Critical Care Nurse. 2009;29: 22-36 doi:10.4037/ccn2009553
Copyright © 2009 by the American Association of Critical-Care Nurses.
Cover Article
CE Article
Transcatheter and Transapical Aortic Valve Replacement
Marion E. McRae, RN-BC, MScN, CCRN-CSC-CMC, CCN(C), ACNP-BC, ACNPC
Marnie Rodger, RN, MN, CCN(C)
Barbara A. Bailey, RN, MN, CNCC(C), CCN(C)
All authors are nurse practitioners in cardiovascular surgery at the Peter Munk Cardiac Centre, Toronto General Hospital in Toronto, Ontario, Canada. In addition, Marion McRae is a clinical associate in the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto.
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dotmore
To learn more about aortic valve replacement, read "Reducing Mortality With Device Therapy in Heart Failure Patients Without Ventricular Arrhythmias," by Deborah W. Chapa et al in the American Journal of Critical Care 2008; 17: 443-452. Available at www.ajcconline.org.
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Financial Disclosures
None reported.
This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:- List 3 indications and contraindications for performing transcatheter and transapical aortic valve replacement (AVR) on specific patient populations
- Discuss the advantages of less-invasive insertion techniques for higher risk AVR
- Identify 4 potential postoperative complications that could occur following transcatheter and transapical AVR and describe nursing interventions for each
Corresponding author: Marion E. McRae, Nurse Practitioner, Cardiovascular Surgery, Toronto General Hospital, NCSB 4B-453, 585 University Ave, Toronto, ON, Canada M5G2N2 (e-mail: marion.mcrae{at}uhn.on.ca).
Aortic valve replacement (AVR) is a common cardiac surgical procedure. An estimated 106 000 cardiac valve operations were performed in the United States in 2005 (the most recent year for which procedure numbers are available).1 AVR is the most widely performed valve replacement.2,3 Aortic stenosis affects from 2% to 7% of persons more than 65 years old in the United States and is likely to increase in prevalence as the population ages. The current American Heart Association guidelines4 for valvular heart disease recommend AVR to improve signs and symptoms and survival rates in patients with symptomatic aortic stenosis or in asymptomatic patients with an ejection fraction less than 50%. In a retrospective cohort study, Pai et al5 found that asymptomatic patients with severe aortic stenosis had a significant survival improvement with AVR. Therefore, the need for AVR will most likely increase over time, and with people living longer, AVR will be increasingly needed in elderly patients or patients with significant comorbid diseases.
Many larger, experienced centers have an operative mortality of less than 1% for AVR.6 Mortality data from several large databases are presented in Table 1
. Operative mortality depends on many factors such as the patient’s age, ventricular function, and associated cardiac and noncardiac diseases. Figure 1 illustrates the effect of age on mortality. Postoperative complication rates may also be affected by the patient’s age. Edwards and Taylor9 reported that 77% of patients more than 90 years of age experienced postoperative complications. Although researchers in other studies did not report overall complication rates by age group, rates of specific complications in the Society of Thoracic Surgeons database from more than 400 000 valve operations between 1994 and 2003 were as follows: atrial fibrillation, 27%; prolonged ventilation, 19%; renal failure, 7.1%; reoperation for bleeding, 5.5%; heart block, 5.2%; pneumonia, 4.5%; gastrointestinal problems, 43%; cardiac arrest, 3.3%; stroke, 2.8%; sepsis, 2.5%; and cardiac tamponade, 1.4%.3 Less-invasive AVR may be more desirable in higher risk groups of patients such as elderly patients because it may reduce complications.
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Figure 1 Effect of age on 30-day mortality after aortic valve replacement.
Based on data from Edwards and Taylor.9
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In this article, we discuss the development of minimally invasive AVR and focus on the differences between conventional AVR, transcatheter AVR, and transapical AVR. We review the nursing care of patients who have transcatheter and transapical AVR, and to emphasize the key points, we present a case study of a woman with severe aortic stenosis who underwent transapical AVR.
