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1.
Catheter Cardiovasc Interv ; 103(6): 1023-1034, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38639143

RESUMO

BACKGROUND: The clinical efficacy and safety of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) have been well-established; however, less is known about outcomes in patients undergoing preemptive ASA before transcatheter mitral valve replacement (TMVR). AIMS: The goal of this study is to characterize the procedural characteristics and examine the clinical outcomes of ASA in both HCM and pre-TMVR. METHODS: This retrospective study compared procedural characteristics and outcomes in patient who underwent ASA for HCM and TMVR. RESULTS: In total, 137 patients were included, 86 in the HCM group and 51 in the TMVR group. The intraventricular septal thickness (mean 1.8 vs. 1.2 cm; p < 0.0001) and the pre-ASA LVOT gradient (73.6 vs. 33.8 mmHg; p ≤ 0.001) were higher in the HCM group vs the TMVR group. The mean volume of ethanol injected was higher (mean 2.4 vs. 1.7 cc; p < 0.0001). The average neo-left ventricular outflow tract area increased significantly after ASA in the patients undergoing TMVR (99.2 ± 83.37 mm2 vs. 196.5 ± 114.55 mm2; p = <0.0001). The HCM group had a greater reduction in the LVOT gradient after ASA vs the TMVR group (49.3 vs. 18 mmHg; p = 0.0040). The primary composite endpoint was higher in the TMVR group versus the HCM group (50.9% vs. 25.6%; p = 0.0404) and had a higher incidence of new permanent pacemaker (PPM) (25.5% vs. 18.6%; p = 0.3402). The TMVR group had a higher rate of all-cause mortality (9.8% vs. 1.2%; p = 0.0268). CONCLUSIONS: Preemptive ASA before TMVR was performed in patients with higher degree of clinical comorbidities, and correspondingly is associated with worse short-term clinical outcomes in comparison to ASA for HCM patients. ASA before TMVR enabled percutaneous mitral interventions in a small but significant minority of patients that would have otherwise been excluded. The degree of LVOT and neoLVOT area increase is significant and predictable.


Assuntos
Técnicas de Ablação , Cateterismo Cardíaco , Cardiomiopatia Hipertrófica , Etanol , Implante de Prótese de Valva Cardíaca , Valva Mitral , Humanos , Estudos Retrospectivos , Masculino , Etanol/administração & dosagem , Etanol/efeitos adversos , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/terapia , Cardiomiopatia Hipertrófica/cirurgia , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Resultado do Tratamento , Técnicas de Ablação/efeitos adversos , Técnicas de Ablação/mortalidade , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Cateterismo Cardíaco/instrumentação , Pessoa de Meia-Idade , Fatores de Risco , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Fatores de Tempo , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Valva Mitral/cirurgia , Recuperação de Função Fisiológica , Idoso de 80 Anos ou mais , Septos Cardíacos/diagnóstico por imagem , Septos Cardíacos/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/cirurgia , Insuficiência da Valva Mitral/mortalidade
2.
Catheter Cardiovasc Interv ; 98(6): 1193-1203, 2021 11 15.
Artigo em Inglês | MEDLINE | ID: mdl-34106514

RESUMO

BACKGROUND: Due to elevated surgical risk, transcatheter mitral valve replacement (TMVR) is used as an alternative for treating failed bioprosthetic valves, annuloplasty repairs and mitral annular calcification (MAC). We report the procedural and longitudinal outcomes for each subtype: Mitral valve-in-valve (MVIV), mitral valve-in-ring (MViR), and valve-in-MAC (ViMAC). METHODS: Consecutive patients undergoing TMVR from October 2013 to December 2019 were assessed. Patients at high risk for left ventricular outflow tract obstruction had either alcohol septal ablation or intentional laceration of the anterior leaflet (LAMPOON). RESULTS: Eight-eight patients underwent TMVR; 38 MViV, 31 MViR, and 19 ViMAC procedures were performed. The median Society of Thoracic Surgery 30-day predicted risk of mortality was 8.2% (IQR 5.2, 19.9) for all. Sapien 3 (78%) and transseptal access (98%) were utilized in most cases. All-cause in-hospital mortality, technical, and procedural success were 8%, 83%, and 66% respectively. Median follow up was 1.4 years (IQR 0.5-2.9 years) and overall survival was 40% at 4 years. Differential survival rates were observed with MViV doing the best, followed by MViR and ViMAC having a <20% survival at 4 years. After adjusting for co-variates, MViV procedure was the strongest predictor of survival (HR 0.24 [95% CI 0.079-0.7]). CONCLUSION: TMVR is performed in at high-risk patients with attenuated long-term survival. MViV has the best success and survival rate, but long-term survival in MViR and ViMAC is guarded.


