Facilitated Data Relay and Effects on Treatment of Severe Aortic Stenosis in Europe.

Background Many patients with severe aortic stenosis are referred late with advanced symptoms or inappropriately denied intervention. The objective was to investigate whether a structured communication to referring physicians (facilitated data relay) might improve the rate and timeliness of intervention. Methods and Results A prospective registry of consecutive patients with severe aortic stenosis at 23 centers in 9 European countries with transcatheter as well as surgical aortic valve replacement being available was performed. The study included a 3-month documentation of the status quo (phase A), a 6-month intervention phase (implementing facilitated data relay), and a 3-month documentation of a legacy effect (phase-B). Two thousand one hundred seventy-one patients with severe aortic stenoses were enrolled (phase A: 759; intervention: 905; phase-B: 507). Mean age was 77.9±10.0 years, and 80% were symptomatic, including 52% with severe symptoms. During phase A, intervention was planned in 464/696 (67%), 138 (20%) were assigned to watchful waiting, 8 (1%) to balloon aortic valvuloplasty, 60 (9%) were listed as not for active treatment, and in 26 (4%), no decision was made. Three hundred sixty-three of 464 (78%) patients received the planned intervention within 3 months. Timeliness of the intervention improved as shown by the higher number of aortic valve replacements performed within 3 months (59% versus 51%, P=0.002) and a significant decrease in the time to intervention (36±38 versus 30±33 days, P=0.002). Conclusions A simple, low-cost, facilitated data relay improves timeliness of treatment for patients diagnosed with severe aortic stenosis, resulting in a shorter time to transcatheter aortic valve replacement. This effect was mainly driven by a significant improvement in timeliness of intervention in transcatheter aortic valve replacement but not surgical aortic valve replacement. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02241447.

Transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is indicated in some patients with severe aortic stenosis for whom surgical intervention is not deemed appropriate. This article explores when TAVR may be the preferred treatment option over surgical aortic valve replacement and discusses various prosthetic valve devices. The TAVR procedure, diagnostic screenings, complications, postoperative management, and nursing considerations are also outlined.

Contemporary nursing care in transcatheter aortic valve replacement.

The purpose of this article is to inform nurses of the latest trend in the care of patients with aortic stenosis using transcatheter aortic valve replacement and pertinent knowledge regarding the care of these patients.

Protocolo de enfermagem no implante de valva aórtica transcateter: um direcionamento para o cuidado / Nursing protocol in transcatheter aortic valve implantation: care guideline

Objective: To validate a nursing care protocol by specialist nurses, contributing to the care delivered to patients undergoing percutaneous valve replacement. Methods: This cross-sectional, prospective, quantitative study adopted the Content Validity Index (CVI) to verify level of agreement regarding this protocol's total set of items. Results: The CVI obtained for each item of the protocol, verified using a validation instrument, was greater than the minimum required that is 0.80, on average. Conclusion: The development of a protocol intended to guide care provided to patients who have undergone TAVI, improves patient safety and minimizes health problems, so that the implementation of specific strategies for the development of actions performed by nurses is essential.

Objetivo: Validar un protocolo de cuidados de enfermería por enfermeros especialistas, contribuyendo para la práctica asistencial del paciente sometido al cambio de válvula percutánea. Métodos: Se trata de un estudio metodológico, transversal y prospectivo, con abordaje cuantitativo, que empleó el Índice de Validez de Contenido (CVI) para verificar el nivel de concordancia en el conjunto total de ítems del instrumento del protocolo. Resultados: Después de la verificación con el CVI para cada ítem del instrumento de validación del protocolo, los valores obtenidos en relación a todos los ítems del protocolo, quedaron con los valores, en media, mayores que el mínimo para el CVI, que es arriba de 0,80. Conclusión: El desarrollo de un protocolo de cuidados dirigido para los pacientes sometidos a TAVI, posibilita el aumento de la seguridad del paciente minimiza los daños a la salud, siendo un factor esencial en la implementación de estrategias específicas para el desarrollo de acciones desempeñadas por el enfermero.

