduling and details of diagnostic imaging requirements, and the expected consultations. The COVID-19 pandemic forced and accelerated the adoption of virtual health platforms to minimize patients’ exposure to the hospital environment and further highlighted the imperative need for a streamlined assessment pathway.
        • Lauck S.
        • Forman J.
        • Borregaard B.
        • et al.
        Facilitating transcatheter aortic valve implantation in the era of COVID-19: recommendations for programmes.
        Additional education may be required to prepare patients for telemedicine consultations, including coaching to successfully connect, accommodations in the case of auditory, visual, or other impairments, and clarity of expectations. Importantly, there may be opportunities to streamline assessment requirements based on clearly defined risk criteria to accelerate access to timely and efficient care. Fig. 1 illustrates components of the accelerated and routine assessment pathways implemented to facilitate the transition to virtual care in TAVR programs.
        Figure thumbnail gr1
        Fig. 1Vancouver accelerated TAVR assessment pathway adapted for COVID-19.
        • Lauck S.
        • Forman J.
        • Borregaard B.
        • et al.
        Facilitating transcatheter aortic valve implantation in the era of COVID-19: recommendations for programmes.
        CAD, coronary artery disease; CCTA, Coronary Computed Tomography Angiography; CT, computed tomography; TF, Transfemoral.
      • 3.
        Preparing for the TAVR clinical pathway: Successful safe and early discharge home hinges on early discharge planning and consistent communication about goals of care from all health care providers at every contact time with patients. This “united front” of uniform communication, inclusive of written resources and clinical interactions with nursing and medicine, is pivotal to avoid confusion, help patients and families prepare “their” discharge plan and availability of social support, manage expectations, and anticipate the important role they play as partners to optimize their outcomes. Key messages for patient and family education must reflect these stated goals (Box 1).
        Key messages for transcatheter aortic valve replacement preprocedure patient and family education
        • Goal #1: Maximize patients’ pre-TAVR conditioning and reduce risks of complications
          • Importance of mobilization and physical functioning
          • “Stay as active as you can. Ask your regular doctor about what level of activity is best for you.”
          • Individualized medical referrals
          • “The TAVR Clinic nurse or doctors may want you to see other medical specialists.”
          • Discharge planning: Endocarditis prophylaxis
          • “Book an appointment with your dentist.”
        • Goal #2: Develop a discharge plan before admission and set patient/family expectations
          • The TAVR journey of care is predictable; standard/goal of care is safe next-day discharge home
          • “Our goal is for you to go home the day after your procedure.”
          • Early mobilization and avoidance of deconditioning are priority activities while in hospital
          • “Our goal is for you to walk and do basic activities on the day of your procedure, and to go home the next day.”
          • Discharge planning requires family coordination
          • “Speak with your family about your Going Home Plan.”
        • Goal #3: Facilitate seamless admission and patient safety on day of procedure
          • Set expectations of same-day admission
          • “Most people come to hospital the morning of the procedure. We let you know what time you should arrive.”
        • Goal #4: Set expectations about periprocedure experience
          • TAVR is a minimalist procedure that is more akin to a “big angiogram” than open heart surgery
          • The default anesthesia strategy is local anesthesia with light sedation
          • TAVR is a short procedure
        • Goal #5: Set expectations about postprocedure experience and early mobilization
          • Postprocedure mobilization after 4- to 6-hour bedrest
          • Importance of early and frequent mobilization
          • “Our goal is for you to have two short walks on the evening of the procedure.”
          • Patient comfort and avoidance of opioids
          • “Most people who have TAVR do not have a lot of pain. We will check with you to make sure you are comfortable.”
        • Goal #6: Set expectations for next-day discharge and safe transition home
          • Target length of stay is next-day discharge
          • Safe transition home
          • “Once at home, your priorities are to recover safely, rest, get back to your regular activities, and do a bit more every day.”
      • 4.
        Early discharge planning: The TAVR Nurse Coordinator plays an important role in coaching patients to prepare for discharge. Effective individualized discharge planning begins before admission to ensure safe transition home. Although the TAVR trajectory of care is standardized and highly predictable,
        • Wood D.A.
        • Lauck S.B.
        • Cairns J.A.
        • et al.
        The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study.
        patients who present with unique health vulnerabilities and social determinants of health may benefit from the development of an adapted discharge plan to improve their outcomes and experiences.
      • The TAVR Nurse Coordinator plays a pivotal role to optimize patients’ pathway, communication, and program efficiencies.
      • The standardized measurement of frailty augments assessment findings and informs treatment decisions.
      • A comprehensive patient education strategy is essential to establish a close partnership with patients.
      • Early discharge planning is an effective intervention to facilitate early and safe transition home.