Assuntos
Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral , Substituição da Valva Aórtica Transcateter , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Resultado do Tratamento
3.
J Cardiothorac Vasc Anesth ; 35(9): 2607-2612, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33441271

RESUMO

OBJECTIVES: Transcaval transcatheter aortic valve replacement (TC-TAVR) is an alternative approach to transcatheter aortic valve replacement involving deployment of the bioprosthetic valve via a conduit created from the inferior vena cava to the descending aorta in patients for whom the traditional transfemoral approach is not feasible. By analyzing the largest known cohort of TC-TAVR patients, the authors wished to compare hospital length of stay and post-procedure outcomes between patients who underwent the procedure under deep sedation (DS) and patients who underwent general anesthesia with an endotracheal tube. DESIGN: Retrospective, single-center study. SETTING: Henry Ford Hospital in Detroit, MI. PARTICIPANTS: Patients undergoing TC-TAVR from 2015 to 2018. MEASUREMENTS AND MAIN RESULTS: Seventy-nine patients were included in the analysis, which consisted of 38 under general anesthesia with an endotracheal tube and 41 under DS. The sample was divided into a general anesthesia (GA) group and DS group. There were no significant differences in implant success rate or post-procedure outcomes, including in-hospital mortality (p = 0.999) and major vascular complication rate (p = 0.481), between the two groups. Patients in the GA group stayed a median of 24 hours longer in the intensive care unit (ICU) (p < 0.001) and one day longer in the hospital (p = 0.046) after the procedure compared to patients in the DS group. The median procedure time was significantly lower (135 minutes) in the DS group compared to the GA group (167 minutes, p < 0.001). CONCLUSIONS: Patients undergoing TC-TAVR under DS had similar postoperative outcomes and shorter post-procedure hospital and ICU lengths of stay compared to general anesthesia. In the authors' experience, DS is the preferred anesthetic technique for TC-TAVR.


Assuntos
Anestesia Geral , Estenose da Valva Aórtica , Sedação Profunda , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Humanos , Intubação Intratraqueal , Tempo de Internação , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
4.
Catheter Cardiovasc Interv ; 96(2): 481-487, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-31957915

RESUMO

OBJECTIVES: To examine the safety of utilizing transapical access during structural interventions. BACKGROUND: Complex interventions of the mitral or aortic region sometimes require coaxial forces to orient and deliver devices. Apical access can provide coaxial countertraction for either transseptal or retrograde aortic access. This manuscript describes the single center experience of small bore transapical access. METHODS: Retrospective review of cases from 2013 to 2018 at Henry Ford Hospital was performed. Patient demographics and procedure characteristics were abstracted to describe the safety of transapical access using small bore sheaths. RESULTS: A total 21 cases were performed at Henry Ford, most of them for transcatheter mitral valve replacement (81%). The mean sheath size used was 4.7 ± 0.9 Fr and protamine was used at the end of 57% of cases. All patients received nitinol-based plugs, 80.1% were from the Amplatz Duct Occluder II type. Four major complications related apical puncture occurred, two pericardial effusions, two hemothorax. Over a median follow time of 430 days (IQR 50-652) a total of five deaths occurred, two related to the procedure and three late deaths with a median time of 362 days (range 205-628 days). No deaths were associated with transapical access. Echocardiographic follow up did not detect any late structural complications from occluder devices. CONCLUSIONS: Transapical access and closure with nitinol-based devices is feasible and facilitates complex interventions where coaxial forces are need for device delivery and alignment. The most common complication is bleeding and this should be kept in perspective when treating high-risk patients.