Objetivo: Validar um protocolo de cuidados de enfermagem realizado por enfermeiros especialistas, contribuindo para a prática assistencial do paciente submetido à troca valvar percutânea. Métodos: Trata-se de um estudo metodológico, transversal e prospectivo, com abordagem quantitativa, que empregou o Índice de Validade de Conteúdo (IVC) para verificar o nível de concordância no conjunto total de itens do instrumento do protocolo. Resultados: Após a verificação com o IVC, para cada item do instrumento de validação do protocolo, os valores obtidos em relação a todos os itens ficaram, em média, maiores que o mínimo para o IVC, que é acima de 0,80. Conclusão: O desenvolvimento de um protocolo de cuidados, voltado para os pacientes submetidos ao TAVI, possibilita o aumento da segurança destes e minimização dos agravos à saúde, sendo um fator essencial na implementação de estratégias específicas nas ações desempenhadas pelo enfermeiro.

Protocolo de enfermagem no implante de valva aórtica transcateter direcionamento para o cuidado / Nursing protocol in transcatheter aortic valve implantation: a guideline for care

Estudo metodológico, transversal e prospectivo com abordagem quantitativa, abordando os cuidados de enfermagem em pacientes submetidos ao implante de valva aórtica transcateter (TAVI). Para a construção da pesquisa foi realizada uma revisão integrativa para a criação de um protocolo de enfermagem para os pacientes submetidos a TAVI e a validação do mesmo por enfermeiros especialistas utilizando o Índice de Validação de Conteúdo (IVC) em um hospital do Rio de Janeiro. Foi delimitado como questão de pesquisa: quais os cuidados que o enfermeiro realiza nos pacientes submetidos a TAVI? Os objetivos propostos foram: criar um protocolo de cuidados de enfermagem para os pacientes submetidos ao implante de valva aórtica transcateter; buscar evidências científicas para a construção do protocolo através de uma revisão integrativa da literatura; validar o protocolo junto aos enfermeiros especialistas com vistas a validade do conteúdo, pertinência, clareza e abrangência. Para a construção do protocolo foram utilizados 10 artigos em publicações internacionais e nacionais, no período de 2006 a 2016, em inglês e português. A base de dados da Scopus foi a que mais evidenciou artigos representando (50%) das publicações do estudo. O ano de 2015 foi o ano com maior número de publicações (40%). Em relação ao idioma, as publicações em inglês representaram (90%) das publicações. As complicações mais descritas nos artigos foram: insuficiência renal (14,8%), acidente vascular cerebral (12,9%), complicações hemorrágicas (12,9%), complicações vasculares e distúrbios de condução (11,1%), vazamento paravalvar (7,4%), dissecção aórtica (5,5%), infarto agudo do miocárdio, endocardite, tamponamento e perfuração do ventrículo (3,7%), entre outros. Em relação a caracterização do perfil dos enfermeiros especialistas, (56,6%) aderiram ao estudo, o sexo feminino obteve a maior representatividade dos participantes (70,6%), a média da idade dos participantes foi de 35,88 anos. A unidade com maior número de participantes foi a UTI de pós-operatório (88,24%) e o tempo de experiência foi de 2,18 anos, sendo a especialização dos participantes com maior frequência a de Terapia Intensiva com (52,9%). Em relação a validação do conteúdo do protocolo, foi distribuído um instrumento de avaliação que constava com uma escala Likert de 1 a 5, no qual o participante verificava em relação aos itens, a validade do conteúdo, pertinência, clareza e a abrangência. O cálculo foi realizado pelo número de respostas que obtiveram 4 (concordo) e 5 (concordo totalmente) dividido pelo número de participantes (17). A média dos valores em relação a validade do conteúdo 0,96, em relação a pertinência foi de 0,93, clareza 0,86 e a abrangência de conteúdo foi de 0,85. A média de concordância entre todos os itens foi de 0,90. Conclui-se que os objetivos desta pesquisa foram alcançados através da criação e validação de um protocolo de cuidados de enfermagem para pacientes submetidos a TAVI. Acreditamos que pesquisas como esta, possam contribuir para a eficácia das tomadas de decisão do profissional enfermeiro acerca da qualidade do seu atendimento, visando a contribuição na construção de evidências relacionados aos cuidados de enfermagem ao paciente submetido a TAVI.