      Periprocedure Best Practices

      The arc of the development and refining of the TAVR procedure started with the earliest innovation days in the cardiac catheterization laboratory with “interventional cardiology-like” practices.
      • Cribier A.
      • Eltchaninoff H.
      • Tron C.
      • et al.
      Treatment of calcific aortic stenosis with the percutaneous heart valve: mid-term follow-up from the initial feasibility studies: the French experience.
      Early clinical trial practices evolved to the adoption of a surgical template to promote patient safety and anticipate the “what ifs” complication scenarios. Most recently, there is increasing evidence that the early vision of a truly minimally invasive and standardized approach is safe, feasible, and efficient.
      • Wood D.A.
      • Lauck S.B.
      • Cairns J.A.
      • et al.
      The Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study.
      Periprocedure best practices include the adoption of a streamlined approach matched to contemporary technology and evidence, and the development of nursing competencies that are uniquely adapted to the needs of TAVR patients.

      Minimalist transcatheter aortic valve replacement

      The transition from historical practices primarily informed by cardiac surgery models to more streamlined contemporary TAVR practices continues to evolve. The definition of what constitutes a minimalist approach remains disputed.
      • Jensen Hanna A.
      • PhD M.D.
      • Condado J.F.
      • et al.
      Minimalist transcatheter aortic valve replacement: the new standard for surgeons and cardiologists using transfemoral access?.
      Important aspects include procedure location, anesthesia strategy, and use of invasive equipment.
      • 1.
        Procedure location: The rapid expansion of the availability of hybrid operating rooms equipped with high-quality imaging and hemodynamic monitoring equipment provided operators with an effective environment to achieve excellent periprocedure outcomes. This tailored space was endorsed in early guidelines as the optimal setting and became a standard of care in most North American programs and other international programs. Increasingly, the cardiac catheterization laboratory is becoming an appropriate or even preferred space for most TAVR procedures. Careful planning, staff training, and emergency preparedness through simulation training can enable programs to significantly increase their periprocedure capacity, reduce the intensity of operating room resource use, and decrease costs without compromising patient safety.
        • Spaziano M.
        • Lefèvre T.
        • Romano M.
        • et al.
        Transcatheter aortic valve replacement in the catheterization laboratory versus hybrid operating room: insights from the France TAVI registry.
        In addition, the intrinsic “nimbleness” of the cardiac catheterization laboratory to accommodate the scheduling of urgent in-patients, and its integration in cardiac service lines offer important operational advantages to improve access to care.
      • 2.
        Anesthesia strategy: There is clinical interest in selecting an anesthesia strategy that aligns with goals of care of contemporary TAVR.
        • Lauck S.
        • Wood D.A.
        • Sathananthan J.
        • et al.
        Anesthesia for TAVR patients: should we focus on goals of care?.
        In light of current evidence, these goals include the following:
        • Patient comfort and experience
        • Capacity to easily communicate with patients during the procedure as required
        • Hemodynamic stability
        • Readiness for mobilization within 4 to 6 hours after the end of the procedure
        • Postprocedure transfer of a consistently stable patient with a predictable recovery
      To this end, the use of local anesthesia with or without light sedation, or conscious sedation has been reported as safe and effective options for most TAVR patients.
      • Feistritzer H.
      • Kurz T.
      • Stachel G.
      • et al.
      Impact of anesthesia strategy and valve type on clinical outcomes after transcatheter aortic valve replacement.
      Potential advantages of the avoidance of general anesthesia include minimal disruptions to hemodynamic status, improved ability to detect early warnings of complications, prevention of delirium, accelerated reconditioning and predictable time to mobilization, and shorter procedure times. An open visual field between the patient, the anesthesiologist, and the implanting team is particularly effective to promote communication.
      To maintain patient safety, periprocedure must retain the ability to convert to general anesthesia, obtain periprocedure imaging within 5 minutes, or initiate femoral-femoral hemodynamic support within 10 minutes. Collaboration consensus agreements between medical and nursing disciplines and regular multidisciplinary simulation training exercises can promote a culture of quality and patient safety, while recalibrating practices to improve care.
      • 3. Best use of invasive monitoring lines: In contemporary TAVR, the avoidance of central venous or urinary catheters is widely accepted across multiple programs and regions.
        • Lauck S.B.
        • Kwon J.
        • Wood D.A.
        • et al.
        Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: an observational study.
        Patient skin preparation and draping aligned with interventional cardiology practice instead of the more extensive practices of cardiac surgery are in keeping with contemporary TAVR. These practices also convey an important message to the patient that the team is conducting a minimalist procedure, and not cardiac surgery. The avoidance of surgical draping and the systematic opening of cardiac surgery instruments have significant cost savings implications. Implanting physicians’ systematic use of ultrasound-guided sheath insertion technique and the monitoring of activated clotting time with partial reversal of anticoagulation at the end of the procedure can significantly improve postprocedure hemostasis and contribute to early mobilization. Last, the timely removal of the temporary pacemaker if used at the time of valve deployment in the absence of new conduction delays can further facilitate a rapid return to baseline status and reduce the requirements for postprocedure critical care.

