TAVR Efficiency Albany Medical Center

Transcription

1 TAVR Efficiency Albany Medical Center Augustin J. DeLago, MD, FACC Albany Medical Center Director, Cardiac Catheterization Laboratory Director, Structural Heart Program

2 Disclosure The information provided is the experience of the Albany Medical Center, and Edwards Lifesciences has not independently evaluated these data. Outcomes are dependent upon a number of facility and surgeon factors which are outside Edwards control. These data should not be considered promises or guarantees by Edwards that the outcomes presented here will be achieved by an individual facility. Augustin J. DeLago a paid consultant to Edwards Lifesciences 2

3 TAVR-The Minimalist Approach: Transition from OR to Cath Lab Improvements in equipment and technique have allowed for the safe transfer of patient care from the operating room to the catheterization laboratory. 3

4 TAVR-The Minimalist Approach: Transition from OR to Cath Lab This transition has lead to: Decreased length of stay Reduction in complications Increased efficiency 4

5 As the indications for TAVR broaden the demands on already stressed cath labs and operating rooms will continue to increase The patients we see today in our TAVR clinics are not the same group of patients we saw 5 years ago when we were only performing TAVR on inoperable or very high risk patients. With the introduction and approval of TAVR in intermediate risk patients, we see younger patients with less co-morbid conditions.

6 Given the fact that the patients are less sick, do they really need the same level of intensive care as those who are deemed high risk? We must ask ourselves: What do we really need to do to take care of this less sick population? 6

7 Taking care of TAVR patients 2017 & beyond Do we need to do all procedures in a hybrid room or operating room? Do we need general anesthesia? Do we need invasive hemodynamics? Do we need central lines? Do we need TEE? Do we need to admit patients to the ICU? Do we need to keep patients in the hospital multiple days as inpatients? 7

8 I would argue that in most intermediate risk patients, we do not need: An Operating Room General anesthesia Invasive hemodynamic monitoring Central lines TEE Intensive Care Unit Early discharge between hours should be expected. 8

9 Albany Medical Center First TAVR: December, TAVR procedures to date Average 6 TAVR per week for the past 16 months Minimum 5 TAVR procedures every Wednesday Procedures performed with 1 operating room and 1 cath lab (1 case in OR the rest done in cath lab) Two Cardiac Anesthesiologists

10 Albany Medical Center TAVR Statistics Average case time: 32 MIN Average fluoro time:11 MIN Average room turnaround time: 10 MIN Average total room time: 56 MIN 70% MAC 20% LMA 10% General * The PARTNER II S3i trial SAPIEN 3 valve patients had a mean case time of 84.5 mins and mean total room time of minutes. 10

11 Albany Medical Center TAVR Statistics Access: 90% transfemoral 10% alternative access Length of stay: 2.7 days 15% home within 24 hours 70% home within 48 hours 10% home within 5 days 5% home > 5 days * The PARTNER II S3i trial SAPIEN 3 valve patients had a mean LOS of 5.6 days and ICU stay of 2.7 days 11

12 Pre-Procedure Anesthesia Meeting Image review Valve type and size Implant angle (coplanar view) Blood type and screen Evaluate for antibodies, etc. Access site and size Evaluate for calcium and tortuosity (bailout plan TA/SC) Previous pacemaker? Temporary pacemaker site: Leg vs. neck EKG evaluation to look for conduction abnormalities / need for permanent pacemaker Type of anesthesia (general vs. LMA vs. MAC) Arterial line Central line (Y/N) Pulmonary Artery Catheter (Y/N) TEE (Y/N)

13 OR vs. Cath Lab-Who goes where? Operating Room: Cath Lab: Bad Lungs All Others!! Difficult air way Low LVEF < 25% Bad vascular disease Obesity Hemodialysis patients * This is not an exhaustive list and there may be many other contributing factors that determine the location of the TAVR procedure. The decision of location for the procedure should be based solely on clinical judgment. 13