Methodological, transversal and prospective study with a quantitative approach, addressing nursing care in patients submitted to transcatheter aortic valve (TAVI) implantation. For the construction of the research, an integrative review was carried out for the creation of a nursing protocol for patients submitted to TAVI and validation of it by specialist nurses using the Content Validation Index (IVC) in a hospital in Rio de Janeiro. It was delimited as a research question: what care does the nurse perform in patients undergoing TAVI? The proposed objectives were: to create a nursing care protocol for patients undergoing transcatheter aortic valve implantation; to seek scientific evidence for the construction of the protocol through an integrative literature review; validate the protocol with the specialist nurses for the validity of content, pertinence, clarity and comprehensiveness. For the construction of the protocol, 10 articles were used in international and national publications, from 2006 to 2016, in English and Portuguese. The Scopus database was the one that most evidenced articles representing (50%) of the study publications. The year 2015 was the year with the highest number of publications (40%). In terms of language, English publications represented (90%) of the publications. The complications most described in the articles were: renal failure (14.8%), stroke (12.9%), hemorrhagic complications (12.9%), vascular complications and conduction disorders (11.1%), aortic dissection (5.5%), acute myocardial infarction, endocarditis, tamponade and ventricular perforation (3.7%), among others. Regarding the characterization of the profile of specialist nurses (56.6%), participants were the most representative of the participants (70.6%), the mean age of participants was 35.88 years. The unit with the highest number of participants was the postoperative ICU (88.24%) and the experience time was 2.18 years, with the specialization of the participants being more frequent the Intensive Therapy with (52.9%). In relation to the validation of the content of the protocol, an evaluation instrument was distributed that included a Likert scale of 1 to 5, in which the participant verified in relation to the items, the validity of the content, pertinence, clarity and comprehensiveness. The calculation was performed by the number of responses that obtained 4 (agree) and 5 (totally agree) divided by the number of participants (17). The mean values with respect to content validity of 0.96, relative to relevance was 0.93, clarity 0.86 and content coverage was 0.85. The mean of agreement among all items was 0.90. It is concluded that the objectives of this research were achieved through the creation and validation of a nursing care protocol for patients submitted to TAVI. We believe that research such as this one can contribute to the effectiveness of nursing professional decision-making about the quality of care, aiming to contribute to the construction of evidence related to nursing care to patients submitted to TAVI.

Nursing leadership of the transcatheter aortic valve implantation Heart Team: Supporting innovation, excellence, and sustainability.

Transcatheter Aortic Valve Implantation (TAVI) is an innovative and resource-intensive treatment of valvular heart disease. Growing evidence and excellent outcomes are contributing to increased patient demand. The Heart Team is foundational to TAVI programs to manage the complexities of case selection and other aspects of care. The competencies and expertise of nurses are well suited to provide administrative and clinical leadership within the TAVI Heart Team to promote efficient, effective, and sustainable program development. The contributions of nursing administrative and clinical leaders exemplify the leadership roles that nurses can assume in healthcare innovation.

Fragilidad en el paciente con estenosis aórtica severa: una valoración enfermera multidimensional / Fragility in severe aortic stenosis patient: a multidimensional assessment from nursing

El interés por estudiar la fragilidad en adultos mayores es un hecho emergente en cardiología por la incidencia de pacientes que se someten a cirugías de recambio valvular en unas condiciones de salud difícilmente cuantificables desde el punto de vista meramente clínico. En este sentido, el perfil de los pacientes ha ido cambiando y frecuentemente se identifican personas mayores con una mayor vulnerabilidad manifestada por diferentes aspectos que pueden relacionarse con la lentitud en la marcha, la fuerza de prensión, la independencia para las actividades de la vida diaria o aspectos emocionales que condicionen su calidad de vida. Este tipo de pacientes requieren ser identificados previamente a la cirugía con la finalidad de ofrecer la mejor alternativa terapéutica. Por ello, en nuestro centro nos propusimos identificar a este grupo de población frágil con una valoración multidimensional donde la enfermera, a través de un test específico, puede establecer el grado de fragilidad de aquellos pacientes que presenten una mayor vulnerabilidad. En este artículo se describe la valoración multidimensional enfermera llevada a cabo en una experiencia piloto con 115 pacientes, donde se analizaron las características de los pacientes, proporcionando una visión global del perfil de fragilidad en el adulto mayor con valvulopatía aórtica

