What’s new in cardiac ? Transapical valves! By Victoria A. Kark, MSN, RN, CCNS, CCRN, CSC

MIRIAM JENNINGS, 78, visits her primary care pro- disease occurs in 4 to 50 of 1,000 people in the general vider complaining of shortness of breath, inability to population.3 More patients with congenital disease sleep lying down, and increasing fatigue. After a physi- are surviving to old age, resulting in the need for valve re- cal exam, she’s referred to a cardiologist, who performs pair or replacement via less-invasive techniques that are a comprehensive workup and diagnoses aortic . associated with a reduced mortality.2 Ms. Jennings isn’t a good candidate for conventional replacement due to multiple comorbidities, Recognizing trouble including a history of heavy smoking, chronic kidney Initially, a patient developing chronic valve disease may disease, and heart failure. She’s referred to a cardiac be asymptomatic, and depending on the type of valvular surgical team to be evaluated for a transapical valve defect, the symptoms may vary. Mild symptoms such as placement. fatigue, heart palpitations, chest pain, or changes in BP The newest, most innovative procedure available might be confused with other conditions. If undiagnosed for treating heart disease, the transapical valve is a or untreated, the patient may develop heart failure with compressed that can be positioned directly shortness of breath, edema of the extremities, general into the diseased aortic valve through a transfemoral or weight gain, and unexplained cough. transapical approach. This valve provides an alternative Diagnosis of valvular disease is based on a compre- treatment option for the highest-risk older adults with hensive physical exam that should include: valve disease. Although this type of heart valve initially • an ECG, to determine cardiac rate and rhythm, and received mixed reviews, recent research appears to identify dysrhythmias (atrial fi brillation [AF] is common show improved results for patients. The device is now in patients with valvular disease) being studied in high-risk, symptomatic patients with • a chest X-ray, to indicate the size and shape of the heart severe . and provide information about its general condition. More than 99,000 or replacement • an echocardiogram, to visualize cardiac function in- are performed each year for stenosis, insuffi - cluding the ejection fraction. ciency, and related congenital valve disorders.1 The is the gold standard for eval- causes of valvular disease may be congenital or ac- uating valve disease.4 This test analyzes cardiac function quired. Valve disease may develop acutely, but usually through an analysis of chamber pressures and ejection is a chronic process. Because of the higher pressures in- fraction. The cardiologist will determine whether the pa- volving the mitral and aortic valves, valvular disease is tient has as well as examine the more common on the left side of the heart. function of the heart valves. In developed countries, the most common causes of are now myocardial infarction Treatment goals (MI), birth defects, severe lung disease, age-related calci- Treatment of valvular heart disease depends on the fi cation of valves, and cardiomyopathies with valve dam- type and severity of the disease. The age and the age due to chamber distortion.2 Congenital valvular general health of the patient also must be consid-

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. ered, as well as the patient’s ability to adhere to cision of the old valve or repair of the damaged valve treatment. root. This open-heart procedure is performed under The primary goals of therapy are to minimize the anesthesia with the assistance of cardiopulmonary by- risk of death, control bleeding, improve tissue oxygen- pass. In the most traditional types of valve repair or ation, improve perfusion to end organs, achieve hemo- replacement procedures, the heart is stopped with dynamic stability, treat dysrhythmias, and prevent and blood is diverted from the surgical complications such as stroke or pulmonary embolism. fi eld to the machine. These In general, there are two options for treatment of valve are relatively common procedures in , disease: pharmacologic therapy or surgery. but pose great risks to older patients. Pharmacologic therapy for valvular disease may The most common for young be prescribed when the disease is in the early stages, patients is a mechanical valve. Older patients will often or for patients who may not survive valvular surgery, receive a biological or tissue valve such as a cadaver, bo- and should follow the American College of Cardiolo- vine, or porcine valve. A small percentage of patients will gists (ACC)/American Heart Association (AHA) receive a human donor valve. guidelines for the management of patients with valvu- • Percutaneous valve replacement, done in the lar heart disease.4 Valvular heart disease usually re- or OR, in which a special valve is inserted using a trans- sponds well to medications depending on the patient’s femoral or transapical approach. symptoms. In 2000, Bonhoeffer implanted the fi rst - For patients with dysrhythmias, such as AF, drugs based stent valve into a 12-year-old boy with severe pul- may be prescribed to help control the ventricular rate monary valve stenosis.5 This innovative procedure used and maintain a regular heart rhythm. Anticoagulants a bovine jugular vein valve sutured onto a platinum may be administered to prevent left atrial thrombi sec- stent that was placed percutaneously into the boy’s ondary to the irregular rhythm. Cardiotonics may also heart via the femoral vein. Two types of valves are avail- be given to increase the force of the cardiac contraction able in the United States for implantation at present.6 and decrease stasis of blood in the ventricles. Determining the correct procedure for the appro- priate patient isn’t an easy decision. The ACC and AHA Surgical intervention have developed guidelines to assist with the decision- If pharmacologic therapy is no longer effective or the pa- making process.4 Aortic balloon is indi- tient’s condition deteriorates, surgery may be required. cated if the patient has symptomatic disease without Several procedures can be done in the cath lab. Treat- aortic calcifi cation or aortic regurgitation. The pres- ment options may include: ence of calcifi cation on the valve poses signifi cant risk • Percutaneous balloon valvuloplasty performed in the for stroke and other related complications, especially in cath lab. A catheter is inserted into a stenotic valve to older patients. Valvulotomy should be considered care- open it. fully if the patient’s valve has signifi cant calcifi cation. • Valvulotomy, a cardiac surgery procedure, used to Because valve surgery is frequently performed on repair a damaged valve. older adults, it may be associated with an even higher • Minimally invasive heart valve surgery performed mortality due to comorbidities. Published estimates through a small incision in the patient’s chest. This for mortality associated with conventional valve replace- technique can be used to repair a damaged heart ment have indicated a rate between 12% and 50%.7 valve, depending on the severity of disease and if the This discrepancy demonstrates a signifi cant variance in patient is a candidate for this type of surgery. Compli- mortality and refl ects the varying degree of illness for cations from a minimally invasive approach are com- this population of cardiac patients. Originally, percuta- parable to conventional procedures. Length of stay neous valve replacement was developed for the sickest may be slightly shorter, but patient age, complica- classifi cation patients who might not survive conven- tions, and type of procedure will usually affect the tional valve replacement. patient outcome. Typically, the average length of stay in the hospital • Conventional valve replacement surgery, in which for conventional valve replacement is 5 to 7 days, of the diseased valve is replaced with either a mechanical which 2 to 3 days may be spent in the CCU. The cost of or a biological valve. Surgical valve replacement is still the average valve replacement surgery can vary greatly considered the gold standard for treating valvular dis- because of the less-predictable postoperative course of ease. Current treatment for valve disease involves ex- valve replacement patients. Comparatively, there’s little

