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Melanie Cole (Host):  If you have valve disease, and you’re not a candidate for certain types of heart surgery, TAVR may be an option to discuss with your physician, and here to tell us about it is Justin Catcho.  He’s a registered nurse and the TAVR coordinator at Temecula Valley Hospital.  So, Justin, how do patients even know if they have aortic stenosis—either some symptoms?  Is there some way that they would know to see a cardiologist about this?
 
Justin Catcho, RN, TAVR Coordinator (Guest): Well, that’s the thing is—is often patients may not even notice anything at first.  Their doctor or cardiologist may tell them that they have a heart murmur just in a routine exam, but many patients often confuse signs and symptoms of aortic stenosis with signs of normal aging, but they may feel weak, short of breath, or overly tired.  This is especially true with activity, but this is not a normal sign of aging, especially if you were able to do these activities six months ago without feeling these symptoms.  As things start to progress, they may feel faint, or they may feel chest pain or dizziness.  If they’re feeling these symptoms, it’s definitely important to consult their doctor.  Especially, the best way for patients to know—to be sure—is to see their cardiologist for an ultrasound of the heart called an echocardiogram.   

Melanie:  Well, so, then, you’re getting into my next question here.  How are patients with aortic stenosis evaluated for TAVR?  So, first, they’re going to have an echo to see if that’s even what they have.  Then how is this decision made?  What goes into that process? 

Justin:  So, patients have the echocardiogram first to give us measurements in the ultrasound as a diagnosis for aortic stenosis, but it’s a very complex diagnosis that requires a heart team to perform a very comprehensive evaluation.  So, our goal is to get a complete understanding of how it’s affecting the patient’s quality of life.  So, once a referral has been sent from the patient’s primary provider or cardiologist, then we start doing this sequence of testing and imaging.  First, we do several blood tests along with lung functioning tests to assess each patient’s baseline before we add in any medications or procedures.  Second, a cardiac catheterization is scheduled, if it hasn’t already been done within the last six months to look for any coronary artery blockages, but one of the most important tests that’s performed is actually a CTA scan—a CAT scan with contrast.  It’s an advanced type of X ray that requires an IV and the use of contrast dye, and what they’re looking at is they’re looking at the arteries starting all the way from the leg through the aorta, which is the largest arch artery in the body, and it scans all the way to the heart and the aortic valve itself.  This scan is necessary because it helps us determine the size of the new valve and how that new valve would enter the body.  The scan doesn’t take very long, but because it requires contrast dye, sometimes our patients do need to stay in the hospital to receive some IV fluids to protect their kidneys.

Melanie:  Isn’t that amazing how you can see all the way up?  I mean, that’s just really fascinating to me.  So, while they’re going through this evaluation, do they also see a cardiac surgeon, and then what are the criteria?  What makes them qualified for TAVR?

Justin:  So, TAVR is approved for patients with symptomatic aortic stenosis—so symptoms that we mentioned earlier—feeling weakness or shortness of breath or tiredness or chest pain or dizziness, but a surgeon is required to see the patient for the workup.  Surgeons help to calculate each patient’s individual risk of undergoing an open chest valve surgery.  They also give an independent opinion on the best course of care for each patient because TAVR may not be best for all patients in their current health situation.  So, in that case, they would be referred back to their surgeon for care.  

Melanie:  Why don’t we back up for just a second and tell patients what TAVR actually is and what it means?

Justin:  So, TAVR is transcatheter aortic valve replacement.  What it is is traditionally valve replacement has been done with actually cutting open a person’s chest, cutting into the aorta while the person is on bypass machine for their heart and actually was surgically replacing the valve.  So, we’re able to do that now transcatheter.  So, transcatheter aortic valve replacement where the patient is often given a small incision in the artery in their groin, and a catheter is placed and fed up through their arteries and their aorta all the way to their heart and that valve is actually replaced via catheter without ever having to open up their chest or stopping their heart.