      Periprocedure models of nursing care

      Multiple factors influence the models of periprocedure nursing staffing models, including procedure room location (operating room or cardiac catheterization laboratory), primary implanting physicians’ specialty (interventional cardiology or cardiac surgery), program historical practice, and competing hospital demands. The expertise of operating room nurses prioritizes the asepsis imperatives of valve implantation, assistance with anesthesia, and management of emergency strategy. Similarly, the expertise of the cardiac catheterization team with transcatheter techniques and invasive hemodynamic monitoring, and their competencies in the setting of emergency percutaneous coronary intervention are well suited to the needs of a safe TAVR procedure. The required ratio of distribution of these skillsets remains disputed; nevertheless, TAVR increasingly requires a “hybrid model of staffing” to ensure the availability of the required competencies.
      • Hinterbuchner L.
      • Coelho S.
      • Esteves R.
      • et al.
      A cardiac catheterisation laboratory core curriculum for the continuing professional development of nurses and allied health professions (EAPCI) 2016.
      The contributions of operating room and interventional cardiology nursing competencies to augment the unique requirements of periprocedure TAVR nursing, and an example of periprocedure staffing model, are illustrated in Fig. 2.
      Figure thumbnail gr2
      Fig. 2Conceptual illustration of periprocedure TAVR nursing competencies and example of staffing model. CATH LAB, cardiac catheterization laboratory; OR, operating room; PCI, percutaneous coronary intervention.
      Importantly, change in management strategies, communication, education and training, and practice leadership is essential to achieve role clarity and satisfactory selective cross-training of competencies and attend to the challenges of “merging” distinct areas of nursing practice and expertise.
      • Shirey M.
      Lewin’s theory of planned change as a strategic resource.
      Careful attention to equipping nurses to participate in emergency intervention planning and simulation training should focus on emergency vascular repair, percutaneous coronary intervention, management of severe hemodynamic instability and pericardial tamponade, and conversion to open heart surgery.
      • TAVR can be safely performed in a cardiac catheterization laboratory with close scrutiny of all aspects of the procedure.
      • The selection of anesthesia strategies for TAVR should reflect the goals of care.
      • The avoidance of invasive lines, the adoption of best practices to avoid vascular injury, and the rapid removal of the temporary pacemaker when appropriate are effective strategies to prepare patients for rapid reconditioning.

      Postprocedure Best Practices

      Procedural success must be followed by the same degree of excellence in postprocedure care aimed at helping patients to return home safely and early, without sustaining any in-hospital complications or need for readmission, to enjoy the survival and quality-of-life benefits of their new valve. To this end, postprocedure nurses play an essential role in the TAVR clinical pathway to facilitate patients’ rapid reconditioning and safe discharge.
      • Lauck S.B.
      • Sathananthan J.
      • Park J.
      • et al.
      Post-procedure protocol to facilitate next-day discharge: results of the multidisciplinary, multimodality but minimalist TAVR study.
      The early recognition of potential complications associated with TAVR, and the significant risks associated with the hospitalization of the primarily older AS patient population warrant a standardized postprocedure pathway to achieve these goals of care.