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. published evidence about the length of stay or cost of onto a catheter that is passed through the incision in the percutaneous valve replacement procedures. chest wall and again through the apex of the heart. The valve is deployed into the annulus of the damaged valve, Recent research in the same manner as in the cath lab procedure. The The early studies on percutaneous valves cited a higher- apex of the heart is closed with a purse-string suture. than-expected mortality, and the transfemoral approach The patient is transported to the cardiac surgery ICU had better results than the transapical.8 In Germany, where recovery is achieved through standard protocols transapical placement had much better results in the for postoperative cardiac surgery procedures. early phase of the investigation. Problems with the Problems with the transapical valve have been attrib- transapical valve have been attributed to patient selec- uted to patient selection, correct placement of the valve, tion, correct placement of the valve, and comorbidities. and comorbidities. Several cardiac interventionalists have These few studies also noted that tremendous skill was been very outspoken about the high transapical valve required for the operator to successfully implant this mortality and have voiced concern that the initial poor type of valve.8 Studies also indicated the importance outcomes could prevent the adoption of transapical of appropriate patient selection for percutaneous valve valves in the United States.8 Surgeons involved in the implantation. early studies feel that the procedure is rapidly improving In a study of 50 patients, aortic valves were implanted and should become a viable option for patients. No ran- transapically via minimally invasive technique and with- domized studies have compared transfemoral, transapi- out cardiopulmonary bypass.8 Although these were high- cal, and conventional , so it’s risk patients, the overall success was positive. Evaluation diffi cult to discern which procedure is the best procedure of long-term effectiveness of percutaneous valve implan- for a particular population of patients. tation and the complications associated with the valve have yet to be adequately studied. Who can and can’t have percutaneous Placing a valve via the transfemoral approach can valve replacement be done in the cardiac catheterization lab with local Percutaneous valve replacement is indicated for patients anesthesia or moderate sedation and analgesia with who are predicted to have more than 15% chance of death fl uoroscopy guidance. An open-chest procedure isn’t re- because of associated comorbidities, aortic valve stenosis quired, as with the transapical approach. Patients must be with a mean gradient higher than 40 mm Hg, and a New prepared in standard fashion for the cath lab including York Heart Association functional class of II or higher. chest X-ray, routine labs, echocardiogram, and ECG. Patients who may be excluded from receiving a Using a femoral approach, the catheter is advanced into percutaneous valve replacement include those who had position with the valve crimped onto the catheter. The evidence of an acute MI within the last month; a con- catheter has a unique mechanism that facilitates place- genital valve, which doesn’t permit placement of this ment of the valve into the proper position. The new pros- type of valve due to severe structural abnormality; pres- thetic valve is usually inserted over the calcifi ed valve ence of both stenosis and regurgitative states; presence of leafl ets. The native valve may be left in place. In some a preexisting prosthetic heart valve in any position or cases, a valvuloplasty may be performed before the de- prosthetic ring; disorders of blood coagulation; coronary ployment of the new valve to dilate the annulus so it can artery disease requiring revasculation; hemodynamic accommodate the new valve. After the valve is success- instability requiring inotropic support; hypertrophic fully deployed into the annulus, the catheter is with- cardiomyopathy; severe ventricular dysfunction with an drawn. Complications of this procedure include stroke, ejection fraction of less than 20%; presence of intracar- bleeding from the femoral site, and dysrhythmias.3 diac mass; or relative aortic annulus size that’s too small Recovery usually occurs in the cardiac surgery ICU or too large.2 Additional exclusion criteria include pa- and requires standard protocols for care. tients who’ve had a previous stroke; renal insuffi ciency Transapical valve placement may be used as treat- or failure; iliofemoral disease, which prevents cannula- ment for either valvular stenosis or regurgitation. tion; and patients who aren’t expected to survive for This approach is performed in the OR under anesthesia. 1 year because of other conditions. The patient is prepped in the same manner as for any Surgeons have been interested in fi nding alternative cardiac or thoracic surgery procedure. The surgeon methods to provide therapies for the sickest cardiac makes an incision through the chest wall and another patients, who wouldn’t survive conventional surgery. The incision into the apex of the heart. The valve is crimped higher mortality seen in the initial percutaneous valve

