2017 Buyer’s Guide

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Collaboration Allows TAVR to Reach its Potential

By Christopher U. Meduri, MD, MPH; Meredith Brazell, PA-C; Bryan Griffith; Morris Brown, MD; Jim Kauten, MD; and Vivek Rajagopal, MD; on behalf of the Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA
 

The advent of transcatheter aortic valve replacement (TAVR) has ushered in a new era of interdisciplinary collaboration in valve therapy and transformed the fields of both cardiology and cardiac surgery. Much of the attention to date has appropriately centered on optimizing the valve and delivery system design to reduce procedural complications and rates of paravalvular leak. Certainly, we can look forward to other technologic advancements in the coming years. On the other hand, it behooves the medical community to ensure the optimization of all aspects of patient care and the seamless integration of these technologic advances in order to allow TAVR to reach its full potential. This impetus drove a transformation in TAVR care at the Piedmont Heart Institute in Atlanta, Georgia.

THE PIEDMONT EXPERIENCE

In the spring of 2014, our center felt the effect of having a TAVR program. We had an average length of stay of more than 7 days, struggled with care efficiencies, and were at a significant financial loss. We had recently received a grant of $20 million from the Marcus Foundation to start the Marcus Heart Valve Center to enhance the outcomes and experience of patients diagnosed with valvular heart disease and thought this would be a perfect opportunity for change.

Implementation of a broad range of strategies designed to optimize all aspects of TAVR began in August 2014. Our primary goal was to provide the best possible outcomes for our patients, with a secondary goal of measuring the effect of these interventions on the length of stay and the average per-patient cost of TAVR. Although these measures seem logical, intuitive, and had been proven in other areas of medicine, they remained to be fully validated for TAVR.

Our center used a three-tiered approach involving an explicit transition away from general anesthesia, staff education initiatives, and the implementation of postprocedure clinical pathways. Over a period of 3 months, our goal was to transition to optimized care for our patients. During this time, the most significant changes were the transition from 100% general anesthesia to 100% conscious sedation for transfemoral cases and the implementation of postprocedure pathways.

Transition to Conscious Sedation

To accomplish our goal, we held numerous sessions to explain both the rationale and the implementation of the proposed care changes to cardiologists, anesthesiologists, and cath lab and operating room staff. We worked at length with our supportive anesthesia team to help form a system using light sedation that focused on patient safety while keeping the patients comfortable and giving them the ability to recover quickly. There were also multiple meetings made with our imaging team to ensure that our transition away from transesophageal echocardiograms would not compromise our ability to detect paravalvular leak. These included having excellent transthoracic echocardiograms, optimizing our hemodynamic assessments, and using more aortography. Such efforts paid off by fostering broad stakeholder buy-in for the transition.

Our first cases involved a few select patients that had tolerated their pre-TAVR cardiac catheterization with minimal sedation. After the first patients did well, we then met as a valve team to determine additional ways to optimize the experience. Several small changes were made after several cases, staff became more comfortable, and we then expanded treatment to the majority of our patients. Within 3 months, we transitioned from 100% general anesthesia to close to 100% conscious sedation for our transfemoral patients.

Postprocedure Pathways

Figure 1. Piedmont’s transfemoral TAVR pathway.

We worked closely with a dedicated team of clinical efficiency experts to develop concrete postprocedure care pathways that were specifically tailored for our institution and patients (Figure 1). The goal of pathway development was standardization of postprocedure care to reduce variation in management. After the development of the pathways, we had numerous meetings with care providers to educate them on the changes as well as the goal of our changes. In order to achieve consistent implementation of the pathways, we spent numerous hours educating the staff, implementing them, and then providing accountability for those who did not. The pathways focused on clinical objectives to be met in the first 0 to 6 hours, 6 to 12 hours, and the day after the procedure, as well as criteria for discharge and follow-up. A detailed list of objectives are shown in Figure 1. Highlights included the avoidance of narcotics and sedatives, early extubation and line removal, and early mobilization and ambulation.

Results

Figure 2. Trends in median length of stay for Piedmont’s TAVR program.

Although there were challenges along the way, the results have been remarkable. After a run-in period where we field tested and refined the pathways, we set an ambitious goal of a 1- to 2-day length of stay for all transfemoral patients. Since implementation, our median length of stay has been 2 days in all TAVR patients in the past 24 months compared to a median length of stay of 6.5 days in the year before implementation (Figure 2). This remarkable reduction in length of stay has been accomplished with mortality and stroke rates well below the national average. At discharge, 88% of our patients go directly home without assistance, compared to a national average of 68%, according to Medicare data from 2015. Of the 12% requiring any level of assistance after discharge, 72% were requiring the same level of assistance before admission. Most importantly, we have seen no adverse events from an early discharge and the patients and families are grateful for the quick recovery.

To prevent readmissions and ensure optimal care for patients, we have them check their heart rate, blood pressure, and weight on a daily basis, and we make follow-up phone calls on postdischarge days 1, 5, 14, and 21. This has allowed us to identify any potential issues, which can frequently be addressed by phone. As a result, our 30-day readmission rate is < 6%.

Not only have the clinical outcomes been outstanding, with extremely high levels of patient satisfaction, but there has been a significant financial effect as well. On a per-patient level, there has been a reduction in cost of $9,913 per hospital stay. We have had success utilizing the Post-TAVR Optimization app* to stay advised on any early patient discharges, which are subject to Medicare's postacute care transfer (PACT) policy.

SUMMARY

Although TAVR appears destined to be a lasting technology, the field continues to evolve, and there are still significant opportunities for improving patient care. Many opportunities exist for optimization and each center must determine how they can customize the program to enhance the outcomes and experience for their patients. At Piedmont, we have accomplished this by transitioning to conscious sedation and by implementing postprocedure clinical pathways. This transition has fostered greater engagement on the part of the medical team and administrators, improved patient outcomes and patient satisfaction, and has led to an ancillary benefit of both improving the financial viability of our TAVR program and ensuring that we can further fulfill our mission of providing excellent care to the largest number of patients. Optimizing patient care for TAVR can therefore be to the benefit of patients, programs, and society as a whole.

Christopher U. Meduri, MD, MPH
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
christopher.meduri@piedmont.org
Disclosures: Grant support from Medtronic, Edwards
Lifesciences; consultant to Medtronic, Boston Scientific
Corporation; proctor for Medtronic, Boston Scientific
Corporation, Edwards Lifesciences, Mitralign.

Meredith Brazell, PA-C
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
Disclosures: None.

Bryan Griffith
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
Disclosures: None.

Morris Brown, MD
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
Disclosures: None.

Jim Kauten, MD
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
Disclosures: None.

Vivek Rajagopal, MD
Marcus Heart Valve Center
Piedmont Heart Institute
Atlanta, Georgia
Disclosures: Consultant to Medtronic; proctor for
Edwards Lifesciences, Boston Scientific Corporation,
Medtronic.

 

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About Cardiac Interventions Today

Cardiac Interventions Today (ISSN 2572-5955 print and ISSN 2572-5963 online) is a publication dedicated to providing comprehensive coverage of the latest developments in technology, techniques, clinical studies, and regulatory and reimbursement issues in the field of coronary and cardiac interventions. Cardiac Interventions Today premiered in March 2007 and each edition contains a variety of topics in a flexible format, including articles covering various perspectives on current clinical topics, in-depth interviews with expert physicians, overviews of available technologies, industry news, and insights into the issues affecting today's interventional cardiology practices.