      “The Big 5”: Monitoring for Potential Complications after Transcatheter Aortic Valve Replacement

      Contemporary TAVR patients achieve outstanding outcomes, including rapid and significant improvement in quality of life, and risk of 30-day mortality that is as low as less than 0.5%. Device modification, lower profile systems, use of computed tomography sizing, and increased operator experience have contributed to substantial reduction in most complications.
      • Arnold S.V.
      • Zhang Y.
      • Baron S.J.
      • et al.
      Impact of short-term complications on mortality and quality of life after transcatheter aortic valve replacement.
      Nevertheless, clinical awareness of these adverse outcomes and close monitoring remain essential to mitigate risks and ensure patients have the best possible outcomes.
      • Grube E.
      • Sinning J.
      The “Big Five” complications after transcatheter aortic valve replacement: do we still have to be afraid of them?.
      The following important, albeit increasingly infrequent, complications require early recognition and timely and effective treatment (Figs. 3 and 4).
      Figure thumbnail gr3
      Fig. 3Major in-hospital complications associated with TAVR
      (From Grube E, Sinning JM. The “big five” complications after transcatheter aortic valve replacement: do we still have to be afraid of them? JACC Cardiovasc Interv 2109;12(4):370 to 372)
      Figure thumbnail gr4
      Fig. 4Summary of TAVR postprocedure nursing protocol.
      • Lauck S.B.
      • Sathananthan J.
      • Park J.
      • et al.
      Post-procedure protocol to facilitate next-day discharge: results of the multidisciplinary, multimodality but minimalist TAVR study.
      CBC, complete blood count; CWMS, colour, warmth, movement and sensitivity; ECG, electrocardiogram; Hgb, hemoglobin; HOB, head of bed; IV, intravenous; POD, post-operative day; PV, paravalvular; TTE, transthoratcic echocardiogram.
      (From Lauck SB, Sathananthan J, Park J, et al. Post-procedure protocol to facilitate next-day discharge: Results of the multidisciplinary, multimodality but minimalist TAVR study. Catheterization and Cardiovascular Interventions. 2020;96(2):450 to 458. https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.28617. https://doi.org/10.1002/ccd.28617.)

      Stroke

      Different mechanisms and potential contributing factors, including patients’ demographics, clinical characteristics, and procedural factors, can contribute to the risk of stroke. Early stroke is considered to be related to particle embolization.
      • Davlouros P.A.
      • Mplani V.C.
      • Koniari I.
      • et al.
      Transcatheter aortic valve replacement and stroke: a comprehensive review.
      Embolic neurologic events can range from a minor transient ischemic attack to a major event causing permanent disability or death. Overall, recent clinical trials and large registry observational studies report stroke rates that continue to decrease.
      • Carroll J.D.
      • Mack M.J.
      • Vemulapalli S.
      • et al.
      STS-ACC TVT registry of transcatheter aortic valve replacement.
      The use of cerebral embolic protection devices remains under evaluation to reduce the risk of stroke.
      • Giustino G.
      • Mehran R.
      • Veltkamp R.
      • et al.
      Neurological outcomes with embolic protection devices in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis of randomized controlled trials.
      A comprehensive neurologic assessment on admission, and in conjunction with vital signs and vascular access checks, should screen the patient for (1) facial symmetry or changes from baseline when smiling, (2) speech characteristics and presence of slurring, and (3) asymmetrical weakness, numbness, and/or drift when arms are raised. The acronym FAST (Face drooping; Arm weakness; Speech difficulty; Time to call for help) is an easy guiding reference to conduct a preliminary standardized assessment.

      Paravalvular leak

      As the native or failed surgical valve is not removed in TAVR, suboptimal placement of the device with incomplete sealing of the annulus, incomplete apposition of the valve stent frame owing to the calcification of the annulus and/or leaflets, or undersizing of the device can cause the onset of paravalvular leak between the device and the annulus.
      • Lerakis S.
      • Hayek S.S.
      • Douglas P.S.
      Paravalvular aortic leak after transcatheter aortic valve replacement: current knowledge.
      This can cause severe aortic regurgitation and hemodynamic instability. Nurses should anticipate the need for urgent echocardiography and possibly angiography to confirm device function and establish a plan of care. Vasoactive or mechanical support may be needed in the setting of severe instability.

      Acute kidney injury

      Although there is increasing awareness and strategies to limit periprocedure contrast dye exposure, some TAVR patients remain at higher risk for acute kidney injury (AKI) because of their preexisting renal dysfunction, atherosclerotic vascular disease, advanced age, and/or high frailty.
      • Peillex M.
      • Marchandot B.
      • Matsushita K.
      • et al.
      Acute kidney injury and acute kidney recovery following transcatheter aortic valve replacement.
      The onset of AKI is associated with significant morbidity and mortality.
      • Adachi Y.
      • Yamamoto M.
      • Shimura T.
      • et al.
      Late kidney injury after transcatheter aortic valve replacement.
      Close monitoring of periprocedure contrast use, renal function, and rapid resumption of normal hydration can effectively reduce patients’ risk and promote an accelerated return to baseline renal function.