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Development of Trans-catheter Valve Procedures
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Many factors have promoted the development of less-invasive valve procedures. AVR that does not require full sternotomy may be more cosmetically attractive to patients. Being able to perform AVR in patients with severe aortic atherosclerosis or calcification without the risk of stroke from cross-clamping a calcified aorta is not only beneficial in terms of improved outcomes for patients but also might reduce hospital stays due to complications such as stroke. Conventional AVR must be done with cardiopulmonary bypass with the attendant risks of elevating creatinine level (particularly in patients with renal disease), bleeding, and impaired lung function due to deflation of the lungs during bypass. The avoidance of the use of cardiopulmonary bypass could prevent some of these complications in high-risk patients. In addition, AVR could be extended to patients with conditions previously considered inoperable if the avoidance of cardiopulmonary bypass and sternotomy improved outcomes.
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Balloon Aortic Valvuloplasty
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Until recently, transcatheter aortic valve interventions have been limited to balloon aortic valvuloplasty, in which a balloon is placed across the stenotic aortic valve and inflated to reduce aortic stenosis. Balloon aortic valvuloplasty has been useful in treating children with aortic stenosis, but it is recommended solely for younger adults without valve calcification. The 2006 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for valvular disease management4 recommend balloon aortic valvuloplasty in adults solely as a bridge to surgery in patients with aortic stenosis who have unstable hemodynamic status and are at high risk for AVR or for patients with aortic stenosis in whom AVR cannot be performed because of serious comorbid conditions. The ACC/AHA recommendations were based on a review of the literature that cited greater than 10% frequency of serious complications and the fact that restenosis and clinical deterioration typically occur within 6 to 12 months of balloon aortic valvuloplasty. However, the studies cited in the ACC/AHA recommendations are dated, and some technical improvements have occurred since the studies were done that may lead to further study of balloon aortic valvuloplasty,10 especially in nonagenarians.11
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Transcatheter Pulmonary Valve Replacement
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In 2000, the first valve replacement that became available by catheter delivery was the pulmonary valve replacement (PVR) performed by Bonhoeffer’s group with a bovine jugular vein valve that was intended for use inside surgically placed conduits from the right ventricle to the pulmonary artery.12 The results of the first North American trial of transcatheter PVR were recently reported13; no significant complications or urgent surgical intervention occurred. Transcatheter PVR is intended for patients with congenital heart disease in whom reoperation could be delayed until a future date by the implantation of one of these valves.
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Transcatheter AVR
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Andersen et al14 reported the first transcatheter AVR in 1992 in pigs. The first transcatheter AVR in humans was reported by Cribier et al15 in 2002. Transcatheter and transapical AVR are currently in clinical trials in a few centers in Canada, the United States, and Europe.
In a position paper,16 the Society of Thoracic Surgeons, the American Association for Thoracic Surgery, and the Society for Cardiovascular Angiography and Interventions recommended that the initial patients to undergo percutaneous AVR strategies should be at extremely high operative risk (generally >20% operative mortality) as indicated by an established risk scoring system such as the logistic EuroSCORE17 or the Society of Thoracic Surgeons risk calculator.18 The guidelines reported by Vassiliades et al16 state that use of such devices is not acceptable for patients who simply refuse open heart surgery on the basis of personal preference. It was also recommended that initial feasibility studies be conducted in a small number of high-volume cardiology and cardiac surgery programs (minimum 100–150 valve operations per year with each surgeon performing a minimum of 40–50 valve repairs or replacements annually). Some of the indications and contraindications for minimally invasive AVR are indicated in Tables 2 and 3, respectively.
