When Is Dental Cleaning Allowed Post Tavr

Takeaways

• Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement for some patients.
  
• Understanding TAVR approaches, mail-process monitoring, and potential complications will help nurses amend intendance for patients undergoing TAVR.

Past Kelly Haight, MSN, APRN, ACNS-BC, PCCN

For many years, surgical aortic valve replacement (SAVR) was the gold-standard treatment for severe, symptomatic aortic stenosis (AS). For eligible patients, this procedure tin can improve symptoms and extend life. Merely information technology has a major drawback: Whether the surgical approach is open (using a full sternotomy) or less invasive (using a ministernotomy or minithoracotomy), SAVR requires cross-clamping of the aorta and cardiopulmonary bypass.

Improvements in medical therapies and aging of the population mean more elderly patients are living with severe Equally and other comorbidities. For the 1-third of those patients who aren't eligible for SAVR, medical direction may meliorate symptoms merely tin can't extend life or deadening disease progression. Without surgery, their life expectancy is 2 to three years; merely 50% alive more than than 2 years after symptom onset.

Enter TAVR: Transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR), which involves a collapsible prosthetic valve placed directly over the native diseased valve, has emerged as a minimally invasive culling to SAVR. A guidewire is fed through the aorta; then a catheter with a prosthetic valve on the end is fed over the wire and placed over the aortic valve. The prosthetic valve tin can be deployed percutaneously or through a small incision in the chest wall. The process takes iv to 5 hours and is done in a hybrid cardiac catheterization laboratory.

This article reviews patient eligibility for TAVR, procedural approaches, prosthetic valve types, potential complications, nursing care, and patient teaching.

Patient assessment and eligibility

Determining if a patient is a better candidate for SAVR or TAVR involves an interdisciplinary evaluation past a heart-valve team with members from cardiac surgery, cardiac imaging, interventional cardiology, and cardiac anesthesia, equally well as nursing professionals. The team assesses surgical gamble, valve anatomy and function, signs and symptoms, overall cardiovascular disease and health status, comorbidities, physical and cognitive function, and life expectancy.

The first step is to identify the patient's overall surgical run a risk. (See Determining surgical risk for patients with heart-valve disease.) The Society of Thoracic Surgeons' Predicted Risk of Mortality (STS-PROM) can be used to assess gamble. Information technology calculates predicted gamble of death with surgery or all-crusade death after cardiac surgery based on specific patient characteristics (for example, age, gender, tiptop, weight, and race) and clinical variables (such every bit cardiac history, previous myocardial infarction, heart failure symptoms, endocarditis, previous coronary artery bypass grafting, and other comorbidities).

Once the team establishes surgical adventure, they must decide whether SAVR or TAVR is the patient'southward best option. (See SAVR or TAVR?) Diagnostic techniques that help this decision include transthoracic echocardiography (TTE) and multidetector computed tomography (MDCT). MDCT helps notice the right replacement-valve size and identifies possible peripheral vascular complications to ensure the best transcatheter approach. To encourage shared conclusion making, the team should consider patient and family preferences, goals, and expectations.

TAVR approaches

Canonical TAVR techniques include percutaneous approaches (transfemoral [TF] and transaxillary/subclavian [Revenue enhancement]) and traditional open approaches (transapical [TA] and transaortic [TAo]), which require small surgical incisions. Minimally invasive percutaneous procedures (such every bit TF and TAx) are the most mutual. (Run into Approaches to TAVR.)

Percutaneous approaches

Most 90% of TAVRs use the TF arroyo. A sheath is inserted into the femoral artery, through which the guidewire and catheter are fed through the aorta into the middle. The arterial insertion site is typically closed using a vascular closure device, such as a vessel plug, clip, or internal suture. The TF approach may not exist suitable for patients with peripheral vascular disease because of potential bug with vessel size.

In the Revenue enhancement approach, access is gained through the subclavian artery, with a sheath catheter fed into the aortic arch to the aortic valve. Although this approach offers a shorter catheter-insertion route, the smaller vessel tin cause difficulty with maneuvering the catheter and may lead to brachial-nerve injury.