Assuntos
Cateterismo Cardíaco , Cardiopatias/terapia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/mortalidade , Cateteres Cardíacos , Bases de Dados Factuais , Desenho de Equipamento , Feminino , Cardiopatias/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Dispositivo para Oclusão Septal , Resultado do Tratamento
5.
Catheter Cardiovasc Interv ; 96(3): 659-663, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32251546

RESUMO

The coronavirus disease-2019 (COVID-19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment, as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.


Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Infecções por Coronavirus/epidemiologia , Cardiopatias/cirurgia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Triagem/normas , COVID-19 , Procedimentos Cirúrgicos Cardíacos/métodos , Cardiologia/métodos , Cardiologia/normas , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Feminino , Cardiopatias/diagnóstico por imagem , Humanos , Masculino , Saúde Ocupacional/estatística & dados numéricos , Pandemias/prevenção & controle , Segurança do Paciente , Pneumonia Viral/prevenção & controle , Sociedades Médicas , Triagem/estatística & dados numéricos , Estados Unidos
6.
J Cardiothorac Vasc Anesth ; 33(12): 3303-3308, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30850225

RESUMO

OBJECTIVE: To compare outcomes among patients with and without preprocedural radial arterial catheters who underwent transfemoral transcatheter aortic valve replacement (TF-TAVR) under deep intravenous (IV) sedation and to assess predictive variables for preprocedural placement. DESIGN: Single-center, retrospective, cohort analysis. SETTING: Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, which is a tertiary care, university-affiliated hospital. PARTICIPANTS: The study comprised 157 patients. The primary focus was the 106 patients who underwent TF-TAVR when routine placement of preprocedure radial arterial catheters was abandoned. They were analyzed for hospital length of stay, 30-day mortality, and predictive factors of preprocedure placement. The remaining patients served as historical controls when routine radial artery catheter placement was practiced. INTERVENTIONS: Patient, procedure, and provider factors were analyzed. The transitional period consisted of 169 consecutive days from April 13 to September 28, 2017. A reference group of historical patients served as a control. MEASUREMENTS AND MAIN RESULTS: Seventy-five of 106 patients did not have a preprocedural radial arterial catheter. The primary outcome measures of length of stay and 30-day mortality within the transitional group were not different. Secondary outcome measures included identification of predictive variables for preprocedure placement and outcome comparisons between the transitional and historical groups. Anesthesia provider (p = 0.015) and ejection fraction (p = 0.039) were significant factors. There were no differences in outcome measures. CONCLUSION: There was no difference in primary outcomes in patients with or without radial arterial catheters for TF-TAVR. The findings of this study suggest anesthesia provider and ejection fraction were significant factors for preprocedural placement.


Assuntos
Estenose da Valva Aórtica/cirurgia , Pressão Sanguínea/fisiologia , Cateterismo Periférico/métodos , Sedação Consciente/métodos , Monitorização Fisiológica/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Ecocardiografia Transesofagiana , Feminino , Artéria Femoral , Seguimentos , Humanos , Tempo de Internação/tendências , Masculino , Artéria Radial , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
7.
Catheter Cardiovasc Interv ; 92(2): 401-407, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29388306

