Early mobilization after transcatheter aortic valve implantation: observational cohort study

AIMS

Early mobilization is associated with improved outcomes in hospitalized older patients. We sought to determine the effect of a nurse-led protocol on mobilization 4 h after transfemoral transcatheter aortic valve implantation (TAVI) across different units of care.

METHODS AND RESULTS

We conducted a prospective observational cohort single-centre study of consecutive patients. We implemented a standardized protocol for safe early recovery and progressive mobilization in the critical care and cardiac telemetry units. We measured the time to first mobilization and conducted descriptive statistics to identify patient and system barriers to timely ambulation. We recruited 139 patients (82.5 years, SD = 6.7; 46% women). At baseline, patients who were mobilized early (≤4 h) and late (>4 h) did not differ, except for higher rates of diabetes (25.5% vs. 43.9%, P = 0.032) and peripheral arterial disease (8.2% vs. 26.8%, P = 0.003) in the late mobilization group. The median time to mobilization was 4 h [inter-quartile range (IQR) 3.25, 4]; 98 patients (70.5%) were mobilized successfully after 4 h of bedrest; 118 (84.9%) were walking by the evening of the procedure (<8 h bedrest); and 21 (15.1%) were on bedrest overnight and mobilized the following day. Primary reasons for overnight bedrest were arrhythmia monitoring (n = 10, 7.2%) and haemodynamic and/or neurological instability (n = 6, 4.3%); six patients (4.3%) experienced delayed ambulation due to system issues. Procedure location in the hybrid operating room and transfer to critical care were associated with longer bedrest times.

CONCLUSION

Standardized nurse-led mobilization 4 h after TF TAVI is feasible in the absence of clinical complications and system barriers.

Psychometric Properties of the Kansas City Cardiomyopathy Questionnaire in a Surgical Population of Patients With Aortic Valve Stenosis

The 12-item version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12) was originally developed for patients with heart failure but has been used and tested among patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation. Whether the instrument is suitable for patients with AS who underwent surgical aortic valve replacement (SAVR) is currently unknown. Thus, we aimed to investigate the psychometric properties of the KCCQ-12 before and after SAVR among patients with severe AS. We conducted a prospective cohort of 184 patients with AS who completed the KCCQ-12 and the EuroQol 5 Dimension 5 Levels before and 4 weeks after surgery. Construct validity was investigated with hypothesis testing and an analysis of Spearman's correlation between the two instruments. Structural validity was investigated with explorative and confirmatory factor analyses and reliability with Cronbach's α. All analyses were conducted on data from the two time points (preoperatively and four weeks after surgery). The hypothesis testing revealed how the New York Heart Association class was significantly correlated with the preoperative KCCQ-12 total score (higher New York Heart Association class, worse score). A longer length of hospital stay and living alone were significantly associated with poorer postoperative KCCQ-12 total score. KCCQ-12 and EuroQol 5 Dimension 5 Levels were moderately correlated in most domains/the total score/Visual Analogue Scale score. Principal component analyses revealed two 3-factor structures. The confirmatory factor analyses did not support the original model at any time point. Cronbach's α ranged from 0.22 to 0.84 in three preoperative factors and from 0.39 to 0.76 in the postoperative factors. The total Cronbach's α was 0.83 for the suggested preoperative 3-factor model and 0.83 for the postoperative model. In conclusion, the Danish version of the KCCQ-12 tested in a population of patients with AS who underwent SAVR appears to have acceptable construct validity, whereas structural validity cannot be confirmed for the original four-factor model. Overall reliability is good.

Accelerating knowledge translation to improve cardiovascular outcomes and health services: opportunities for bridging science and clinical practice

Knowledge translation (KT) is the exchange between knowledge producers and users to understand, synthesize, share, and apply evidence to accelerate the benefits of research to improve health and health systems. Knowledge translation practice (activities/strategies to move evidence into practice) and KT science (study of the methodology and approaches to promote the uptake of research) benefit from the use of conceptual thinking, the meaningful inclusion of patients, and the application of intersectionality. In spite of multiple barriers, there are opportunities to develop strong partnerships and evidence to drive an impactful research agenda and increase the uptake of cardiovascular research.

Temporal Changes in Quality Indicators in a Regional System of Care After Surgical and Transcatheter Aortic Valve Replacement

Background

Historically, quality-of-care monitoring was performed separately for transcatheter and surgical aortic valve replacement (TAVR, SAVR). Using consensus indicators, we provide a global report on the quality of care for treatment of aortic stenosis across the highest-volume treatments: transfemoral (TF) TAVR, isolated SAVR, and SAVR combined with coronary artery bypass graft.

Methods

Retrospective observational cohort study of consecutive patients in a regional system of care. Primary endpoint was 30-day and 1-year mortality (2015-2019). Secondary endpoints included rate of new pacemaker, rate of readmission, and length of stay (2012-2019). Following multivariable logistic regressions, we developed mortality case-mix adjustment models to report risk estimates.

