TAVR Critical pathway

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Patients with severe AS should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered. It is important to have a pathway to schedule the appropriate patient for this procedure.

Heart valve team

Patients with severe AS should be evaluated by a multidisciplinary Heart Valve Team when intervention is considered.
Team members include:

• Cardiology Valve Expert
• Cardiovascular Imaging Expert(s)
• Interventional Cardiologist
• Cardio-Thoracic Surgeon
• Cardiovascular Anesthesiologist
• Valve Clinic Care Coordinators

Their specific tasks are:

1. Review the patient's medical condition and the severity of the valve abnormality
2. Determine which interventions are indicated, technically feasible, and reasonable
3. Discuss benefits and risks of these interventions with the patient and family, keeping in mind their values and preferences.

Critical pathway

Abbreviations: CV: Cardiovascular, AVR: aortic valve replacement, AS: aortic stenosis, MR: Mitral regurgitation, AR: Aortic regurgitation, PAP: Pulmonary artery pressure, RV: right ventricle, CTA: CT angiography, PA: Pulmonary artery, TEE: Trans Esophageal Echocardiography, TTE: Trans Thoracic Echocardiography

Care Providing Team

Primary Care Provider                     Clinical Cardiologist                     Heart Valve Team: Cardiology Valve Expert CV Imaging Expert(s) Interventional Cardiologist CT Surgeon CV Anesthesiologist Valve Clinic Care Coordinators                     Hands off back to the Primary Care Provider and Clinical Cardiologist

Clinical Evaluation

AS Symptoms or Signs                   Severe AS with Indication for AVR                   Potential TAVR Candidate                   Patient Selection & Evaluation Shared Decision Making ❑ Goals of Care Clinical Information • Major CV comorbidites • Major non-CV comorbidities • Risk score assessment ❑ Functional Assessment • Frailty • Physical and cognitive function ❑ Risk Categories • Low risk • Intermediate risk • High or extreme risk                   TAVR Procedure ❑ Preplanning • Valve choice and access options • Anesthesia and procedure location • Anticipated complication management ❑ Procedural Details • Vascular access and closure • Valve delivery and deployment • Postdoploymont evaluation • Management of complications                   Post TAVR Management ❑ Early Post TAVR • Postprocedure monitoring and pain management • Early mobilization and discharge planning • Monitor for conduction abnormalities ❑ Long term Management • Antithrombotic therapy and endocarditis prophylaxis • Management of concurrent cardiac disease • Post-TAVR complications

Cardio-vascular Imaging

Pre TAVR ❑ Echo • Aortic valve anatomy • Confirm AS severity • LV function • MR. AR. PAP. RV function ❑ TAVR protocol CTA • Vascular access • Annular sizing • Aortic root anatomy • Interventional planning                   Echo ❑ (TEE or TTE) • Annular sizing • Valve placement • Paravalvular leak • Procedural complications                   Post TAVR Imaging ❑ Echo and ECG post-procedure, at 30 days and then annually • Valve function • LV size and function • PA systolic pressure • Cardiac rhythm