In the not-so-long-ago early days of transcatheter aortic valve replacement (TAVR), most eyes focused on the physicians who performed the procedures even as behind-the-scenes contributions from nursing also helped make TAVR a success story. Recognition of their value also is raising nursing’s profile in the cardiovascular community.
Learning by doing
When the Centers for Medicare & Medicaid Services (CMS) released its national coverage determination for TAVR in 2012, it specified that programs establish a heart team with cardiovascular surgeons and interventional cardiologists as well as “additional members … such as echocardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses and social workers.” The agency took its cue from the aptly named PARTNER (Placement of AoRTic TraNscathetER Valve) studies, Edwards Lifesciences’ pivotal clinical trials that followed a heart team concept.
“In the guidelines, it is embedded as the forced collaboration between cardiac surgery and cardiology,” says Sandra Lauck, PhD, RN, clinical nurse specialist in the Transcatheter Heart Valve Program at St. Paul’s Hospital in Vancouver. She participated in first-in-human TAVR cases, then worked as a cath lab nurse at St. Paul’s with John G. Webb, MD. Webb also contributed to the PARTNER trials and continues as a top investigator.
“One of the things that we learned early on is that the success of the procedure depends on far more than simply getting the valve in and procedural expertise,” Lauck says. “One of the early lessons was that the heart team needed to look quite different depending on where the patient was in his or her journey.”
Nursing plays a critical role before and after the patient enters an operating room. Preprocedurally nurses may help screen and evaluate potential candidates, ensure they receive necessary diagnostic testing, educate the patient and family about the procedure and discharge, organize heart team meetings and keep everyone abreast of the case. Nurses may contribute to procedure planning and postprocedurally monitor recovery, prepare the patient and family for discharge to a safe setting, arrange follow-up and stay in contact once the patient goes home or to another facility.
Added to that are collecting data for the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry (a CMS mandate), overseeing coding, handling financial matters, ensuring efficiencies and participating in patient satisfaction and quality initiatives, all the while serving as a point of contact for patients, families, referring physicians, the heart team and other staff involved in TAVR patients’ care. Titles may vary by institution, but they almost always include the word “coordinator” and often are nurses.
“They are the glue between all of the moving parts that are involved in a transcatheter valve team,” says Marian C. Hawkey, RN, director of clinical research at the Center for Interventional Vascular Therapy at New York Presbyterian/Columbia University Medical Center in New York City, where Martin B. Leon, MD, and Craig R. Smith, MD, were PARTNER’s co-principal investigators.
These nursing pioneers had few good models to guide them at the start. Neither the pathways of care for percutaneous coronary intervention (PCI) nor surgical patients perfectly suited TAVR and a patient population that was on average in their 80s. “Unlike a heart surgery program or a PCI program, the complex stakeholders and the extensive team sport that is involved in TAVR really needs central orchestration,” Lauck says. “We like to think the physicians can do it all, but they have busy schedules. They also sometimes lack that expertise needed to have really good multidisciplinary development. Nurses are well suited to that.”
The team-based approach used in heart failure and transplantation offered some direction. But for the most part, TAVR entered uncharted waters. “We laid the groundwork,” Hawkey recalls. “There was that foundational period where we figured out, ‘How do we do this?’ And then, ‘This is what we need to do, and these are the steps we need to take.’”
Commercialization of TAVR devices in the United States, first with Sapien in 2011 and then with Medtronic’s CoreValve device in 2014, opened the doors for the creation of TAVR centers beyond trial sites. That development prompted Hawkey, Lauck and some other nursing leaders to write recommendations for best