Melanie:  If someone is told—and thank you for that explanation, that was very comprehensive—if someone’s told that they are a candidate and that they qualify for TAVR, what’s the procedure day like for them?  What’s it like for the patient?  What’s the recovery time and tell us a little bit about the kind of support that they might need after the procedure.  

Justin:  Alright.  So, the day of the procedure, often the patient comes in in the morning to get evaluated by our heart team staff and make sure that everything is in order for the procedure itself.  We have an anesthesiologist see the patient and evaluate them to make sure that they’re able to undergo the procedure that day as well as we review bloodwork, lab tests, imaging, and make sure that the patient is fully prepared.  The procedure itself can last anywhere between an hour and a half up to three hours, depending on the patient’s current situation, and once the procedure is done, often our patients will be discharged out of the cath lab up to our cardiac floor or possibly the ICU to recover for a night.  After the procedure is done itself, it is advised that when we discharge the patient home, they have a family member or somebody with them for the first 48 hours after discharge.  Our goal is to also have an initial cardiology appointment arranged for them for one week following the TAVR to evaluate their progress after they go home.

Melanie:  What lifestyle changes do they have to make after this type of a valve replacement?  What do you tell them as the TAVR coordinator about changes that are really important for them to make so that this valve that they just got really functions at its best?

Justin:  Well, what our goal is to, especially in our initial recovery period as the patient is—even if they go to ICU—is we really want them up and moving and trying to get back to their baseline as soon as possible.  We do have check-ins for the new valve scheduled.  That’s actually required that we get a new ultrasound of the replacement valve at 30 days and one year after the procedure to confirm that there are no leaks around the valve and that the placement is accurate and that they’re doing well, but we really do want patients up and moving around and getting back to their lifestyle as soon as possible, and that’s actually part of my role is that I like to say I become this patient’s best friend for about a year because I’m helping them set up appointments with their cardiologist.  I’m doing a 30-day check-in with them to see how they’ve improved their quality of life.  I’m even connecting with them and their families up until one year after the procedure to make sure that they’re still having a successful outcome.

Melanie:  As we wrap up and what great information, Justin, speak to us about successful outcomes, and what it is like in that year.  What have you seen?  Tell us something really great that you’ve seen when you’ve released a TAVR patient and said, “Ok, you know, you did great; so, keep doing what you’ve been doing.”

Justin:  Well, I do actually have an interesting story of the patient that we’ve treated and everything went according to plan with the procedure.  Actually, the patient discharged home in just over 24 hours.  I brought him back for his post-procedure echocardiogram at the 30-day mark, and this patient was feeling so well that he actually donated his walker back to the hospital because he didn’t need it anymore.

Melanie:  That’s what I’m talking about.  What a great story.  Do you have any best advice for us as we wrap for people that are considering TAVR or may have valve replacement needs?  What would you like to tell them?

Justin:  Well, I’d just like to say that we definitely have an excellent and experienced heart team here at Temecula Valley Hospital, and we’re very invested in helping our community and surrounding areas.  I would just encourage any patients who have further questions regarding TAVR, any patient’s families that have any questions, they can contact my cell from the valve coordinator.  They can call me at 951-285-6782, or if they are also seeing a cardiologist, they’re encouraged to discuss their options with their cardiologist.

Melanie:  Thank you, so much, Justin for coming out and explaining it to us so very well, and that wraps up this episode of TVH Health Chat with Temecula Valley Hospital.  You can head on over to our website at temeculavalleyhospital.com for more information and to get connected with one of our providers.  If you found this podcast as educational and interesting as I did, please share on your social media.  Be sure to check out all the other fascinating podcasts in our library and share with your friends and family and that way we all learn from the experts at Temecula Valley Hospital together.  Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital.  The hospital shall not be liable for actions or treatments provided by physicians.  Until next time, this is Melanie Cole.