RESUMO

BACKGROUND: Preliminary data comparing 3-dimensional computed tomography (3D-CT) to transesophageal echocardiography (TEE) for left atrial appendage occlusion (LAAO) indicates that 3D-CT provides more accurate measurements and improves case planning. Therefore, we conducted a pilot study comparing 3D-CT to TEE in occluder selection accuracy and procedural efficiency. METHODS: From May 2016 to February 2017, 24 patients were prospectively randomized to undergo LAAO using either TEE or 3D-CT. The primary endpoint was device accuracy while the secondary endpoints included # devices per case, # guide catheters used per case, # fluoroscopy angles used, procedure time, fluoroscopy time, radiation dose, and major adverse events (stroke, MI, device embolization, perforation, death). RESULTS: Procedure success was 100% and 92% for the 3D-CT and 2D-TEE cohorts respectively. Accuracy for 1st device selection 92% and 27% (P = .01) for 3D-CT and 2D-TEE respectively but with intra-procedural upsizing in the 2D-TEE cohort, the 2D-TEE cohort accuracy increased to 64% while the 3D-CT groups 92% was accurate (P = .33). Case planning using 3D-CT was significantly more efficient with respect to device utilization (CT 1.33 ± 0.7 vs. 2D-TEE 2.5 ± 1.2 P = .01), guide catheters (CT 1 vs. 2D-TEE 1.7 ± 0.8 P = .01) and procedure time (3D-CT 55 ± 17 min vs. 2D-TEE 73 ± 24 min P < .05). One major adverse event, a stroke occurred in the 2D-TEE group. CONCLUSION: In this single-center pilot study, CT guided LAAO case planning was associated with improved device selection accuracy and procedural efficiency. This study data supports the notion that comprehensive 3D assessment significantly simplifies LAAO, minimizing the time and number of steps needed.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Cateterismo Cardíaco/métodos , Ecocardiografia Transesofagiana , Imageamento Tridimensional , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Ecocardiografia Transesofagiana/efeitos adversos , Feminino , Humanos , Imageamento Tridimensional/efeitos adversos , Masculino , Michigan , Projetos Piloto , Valor Preditivo dos Testes , Impressão Tridimensional , Estudos Prospectivos , Doses de Radiação , Exposição à Radiação , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista/efeitos adversos , Reprodutibilidade dos Testes , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X/efeitos adversos , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos
8.
Catheter Cardiovasc Interv ; 90(2): 321-328, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28185392

RESUMO

BACKGROUND: Degenerated surgical mitral valve repairs or surgical prostheses are currently being treated with transcatheter mitral valve replacement (TMVR). We report the procedural and mid-term assessment of thirteen cases. METHODS: From 12/2013 to 12/2015, 13 consecutive patients with degenerated mitral valve repair or valve replacement were treated. Patients were assessed for mitral valve academic valve consortium (MVARC) defined outcomes. RESULTS: Immediate procedural MVARC defined technical success was 92%. At 30 days MVARC device and procedure success were 61% and 84%, respectively. Mean follow-up was 150 days [IQR 40-123 days]. There were 2 late major adverse outcomes, a noncardiac related death (628 days) and a stroke (382 days). The mean mitral gradient decreased from 9.5 ± 3.4 to 5.5 ± 2.6 mm Hg (P < 0.01). Three patients were found to have high gradients, two presented with heart failure while another patient was found to have reduced leaflet motion and abnormal thickening postprocedure. The two patients with heart failure were treated with enoxaparin, which caused subsequent resolution of increased valve gradients in one patient. The other patient could not tolerate prolonged treatment from anticoagulation due to gastrointestinal bleeding. Three of 13 patients were treated with dual-antiplatelet therapy and were suspected to have valve thrombosis. CONCLUSION: Thrombotic related dysfunction post-TMVR occurred in 15% (2/13) of patients and one patient had abnormal leaflet thickening that may have been thrombus related. Dual-antiplatelet therapy was used in all 3 cases suggesting the possible need for oral anticoagulation postmitral valve-in-valve therapy. © 2017 Wiley Periodicals, Inc.