Open approaches

A minithoracotomy is used for access in the TA approach. Benefits include fugitive a diseased aorta or femoral artery, unlimited delivery organisation size, and easier valve commitment. Drawbacks include risk of myocardial injury, increased risk of wall-move abnormalities, upmost bleeding, and incision hurting. Additionally, this technique requires a surgical incision through the chest wall and intubation, increasing patient discomfort and pain.

The TAo approach involves direct puncture of the aorta through a fractional sternotomy or right thoracotomy. Benefits resemble those of the TA approach, with a small working altitude to the valve and no limit to access size. In addition to incision and intubation, drawbacks include limited access if the vessel is diseased or the ascending aorta is heavily calcified.

Replacement-valve options

The Food and Drug Administration (FDA) has approved 2 valves for TAVR: Edwards LifeSciences SAPIEN® valves and the Medtronic CoreValve®. (See FDA-canonical valves for TAVR.)

Made with bovine pericardium, the SAPIEN XT® and SAPIEN three® valves are attached to an expandable chromium cobalt balloon stent. Both require a smaller sheath size than other valve deployment systems—as low as 14 Fr. The SAPIEN XT is approved for valve-in-valve procedures for patients with failed or deteriorating previously replaced tissue valves. The SAPIEN 3 has a sealing gage to minimize paravalvular regurgitation (PVR), a TAVR complication.

The trileaflet porcine pericardial Medtronic CoreValve is affixed to a nickel titanium (nitinol) stent. Nitinol provides super elasticity for shape memory, even nether stress. This valve can exist recaptured and repositioned during placement for the all-time fit. The CoreValve Evolut R® was approved by the FDA in 2015 for valve-in-valve handling of failed bioprosthetic valves.

Most patients can exist treated successfully using either type of valve, with similar outcomes. However, one valve may exist preferable in specific circumstances. For example, a repositionable cocky-expanding valve may be preferred if a patient has severe valvular calcification, which increases the risk of annulus rupture. Also, a patient who requires a particular approach will need the valve that has been canonical for it. For instance, a airship-expandable valve would be used for a TA approach.

Because TAVR was approved only in 2011, no substantive longitudinal valve durability information have been established. Electric current and hereafter studies should focus on long-term durability, especially in low-cal of FDA approval for apply of TAVR valves in intermediate-run a risk patients who accept longer life expectancies than traditionally treated high-risk patients.

Handling approach for patients with astringent symptomatic aortic stenosis is based partly on the patient'due south surgical take a chance. This table provides risk-level definitions and recommended approaches.

STS-PROM = Lodge of Thoracic Surgeons' predicted risk of mortality, SAVR = surgical aortic valve replace- ment, TAVR = transcatheter aortic valve replacement

All approaches are made with a center-valve team give-and-take; however, some approaches require other con- siderations. Red = non appropriate. Yellowish = non preferred but possible, based on decision of team afterward evaluation of patient-specific factors. Green = preferred.

Sources: Nishimura RA, et al. Apportionment. 201;129(23):2440-92; Otto, et al. J Am Coll Cardiol. 2017;69(ten): 1313-46.

Postprocedure complications

Vascular complications associated with femoral access include hematomas, retroperitoneal bleeding, and arterial occlusion.

Hematomas, the most common vascular access complication, develop when blood leaks from the puncture point into the soft tissue. The afflicted expanse may exist firm, bloated, and discolored, and the patient may complain of tenderness and pain. Because the internal arterial puncture site is proximal to the external incision, apply pressure 1 to ii cm higher up the puncture site until hemostasis is achieved. Report the findings to the provider, marking the boundaries of the area, and evaluate the site for changes such as thigh enlargement, discoloration exterior the marked boundaries, and changes in vital signs and pain level or location.

Retroperitoneal bleeding is more probable to occur when the femoral avenue is punctured above the inguinal ligament (ordinarily known as a "high stick"). Clinical findings include back, flank, or intestinal pain; decreases in blood pressure, hemoglobin, and hematocrit; and increased heart rate. Yous may not see obvious signs of haemorrhage.

Study suspected retroperitoneal bleeding to the provider, who will club computed tomography to diagnose the problem. Patients with this complexity must remain on bed rest. Administer I.Five. fluids and blood transfusions, every bit ordered. Surgical repair may be necessary.Suspect an arterial apoplexy if the patient has hurting, paresthesia, pallor, absent pulses in the affected extremity, and inability to motion the limb. Treatment depends on occlusion size and location, every bit well as symptom severity. The thrombus may lyse spontaneously. If information technology doesn't, surgery or thrombolytic agents may be warranted, if not contraindicated.