      New conduction delay

      The close proximity between the aortic valve and the conduction system is the primary reason the TAVR device can cause a mechanical insult to the conduction tissue, including various degrees of edema, hematoma, and ischemia.
      • Rodés-Cabau J.
      • Muntané-Carol G.
      • Philippon F.
      Managing conduction disturbances after TAVR: toward a tailored strategy.
      The subsequent development of a high-degree atrioventricular block may require the implantation of a new permanent pacemaker, whereas the new onset of a left bundle branch block may be associated with increased mortality and need for pacemaker.
      • Auffret V.
      • Puri R.
      • Urena M.
      • et al.
      Conduction disturbances after transcatheter aortic valve replacement: current status and future perspectives.
      In the immediate postprocedure period, TAVR patients require continuous cardiac monitoring as nurses stay alert for the risk of electrocardiographic changes, especially in atrioventricular conduction (ie, measurement of P-R interval). Increasingly, TAVR programs are endorsing continuity of medical care and the adoption of standardized approaches to the management of new conduction delays to improve outcomes and reduce the risks of pacemaker without compromising patient safety.
      • Lauck S.B.
      • Sathananthan J.
      • Park J.
      • et al.
      Post-procedure protocol to facilitate next-day discharge: results of the multidisciplinary, multimodality but minimalist TAVR study.

      Bleeding

      The incidence of vascular injuries continues to improve with the availability of smaller sheath sizes, flexible delivery systems, computed tomography imaging of the peripheral vasculature, and operator experience.
      • Scarsini R.
      • De Maria G.L.
      • Joseph J.
      • et al.
      Impact of complications during transfemoral transcatheter aortic valve replacement: how can they be avoided and managed?.
      In addition, periprocedure best practices described in the previous section significantly increase the likelihood that most patients will have a predictably stable vascular access site and will achieve timely hemostasis. Standardized and expert assessment of potential bleeding (including in the retrosternal location) is an essential nursing intervention to ensure early identification and treatment. There are on-going efforts to define and measure the range of bleeding and vascular injury complications to drive quality improvement.
      • Généreux P.
      • Piazza N.
      • Alu M.C.
      • et al.
      Valve academic research consortium 3: updated endpoint definitions for aortic valve clinical research.

      Standardized Postprocedure Clinical Pathway

      The postprocedure care of TAVR patients evolved from earlier protocols informed by cardiac surgery to the increasing adoption of contemporary standardized and streamlined practices based on new evidence. In most programs, TAVR nursing care is now well established and integrated in practice; given the low rates of complications and the predictability of patients’ journey, this group of patients has become somewhat “less special” over time and now requires substantially fewer health care resources during their early in-hospital recovery. Research supports the transition of historical postprocedure admission to a critical care unit to the preferred use of cardiac telemetry ward for most patients, and the safety and feasibility of next-day discharge home.
      • Sathananthan J.
      • Webb J.G.
      • Polderman J.
      • et al.
      Safety of accelerated recovery on a cardiology ward and early discharge following minimalist TAVR in the catheterization laboratory: the Vancouver accelerated recovery clinical pathway.
      This recalibration of nursing practices and resources continues to warrant excellent cardiovascular nursing care, albeit not always critical care nursing, that focuses on close monitoring, nurse-led accelerated reconditioning, and communication, patient teaching, and criteria-driven safe discharge home. A standardized TAVR postprocedure clinical pathway provides guidance for nurses to focus on priorities of care.
      • Lauck S.B.
      • Sathananthan J.
      • Park J.
      • et al.
      Post-procedure protocol to facilitate next-day discharge: results of the multidisciplinary, multimodality but minimalist TAVR study.

      Monitoring

      The assessment of vital signs, cardiac rhythm, neurologic status, vascular access site, and pain/discomfort requires an intensive period of close observation in the immediate postrecovery period, followed by routine cardiovascular care. Immediate postprocedure assessment of hemoglobin and renal function, as well as serial 12-lead electrocardiograms can effectively identify the onset of complications. The documentation of postimplantation echocardiography, completed either at the end of the procedure or before discharge, provides necessary information to determine procedural success and inform long-term follow-up.