Results

The proportion of patients receiving TAVR grew from 32% to 53% (2015-2019). Those receiving TF TAVR were significantly older, with higher rates of comorbidities. Observed 30-day and 1-year all-cause mortality after TF TAVR decreased from 3.1% to 0.6% (P = 0.03), and 13.6% to 6.6% (P = 0.09), respectively; surgical mortality rates for isolated SAVR and SAVR combined with coronary artery bypass graft were low and did not change significantly over time, ranging from 0.3% to 1.4% and from 0.9% to 3.4%, respectively at 30 days, and from 0.9% to 3.4% and from 4.7% to 6.7 at 1 year. In the TF TAVR cohort, the observed vs expected ratio for 30-day and 1-year mortality decreased significantly from 1.9 (95% confidence interval [CI] 0.9, 3.5) to 0.3 (95% CI 0.1, 0.8), and from 1.3 (95% CI 0.9, 1.7) to 0.7 (95% CI 0.5, 0.99), respectively; no change occurred in risk-adjusted surgical mortality.

Conclusions

Consensus quality indicators provide unique insights on the quality of care for patients receiving treatment for aortic stenosis.

Is the outcome of elective vs non-elective patients undergoing transcatheter aortic valve implantation different? Results of a single-centre, observational assessment of outcomes at a large university clinic

BACKGROUND

Transcatheter aortic valve implantation (TAVI) can either be conducted as an elective (scheduled in advance) or a non-elective procedure performed during an unplanned hospital admission. The objective of this study was to compare the outcomes of elective and non-elective TAVI patients.

METHODS

This single-centre study included 512 patients undergoing transfemoral TAVI between October 2018 and December 2020; 378 (73.8%) were admitted for elective TAVI, 134 (26.2%) underwent a non-elective procedure. Our TAVI programme entails an optimized fast-track concept aimed at minimizing the total length of stay to ≤ 5 days for elective patients which in the German healthcare system is currently defined as the minimal time period to safely perform TAVI. Clinical characteristics and survival rates at 30 days and 1 year were analysed.

RESULTS

Patients who underwent non-elective TAVI had a significantly higher comorbidity burden. Median duration from admission to discharge was 6 days (elective group 6 days versus non-elective group 15 days; p < 0.001), including a median postprocedural stay of 5 days (elective 4 days versus non-elective 7 days; p < 0.001). All-cause mortality at 30 days was 1.1% for the elective group and 3.7% for non-elective patients (p = 0.030). At 1 year, all-cause mortality among elective TAVI patients was disproportionately lower than in non-elective patients (5.0% versus 18.7%, p < 0.001). In the elective group, 54.5% of patients could not be discharged early due to comorbidities or procedural complications. Factors associated with a failure of achieving a total length of stay of ≤ 5 days comprised frailty syndrome, renal impairment as well as new permanent pacemaker implantation, new bundle branch block or atrial fibrillation, life-threatening bleeding, and the use of self-expanding valves. After multivariate adjustment, new permanent pacemaker implantation (odds ratio 6.44; 95% CI 2.59-16.00), life-threatening bleeding (odds ratio 4.19; 95% confidence interval 1.82-9.66) and frailty syndrome (odds ratio 5.15; 95% confidence interval 2.40-11.09; all p < 0.001, respectively) were confirmed as significant factors.

CONCLUSIONS

While non-elective patients had acceptable periprocedural outcomes, mortality rates at 1 year were significantly higher compared to elective patients. Approximately only half of elective patients could be discharged early. Improvements in periprocedural care, follow-up strategies and optimized treatment of both elective and non-elective TAVI patients are needed.

Perceived self-efficacy and empowerment in patients at increased risk of sudden cardiac arrest

Background

The role of multidisciplinary clinics for psychosocial care is increasingly recognized for those living with inherited cardiac conditions (ICC). In Canada, access to healthcare providers differ between clinics. Little is known about the relationship between access to specialty care and a patient's ability to cope with, and manage their condition.

Methods

We leveraged the Hearts in Rhythm Organization (HiRO) to conduct a cross-sectional, community-based survey of individuals with ICC and their family members. We aimed to describe access to services, and explore the relationships between participants' characteristics, cardiac history and self-reported health status and self-efficacy (GSE: General Self-Efficacy Scale) and empowerment (GCOS-24: Genetic Counseling Outcome Scale).

Results

We collected 235 responses from Canadian participants in 10 provinces and territories. Overall, 63% of participants reported involvement of a genetic counsellor in their care. Access to genetic testing was associated with greater empowerment [mean GCOS-24: 121.14 (SD = 20.53) vs. 105.68 (SD = 21.69); p = 0.004]. Uncertain genetic test results were associated with lower perceived self-efficacy (mean GSE: uncertain = 28.85 vs. positive = 33.16, negative = 34.13; p = 0.01). Low global mental health scores correlated with both lower perceived self-efficacy and empowerment scores, with only 11% of affected participants reporting involvement of psychology services in their care.

Conclusion

Differences in resource accessibility, clinical history and self-reported health status impact the perceived self-efficacy and empowerment of patients with ICC. Future research evaluating interventions to improve patient outcomes is recommended.