Approaches to TAVR

Minimally invasive transcatheter aortic valve replacement (TAVR) may involve either a percutaneous (transfemoral or transaxillary/ subclavian) approach or an open up (transapical or transaortic) approach. The options are illustrated below.

Another complication is PVR, which can be balmy, moderate, or severe. It tin be caused by a mismatch of the prosthetic valve and the native valve annulus, incomplete valve stent frame positioning due to calcification on the native annulus, or prosthetic valve placement with incomplete annulus sealing of the valve skirt or cuff. Modifications to 3rd-generation valves, including the sealing cuff and the ability to reposition the valve, may subtract risks of PVR.

Other significant complications include stroke or transient ischemic attack, myocardial infarction, cardiac conduction abnormalities, and acute renal injury. (See Nursing care for patients with TAVR complications.)

Nursing care

Upwards to i-third of patients experience complications afterwards TAVR, and then nursing care focuses mainly on patient monitoring and assessment and on educating patients well-nigh activeness, nutrition, medications, and pain management.

Postprocedure monitoring

Postprocedure care begins with the handoff report. Obtain pertinent data, including vital signs, medications administered during the procedure, current level of alertness, access difficulties (including placement of the access point and need for reaccess attempts), and overall procedure events, such as complications, arrhythmias or other cardiac events, or difficulties with placement. As ordered, place the patient on continuous telemetry monitoring and observe for eye charge per unit and rhythm changes. Auscultate heart sounds to detect changes from baseline, and monitor vital signs frequently per protocol or orders.

If percutaneous access was performed, monitor the site distal to the puncture for adequate circulation. When checking vital signs, perform neurovascular assessment of the affected extremity, including colour, temperature, pulse, numbness, tingling, and swelling. Assess the insertion site for signs of haemorrhage, hematoma, and infection. Keep dressings clean, dry, and intact and look for bleeding. Promptly report the need for dressing changes due to bleeding. Dressings may typically be removed 24 to 48 hours after the procedure.

Patients at risk for cardiac conduction abnormalities, such every bit heart block, typically receive a temporary transvenous external pacemaker. Ostend that pacemaker settings friction match those ordered. Monitor routine laboratory results, such equally renal function tests, blood cell counts, electrolytes, and partial thromboplastin times. Report findings of concern.

Patients with AS are preload dependent considering of left ventricular hypertrophy and impaired relaxation from cardiac remodeling. Advisedly monitor fluid balance for incresed preload, which may cause pulmonary congestion, and decreased
preload, which may impair cardiac output and reduce perfusion to extremities. Track fluid condition through intake and output records, laboratory results, and daily weights.

Additional considerations related to open up approaches include a chest tube and surgical incisions. Assess incisions for signs of haemorrhage or infection and observe chest-tube drainage for increases and bleeding.

If the patient received modified anesthesia or conscious sedation, monitor for tolerance and recovery from sedation.

FDA-approved valves for TAVR

The Food and Drug Administration (FDA) has approved two types of valves for transcatheter aortic valve replacement (TAVR).

PVR = paravalvular regurgitation, TA = transapical, TAo = transaortic, Taxation = transaxillary/subclavian, TF = transfemoral

Activity and nutritionAfter the procedure, patients who had a percutaneous arroyo typically are placed on 6 hours of bed rest. If the femoral artery was accessed during the process, keep the caput of the bed elevated 30 degrees or less to minimize bending at the groin and avoid disrupting the closure device at the puncture site.

Afterward bed residual ends, assist the patient with walking as needed to aid forestall complications. Check orthostatic vital signs the start time the patient gets out of bed, and assess overall mobility.

Advance the patient's diet equally tolerated in one case bed rest ends. Encourage the patient to consume meals out of bed to promote greater activeness.