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Transcatheter and Transapical Valve Design
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Traditional heart valves consist of homografts from another human being, bioprosthetics (valves constructed from bovine pericardium or porcine valves mounted in a metallic stent to preserve their shape or prepared as stentless valves), or mechanical valves mounted in a fabric sewing ring. The valves are sutured into the heart after the diseased valve is excised. Traditional bioprosthetic valves last a mean of 10 to 15 years, and mechanical valves could potentially last a lifetime. In contrast to traditional heart valves, implantation of the transcatheter valve does not require removal of the native heart valve. The transcatheter valves are bioprosthetic valves that are crimped or loaded onto a stent or frame. Once in place, the stent or frame containing the valve is expanded to anchor the valve in the aortic annulus. The transcatheter valves are sutureless and are held in place by the stent or frame. The valves currently in clinical trials are the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, California), also referred to as the Cribier-Edwards valve (Figure 2), and the CoreValve (CoreValve Inc, Irvine, California; Figure 3). A number of other valves are in development.6,25
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Figure 2 The Edwards SAPIEN transcatheter bovine pericardial valve mounted on a stainless steel stent.
Courtesy of Edwards Lifesciences, Irvine, California.
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Figure 3 The CoreValve porcine valve on a self-expanding nitinol frame (part of the CoreValve ReValving system).
Courtesy of CoreValve Inc, Irvine, California.
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The Edwards SAPIEN transcatheter heart valve was an equine and is now a bovine trileaflet pericardial valve on a balloon-expandable stainless steel stent. It is currently available in 23- and 26-mm sizes and can be used for transcatheter and transapical AVR. A sewn fabric cuff covers the left ventricular part of the prosthesis. The valve is approximately 14 mm in height with cloth covering the proximal 6 mm of the valve. The cloth-covered part of the valve must sit in the annulus to prevent regurgitation though the stent into the left ventricle.26 In order to use the Edwards valve, a balloon valvuloplasty must be undertaken first to dilate the native valve and allow placement of the new valve.
The CoreValve ReValving System consists of a porcine pericardial valve on a multilevel self-expanding nitinol frame in an hourglass shape (expands with blood temperature), a delivery catheter, and a disposable loading system. The current generation catheter is 18F. The shape of the frame allows secure positioning within the aortic annulus while the valve functions in the supraannular position. Two valve sizes are available for use in aortic annuli between 20 and 27 mm. To date, more than 1800 patients have been treated with the CoreValve device. This system is neither commercially nor investigationally available in the United States at the present time (Rob Michiels, CoreValve Inc, written communication, September 25, 2007).
| CASE STUDY Ms L. was a 71-year-old who had previously undergone a triple coronary artery bypass in 1997. She had mild aortic stenosis at this operation. She was well until 2006, when she experienced dyspnea, and an echocardiogram showed severe aortic stenosis. The aortic valve area was 0.5 cm2, and the peak aortic valve gradient was 75 mm Hg with a normal left ventricular ejection fraction. Angiography revealed a patent graft from the left internal mammary artery to the left anterior descending coronary artery and a patent saphenous vein graft to the obtuse marginal artery. The saphenous vein graft to the posterior interventricular artery was occluded. Comorbid diseases included type 2 diabetes requiring oral hypoglycemics, a 30-pack-year history of smoking (stopped smoking 1 year ago), hyperlipidemia treated with a statin, severe stenosis of the right carotid artery, osteoporosis, and arthritis. Unfortunately, the angiogram also revealed a porcelain aorta, which was the primary reason why it was considered unsafe to cross-clamp her aorta for a conventional AVR.
Ms L. was treated with 300 mg of clopidogrel and given her usual daily dose of aspirin (81 mg) preoperatively. Standard intravenous antibiotic prophylaxis was given just before surgery. She underwent transapical AVR with a 23-mm Edwards SAPIEN transcatheter heart valve under general anesthesia in the operating room (her aortic annulus was sized at 20 mm during angiography, and the valve was oversized to prevent aortic insufficiency). Intravenous heparin was used during the procedure to maintain the activated clotting time at greater than 250 seconds and prevent clot formation during catheter and valve positioning. The transapical incision is depicted in Figure 4. One chest drain was placed for 24 hours to drain blood from the surgical site.
