Validity of standard gamble utilities in patients referred for aortic valve replacement.

PURPOSE: Standard gamble (SG) is the preferred method of assessing preferences in situations with uncertainty and risk, which makes it relevant to patients considered for aortic valve replacement (AVR). The present study assesses SG preferences in patients with severe aortic stenosis (AS). METHODS: All patients >18 years old with severe AS referred for AVR to our institution were invited to enroll in the study. The SG was administered by a clinical research nurse. The SF-36, EQ-5D 3L, Hospital Anxiety and Depression Scale (HADS), and AS symptoms were administered by self-completed questionnaire. We hypothesized that SG utilities would have low-to-moderate correlations with physical and mental aspects of health based on our pathophysiological understanding of severe AS. No correlations were expected with echocardiographic measures of the aortic valve. RESULTS: The response rate for SG was 98 %. SG moderately correlated with physical aspects of SF-36 (PCS, role-physical, vitality), health transition, AS symptoms, and EQ-VAS (ρ S = 0.31-0.39, p < 0.001) and had low correlation with mental aspects of SF-36 and EQ-5D (ρ S = 0.17-0.28, p < 0.001). No correlation was found between SG and HADS, echocardiographic measures, age, gender, or education level (ρ S = 0.01-0.06). CONCLUSIONS: SG is an acceptable and feasible method of assessing preferences in patients with severe AS that has evidence for validity. The inclusion of uncertainty lends the SG face validity in this population as a direct approach to assessing preferences and basis for QALY calculations.

Screening for rheumatic heart disease: evaluation of a focused cardiac ultrasound approach.

BACKGROUND: Rheumatic heart disease (RHD) remains a major public health problem worldwide. Although early diagnosis by echocardiography may potentially play a key role in developing active surveillance, systematic evaluation of simple approaches in resource poor settings are needed. METHODS AND RESULTS: We prospectively compared focused cardiac ultrasound (FCU) to a reference approach for RHD screening in a school children population. FCU included (1) the use of a pocket-sized echocardiography machine, (2) nonexpert staff (2 nurses with specific training), and (3) a simplified set of echocardiographic criteria. The reference approach used standardized echocardiographic examination, reviewed by an expert cardiologist, according to 2012 World Heart Federation criteria. Among the 6 different echocardiographic criteria, first tested in a preliminary phase, mitral regurgitation jet length≥2 cm or any aortic regurgitation was considered best suited to be FCU criteria. Of the 1217 subjects enrolled (mean, 9.6±1 years; 49.6% male), 49 (4%) were diagnosed with RHD by the reference approach. The sensitivity of FCU for the detection of RHD was 83.7% (95% confidence interval, 73.3-94.0) for nurse A and 77.6% (95% confidence interval, 65.9-89.2) for nurse B. FCU yielded a specificity of 90.9% (95% confidence interval, 89.3-92.6) and 92.0% (95% confidence interval, 90.4-93.5) according to users. Percentage of agreement among nurses was 91.4%. CONCLUSIONS: FCU by nonexperts using pocket devices seems feasible and yields acceptable sensitivity and specificity for RHD detection when compared with the state-of-the-art approach, thereby opening new perspectives for mass screening for RHD in low-resource settings.

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.

Takayasu's arteritis with associated aortic insufficiency and coronary ostial obliteration.

PURPOSE: To describe the presentation, assessment, and management of Takayasu's arteritis (TA), a rare vascular condition exhibited predominantly in females in their second and third decades of life. DATA SOURCES: Thorough review of current scientific literature was obtained from electronic databases and medical journals (CINAHL and PubMed). A case study is presented to illustrate TA, which was reviewed and approved by the Human Subjects Committee for the release of protected health information. CONCLUSIONS: Clinical presentation of TA varies depending on the location of vessel involvement. Diagnosis is challenging because of the complex pathogenesis of TA. The chronic nature of TA requires ongoing evaluation and adjustment of medication regimens. The patient's quality of life is improved with maintenance of TA in a quiescent state. IMPLICATIONS FOR PRACTICE: Presentation of a young woman with symptoms suggestive of vascular inflammatory changes should prompt consideration of TA within the differential diagnosis.

A patient's bold voice: a journey through cardiac surgery.

Cardiac surgery is one of the most common operations performed on adults. The physiology, pathophysiology, pharmacology, and technologies relating to this complex patient population are researched and discussed frequently in critical care journals. Most of this article is written by a patient who has had cardiac surgery, specifically an aortic valve replacement. The patient shares his journey from diagnosis to recovery. The discussion includes the discovery and monitoring of aortic regurgitation, surgical options, valve replacement surgery, postoperative pericarditis, pain, family and visitors, and life on warfarin. The current practice is reviewed by the patient's wife, a critical care clinical nurse specialist. When we really listen to the patient, we can learn how to provide more holistic and humanistic care.

Aortic valve replacement.

From hospital to home care, patients receiving prosthetic valves benefit from nurses who understand their condition and know the essentials for avoiding complications of the procedure--and the anticoagulant therapy they may be on for a lifetime.

[Ambulatory nursing care for patients with aortic valve disease]. / Levantamento de subsídios para assistência de enfermagem ambulatorial a pacientes portadores de valvopatia aórtica.

This study aimed at characterizing the profile of outpatients with aortic valve dysfunction, identifying their knowledge about the disease, their major limitations during everyday activities and their means of coping with their predicament. The data obtained by semi-structured interviews with 12 patients and analyzed by quantitative and qualitative methods enabled to identify how the patients perceive the illness and the treatment as well as the implications to their everyday activities, that is, they allowed to capture reality from the subject's perspective, which is the knowledge for the elaboration of an educational proposal.

Prosthetic valve endocarditis leading to valve replacement: a case study.

Infective endocarditis (IE) is a pathologic condition of native or prosthetic heart valves or endocardium, which may result in valve destruction and congestive heart failure. It occurs more frequently in men than in women, and there is an increased trend in the elderly. The following conditions predispose patients to IE: congenital and rheumatic heart disease, calcification or stenosis of a valve, prosthetic valve surgery, a previous episode of endocarditis, poor dentition, parenteral drug abuse, and placement of intravascular lines or devices. Effective treatment frequently involves a combination of intense antibiotic therapy and surgical repair. Risk of death from IE is related to age over 60, diagnosis of staphylococcal infection, involvement of an aortic or prosthetic valve, and the presence of any of the following sequelae of endocarditis: congestive heart failure, embolic phenomenon, and neurologic deficit. Clinicians should suspect endocarditis in patients presenting with fever of unknown origin and who are at risk for endocarditis. Timely evaluation with transthoracic or transesophageal echocardiography may identify patients in the early stages of endocarditis and direct the patient to definitive therapy. Early treatment of native and prosthetic valve endocarditis may decrease its overall morbidity and mortality. This case study illustrates some of the challenges in effectively managing prosthetic valve endocarditis.

The Ross procedure: aortic valve replacement using autologous pulmonary valve.

The use of pulmonary autologous valve in aortic valve replacement pioneered by Dr. Donald Ross in 1967 has been employed in young patients for more than two decades with impressive results. This procedure is recommended for young patients with isolated aortic disease who are expected to have a longer life span. Because of its lack of tissue degenerative changes, the autologous pulmonary valve has the potential to function longer than other biologic valves and mechanical valves while exhibiting the same inherent hemodynamic advantages. The assessment of the long-term performance of the pulmonary autograft in the aortic position suggests that the pulmonary autologous valve is the best choice for isolated aortic valve replacement in young patients.