Economics of Minimalist Transcatheter Aortic Valve Replacement: Results From the 3M-TAVR Economic Study

BACKGROUND

The 3M-TAVR trial (3M-Transcatheter Aortic Valve Replacement) demonstrated the feasibility and safety of next-day hospital discharge after transfemoral TAVR with implementation of a minimalist pathway. However, the economic impact of this approach is unknown. Therefore, we evaluated costs for patients undergoing minimalist TAVR compared with conventional TAVR.

METHODS

We used propensity matching to compare resource utilization and costs (from a US health care system perspective) for patients in the 3M-TAVR trial with those for transfemoral TAVR patients enrolled in the contemporaneous S3i trial (PARTNER SAPIEN-3 Intermediate Risk). Procedural costs were estimated using measured resource utilization for both groups. For the S3i group, all other costs through 30-day follow-up were assessed by linkage with Medicare claims; for 3M, these costs were assessed using regression models derived from S3i cost and resource utilization data.

RESULTS

After 1:1 propensity matching, 351 pairs were included in our study (mean age 82, mean Society of Thoracic Surgery risk score 5.3%). There were no differences in death, stroke, or rehospitalization between the 3M-TAVR and S3i groups through 30-day follow-up. Index hospitalization costs were $10 843/patient lower in the 3M-TAVR cohort, driven by reductions in procedure duration, anesthesia costs, and length of stay. Between discharge and 30 days, costs were similar for the 2 groups such that cumulative 30-day costs were $11 305/patient lower in the 3M-TAVR cohort compared with the S3i cohort ($49 425 versus $60 729, 95% CI for difference $9378 to $13 138; P<0.001).

CONCLUSIONS

Compared with conventional transfemoral TAVR, use of a minimalist pathway in intermediate-risk patients was associated with similar clinical outcomes and substantial in-hospital cost savings, which were sustained through 30 days.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02287662.

The Road to a Transcatheter Edge to Edge Repair: Patient Experiences Leading Up to the Procedure and in the Early Recovery Period

AIM

Mitral valve transcatheter edge-to-edge repair (TEER) is a minimally invasive treatment option for patients with severe symptomatic mitral regurgitation who are at increased risk for cardiac surgery and are receiving optimal medical therapy. Little is known about patients' perspectives of their journey of care, including their experiences leading up to treatment, and their early recovery period. The aim of this study was to explore patients' experiences of their journey to TEER and their perspectives on their early recovery.

METHODS AND RESULTS

We conducted a qualitative study using interpretive description. A purposive sample of 12 patients, 3 to 6 months post TEER procedure, were recruited from a tertiary hospital. The median age was 79 years and 7 were male and 5 were female. Data collection included semi-structured interviews via the telephone. Data analysis followed an iterative process and utilized thematic analysis. There were four central themes highlighting the experiences of the patients leading up to their procedure: (1) escalating challenges with everyday life; (2) plummeting losses; (3) choosing and readiness to proceed with TEER; and (4) the long and uncertain wait. The theme improved health status highlights the experiences of patients in their early recovery.

CONCLUSION

Patients' experiences of waiting for TEER are complex and involve multifaceted challenges related to their worsening cardiac symptoms and navigating the health care system. Care pathways must be in place to provide continuity of care and support.

Temporal Changes in Mortality After Transcatheter and Surgical Aortic Valve Replacement: Retrospective Analysis of US Medicare Patients (2012-2019)

Background

The treatment of aortic stenosis is evolving rapidly. Pace of change in the care of patients undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differs. We sought to determine differences in temporal changes in 30‐day mortality, 30‐day readmission, and length of stay after TAVR and SAVR.

Methods and Results

We conducted a retrospective cohort study of patients treated in the United States between 2012 and 2019 using data from the Medicare Data Set Analytic File 100% Fee for Service database. We included consecutive patients enrolled in Medicare Parts A and B and aged ≥65 years who had SAVR or transfemoral TAVR. We defined 3 study cohorts, including all SAVR, isolated SAVR (without concomitant procedures), and elective isolated SAVR and TAVR. The primary end point was 30‐day mortality; secondary end points were 30‐day readmission and length of stay. Statistical models controlled for patient demographics, frailty measured by the Hospital Frailty Risk Score, and comorbidities measured by the Elixhauser Comorbidity Index (ECI). Cox proportional hazard models were developed with TAVR versus SAVR as the main covariates with a 2‐way interaction term with index year. We repeated these analyses restricted to full aortic valve replacement hospitals offering both SAVR and TAVR. The main study cohort included 245 269 patients with SAVR and 188 580 patients with TAVR, with mean±SD ages 74.3±6.0 years and 80.7±6.9 years, respectively, and 36.5% and 46.2% female patients, respectively. Patients with TAVR had higher ECI scores (6.4±3.6 versus 4.4±3) and were more frail (55.4% versus 33.5%). Total aortic valve replacement volumes increased 61% during the 7‐year span; TAVR volumes surpassed SAVR in 2017. The magnitude of mortality benefit associated with TAVR increased until 2016 in the main cohort (2012: hazard ratio [HR], 0.76 [95% CI, 0.67–0.86]; 2016: HR, 0.39 [95% CI, 0.36–0.43]); although TAVR continued to have lower mortality rates from 2017 to 2019, the magnitude of benefit over SAVR was attenuated. A similar pattern was seen with readmission, with a lower risk of readmission from 2012 to 2016 for patients with TAVR (2012: HR, 0.68 [95% CI, 0.63–0.73]; 2016: HR, 0.43 [95% CI, 0.41–0.45]) followed by a lesser difference from 2017 to 2019. Year over year, TAVR was associated with increasingly shorter lengths of stay compared with SAVR (2012: HR, 1.91 [95% CI, 1.84–1.98]; 2019: HR, 5.34 [95% CI, 5.22–5.45]). These results were consistent in full aortic valve replacement hospitals.