After the procedure, Ms L. was admitted to the cardiovascular intensive care unit for 24 hours and was extubated within 2.5 hours of arrival in the unit. An intercostal nerve block was performed soon after the procedure for pain control, and then intravenous narcotic analgesia and then oral narcotic analgesia were used several days later. Intravenous nitroglycerin was administered for 6 hours for hypertension. An intravenous insulin infusion was used for 24 hours to maintain optimal glycemic control until a full diabetic diet was possible. Ms L. was transferred to the cardiovascular surgery unit on the day after surgery.
Ms L. was taking clopidogrel 75 mg daily, to continue for at least 6 months, and aspirin 81 mg daily, to continue indefinitely, for the aortic valve, previous bypass grafts, and carotid stenosis. She had a brief postoperative episode of atrial fibrillation that was treated with oral amiodarone and metoprolol with conversion to sinus rhythm. Her postoperative echocardiogram revealed an aortic valve area of 0.97 cm2 with peak and mean aortic valve gradients of 34 and 12 mm Hg, respectively. Two small jets of paravalvular aortic insufficiency were noted, as is common with this type of valve. The aortic insufficiency evident on the echocardiogram done on postoperative day 4 was unchanged from that revealed on the intraoperative transesophageal echocardiogram. Ms L. was discharged home on postoperative day 5.
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Figure 4 Incision for transapical replacement of aortic valve (mini left anterolateral thoracotomy usually in the sixth intercostal space).
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Valve Insertion Procedure
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Transcatheter AVR is performed with either local or spinal anesthesia with sedation or with general anesthesia in a cardiac catheterization laboratory or an operating room equipped with fluoroscopy and transesophageal echocardiography. Transcatheter AVR may require surgical cutdown and may require placement of femoral grafts in order to insert the large transcatheter delivery systems. The large size of the delivery catheters limits the transcatheter approach to patients with vessels large enough to accommodate the catheters. An angiogram or a computed tomographic angiogram (and probably femoral Doppler imaging) is required before transcatheter AVR to ensure that the femoral and iliac vessels are not tortuous and are large enough to accommodate the valve delivery catheters.
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Transcatheter AVR: Deployment
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Two approaches have been described for deployment in transcatheter AVR. In the antegrade, transeptal approach, access is via the femoral vein; the catheter is passed into the right ventricle and then punctures the septum to be placed ante-grade across the aortic valve. This approach is technically difficult and may cause mitral valve damage, including acute mitral regurgitation, if not carefully performed.23,26,27 In the retrograde approach, a femoral artery puncture is used. The catheter is advanced retrograde through the aorta to cross the aortic valve. Limitations of the retrograde approach include the small size of the femoral artery compared with the femoral vein, a situation that makes the approach difficult to use in older patients with peripheral vascular disease or small patients whose vessels cannot accommodate the 18F to 24F sheath sizes. With the retrograde technique, atherosclerotic material can be embolized from the aorta into the distal circulation.26 Gupta et al28 compared 52 antegrade vs 111 retrograde AVRs and found no difference in outcomes except that antegrade deployment avoided vascular complications (7% in retrograde vs 0% in antegrade approach, P<.05).
Contrast medium is used to ensure correct positioning of the catheter valve across the aortic annulus. Transcatheter AVR with the Edwards valve requires rapid pacing of the heart (rate, 150–220/min) to decrease cardiac output to place the valve. Failure to stop the cardiac output with pacing while the valve is placed could result in ejection of the valve into the aorta. The alternative would be brief femoral-femoral cardiopulmonary bypass to place the valve. In some centers, the femoral vessels are cannulated for possible emergent cardiopulmonary bypass in case of problems such as valve embolization into the aorta. Great care must be used in positioning the valve to ensure that the coronary ostia are not blocked or that a bulky native aortic valve leaflet does not block the ostia when pushed back by the stent.24
The CoreValve ReValving system uses a suture-mediated closure device (Prostar, Abbot Vascular Devices, Redwood City, California) for femoral percutaneous closure (Rob Michiels, CoreValve Inc, written communication, September 25, 2007). The Edwards SAPIEN transcatheter heart valve system uses a femoral graft closure.