14 Pre-Procedure Anesthesia Meeting, Continued Where will patient be pre-procedure? Where will patient be recovered post-procedure? Where will patient go once recovered? ICU vs. Telemetry Floor When can patient be reasonably expected to arrive at the hospital? Patient schedule Distance traveling from home 14

15 Pre-Procedure/DAY OF PROCEDURE Anesthesia and procedural consent by MD, Fellows, Mid-Levels Home medication reconciliation Labs Blood type/screen EKG evaluation Standard procedure prep. Central/Arterial line procedures are performed in a location other than the main procedure room. Lines placed by Anesthesia or Cardiology 15

16 Pre-Procedure/DAY OF PROCEDURE Pre-Procedure review with cath lab technologists: CT review: valve sizing again Review access sites with technologists Sheath sites and sizes Valve size and delivery system Wires needed Pacemaker needs 16

17 Procedure/DAY OF PROCEDURE Tables are pre-prepped prior to patient arrival in the procedure room All equipment in room No routine use of TEE Access in femoral cases: two operators obtain access in each femoral artery or vein as needed (Pre-close) No femoral angiography No crossover technique No dilation: direct sheath placement 17

18 Procedure/DAY OF PROCEDURE Coplanar view If you don t have one, start 10 degrees LAO and 10 degrees caudal Have an operator pre-bend the working wire as a second operator crosses the aortic valve (if not using pre-shaped wires) Once valve is deployed, remove wire and balloon out of the newly implanted aortic valve. 18

19 Procedure/DAY OF PROCEDURE Supravalvular aortogram once mean arterial pressure is greater than 70 mmhg Accept trace or mild aortic insufficiency Evaluate hemodynamics and rhythm Place soft wire through delivery system Give protamine No femoral angiography Perclose and Angioseal both femoral access sites Remove pacemaker if rhythm is stable Wake and extubate patient in room Patient transported to recovery area and cath lab staff turn the room over to get ready for the next patient 19

20 Recovery Keep patient close to the cath lab for the next 4 hours Evaluate access sites Evaluate rhythm Electrophysiology consult if needed Evaluate for early discharge Central lines out Chest X-Ray TTE in outpatient area (helps with early discharge and registry requirements) If stable, transfer to cardiac telemetry floor 20

21 Pacemaker Dependence (ICU) Get pacer out quickly if possible (based on the type of conduction abnormality) Keep patients at least 24 hours if they have: Complete heart block High degree AV block New LBBB If you are going to keep a temporary pacemaker in place, move it to the neck If patient requires a pacemaker post-procedure, consult EP immediately and get patient on the schedule for the next day Procedure can always be cancelled 21

22 Post-Procedure Disposition: ICU vs. Telemetry Floor Decision is made up to 4 hours after the procedure It is important to make the final decision in the recovery area if possible Most patients go to the telemetry floor If procedure is performed in the OR, the patient is likely going to need ICU care If procedure done in the OR because of comorbidities 22

23 ICU Patient with procedure performed in the OR Pacemaker dependence Any respiratory failure Vascular complications 23

24 All Patients should be considered for conscious sedation The majority of our patients have not needed the OR The majority of our patients have not needed General Anesthesia The majority of our patients have not needed intra procedure TEE The majority of our patients have not needed invasive hemodynamic monitoring The majority of our patients have not needed the ICU 24

25 TAVR is like Pit Stop Perfection Ferrari F1 Pit Stop Perfection - YouTube 25

26 Conclusion Room turn over Room turn over Room turn over Room set up Room set up Room set up 26

27 Conclusion Pre lining patients Pre lining patients Pre lining patients Pre lining patients 27

28 Questions?

29 Please see the important safety information available at the podium Edwards, Edwards Lifesciences, the stylized E logo, PARTNER, PARTNER II, SAPIEN, and SAPIEN 3 are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. PP--US-2383 v1.0