Medications and pain management

When patients are able to eat and drink, look to resume oral medications to control hypertension or other comorbidities. To reduce thromboembolism chance, providers typically prescribe dual antiplatelet medications. Patients will need to take aspirin (75 to 100 mg/day) for the rest of their lives, forth with clopidogrel or prasugrel for varying durations. For case, those with self-expanding valves may exist prescribed clopidogrel 75 mg daily for 3 months, whereas those with airship-expandable valves may need to take it for half dozen months. Some patients require antithrombotic therapy for other reasons, such as coronary stents or atrial fibrillation, so therapy elapsing may be managed co-ordinate to other guidelines or specifications.

Requite pain medication, as ordered. Monitor the patient for tolerance and efficacy, and report concerns to the provider.

Nursing care for patients with TAVR complications

This chart describes complications of transcatheter aortic valve replacement (TAVR), along with their causes and corresponding nursing interventions.

Rubber and patient pedagogy

Throughout the patient'south stay, make safety a nursing care priority. Be sure to screen for fall gamble and put appropriate interventions in place based on the results. In patients with a fundamental line or urinary catheter, assess the need for using them every twenty-four hour period, and obtain an order to remove them as soon as possible. This will help reduce the chance of hospital-acquired infections. To reduce the adventure of venous thromboembolism, apply sequential pinch devices as ordered and provide appropriate didactics.

Teach the patient and family about the risk of haemorrhage acquired by antiplatelet or antithrombotic medications. Advise patients to contact their cardiologist if another healthcare provider tells them to stop the medications. Explain that ongoing follow-upward volition include periodic visits with a cardiologist. Inform them that the American Heart Association/American College of Cardiology recommend antibiotic prophylaxis before certain dental procedures for patients with a prosthetic valve.

The future of TAVR

As the population eligible for TAVR expands and more than prosthetic valves are approved, you're likely to come across more patients who undergo this procedure. By agreement the diverse TAVR approaches and postprocedure care, yous can help ensure the best possible patient outcomes.

Hours: one.58

Illustrations reprinted with permission, Cleveland Dispensary Center for Medical Art & Photography © 2006-2017. All Rights Reserved.

Kelly Haight is a clinical nurse specialist at the Cleveland Clinic in Cleveland, Ohio.

Selected references

Arora Due south, Misenheimer JA, Jones W, et al. Transcatheter versus surgical aortic valve replacement in intermediate risk patients: A meta-assay. Cardiovasc Diagn Ther. 2016;vi(3):241-ix.

Arsalan Chiliad, Walther T. Durability of prostheses for transcatheter aortic valve implantation. Nat Rev Cardiol. 2016;xiii(half dozen):360-7.

Bhatheja S, Panchal HB, Barry Northward, Mukherjee D, Uretsky BF, Paul T. 5alvular performance and aortic regurgitation following transcatheter aortic valve replacement using Edwards valve versus CoreValve for severe aortic stenosis: A meta-analysis. Cardiovasc Revasc Med. 2016;17(4):248-55.

Ellis MF. Transcatheter aortic valve replacement: An evolving choice for severe aortic stenosis. Advance Healthcare Network for Nurses. 2015.

Kondur A, Briasoulis A, Palla M, et al. Meta-analysis of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with severe aortic stenosis. Am J Cardiol. 2016;117(ii):252-7.

Malaisrie SC, Iddriss A, Flaherty JD, Churyla A. Transcatheter aortic valve implantation. Curr Atheroscler Rep. 2016;18(5):27.

Merriweather N, Sulzbach-Hoke LM. Managing take a chance of complications at femoral vascular access sites in percutaneous coronary intervention. Crit Intendance Nurse. 2012;32(v):16-29.

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for management of patients with valvular center disease: Executive summary: A report of the American Higher of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):2440-92.

Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: A report of the American Higher of Cardiology Chore Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2017;69(ten):1313-46.

Urena Grand, Hayek S, Cheema AN, et al. Arrhythmia brunt in elderly patients with astringent aortic stenosis as adamant by continuous electrocardiographic recording: Toward a better understanding of arrhythmic events after transcatheter aortic valve replacement. Circulation. 2015;131(5):469-77.

Vahl TP, Kodali SK, Leon MB. Transcatheter aortic valve replacement 2016: A modern-twenty-four hours "through the looking-glass" hazard. J Am Co

Source: https://www.myamericannurse.com/caring-patients-transcatheter-aortic-valve-replacement/

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