Conclusions

The rate of improvement in TAVR outpaced SAVR until 2016, with the recent presence of U‐shaped phenomena suggesting a narrowing gap between outcomes. Future longitudinal research is needed to determine the long‐term implications of lowering risk profiles across treatment options to guide case selection and clinical care.

Can you picture it? Photo elicitation in qualitative cardiovascular health research

Photo elicitation offers novel opportunities to augment the qualitative research toolbox. The use of photographs can enrich connections with participants, and empower them to be creative and engaged to communicate their insights, priorities, and perspectives. There is growing evidence of the effective use of photo elicitation in health research, with emerging interest in the cardiovascular community. Careful study planning, including attention to equipment, participant training, photograph selection, data collection, and ethical consideration, is essential. Detailed reporting of the study design and rationale for use of photographs, conceptual thinking underpinnings, elicitation process, and analytical plan contribute to strengthening the methodological approach.

Responding to the COVID-19 pandemic: Development of a critical care nursing surge model to meet patient needs and maximise competencies

Background

The current coronavirus disease 2019 (COVID-19) pandemic is creating unprecedented and unchartered demands on critical care units to meet patient needs and adapt the delivery of health services. Critical care nurses play a pivotal role in developing models of care that are effective, flexible, and safe.

Objectives

We report on the accelerated development of a critical care nursing surge model responsive to escalating needs for intensive care capacity.

Methods

We conducted an exploratory prospective observational cohort study that included (i) a self-assessment and survey of learning needs of noncritical care nurses identified as candidate groups for redeployment in the intensive care unit and (ii) a pilot implementation of a team nursing model evaluated by individual questionnaires and the conduct of focus groups. We used descriptive statistics and qualitative content analysis to analyse the exploratory findings.

Results

We surveyed 147 noncritical care nurses; 99 (67.3%) self-assessed at the lowest level of critical care competency, whereas 33 (24.3%) reported feeling able to help care for a critically ill patient under the direction of a critical care nurse. Identified learning needs included appropriate use of personal protective equipment in the intensive care unit (n = 123, 83.7%), use of specialised equipment (n = 103, 85.1%), basic mechanical ventilation, and vasoactive medication. We completed 11 team nursing pilot assignments with dyads of critical care and noncritical care nurses categorised in tiers of competencies. Nurses reported high levels of perceived support and provision of safe care; multiple recommendations were identified to improve the model of care delivery and communication.

Conclusions

The complexity, acuity, and unpredictability of the COVID-19 pandemic is placing new demands on critical care nurses to modify existing processes for care delivery while ensuring excellent outcomes and professional satisfaction. The study findings provide a road map to support nursing engagement in meeting patient needs.

"What Is the Right Decision for Me?" Integrating Patient Perspectives Through Shared Decision-Making for Valvular Heart Disease Therapy

Innovations in the treatment of valvular heart disease have transformed treatment options for people with valvular heart disease. In this rapidly evolving environment, the integration of patients' perspectives is essential to close the potential gap between what can be done and what patients want. Shared decision-making (SDM) and the measurement of patient-reported outcomes (PROs) are two strategies that are in keeping with this aim and gaining significant momentum in clinical practice, research, and health policy. SDM is a process that involves an individualised, intentional, and bidirectional exchange among patients, family, and health care providers that integrates patients' preferences, values, and priorities to reach a high-quality consensus treatment decision. SDM is widely endorsed by international valvular heart disease guidelines and increasingly integrated in health policy. Patient decision aids are evidence-based tools that facilitate SDM. The measurement of PROs-an umbrella term that refers to the standardised reporting of symptoms, health status, and other domains of health-related quality of life-provides unique data that come directly from patients to inform clinical practice and augment the reporting of quality of care. Sensitive and validated instruments are available to capture generic, dimensional, and disease-specific PROs in patients with valvular heart disease. The integration of PROs in clinical care presents significant opportunities to help guide treatment decision and monitor health status. The integration of patients' perspectives promotes the shift to patient-centred care and optimal outcomes, and contributes to transforming the way we care for patients with valvular heart disease.

Promoting cardiovascular nursing practice and research: A model for a university joint appointment

BACKGROUND

University joint appointments promote continuity of academic leadership and the acceleration of nurses' impact on improved outcomes and health service delivery. The role of university-appointed and hospital-located nurse scientists is of growing interest in the academic and clinical settings, and within the nursing profession. There is a pressing need to describe and study models of appointments, responsibilities and contributions to strengthen the integration of this boundary-crossing role across the continuum of the nursing profession.

