CVForward > Implementing the "Minimalist Approach" to TAVR Procedures
The triple aim in healthcare is lower costs, better outcomes, and increased patient satisfaction. With a program that implements a “minimalist approach” for transcatheter aortic valve replacement (TAVR) where appropriate, your facility can accomplish all three.
As far back as 2012, the Journal of the American College of Cardiology highlighted the work of physicians who were pioneering a “minimalist approach” to TAVR—without the use of general anesthesia or transesophageal echocardioagraphy. Their protocol called for conscious sedation and local anesthesia, eliminating sternotomy, cardiopulmonary bypass, and tracheal intubation.1
Those first cases were considered risky, but the safety and benefits of a minimalist approach soon became clear.
In recent studies, patients who underwent “minimalist” TAVR procedures had death rates that were lower than or equivalent to traditional TAVR. Every other outcome was resoundingly favorable. Conscious sedation allowed for monitoring of neurological status during the procedure, giving clinicians the ability to detect early signs of stroke and eliminated the need for ventilators.
Additionally, conscious sedation dramatically reduced procedure time, time in the ICU post-procedure, and patients’ hospital stay, resulting in lower costs, better health outcomes, and greater patient satisfaction. In Europe, where TAVR therapy originated, clinics have long employed a minimalist approach. But North American hospitals were slower to adopt the practice, concerned about the short- and long-term outcomes for patients. Today, nationally-renowned programs such as the Piedmont Heart Institute’s Marcus Heart Valve Center in Atlanta, Georgia, are leading the way toward a less invasive and more efficient TAVR process.
The Piedmont heart team initially struggled with the idea of conscious sedation due to nominal US examples. At first, they started with the simplest patients, which went very well. After that, the team agreed to fully transition to this approach as they felt it helped reduce complications and led to faster recovery times for patients.
Josh Roberts is Executive Director of Cardiovascular Services with Piedmont Healthcare. He helped bring minimalist techniques to the TAVR program in 2014 and continues to guide the team in optimizing the approach.
The team at Piedmont has experienced unmitigated success in implementing an optimized approach to TAVR procedures. Patients undergoing minimalist TAVR at their facility can expect a hospital stay of 1 to 2 days. They are sitting in a chair an average of 4 hours post-procedure and walking after about 6 hours. The team at Piedmont is seeing fewer lung-related issues among TAVR patients; there’s less delirium due to narcotics. And after an initial investment in the new minimalist paradigm, their balance sheet is in the black.
Originally, they had 10–12 people in the room for every procedure, but reduced that number significantly. Now, they have a maximum of 2 cath lab staff and 2 OR staff for every basic TAVR case.
They had a 92-year-old patient on oxygen ask a few hours after the procedure to go home. They, of course, say not today. But this is proof that their patients are feeling better with the minimalist approach and don’t feel they have much to recover from.
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A private, not-for-profit organization serving nearly 2 million patients across Georgia, Piedmont is transforming healthcare, creating a destination known for the best clinicians and a one-of-a-kind experience that always puts patients first. Today, more than 110 years since it was founded, Piedmont is known as a leading health system in cancer care, treatment of heart disease and organ transplantation with 7 hospitals, 20 urgent care centers, 28 Piedmont QuickCare locations, 527 Piedmont Clinic physician practice locations and 1,782 Piedmont Clinic members. Our 16,500 employees dedicate themselves to making a positive difference in every life we touch and our commitment doesn’t stop there. In FY 2017, Piedmont provided more than $215 million in uncompensated care community benefit programming in an effort to better the health and well-being of the people in the communities we serve.
Cath Lab Digest Talks With Christopher U. Meduri, MD, MPH, Atlanta, Georgia
By Lynn Tangorra
Article from Diagnostic and Interventional Cardiology
Hospitals explain what it takes to implement a TAVR program, including the long-term financial, professional, and equipment commitments.
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