Update on Transcatheter Aortic Valve Implantation

Current status of surgical treatment for aortic valve stenosis

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.

Transcatheter aortic valve implantation

Older adults with progressively worsening aortic valve stenosis are limited in their treatment options. Conventional treatment replaces the aortic valve via open-heart surgery, introducing numerous risks and increased mortality in older populations with comorbidities. In recent years, however, transcatheter aortic valve implantation (tAVI) has become a viable option for symptomatic, nonsurgical candidates. Although tAVI is available only to a select population, early randomized and nonrandomized clinical trials are offering insight into the new therapy, with promising results as this treatment continues to evolve.

PURPOSE

This article examined the progression of tAVI therapies, from first-generation to third-generation devices and through 4 studies that address the utility of tAVI in symptomatic, nonsurgical candidates, in an effort to prepare nurses in the management of this newly emerging patient population.

METHODS

A literature search was conducted of studies within the past 5 years that address transfemoral tAVI in adult populations. Transapical approaches were excluded.

RESULTS

Early outcomes demonstrate that successful implantation can improve valvular function and patient functional status. Nurses play a critical role in patient education and monitoring both before and after tAVI.

CONCLUSIONS

With increasing life expectancies and a prediction that many aging adults with aortic valve stenosis will be limited to tAVI, nurses need to gain familiarity with this novel therapy and its role in patient outcomes.

A practical guide to multimodality imaging of transcatheter aortic valve replacement

The advent of transcatheter aortic valve replacement (TAVR) is one of the most widely anticipated advances in the care of patients with severe aortic stenosis. This procedure is unique in many ways, one of which is the need for a multimodality imaging team-based approach throughout the continuum of the care of TAVR patients. Pre-procedural planning, intra-procedural implantation optimization, and long-term follow-up of patients undergoing TAVR require the expert use of various imaging modalities, each of which has its own strengths and limitations. Divided into 3 sections (pre-procedural, intraprocedural, and long-term follow-up), this review offers a single source for expert opinion and evidence-based guidance on how to incorporate the various modalities at each step in the care of a TAVR patient. Although much has been learned in the short span of time since TAVR was introduced, recommendations are offered for clinically relevant research that will lead to refinement of best practice strategies for incorporating multimodality imaging into TAVR patient care.

The golden age of minimally invasive cardiothoracic surgery: current and future perspectives

Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.