AIMS AND OBJECTIVES

We report on the implementation of the inaugural St. Paul's Hospital and Heart & Stroke Professorship in Cardiovascular Nursing at the University of British Columbia, Vancouver Canada.

DISCUSSION

This model was based on recommendations provided by nursing to provincial government policy-makers, co-created and co-funded by academic and practice partners. Appointed by the university, the role is primarily located in the hospital, with the target of contributing 75% of time and focus on clinical research and leadership. The position is facilitated by its academic affiliation and the provision of university research and teaching infrastructure. In clinical practice, the role benefits from integration and visibility in the cardiac programme and leadership team, collaboration with advanced practice and multidisciplinary research groups, and access to office and human resources located on the clinical unit. Deliverables centre on achieving adjusted indicators of university performance to support academic promotion, and delivery of a practice-close research programme that prioritises improved patient outcomes, multidisciplinary practice and improved outcomes.

RELEVANCE TO CLINICAL PRACTICE

The dual appointment aims to provide tangible benefits to both the university and the hospital that match each organisation's needs; this requires sustained senior leadership engagement and support, and modification of conventional indicators of impact and success. Its ongoing evaluation will elucidate required modifications and future strategies required to strengthen nurses' academic and clinical leadership.

Association between frailty and self-reported health following heart valve surgery

Background

Knowledge about the association between frailty and self-reported health among patients undergoing heart valve surgery remains sparse. Thus, the objectives were to I) describe changes in self-reported health at different time points according to frailty status, and to II) investigate the association between frailty status at discharge and poor self-reported health four weeks after discharge among patients undergoing heart valve surgery.

Methods

In a prospective cohort study, consecutive patients undergoing heart valve surgery, including transapical/transaortic valve procedures were included. Frailty was measured using the Fried score, and self-reported health using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL-5 Dimensions 5-Levels Health Status Questionnaire (EQ-5D-5L).To investigate the association between frailty and self-reported health, multivariable logistic regression models were used. Analyses were adjusted for sex, age, surgical risk evaluation (EuroScore) and procedure and presented as odds ratios (OR) with 95% confidence intervals (CI).

Results

Frailty was assessed at discharge in 288 patients (median age 71, 69% men); 51 patients (18%) were frail. In the multivariable analyses, frailty at discharge remained significantly associated with poor self-reported health at four weeks, OR (95% CI): EQ-5D-5L Index 3.38 (1.51-7.52), VAS 2.41 (1.13-5.14), and KCCQ 2.84 (1.35-5.97).

Conclusion

Frailty is present at discharge in 18% of patients undergoing heart valve surgery, and being frail is associated with poor self-reported health at four weeks of follow-up. This supports a clinical need to address the unique risk of frail patients among heart valve teams broadly, and not only to measure frailty as a marker of operative risk.

Can you see frailty? An exploratory study of the use of a patient photograph in the transcatheter aortic valve implantation programme

BACKGROUND

Frailty is an important consideration in the assessment of transcatheter aortic valve implantation patients. The documentation of a patient photograph to augment the objective measurement of frailty has been adopted by some transcatheter aortic valve implantation multidisciplinary (TAVI) programmes.

METHODS

We used a prospective two-part multimethod study design. In part A, we examined the concordance between the Essential Frailty Toolset (EFT) and the score attributed by healthcare professionals based on visual rating of photographs using kappa estimates and linear regression. In part B, we conducted a content analysis qualitative study to elicit information about how the TAVI multidisciplinary team used photographs to form impressions about frailty.

FINDINGS

Part A: 94 healthcare professionals (registered nurses/allied health 65%; physicians 35%) rated 40 representative photographs (women 42.5%; mean age 83.4±7.5; mobility aid 40%) between 0 (robust) and 5 (very frail). The estimate of weighted kappa was 0.2575 (95% confidence interval 0.082-0.433), indicating fair agreement between median healthcare professional visual and EFT score, especially when the EFT was 1 or 4. There was significant discordance among raters (kappa estimate 0.110, 95% confidence interval 0.079-0.141). Age, sex and mobility aid did not have a significant effect on score discordance. Part B: 12 members of the TAVI multidisciplinary team (registered nurses 27.5%; physicians 72.5%) were shown a series of six representative patient photographs. The following themes emerged from the data: (a) looking at the outside; (b) thinking about the inside; (c) use but with caution; and (d) a better approach.

CONCLUSION

A patient photograph offers complementary information to the multimodality assessment of TAVI patients.

Very Early Changes in Quality of Life After Transcatheter Aortic Valve Replacement: Results From the 3M TAVR Trial

BACKGROUND

Patients with severe, symptomatic aortic stenosis derive substantial 30-day quality of life (QOL) benefit from transcatheter aortic valve replacement (TAVR). Whether the QOL benefit of TAVR emerges earlier is unknown. We used data from the Multimodality, Multidisciplinary but Minimalist (3M) TAVR study to assess early changes in QOL after transfemoral (TF) TAVR.

