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Published on May 01, 2018

TAVR Improves Outcomes With Minimalist Approach

Heart Illustration Commander TFTAVR is an innovative option for patients in need of heart
valve replacements but who have comorbidities that make
them poor candidates for open-heart surgery. To improve
outcomes, postoperative care has been optimized.

Three years ago, the heart team at North Kansas City Hospital performed the Northland’s first Transcatheter Aortic Valve Replacement procedure.

Now, the hospital has adopted an alternative minimalist approach that does not require general anesthesia, lowers the risk of complications, decreases
average length of stay and improves recovery.

“By providing a minimalist approach for TAVR, the less traumatic this procedure is for our patients and the more quickly they will recover,” said
Zafir A. Hawa, MD, FACC, FSCAI. Dr. Hawa and James H. Mitchell, MD, FACC, both interventional cardiologists with Meritas Health Cardiology, collaborate with Keith B. Allen, MD, and Alexander F. Pak, MD, cardiothoracic surgeons with Mid America Heart & Lung Surgeons, to perform traditional and minimalist TAVR procedures at NKCH.

TAVR is an innovative option for patients in need of heart valve replacements who have comorbidities that make them poor candidates
for open-heart surgery. The North Kansas City Hospital heart team has performed 114 TAVR procedures since the program began.

The procedure was previously approved only for high-risk patients, but the Food and Drug Administration approved an expanded indication in
August 2016 for patients at intermediate risk for death or complications associated with open-heart surgery.

Specialized Training

Drs. Hawa and Mitchell underwent training for the minimalist approach last year with John A. Webb, MD, who is a leading TAVR expert at the Center for Heart Valve Innovation at St. Paul’s Hospital in Vancouver. Dr. Webb helped develop a clinical pathway involving a minimalist surgical approach, standardized care and discharge criteria to reduce length of stay.

The pathway has demonstrated that several factors contribute to improved outcomes over traditional TAVR, including:

  • Use of local anesthesia
  • Implantation of a balloon expandable device
  • Early removal of a temporary pacemaker
  • Avoidance of a urinary catheter
  • Standardized post-procedure care
  • Early mobilization

Using the pathway as a guide, the NKCH team fine-tuned its approach. “From the start, we wanted to develop criteria to distinguish which patients should go through a traditional versus a minimalist pathway,” said Dr. Hawa, medical director of cardiac clinical research at NKCH.

Less Is More

3M TAVR Study

Initial findings from the 3M TAVR Study of 411 minimalist TAVR patients at 13 centers in Canada were presented at the 2017 Transcatheter Cardiovascular Therapeutics Conference.

Early Results

  • Discharged in 48 hours: 89.5%
  • Discharged next day: 80.1%
  • Mean Society of Thoracic Surgeons risk score: 4.9%
  • Mortality or stroke: 2.9%
  • 30-day all-cause readmission rate: 9.2%
  • Cardiac readmission rate: 5.7%

Source: “3M TAVR: The Multidisciplinary, Multimodality, but Minimalist Approach to Transfemoral Transcatheter Aortic Valve Replacement,” American College of Cardiology, Nov. 17, 2017.

The minimalist TAVR pathway uses the anesthetic agent remifentanil. The cardiologist uses percutaneous access in the groin and X-ray guidance to move a catheter affixed with a new balloon-expandable valve up the femoral artery to the heart to replace the damaged valve.

“A CT scan provides the means to determine the exact valve size,” Dr. Hawa said, adding that minimalist TAVR patients avoid general anesthesia, do not require a breathing tube and have shorter surgeries when compared with the traditional TAVR procedure.

When a valve size is difficult to pinpoint, a traditional TAVR with the patient under general anesthesia is performed. Valve sizing is done using 3-D transesophageal echocardiography. The diseased aortic valve can be accessed using a transfemoral, transapical or transaortic approach under traditional TAVR. Dr. Hawa noted that patients with obesity typically undergo a traditional TAVR procedure because adequate echo windows are difficult
to capture.

When a valve size is difficult to pinpoint, the cardiologist performs a traditional TAVR with the patient under general anesthesia. Valve sizing is done using 3-D transesophageal echocardiography. The diseased aortic valve can be accessed using a transfemoral, transapical or transaortic approach under traditional TAVR. Dr. Hawa noted that patients with obesity typically undergo a traditional TAVR procedure because adequate echo windows are difficult to capture.

Patient Gains

To improve outcomes, postoperative care has been optimized. “As we do with all procedures, we developed protocol-based postoperative care,” Dr. Hawa said. “We remove all of a patient’s cardiac catheters and lines within four hours after the procedure. We ambulate patients early and typically send patients home the next day as long as they have support at home, such as a family member who can stay with them for a few days.”

Dr. Hawa noted he has seen fewer postoperative issues with regard to delirium and confusion for these patients, who are age 85 and older. He attributes the decrease to the one- versus two-day average hospital stay of traditional TAVR. “We’ve found that instead of being resistant to a short stay, patients have embraced it. The older the patient, the happier they are to go home sooner,” he added.

Dr. Hawa recognizes these gains could not have come to fruition without support from NKCH. “We could not do this without hospital backup through multiple departments, including anesthesia, surgery and especially nursing. Postop care is 100% nursing,” Dr. Hawa said. “We hope that more of the cases will be with this minimalist approach. Our goal is to do 40% as traditional and 60% as minimalist.”

Zafir A. Hawa, MD, FACC, FSCAI

Zafir A. Hawa, MD, FACC, FSCAIAfter Dr. Hawa earned his medical degree from the University of Bombay, India, he completed his postgraduate training. He was an internal medicine resident at the University of North Dakota Medical Center, Grand Forks, and a critical care fellow at the University of Pittsburgh Medical Center. He also did fellowships in cardiology research, cardiology and interventional cardiology at Western Pennsylvania Hospital, Pittsburgh.