Assuntos
Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Valva Mitral/cirurgia , Trombose/etiologia , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/mortalidade , Ecocardiografia Transesofagiana , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemorragia/induzido quimicamente , Humanos , Masculino , Michigan , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Falha de Prótese , Radiografia Intervencionista , Estudos Retrospectivos , Fatores de Risco , Trombose/tratamento farmacológico , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Falha de Tratamento
9.
Catheter Cardiovasc Interv ; 87(4): E166-71, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26255796

RESUMO

OBJECTIVE/BACKGROUND: As smaller TAVR delivery systems emerge we sought to identify differences in vascular access use. METHODS: We analyzed all patients who had undergone TAVR in a single-center from March 2012 to May 2014. We identified all patients who had undergone nonfemoral TAVR and reviewed their femoral dimensions using CT imaging taking into vascular pathology and minimal lumen diameter (MLD). We then identified those patients in whom a smaller delivery system could have been used if such technology was available at that time. RESULTS: In total 208 consecutive TAVRs were performed, 129 cases using femoral arterial access and 75 cases using non-femoral access; 28 transapical, 27 transcaval, 12 transaortic, and 8 via an antegrade transseptal venous approach. Of the 75 nonfemoral access cases, 63 were completed using commercially available first-generation valves (Sapien Valve) and 12 using second-generation valves under research protocols (Sapien XT Valve). Of the 63 cases performed via a non-femoral route using a first generation valve, 31 cases could have been approached via a transfemoral (TF) route using second-generation delivery systems; and 48 cases could have been approached via a TF route using third generation delivery systems (S3 Valve). Of the 12 cases performed via a nonfemoral route using a second-generation valve, 4 cases could have been approached via a TF route using a third-generation delivery system. In total, only 11% of patients undergoing TAVR could not accommodate smaller second and third generation devices. CONCLUSIONS: As second and third generation devices become commercially available, we anticipate that 89% of cases will be preformed using a TF approach.


Assuntos
Valva Aórtica , Cateterismo Cardíaco/estatística & dados numéricos , Cateterismo Periférico/estatística & dados numéricos , Artéria Femoral , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/instrumentação , Cateterismo Periférico/instrumentação , Angiografia por Tomografia Computadorizada , Desenho de Equipamento , Feminino , Artéria Femoral/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico , Próteses Valvulares Cardíacas/estatística & dados numéricos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento , Dispositivos de Acesso Vascular/estatística & dados numéricos
10.
J Healthc Manag ; 58(3): 173-85; discussion 185-6, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23821897

RESUMO

The Resource-Based Relative Value Scale is widely used to measure healthcare provider productivity and to set payment standards. The scale, however, is limited in its assessment of pre- and postservice work and other potentially non-revenue-generating healthcare services, what we have termed service-valued activity (SVA). In an attempt to quantify SVA, we conducted a time and motion study of providers to assess their productivity in inpatient and outpatient settings. Using the Standard Time and Motion Procedures checklist as a methodological guide, we provided personal digital assistants (PDAs) that were prepopulated with 2010 Current Procedural Terminology codes to 19 advanced practice providers (APPs). The APPs were instructed to identify their location and activity each time the PDA randomly alarmed. The providers collected data for 3 to 5 workdays, and those data were separated into revenue-generating services (RGSs) and SVAs. Multiple inpatient and outpatient departments were assessed. The inpatient APPs spent 61.6 percent of their time on RGSs and 35.1 percent on SVAs. Providers in the outpatient settings spent 59.0 percent of their time on RGSs and 38.2 percent on SVAs. This time and motion study demonstrated an innovative method and tool for the quantification and analysis of time spent on revenue- and non-revenue-generating services provided by healthcare professionals. The new information derived from this study can be used to accurately document productivity, determine clinical practice patterns, and improve deployment strategies of healthcare providers.


Assuntos
Avaliação de Desempenho Profissional/economia , Profissionais de Enfermagem/economia , Assistentes Médicos/economia , Estudos de Tempo e Movimento , Centros Médicos Acadêmicos/economia , Lista de Checagem , Computadores de Mão , Coleta de Dados/métodos , Eficiência Organizacional , Departamentos Hospitalares/economia , Humanos , Michigan , Padrões de Prática em Enfermagem/economia , Padrões de Prática Médica/economia , Escalas de Valor Relativo
11.
Nurs Clin North Am ; 58(3): 357-378, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37536786

RESUMO

Over the last few decades, there have been dramatic advances in the understanding of the mechanisms of valvular heart disease and development of percutaneous treatment options. These innovations have resulted in the need for a multidisciplinary heart team approach for quality patient outcomes, a team in which nursing is an integral member. This update provides an overview of the major valve diseases, current guideline recommendations, catheter-based treatment options and key elements of nursing care: physical examination, diagnostic testing, pre- and post-procedure care protocols, and patient education elements.