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Transapical AVR
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Because of the possible vascular complications of transfemoral catheter approaches, the transapical approach has been developed. The transapical approach can be used in persons who have small or tortuous femoral or iliac vessels or severe peripheral vascular disease such as persons with previous aortobifemoral grafting. It would be a preferential approach if a porcelain (heavily calcified) aorta prevented cannulation for cardiopulmonary bypass or aortic cross-clamping or if aortic atheroma was marked. The transapical approach is quicker and less technically difficult than the transcatheter technique.27 The transapical approach could be a problem, however, if a left ventricular apical thrombus, a left ventricular aneurysm, or apical scarring from previous surgery or chest radiation was present.
The transapical AVR is placed via a 5- to 8-cm anterolateral left thoracotomy usually in the sixth intercostal space (Figure 4
). The pericardium is opened, and a small transapical stab incision of the left ventricle is made to accommodate the delivery catheter.23 A total of 1 bipolar or 2 unipolar epicardial pacing wires are placed on the left ventricle to pace the heart during valve placement. A balloon aortic valvuloplasty is performed to dilate the native aortic valve before placement of the new valve. The new valve is then placed on a catheter across the native aortic valve (Figure 5) and uncrimped by balloon expansion of the stent (Figure 6). Cardiac output must be momentarily stopped by the use of high-rate pacing of the heart (rate, 150–220/min) until the valve is positioned. Transapical placement of an AVR requires a collaborative team approach between cardiology and cardiovascular surgery to ensure that imaging and pacing capabilities merge to allow the surgeon to place the valve precisely and at exactly the appropriate time to prevent valve embolization. At the end of the procedure, the pacing wires are removed, the pericardium is closed to prevent herniation of the heart through the pericardium, and the minithoracotomy is closed, with a chest tube left in situ for overnight drainage. An example of a stented aortic valve placed via a transapical approach is seen on a chest radiograph in Figure 7.
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Figure 5 Fluoroscopic view of the delivery catheter with the Edwards SAPIEN transcatheter heart valve in the crimped position before expansion of the stent.
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Figure 6 Fluoroscopic view of the delivery catheter with the Edwards SAPIEN transcatheter heart valve expanded in position at the aortic annulus.
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Figure 7 Edwards SAPIEN transcatheter heart valve in position in the aortic annulus as seen on lateral chest radiograph (not the case patient).
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Important Points About Trans-catheter and Transapical AVR
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Valves used for transcatheter and transapical AVR must be oversized to ensure stability within the aortic valve annulus without perivalvular regurgitation. Paravalvular insufficiency can be caused by undersizing or inadequate dilatation of the valve stent.23 Therefore, the aortic annulus is measured, and a valve size is selected that is slightly larger than the patient’s own annulus. Because of the current limitation in sizes available in these new valves, patients with larger annuli cannot currently receive the valve. Lichtenstein et al23 stated that an unusually bulky coronary leaflet could be displaced by the valve stent or frame and would therefore be a contraindication.
Anomalous coronary ostia might be a contraindication to the use of these valves. The valve stent or frame may interfere with introducing catheters into the coronary arteries.23 Such interference could be an issue if catheterization or stenting of coronary arteries should be required at a later date. Therefore, before these valves are placed surgeons must ensure that patients have no marked coronary disease. Open bypass grafts would provide a safety margin in the situation of a short distance between the annulus and the coronary ostia.21
If the valve is placed via the femoral vessels, the vessels must not have a tortuous course or be severely calcified. The catheters used to deliver the valves are relatively stiff and large. Therefore, vessel rupture, dissection, formation of a pseudoaneurysm, bleeding, and thrombus formation can be problems,29 as can myocardial perforation and cardiac tamponade.23 Embolization of calcified material could also occur during the balloon valvuloplasty,22 or atheromatous material in the aorta could be embolized during retrograde valve placement.