METHODS

Health status was assessed at baseline, 2-weeks, 30-days, and 1-year after TAVR using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Medical Outcomes Study Short-Form 12 (SF-12). The KCCQ overall summary (KCCQ-OS) score (range 0-100; higher scores = better health) was the primary health status outcome. Linear mixed effects models were used to describe trajectories of QOL scores over time. A good outcome was defined as being "alive and well", with a KCCQ-OS score ≥ 60 points with no decrease from baseline ≥10 points.

RESULTS

A total of 358 patients (87.1%) completed the baseline and at least one follow-up survey. Between baseline and 2-weeks, the KCCQ-OS increased by 21.3 points (95% confidence interval [CI]: 19.3-23.2). This improvement was sustained over time with only slight further improvement between 2-weeks and 1-month (3.4 points; 95% CI: 1.4 to 5.5) and no significant change between 1-month and 1-year (1.9 points; 95% CI: -0.2 to 4.1). Scores for the KCCQ subscales and SF-12 physical and mental component summary scales showed a similar pattern. Most patients (74.4%) were "alive and well" at 2 weeks with similar rates at 1-month and 1-year (79.5% and 77.3%, respectively).

CONCLUSIONS

Among patients undergoing TF-TAVR, both disease-specific and generic health status improved substantially within the first 2 weeks, with only minimal further improvement thereafter.

Priorities for Patient-Centered Research in Valvular Heart Disease: A Report From the National Heart, Lung, and Blood Institute Working Group

Over the past decade, the field of valvular heart disease (VHD) has rapidly transformed, largely as a result of the development and improvement of less invasive transcatheter approaches to valve repair or replacement. This transformation has been supported by numerous well-designed randomized trials, but they have centered almost entirely on devices and procedures. Outside this scope of focus, however, myriad aspects of therapy and management for patients with VHD have either no guidelines or recommendations based only on expert opinion and observational studies. Further, research in VHD has often failed to engage patients to inform study design and identify research questions of greatest importance and relevance from a patient perspective. Accordingly, the National Heart, Lung, and Blood Institute convened a Working Group on Patient-Centered Research in Valvular Heart Disease, composed of clinician and research experts and patient advocacy experts to identify gaps and barriers to research in VHD and identify research priorities. While recognizing that important research remains to be done to test the safety and efficacy of devices and procedures to treat VHD, we intentionally focused less attention on these areas of research as they are more commonly pursued and supported by industry. Herein, we present the patient-centered research gaps, barriers, and priorities in VHD and organized our report according to the "patient journey," including access to care, screening and diagnosis, preprocedure therapy and management, decision making when a procedure is contemplated (clinician and patient perspectives), and postprocedure therapy and management. It is hoped that this report will foster collaboration among diverse stakeholders and highlight for funding bodies the pressing patient-centered research gaps, opportunities, and priorities in VHD in order to produce impactful patient-centered research that will inform and improve patient-centered policy and care.

Exploring the synergies between focused ethnography and integrated knowledge translation

Background

Issues with the uptake of research findings in applied health services research remain problematic. Part of this disconnect is attributed to the exclusion of knowledge users at the outset of a study, which often results in the generation of knowledge that is not usable at the point of care. Integrated knowledge translation blended with qualitative methodologies has the potential to address this issue by working alongside knowledge users throughout the research process. Nevertheless, there is currently a paucity of literature about how integrated knowledge translation can be integrated into qualitative methodology; herein, we begin to address this gap in methodology discourse. The purpose of this paper is to describe our experience of conducting a focused ethnography with a collaborative integrated knowledge translation approach, including the synergies and potential sources of discord between integrated knowledge translation and focused ethnography.

Methods

We describe the specific characteristics and synergies that exist when using an integrated knowledge translation approach with focused ethnography, using a research exemplar about the experiences of frail, older adults undergoing a transcatheter aortic valve implantation.

Results

Embedding integrated knowledge translation within focused ethnography resulted in (1) an increased focus on the culture and values of the context under study, (2) a higher level of engagement among researchers, study participants and knowledge users, and (3) a commitment to partnership between researchers and knowledge users as part of a larger programme of research, resulting in a (4) greater emphasis on the importance of reciprocity and trustworthiness in the research process.

Conclusions

Engaging in integrated knowledge translation from the outset of a study ensures that research findings are relevant for application at the point of care. The integration of integrated knowledge translation within focused ethnography allows for real-time uptake of meaningful and emerging findings, the strengthening of collaborative research teams, and opportunities for sustained programmes of research and relationships in the field of health services research. Further exploration of the integration of knowledge translation approaches with qualitative methodologies is recommended.

Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement

Background:

Transcatheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait times. Our objective was to evaluate temporal trends in TAVR wait times and the associated clinical consequences.

Methods:

In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010, to March 31, 2016. The primary outcome was the median total wait time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait list.

Results:

The study cohort included 4461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons, and 11% remained on the wait list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait time in the postreimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was ≈2% and 12%, respectively, with a relatively constant increase in events with increased wait times.

Conclusions:

Postreimbursement wait time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.