Assuntos
Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Enfermeiras e Enfermeiros , Humanos , Implante de Prótese de Valva Cardíaca/métodos , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/cirurgia
12.
JACC Adv ; 2(1): 100160, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-38939019

RESUMO

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardiovascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care, best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and the future challenges facing them.

13.
J Am Assoc Nurse Pract ; 34(6): 844-849, 2022 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-35472192

RESUMO

BACKGROUND: As transcatheter aortic valve replacement (TAVR) becomes a preferred treatment option for patients with aortic valve stenosis, and demand for TAVR increases, it is imperative that length of stay (LOS) is reduced while maintaining safety and effectiveness. LOCAL PROBLEM: As TAVR procedures have become less invasive and more streamlined, current protocols have not been updated to reflect today's postprocedure requirements. METHODS: The next-day discharge (NDD) protocol was established using available literature. A convenience sample was evaluated for NDD protocol inclusion during aortic multidisciplinary team conference using predetermined inclusion and exclusion criteria. Length of stay for NDD protocol participants was compared with LOS from a retrospective convenience sample of patients undergoing TAVR in the time frame mirroring NDD protocol initiation of the year prior. INTERVENTIONS: Patients meeting inclusion criteria were enrolled in the NDD protocol with a goal of discharge to home on postprocedural day 1 by 2:00 p.m. The NDD protocol included preprocedure expectation setting, prescheduled same-day postprocedure imaging, and discharge priority on postprocedure day 1. RESULTS: There is a significant difference in LOS between the NDD eligible retrospective and prospective groups. The prospective group has a significantly lower LOS than the retrospective group (M = 1.6 vs 2.1, respectively; p = .0454). CONCLUSIONS: An NDD protocol can help reduce LOS after TAVR in appropriately selected patients. Further protocol revision will be required to optimize LOS outcomes.


Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Humanos , Tempo de Internação , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento
14.
J Am Geriatr Soc ; 70(12): 3378-3389, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-35945706

RESUMO

BACKGROUND: Little is known about policies and practices for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who have a documented preference for Do Not Resuscitate (DNR) status at time of referral. We investigated how practices across TAVR programs align with goals of care for patients presenting with DNR status. METHODS: Between June and September 2019, we conducted semi-structured interviews with TAVR coordinators from 52/73 invited programs (71%) in Washington and California (TAVR volume > 100/year:34%; 50-99:36%; 1-50:30%); 2 programs reported no TAVR in 2018. TAVR coordinators described peri-procedural code status policies and practices and how they accommodate patients' goals of care. We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, stratified by programs' DNR practice, to examine differences in program size, patient characteristics and risk status, and outcomes. RESULTS: Nearly all TAVR programs (48/50: 96%) addressed peri-procedural code status, yet only 26% had established policies. Temporarily rescinding DNR status until after TAVR was the norm (78%), yet time frames for reinstatement varied (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). For patients with fluctuating code status, no routine practices for discharge documentation were well-described. No clinically substantial differences by code status practice were noted in Society of Thoracic Surgeons Predicted Risk of Mortality risk score, peri-procedural or in-hospital cardiac arrest, or hospice disposition. Six programs maintaining DNR status recognized TAVR as a palliative procedure. Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements. CONCLUSIONS: Marked heterogeneity exists in management of peri-procedural code status across TAVR programs, including timeframe for reestablishing DNR status post-procedure. These findings call for standardization of DNR decisions at specific care points (before/during/after TAVR) to ensure consistent alignment with patients' health-related goals and values.


Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Humanos , Estados Unidos , Substituição da Valva Aórtica Transcateter/métodos , Estenose da Valva Aórtica/cirurgia , Assistência ao Convalescente , Medição de Risco , Resultado do Tratamento , Alta do Paciente , Fatores de Risco , Sistema de Registros , Políticas , Valva Aórtica/cirurgia
15.
Cardiovasc Revasc Med ; 27: 7-13, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-32741589

RESUMO

BACKGROUND: Detailed procedural analysis and long-term data is limited for coronary protection (CP) during transcatheter aortic valve replacement (TAVR) for patients with high anatomical risk for coronary occlusion (CO). We aim to assess the procedural and mid-term outcomes of CP during TAVR. METHODS: We retrospectively analyzed patients who underwent TAVR at Henry Ford Hospital, USA from January 2015 to August 2019 and identified those considered at risk of CO and underwent pre-emptive CP with or without subsequent "chimney" stenting (i.e. coronary stenting with intentional protrusion into the aorta). Procedural features, immediate and mid-term clinical outcomes were reviewed. RESULTS: Twenty-five out of 1166 (2.1%) patients underwent TAVR with CP, including 10 (40%) valve-in-valve procedures. Twenty-eight coronary arteries (Left: n = 11, Right: n = 11; Left + Right: n = 3) were protected. Eleven coronaries (39.3%) were electively "chimney"-stented due to angiographic evidence of coronary impingement (63.6%), tactile resistance while withdrawing stent (27.3%) and electrocardiogram change (9.1%). Twenty-four patients (24/25, 96%) had successful TAVR without CO. Procedure-related complications included stent-balloon entrapment (n = 1), stent entrapment (n = 1) and occlusive distal stent edge dissection (n = 1). After a mean follow-up of 19.1 months, there was 1 cardiac death but no target vessel re-intervention or myocardial infarction. CONCLUSIONS: Our study found that angiographic evidence of coronary impingement (63.6%) was the most common reason for stent deployment during TAVR with CP. The mid-term clinical outcome of CP with TAVR was favorable.


Assuntos
Estenose da Valva Aórtica , Oclusão Coronária , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/cirurgia , Humanos , Estudos Retrospectivos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
17.
J Am Coll Cardiol ; 76(20): 2391-2411, 2020 11 17.
Artigo em Inglês | MEDLINE | ID: mdl-33190683

RESUMO

Consensus regarding a reasonable strategy to manage cardiac conduction disturbances after transcatheter aortic valve replacement (TAVR) has been elusive. This is due to the absence of adequately powered, randomized controlled trials; the often transient nature of the conduction disturbances; evolving technologies; and the interplay of cardiology subspecialties involved. In the absence of high-quality trials, numerous practice styles have been developed, and prolonged observation, electrophysiological testing, and pre-emptive pacemaker implantation have been described. Although the 2013 European Society of Cardiology guidelines address pacing post-TAVR, they do not provide in-depth discussion of this topic. Furthermore, a summary and proposed strategy for this problem have not been published by cardiovascular societies in the United States, despite an interest in establishing best practices in TAVR, valvular heart disease, and cardiovascular implantable electrical devices. This document reviews existing data and experience regarding the management of conduction disturbances after TAVR and proposes an evidence-based expert consensus decision pathway for their management. Where evidence is lacking or insufficient, the recommendations herein are based on expert opinion.


Assuntos
Valvopatia Aórtica/cirurgia , Doença do Sistema de Condução Cardíaco/terapia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter , Técnicas de Apoio para a Decisão , Humanos
18.
JACC Cardiovasc Interv ; 13(12): 1484-1488, 2020 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-32250751

RESUMO

The coronavirus disease-2019 (COVID-19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.