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Early Results of Trans-catheter and Transapical AVR
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Early outcomes for humans after transcatheter and transapical AVR have been reported by a number of investigators (Table 4). In general, valve implantation is successful in most patients, who have symptomatic improvement after the implant. Because these valves are secured in place by the valve stent or frame, perivalvular regurgitation may occur. Morbidity and mortality are currently higher than with conventional valve implantation and will most likely decrease as experience with transcatheter valves increases and design is improved. Long-term follow-up is limited with these newer valves.
Long-term follow-up is needed to determine the durability of transcatheter valves and to assess what other problems may arise. For those who had SAPIEN equine valves, equine valves have not been tested for durability beyond a few years in humans.32 It is not clear if crimping the valve for delivery will affect long-term function of the valve.21
A number of long-term problems have been reported with percutaneous PVR, and it is unclear whether these problems will occur with the newer AVR techniques.
Stent fractures occurred in 19.5% of the series of 123 percutaneous PVRs reported by Nordmeyer et al33 from 8 to 843 days after insertion of the valve. A total of 4 patients required insertion of a second percutaneous PVR, and 1 required surgical explantation. Endocarditis and hemolysis have also been documented with percutaneous PVR,33 and it is unclear what the incidence of these problems will be with transcatheter and transapical AVR.
Other outcomes that should be monitored include death, stroke, myocardial infarction, paravalvular leaks, device migration, changes in signs and symptoms after implantation of the device, angiographic gradients, and rehospitalization.16 Until it can be determined that the newer AVR technologies are as durable as conventional AVR, it would be unethical to offer this new technology to patients who are at low surgical risk for conventional AVR. For most patients, conventional AVR will remain the gold standard of treatment for the foreseeable future. As more experience is gained with less-invasive valve technology, outcomes most likely will improve.
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Future Directions
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Removal and ablation of the native aortic valve in situ might be possible in the future with lasers to facilitate positioning of a new valve. This procedure would need a filtering mechanism to prevent embolization of valve remnants.34 Tissue-engineered heart valves may be placed by transcatheter or transapical routes in the future. These grafts consist of a scaffold seeded with host cells that eventually cover the scaffold. The valve can then be conditioned to function under normal intracardiac pressures before implantation.
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Nursing Implications of Transcatheter and Transapical AVR
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Table 5 presents the nursing care required by patients undergoing transcatheter and transapical AVR. Because multiple comorbid diseases may have made a patient a candidate for transcatheter and transapical AVR, much of the focus of nursing care is on preventing complications due to these comorbid conditions. The case study highlights key concepts of the nursing care.
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Summary
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Transcatheter and transapical AVR are new technologies that could benefit many patients who are considered high-risk candidates for traditional surgical AVR. Although experiences with transcatheter and transapical AVR are limited, preliminary results indicate that these techniques are feasible in selected high-risk patients and have satisfactory short-term outcomes. Long-term follow-up in a larger population of patients is needed to determine if transcatheter and transapical AVR reduce surgical risk, lower complication rates, and produce satisfactory longer term outcomes.
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PRIME POINTS
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- Minimally invasive valve replacement is limited to bioprosthetic aortic and pulmonary valves for use in very specific populations of patients.
- Replacement via trans-catheter and transapical techniques should be used only in patients in whom traditional surgical replacement is deemed an unacceptable risk.
- Nursing management will focus heavily on care for comorbid conditions because of the high-risk nature of the patients in whom these valves will initially be implanted.
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References
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Development of Trans-catheter...
Balloon Aortic Valvuloplasty