Abstract 179: Temporal Trends and Clinical Consequences of Wait-Times for Trans-Catheter Aortic Valve Replacement: A Population Based Study

Background: Trans-catheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait-times. Our objective was to evaluate temporal trends in TAVR wait-times and the associated clinical consequences.

Methods: In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010 to March 31, 2016. The primary outcome was the median total wait-time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVI wait-times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait-list.

Results: The study cohort included 4,461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons and 11% remained on the wait-list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait-time in the post-reimbursement period stabilized at 82-84 days, and has remained unchanged since September 2012. The cumulative probability of wait-list mortality and heart failure hospitalization was 4.3% and 14.7% respectively, with a relatively constant increase in events with increased wait-times.

Conclusion: Post-reimbursement wait-time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait-time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.

Understanding experiences of undergoing transcatheter aortic valve implantation: one-year follow-up

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for frail, older adults with severe symptomatic aortic stenosis. Although research about long-term clinical outcomes is emerging, there is limited evidence from the perspectives of patients and family caregivers on their perceived benefits and challenges after TAVI.

AIMS

The aim of this study was to describe older adults and family caregivers' perspectives on undergoing TAVI at one year post-procedure.

METHODS

Qualitative description was the method of inquiry. A purposive sample of 31 patients and 15 family caregivers was recruited from a TAVI programme in western Canada. Semi-structured interviews were conducted with participants one year after TAVI. Data were analysed thematically.

RESULTS

All participants were satisfied with the decision to undergo TAVI. There were three central themes. First, recovery was experienced in the context of aging and comorbidities, which was shaped by patients' limited options for care and post-procedure symptom burden. Second, reconciling expectations with reality meant that, for some patients, symptom burden remained prevalent and was also influenced by others' expectations. Third, recommendations for recovery related to having information needs met, keeping informed of evolving care processes, and addressing individualised needs for support.

CONCLUSIONS

The perspectives of participants provide a valuable contribution to the literature about undergoing TAVI. Clinicians need to be attentive to patients' expectations of benefit and temper these with consideration of the individual's broader health situation to provide treatment decision support. Patients and family caregivers also need adequate teaching and support to facilitate safe transition home given the shift towards early discharge after TAVI.

Avoidance of urinary catheterization to minimize in-hospital complications after transcatheter aortic valve implantation: An observational study

Background:

Contemporary transcatheter aortic valve implantation (TAVI) devices and approach present opportunities to review historical practices initially informed by early treatment development and cardiac surgery. The avoidance of urinary catheterization in the older TAVI population is a strategy to minimize in-hospital complications. The purpose of the study was to explore elimination-related complications following the phased implementation of a default strategy of avoiding urinary catheterization in patients undergoing transfemoral (TF) TAVI.

Methods:

We conducted an observational study using a retrospective chart review of patients treated between 2011 and 2013 to identify patient characteristics, peri-procedure details, in-hospital outcomes and elimination-related complications in patients who did or did not receive a peri-procedure indwelling catheter. Descriptive analyses were used to report differences between the groups; we conducted a regression analysis to explore the relationship between the practice of urinary catheterization and total procedure time.

Results:

Of the 408 patients who underwent TF TAVR, 188 (46.1%) received a peri-procedure indwelling urinary catheter and 220 (53.9%) did not. There was no difference in in-hospital mortality (2.2%), disabling stroke (0.5%), or other major cardiac adverse events. The avoidance of a urinary catheter resulted in significantly lower rates of urinary tract infection requiring a new antibiotic regimen (1.4% versus 6.1%, p = 0.014), haematuria documented by medicine or nursing (3.7% versus 17.6%, p = 0.001), and the need for continuous bladder irrigation (2.7% versus 0%, p = 0.027).

Conclusion:

The avoidance of a urinary catheter may contribute to improved outcomes in patients undergoing TAVI. The intervention should be further evaluated within the broader study of minimalist TAVI.

'What else can I do?': Insights from atrial fibrillation patient communication online

BACKGROUND

Many patients with atrial fibrillation experience uncertainty and psychological distress. Internet support groups for atrial fibrillation have yet to be studied.

AIM

To determine the content and dialogue on an online message board for atrial fibrillation with the purpose of elucidating information and support needs from patient perspectives.

METHODS

Interpretative description methodology was undertaken to explore conversation from a publicly available website for atrial fibrillation over a 3-month period.

RESULTS

Individuals interacted with the message board to make sense of their atrial fibrillation events by sharing experiences with medications, complementary and alternative medicine, trigger avoidance and ablation. The opinions of lay experts on the message board, anecdotal stories and hyperlinked Internet data were all highly valued sources of information in the messages. Using the learning gained from the board, individuals proceeded with strategies to treat their atrial fibrillation, often in a trial and error fashion. Throughout the process, individuals came back to the board, to update on their progress and gain assistance from others.

CONCLUSION

The studied atrial fibrillation population had unmet needs for education regarding non-pharmacological approaches to treat atrial fibrillation. In the absence of opportunity to discuss these needs with healthcare professionals, patients may be vulnerable to unproved approaches advocated by Internet peers. Further research is suggested to examine the prevalence of complementary and alternative medicine use in the atrial fibrillation population and to understand better how social media can be utilised to support atrial fibrillation patients.