Assuntos
Betacoronavirus , Procedimentos Cirúrgicos Cardiovasculares , Infecções por Coronavirus/epidemiologia , Cardiopatias/cirurgia , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Triagem , Procedimentos Cirúrgicos Ambulatórios , COVID-19 , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Encaminhamento e Consulta , SARS-CoV-2
19.
JACC Cardiovasc Interv ; 9(22): 2329-2340, 2016 11 28.
Artigo em Inglês | MEDLINE | ID: mdl-27884358

RESUMO

OBJECTIVES: The aim of this study was to examine the impact of 3-dimensional (3D) computed tomographic (CT) guided procedural planning for left atrial appendage (LAA) occlusion on the early operator WATCHMAN learning curve. BACKGROUND: Traditional WATCHMAN implantation is dependent on 2-dimensional transesophageal echocardiographic (TEE) sizing and intraprocedural guidance. METHODS: LAA occlusion with the WATCHMAN device was performed in 53 patients. Pre-procedural case plans were generated from CT studies with recommended device size, catheter selection, and C-arm angle for deployment. RESULTS: All 53 patients underwent successful LAA occlusion with the WATCHMAN. Three-dimensional CT LAA maximal-width sizing was 2.7 ± 2.2 mm and 2.3 ± 3.0 mm larger than 2-dimensional and 3D TEE measurements, respectively (p ≤ 0.0001). By CT imaging, device selection was 100% accurate. There were 4 peri-WATCHMAN leaks (<4.5 mm) secondary to accessory LAA pedunculations. By 2-dimensional TEE maximal-width measurements alone, 62.3% (33 of 53) would have required larger devices. Using 3D TEE maximal-width measurements, 52.8% of cases (28 of 53) would have required larger devices. Three-dimensional TEE length would have inappropriately excluded 10 patients from WATCHMAN implantation. Compared with the average of 1.8 devices used per implantation attempt in PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) (82% success rate), the present site averaged 1.245 devices per implantation attempt (100% success rate). There were no intraprocedural screen failures and no major adverse cardiac events. CONCLUSIONS: Three-dimensional CT image case planning provides a comprehensive and customized patient-specific LAA assessment that appears to be accurate and may possibly facilitate reducing the early WATCHMAN implantation learning curve.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Cateterismo Cardíaco/instrumentação , Competência Clínica , Imageamento Tridimensional , Curva de Aprendizado , Interpretação de Imagem Radiográfica Assistida por Computador , Dispositivo para Oclusão Septal , Terapia Assistida por Computador/métodos , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos , Cateterismo Cardíaco/efeitos adversos , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Michigan , Valor Preditivo dos Testes , Desenho de Prótese , Reprodutibilidade dos Testes , Resultado do Tratamento
20.
J Am Coll Cardiol ; 65(19): 2118-36, 2015 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-25975476

RESUMO

The mission of the American College of Cardiology is "to transform cardiovascular care and improve heart health." Cardiovascular team-based care is a paradigm for practice that can transform care, improve heart health, and help meet the demands of the future. One strategic goal of the College is to help members successfully transition their clinical practices to the future, with all its complexity, challenges, and opportunities. The ACC's strategic plan is aligned with the triple aim of improved care, improved population health, and lower costs per capita. The traditional understanding of quality, access, and cost is that you cannot improve one component without diminishing the others. With cardiovascular team-based care, it is possible to achieve the triple aim of improving quality, access, and cost simultaneously to also improve cardiovascular health. Striving to serve the best interests of patients is the true north of our guiding principles. Cardiovascular team-based care is a model that can improve care coordination and communication and allow each team member to focus more on the quality of care. In addition, the cardiovascular team-based care model increases access to cardiovascular care and allows expansion of services to populations and geographic areas that are currently underserved. This document will increase awareness of the important components of cardiovascular team-based care and create an opportunity for more discussion about the most creative and effective means of implementing it. We hope that this document will stimulate further discussions and activities within the ACC and beyond about team-based care. We have identified areas that need improvement, specifically in APP education and state regulation. The document encourages the exploration of collaborative care models that should enable team members to optimize their education, training, experience, and talent. Improved team leadership, coordination, collaboration, engagement, and efficiency will enable the delivery of higher-value care to the betterment of our patients and society.


Assuntos
Cardiologia/normas , Doenças Cardiovasculares/terapia , Pessoal de Saúde/normas , Política de Saúde , Equipe de Assistência ao Paciente/normas , Guias de Prática Clínica como Assunto , Sociedades Médicas , Comportamento Cooperativo , Humanos
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