      Nurse-led accelerated reconditioning

      In the absence of postprocedure complications, the focus of care shifts to ensuring patients return to their baseline status as soon as possible and prepare for safe discharge home. With a goal of next-day discharge, every hour counts to accelerate this reconditioning. Nurse-led early mobilization is a central component of postprocedure care. The progressive steps include (1) bedrest flat × 2 hours, (2) bedrest with head of bed elevated to 30° × 2 hours, (3) assistance for first mobilization with progression from sitting at side to walking to toilet after 4 to 6 hours in the absence of complications, and (4) goal of mobilization × 2 on procedure day, including up in chair for evening meal. In addition, rapid resumption of oral fluids and nutrition plays a pivotal role in reducing the risks of deconditioning.
      • Lauck S.B.
      • Sathananthan J.
      • Park J.
      • et al.
      Post-procedure protocol to facilitate next-day discharge: results of the multidisciplinary, multimodality but minimalist TAVR study.

      Communication, patient teaching, and discharge

      All postprocedure efforts should be focused on maintaining patients on the clinical pathway and addressing potential complications early and effectively. This requires seamless communication between nursing and the implanting team that enables nurses to raise their concerns in a timely way. In-hospital communication with the patient and their family should build on early discharge planning, with confirmation of the individualized planning for safe transition home, and the availability of social support for the first days at home as required. Patient teaching focused on vascular access site care, medications, progressive activity protocol, when to seek help, and follow-up instructions can be provided in a streamlined format using standardized resources. Last, confirmation of readiness for next-day or subsequent discharge can be guided by the following criteria:
      • 1.
        Absence of persistent (>3 hours) intraventricular conduction delay
      • 2.
        Absence of diagnostic contraindication (ie, stable hemoglobin and renal function)
      • 3.
        Return to baseline mobilization
      • 4.
        Availability of family member for 24 hours to remain with patient
      Importantly, patients should hear consistent messages, from every health care provider, at every encounter from referral to discharge to achieve safe and early discharge home. The key messages outlined in Box 1 must be repeated and endorsed by all providers to clarify expectations and carry individualized discharge planning.
      Last, there is growing interest in accelerating physical functioning in the early recovery period. The health benefits of exercise after TAVR are well documented and represent the foundation of cardiac rehabilitation.
      • Anayo L.
      • Rogers P.
      • Long L.
      • et al.
      Exercise-based cardiac rehabilitation for patients following open surgical aortic valve replacement and transcatheter aortic valve implant: a systematic review and meta-analysis.
      ,
      • Pressler A.
      • Förschner L.
      • Hummel J.
      • et al.
      Long-term effect of exercise training in patients after transcatheter aortic valve implantation: follow-up of the SPORT:TAVI randomised pilot study.
      Cardiac rehabilitation in patients after TAVR is safe, reduces mortality, and improves quality of life and exercise tolerance.
      • Sperlongano S.
      • Renon F.
      • Bigazzi M.C.
      • et al.
      Transcatheter aortic valve implantation: the new challenges of cardiac rehabilitation.
      The 2019 Canadian Cardiovascular Society Position Statement recommends cardiac rehabilitation as a component of long-term management.
      • Asgar A.W.
      • Ouzounian M.
      • Adams C.
      • et al.
      2019 Canadian Cardiovascular Society Position statement for transcatheter aortic valve implantation.
      To date, cardiac rehabilitation has been dramatically underused, and different methods for its delivery (eg, centered-based, home-based, telehealth) have been explored to overcome the presence of barriers to utilization, including referrals and adherence. Regardless of method of delivery, systematic and standardized referrals, combined with patient education regarding the importance of cardiac rehabilitation in the postprocedure recovery, are evidence-based interventions that aim to improve outcomes.

      Clinics care points

      • Complications after transcatheter aortic valve replacement are increasingly rare; nevertheless, nurses need to be vigilant to identify stroke, hemodynamic instability, acute kidney injury, new conduction delay, and bleeding.
      • There is strong evidence that a standardized clinical pathway that prioritizes close monitoring, accelerated nurse-led reconditioning, communication, patient teaching, and criteria-driven discharge is effective to facilitate safe next-day discharge home after transcatheter aortic valve replacement.

      Summary

      The adoption of best practices along the preprocedure, periprocedure, and postprocedure components of TAVR care is informed by contemporary evidence on how to best care for this patient population. It also reflects the essential need to “get it right, for every patient, at every touch point” to ensure TAVR continues to offer the best possible outcomes, irrespective of individual risk profiles. Nurses are increasingly developing the specialized competencies to support patients’ journey of care and to play an essential role to reach these goals and help patients achieve outstanding outcomes. The close scrutiny of the care of TAVR patients offers new opportunities to leverage this evidence across cardiac and other patient populations, and to pursue nurses’ collective goal of improving outcomes and efficient health services.

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