The interest in studying frailty in older adults is an emerging fact in cardiology due to the incidence of patients undergoing valve replacement procedures in conditions difficult to quantify from the purely clinical point of view. In this regard, the profile of patients has been changing and often elderly people identify with greater vulnerability shown by different aspects such as walking speed, grip strength, independence for activities of daily living or emotional issues that condition their quality of life. These patients need to be identified prior to surgery in order to offer the best therapeutic option. Therefore, in our centre we set out to identify this group of fragile population with a multidimensional assessment where the nurse, through a specific assessment test, can set the degree of fragility of those patients who have an increased vulnerability. In this article we describe the multidimensional assessment in a pilot experience with 115 patients, where patient characteristics were analyzed, providing an overview of the profile of frailty in the elderly with aortic valve heart disease

Innovations in Cardiovascular Patient Care: Transcatheter Aortic Valve Replacement.

Aortic valve disease is a common and serious valvular disorder. Transcatheter aortic valve replacement is an option requiring nursing knowledge for the best patient outcome.

Pós-operatório de implante de bioprótese aórtica por cateter: intervenções de enfermagem / Pos-operative of bioprosthesis aortic catheter implant: nursing intervention

Estenose aórtica (EAo) é a doença cardíaca valvar mais comum, afeta, aproximadamente, 3% da população idosa submetida a implante de bioprótese aórtica por cateter. Os enfermeiros necessitam aperfeiçoar o conhecimento para elaborar protocolos de atendimento e cuidados. Objetivo: propor intervenções de enfermagem no período pós-operatório imediato para pacientes submetidos a tratamento da estenose aórtica por cateter. Método: pesquisa retrospectiva, quantitativa, com amostra composta por 418 pacientes cujos dados foram fornecidos pelo Registro Brasileiro de Implante por Cateter de Biotrótese Valvar Aórtica, entre janeiro de 2008 e fevereiro de 2013. Resultados: a média de idade foi de 81,5 anos, 348 pacientes apresentavam classe funcional III ou IV de insuficiência cardíaca, sendo que as complicações com maior incidência foram: bloqueio de ramo esquerdo (129 pacientes), bloqueio átrio ventricular (110) e necessidade de implante de marca-passo (83). Conclusão: Foram propostas as intervenções de enfermagem para avaliação da função neurológica, vascular, hematológica, renal, cardíaca, parâmetros vitais e controle da dor...

Perioperative management of cardiac disease.

Pre-existing cardiac disease contributes significantly to morbidity and mortality amongst patients undergoing non cardiac surgery. Patients with pre-existing cardiac disease or with risk factors for it, have as much as a 3.9% risk of suffering a major perioperative cardiac event (Lee et al 1999, Devereaux 2005). Furthermore, the incidence of perioperative myocardial infarction (MI) is increased 10 to 50 fold in patients with previous coronary events (Jassal 2008).

Transcatheter aortic valve implantation options for treating severe aortic stenosis in the elderly: the nurse's role in postoperative monitoring and treatment.

Severe calcific aortic stenosis (AS) is a progressive cardiac disease that predominantly affects elderly adults. The hallmark symptoms of AS include exertional dyspnea, angina, and syncope. Adults of advanced age do not usually seek treatment for symptoms until their quality of life is greatly diminished. The 2 standard treatments for severe AS are open aortic valve replacement and percutaneous valvuloplasty. As adults age, their comorbid medical conditions often make them too high of a surgical risk for traditional aortic valve replacement, and percutaneous valvuloplasty, although less invasive, often produces only temporary relief of AS symptoms. To provide severe AS patients with alternative less risky treatment options in their later years, transcatheter aortic valve implantation (TAVI) devices were developed. Through this overview of the disease progression of AS and the different TAVI devices and the insertion procedures, a better understanding of the initial postoperative nursing care associated with postoperative TAVI patient management will be achieved.

Integrating a palliative approach in a transcatheter heart valve program: bridging innovations in the management of severe aortic stenosis and best end-of-life practice.