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replacement procedures has been attributed to advanced patient age and extreme infi rmity. More recently, the procedure has been directed at a slightly younger and healthier population with improved results.

What’s next? In addition to a comparison study of patient outcomes among transapical, transfemoral, and conventional valve surgery procedures, several other areas hold research Come home to a better life. Remember what it was like to thrive in an potential, including postprocedure complications. Little environment where you can be who you are? Recapture that spirit at research has been reported about the long-term effects Memorial Medical Center, an integrated system of care built on strong of these types of valves. Perhaps the most important partnerships among all members of our team. consideration is the proper selection criteria for patients Seeking Cardiac Cath Lab RNs who can benefi t from a percutaneous valve. Lastly, de- Ideally, you’ll have a current CA RN license, veloping evidence-based protocols for percutaneous one year of RN experience in an acute care facility OR successful completion of MMC’s valve placement should be undertaken to provide the Clinical Nurse Resident (CNR) program in highest level of care for these patients, who are often the departments where the CNR program is sickest patients requiring valve procedures. ■ available. Find your true self today. Apply at www.memorialmedicalcenter.org or email [email protected] References 1. Texas Heart Institute. Valve repair or replacement. Updated August 2009. http://www.texasheartinstitute.org/hic/topics/proced/vsurg.cfm. 2. Attenhofer Jost CH. Heart murmur—auscultation or echocar- diography in the diagnostic assessment of congenital or valvular heart disease? Ther Umsch. 2006;63(7):463-470. 3. Jackson KA, Majka SM, Wang H, et al. Regeneration of ischemic and vascular endothelium by adult stem cells. J Do You Love Making a Difference? Clin Invest. 2001;107(11):1395-1402. 4. Bonow R, Carabello BA, Chatterjee K, et al. 2008 focused Then Join Our New Open Heart update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of Program Team. the American College of Cardiology/American Heart Association Florida Hospital Waterman is committed to meeting our region’s growing Task Force on Practice Guidelines (Writing Committee to revise need for advanced comprehensive cardiac care. We are expanding our range of the 1998 guidelines for the management of patients with val- service to include interventional cardiology and open heart surgical services. vular heart disease). Endorsed by the Society of Cardiovascular We are interested in highly skilled and dedicated cardiac professionals who Anesthesiologists, Society for Cardiovascular Angiography and share our mission of delivering high level, patient centered cardiac care and Interventions, and Society of Thoracic Surgeons. J Am Coll who will help shape the future of our exciting new programs and services. Cardiol. 2008; 52(13):e1-e142. 5. Bonhoeffer P, Boudjemline Y, Qureshi SA, et al. Percutaneous CVICU Clinical Manager insertion of the pulmonary valve. J Am Coll Cardiol. 2002;39(10): Florida licensed RN; BSN required; MSN preferred. ACLS required; CCRN 1664-1669. preferred. Minimum 5 years progressive management experience with at least 3 recent years managing a CVICU. Ability to assist staff, as needed in providing 6. Del Rosario M, Arora N, Gupta V. Role of percutaneous inter- patient care. ventions in adult congenital heart disease. J Invasive Cardiol. 2008;20(12):671-679. CVICU RN 7. Osswald BR, Gegouskov V, Badowski-Zyla D, et al. Overestimation Florida licensed RN; ACLS required; CCRN preferred. of aortic valve replacement risk by EuroSCORE: implications for Minimum 5 years progressive clinical experience with percutaneous valve replacement. Eur Heart J. 2009;30(1):74-80. at least 3 years recent critical care. Open heart surgical experience preferred. 8. Walther T, Kempfert J, Borger MA, et al. Human minimally invasive off-pump valve-in-a-valve implantation. Ann Thorac Surg. Contact Madge Springer at 877-298-7329 x 3338 2008;85(3):1072-1073. or email: [email protected].

Victoria A. Kark is a doctoral student at Catholic University of www.floridahospitalwaterman.jobs America in Washington, D.C., and the nurse manager mentor for Dimensions Healthcare System. Adapted from Kark VA. What’s new in cardiac surgery? Transapical valves. OR Nurse. 2010;4(5):26-33. Equal Opportunity Employer Tobacco/Smoke-Free Campus DOI-10.1097/01.NURSE.0000389905.78745.5c

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Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.