Nursing leadership of the transcatheter aortic valve implantation Heart Team: Supporting innovation, excellence, and sustainability

Transcatheter Aortic Valve Implantation (TAVI) is an innovative and resource-intensive treatment of valvular heart disease. Growing evidence and excellent outcomes are contributing to increased patient demand. The Heart Team is foundational to TAVI programs to manage the complexities of case selection and other aspects of care. The competencies and expertise of nurses are well suited to provide administrative and clinical leadership within the TAVI Heart Team to promote efficient, effective, and sustainable program development. The contributions of nursing administrative and clinical leaders exemplify the leadership roles that nurses can assume in healthcare innovation.

Factors influencing the decision of older adults to be assessed for transcatheter aortic valve implantation: An exploratory study

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe symptomatic aortic stenosis at increased surgical risk and likely to derive benefit. Multimodality and multidisciplinary assessment is required for the heart team to determine eligibility for TAVI in a primarily older population. Little is known about patients' motivation and perspectives on making the decision to undergo the complex assessment.

AIMS

To explore factors influencing patients' decision making to undergo TAVI eligibility assessment to inform practice, programme development, health policy and future research.

METHODS

An exploratory qualitative approach was used. Semistructured interviews were conducted with 15 patients at the time of their referral for assessment to a quaternary cardiac and high volume TAVI centre.

RESULTS

Multiple, intersecting factors that included biomedical, functional, social and environmental considerations influenced patients' decision. The six distinct factors were symptom burden, participants' perception as 'experienced' patients, expectations of benefit and risks, healthcare system and informal support, logistical barriers and facilitators, and obligations and responsibilities.

CONCLUSIONS

The decision to undergo TAVI eligibility assessment is multifaceted and complex. Programmatic processes of care must be in place to facilitate appropriate and patient-centered decision making and access to TAVI. Strategies are required to mitigate the risks associated with the rapid deterioration of severe aortic stenosis, address patient and referring physicians' education needs, and provide individualised care and equitable access. Future research must focus on patients' experiences throughout the trajectory of TAVI care.

Sex Is Associated With Differences in Individual Trajectories of Change in Social Health After Implantable Cardioverter-Defibrillator

Background—

Social health is a dimension of quality of life, and refers to people’s involvement in, and satisfaction with social roles, responsibilities, and activities. The implantable cardioverter-defibrillator is associated with changes in overall quality of life, but little is known about sex differences in individual trajectories of change in social health.

Methods and Results—

We prospectively measured changes in 3 subscales of the SF-36v2 generic health questionnaire (role physical, role emotional, and social functioning), 2 Patient-Reported Outcomes Measurement Information System short forms (satisfaction with participation in social roles and satisfaction with participation in discretionary social activities), and the Florida Patient Acceptance Survey before and at 1, 2, and 6 months after implantation. Individual growth models of temporal change were estimated. The scores of the 6 indicators improved with time. The unconditional model demonstrated significant (fixed effects: P <0.05; covariance parameters: P <0.10) residual variability in the individual trajectories. In the conditional model, men and women differed significantly in their rates of change in the scores of 3 of the 6 measures. Although men’s mean scores exceeded women’s mean scores on all indicators at baseline (range of relative mean difference: 11.0% to 17.8%), the rate of women’s change resulted in a reversal in relative standing at 6 months after implantation, with the mean scores of women exceeding the men’s by 4.5% to 5.6%.

Conclusions—

Men and women differed in their trajectories of change in social health, both in terms of their starting points (ie, baseline scores) and their rates of change.

Exploring changes in functional status while waiting for transcatheter aortic valve implantation

BACKGROUND

Aortic stenosis (AS) is a structural heart disease primarily associated with ageing. For people with multiple co-morbidities, surgical treatment may not be a safe or feasible option. Transcatheter aortic valve implantation (TAVI) is indicated for patients with symptomatic AS who are at excessive risk for surgical valve replacement and are likely to derive significant benefit. Functional status can deteriorate during the time between referral and procedure because of the rapid disease progression of severe AS and varying wait-times for treatment in Canada.

AIMS

The purpose of this study was to examine changes in functional status between time of eligibility assessment and TAVI procedure date.

METHODS

An exploratory prospective cohort study was conducted to evaluate changes in functional status including gait speed, frailty scores and cognitive status.

RESULTS

Thirty-two patients participated in the study with median age 81 years. Functional status declined between time of eligibility assessment and time of TAVI: gait speed increased by an average of 0.53 s (standard deviation (SD)=1.0, p=0.01) and frailty scores increased by an average of 0.31 (SD=0.64, p=0.01). Patients waiting longer than six weeks for TAVI had a larger decline in gait speed than patients waiting less than six weeks (p=0.02). Patients living alone had a larger increase in frailty scores compared to patients living with another adult (p=0.05).

CONCLUSION

Older adults with life-limiting AS are vulnerable to changes in functional status. In the absence of TAVI wait-time benchmarks, findings may be used to facilitate individualized care and management strategies and inform health-care policy.