Severe aortic stenosis (AS) is the most prevalent structural heart disease and affects primarily older adults in their last decade of life. If the risk for surgery is high, transcatheter aortic valve implantation (TAVI) is the treatment of choice for many patients with suitable anatomy who are likely to derive significant benefit from this innovative and minimally invasive approach. In a large transcatheter heart valve (THV) centre that offers TAVI as one of the treatment options, of 565 consecutive referrals for the assessment of eligibility for TAVI over 18 months, 78 (14%) were deemed unsuitable candidates for TAVI or higher risk surgery by the interdisciplinary Heart Team because of their advanced disease, excessive frailty or comorbid burden. Concerns were raised for patients for whom TAVI is not an option. The integration of a palliative approach in a THV program offers opportunities to adopt best end-of-life practices while promoting innovative approaches for treatment. An integrated palliative approach to care focuses on meeting a patient's full range of physical, psychosocial and spiritual needs at all stages of a life-limiting illness, and is well suited for the severe AS and TAVI population. A series of interventions that reflect best practices and current evidence were adopted in collaboration with the Palliative Care Team and are currently under evaluation in a large TAVI centre. Changes include the introduction of a palliative approach in patient assessment and education, the measurement of symptoms, improved clarity about responsibility for communication and follow-up, and triggering referrals to palliative care services.

Aortic stenosis: pathophysiology, diagnosis, and medical management of nonsurgical patients.

As the average lifespan continues to increase, nurses are managing more patients with aortic stenosis. When an asymptomatic patient begins to manifest signs and symptoms due to progressive narrowing and stiffening of the aortic valve, the only effective therapy is surgical replacement of the valve. But, some patients cannot undergo or do not opt for surgery. Nurses are challenged by the tenuous balance between the narrow range of preload and afterload to maintain forward blood flow and adequate cardiac output in patients with severe aortic stenosis. Understanding the complex normal anatomy and physiology of the aortic valve can help nurses appreciate the consequences of this type of stenosis. Nursing care for patients with aortic stenosis requires advanced skills in patient assessment and an appreciation of the hemodynamic responses to activities of daily living and to nursing interventions such as administration of medications.

Implementation of processes of care to support transcatheter aortic valve replacement programs.

Transcatheter aortic valve replacement (TAVR) is increasingly accepted as a feasible and safe therapeutic alternative to open heart surgery in select patients. Procedural success and technological advances combined with favorable clinical outcomes and demonstrated prolonged survival are establishing TAVR as the standard of care in symptomatic patients who are at higher risk or not candidates for conventional surgery. The growing number of referrals and complexities of care of TAVR candidates warrants a program that ensures appropriate patient assessment and triage, establishes appropriate processes, and promotes continuity of care. To address these needs and prepare for the anticipated growth of transcatheter heart valve (THV) therapeutic options, the TAVR program at St. Paul's Hospital, Vancouver, Canada, implemented an electronic centralized and clinically managed referral and triage program, and a THV Nurse Coordinator position to support the program and patients, conduct a global functioning assessment, and provide clinical triage coordination, waitlist management, patient and family education and communication with clinicians. Interdisciplinary rounds assist in the selection of candidates, while a clinical data management system facilitates standardized documentation and quality assurance from referral to follow-up. The unique needs of TAVR patients and programs require the implementation of unique processes of care and tailored assessment.

Transcatheter aortic valve replacement.

Symptomatic severe aortic stenosis is a serious life-threatening condition that requires surgical intervention. Until recently, the only available treatment options were through an open-heart surgery technique. A transcatheter aortic valve replacement is a minimally invasive aortic valve replacement procedure that is available for symptomatic patients with severe aortic stenosis and who are considered high-risk surgical candidates. It is an effective procedure for individuals with multiple comorbidities and high risk for mortality. This article reviews aortic stenosis and associated morbidity and mortality, treatment options, complications, education, and implications.

Treating calcific aortic stenosis: an evolving science.

Calcific aortic stenosis is a common valvular disease, but its pathophysiology remains undetermined and important considerations exist for treatment. Pathophysiology, treatment by the advanced practice nurse, and literature review are discussed in the context of a case study.

