Background: Aortic stenosis is a common disease that affects older adults. With an expanded indication, low-risk patients can now be offered the option of TAVR. Hospitals will need to effectively and efficiently accommodate the expected increase in demand for the TAVR procedure without compromising patient outcomes. Objective: The purpose of this study was to evaluate the development of a post-transcatheter aortic valve replacement protocol to standardize care and progress the patient from the operating room to discharge. Methods: We used a prospective pre-post design to evaluate the effect of education and a technology-supported intervention on length of stay, quality of life (measured by the Kansas City Cardiomyopathy Questionnaire; KCCQ12), and early mobility in TAVR patients between April 2019 and March 2020. Interventions: Two components of the intervention included team-based education and integration of guideline-based orders in the electronic record (EHR). Education regarding expectations for early mobilization and discharge plan was provided to patient and staff to ensure a timely discharge home. Results: Overall and post-procedural length of stay were significantly improved (5.26 days vs 2.45; p<0.001 and 3.05 days vs 2.16 days; p<0.004) respectively. Quality of life improved in both groups from baseline to 30 day follow up (p=0.012) No significant difference was shown in the 5-meter walk test. Conclusion: These findings suggest that implementation of an evidence based EHR-embedded order set is associated with a significant improvement in overall and post-procedure length of stay at 6 moths and a significant improvement in post-procedure quality of life. Future work is needed to examine strategies to ensure safe next day discharge.
Placement of a pacing lead into a branch of the coronary sinus for biventricular pacing sometimes is difficult or impossible. Surgical completion typically has included immediate or subsequent thoracotomy lead placement with hookup to the device at the time of chest surgery. We describe an alternative procedure of complete device‐lead hookup and permanent pocket closure in the electrophysiology laboratory. The left ventricular lead is an epicardial type. The lead is tunneled to a position where the surgeon subsequently can recover it using the thoracotomy incision and implant the lead on the epicardium using device‐based testing.
The level of radiation exposure received by operators performing transcatheter aortic valve replacement (TAVR) is not well investigated. The aim of this study is to measure the amount of radiation received by operators performing transfemoral TAVR and to identify various patient and procedural characteristics associated with increased radiation exposure.Primary (operator 1) and secondary (operator 2) operators' equivalent radiation doses in micro Sieverts (µSv) were calculated prospectively using real-time radiation dosimeters for a total of 140 consecutive transfemoral TAVRs. Corresponding eye and thorax radiation exposures between the operators were compared. Associations between various patient and procedural characteristics and the radiation exposure were tested using the t-test and Wilcoxon Mann-Whitney rank-sum test with Monte Carlo estimation. Multivariable regression analysis was also conducted.Operator 1 had significantly higher cumulative equivalent radiation exposure than operator 2 (86 µSv vs 38 µSv, p-value: <0.0001) which was consistent at the level of the thorax (67 µSv vs 22 µSv, p-value: <0.0001), but not at the level of the eye (16.5 µSv vs 15 µSv, p-value: 0.30). On multivariable analysis, patient obesity and intraprocedural complications were associated with higher radiation exposure to both operators. Ad hoc percutaneous coronary intervention led to excessive radiation exposure to the secondary operator.Transfemoral TAVR is associated with a modest amount of radiation exposure to operators and is significantly higher for the primary operator than for the secondary operator.
The authors present a case of a 57-year-old male who underwent bioprosthetic mitral valve replacement (MVR) and developed postoperative cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and Impella 5.5 (Abiomed) hemodynamic support.