Cuidado enfermero dirigido a la persona con estenosis aórtica / Nursing care directed at the person with aortic stenosis", "_i": "

La estenosis aórtica se define como la alteración valvular queimpide el vaciamiento de la cámara de salida del ventrículo izquierdo;dicha dificultad se encuentra directamente relacionadacon el área valvular. La localización anatómica de la estenosispuede ser subvalvular, valvular o supravalvular. En el InstitutoNacional de Cardiología Ignacio Chávez, la prevalencia deestenosis aórtica representa 36% del total de valvulopatías; enel año 2007 se realizaron 178 cambios valvulares aórticos, delos cuales egresaron por mejoría 88 y 12% por defunción. Laevidencia señala que 20% de las personas con estenosis aórtica(moderada a severa) presentan muerte súbita. El presentedocumento pretende guiar al profesional de enfermería en latoma de la mejor decisión sobre el cuidado específico de la personacon estenosis aórtica al plasmar explícitamente a manerade Proceso de Atención de Enfermería, con el enfoque filosóficode Virginia Henderson, las intervenciones indispensables y elnivel de evidencia para cada una de ellas. De tal manera que seidentifican los 3 diagnósticos de enfermería prioritarios para lapersona con estenosis aórtica, se elabora la pregunta clínica yse realiza una búsqueda sistemática de evidencia y al sintetizarlase construyeron 3 planes de atención de enfermería

Aortic stenosis is defined as impaired emptying valve that preventsthe camera from left ventricular outflow, such difficultyis directly related to valve area. The anatomical location of thestenosis, can be subvalvular, valvular or supravalvular. For theInstituto Nacional de Cardiología Ignacio Chávez, aortic stenosisrepresents 36% of valvular heart disease, in 2007 were performed178 aortic valve changes, graduating to 88% improvementand 12% for death. Evidence indicates that 20% of peoplewith aortic stenosis (moderate to severe) had sudden death. Thisdocument aims to guide the nurse in making the best decisionon the specific care of the person with aortic stenosis to explicitlycapture how nursing care process, with the philosophical approachof Virginia Henderson, and operations necessary the levelof evidence for each. In that way, which identified 3 prioritynursing diagnosis for the person with aortic stenosis, the clinicalquestion was developed and conducted a systematic searchfor evidence and to synthesize the 3 built nursing care plans

Critical review of health-related quality of life studies of patients with aortic stenosis.

BACKGROUND: While studies of health-related quality of life (HRQOL) are increasing among cardiovascular patients, very few have examined HRQOL in persons with aortic stenosis (AS). PURPOSE: A critical review of studies (1997-2008) of HRQOL in persons with AS was conducted to summarize findings and identify clinical and research implications. RESULTS: Twenty-eight studies were identified, all of which were quantitative and evaluated HRQOL after aortic valve replacement (AVR). No studies conducted by nurses or studies measuring HRQOL in persons who did not undergo AVR were found. The literature focused on age and type of valve as variables influencing HRQOL postoperatively. Although results varied, elderly patients often scored similar or better than comparison groups. Health-related quality of life was found to be affected by valve noise and anticoagulation rather than the specific valve type when comparing patients receiving biological versus mechanical valves. CONCLUSIONS: Selection for surgery should not be based on age alone. Early consideration should be given to symptoms prior to surgery because of evidence that patients with fewer symptoms preoperatively have better HRQOL after AVR. Anticoagulation status should be evaluated as an independent variable of HRQOL in future studies. IMPLICATIONS FOR RESEARCH AND PRACTICE: Researchers need to augment generic HRQOL measures with disease-specific items that may pertain to life areas affected by AS, such as audible valve click, wound healing, and dyspnea. Future research should be inclusive of AS patients who do not undergo surgery. Nurses in a variety of roles can work independently or within a multidisciplinary team to provide interventions for the promotion of HRQOL for patients across all stages of the AS disease process.

Treatment of older patients with aortic valve stenosis.

This article aims to increase knowledge and understanding of aortic valve stenosis to support the treatment options available for older patients in the acute setting. The article discusses a relatively new procedure, transcatheter aortic valve implantation, which is appropriate for selected patients with aortic stenosis, and outlines the aftercare involved.