SUMMA CARDIOVASCULAR INSTITUTE Heart Valve Clinic at Summa Akron City Hospital Transcatheter Aortic Valve Replacement (TAVR)
Getting Ready for the Procedure You recently had tests and offi ce visits with the healthcare team to decide which option would be the best choice for treating the symptoms caused by aortic stenosis. The team recommended transcatheter aortic valve replacement (TAVR) as the best option for you. This means having your aortic valve replaced using this catheter approach, rather than having open heart surgery. You agreed to have the procedure as soon as it could be scheduled. You are now on the waiting list. Your procedure will be performed in The Richard M. and Yvonne Hamlin Hybrid Operating Room Suite which is located in the Hamlin Pavilion on the Summa Akron City Hospital campus at 95 Arch Street. The hybrid OR suite at Summa Akron City Hospital combines the functionality of a traditional operating room, a cardiac catheterization lab and an electrophysiology (EP) lab in a single roomy surgical suite. This new type of operating room is specifi cally designed for performing TAVR and other procedures which require multiple types of heart specialists to work together simultaneously. To prepare for the procedure, please read this booklet and share it with your family. We have included information about: What to expect while on the waiting list How to prepare for the procedure What to do once you know your procedure date What happens while you are in the hospital We hope this answers questions you may have about the procedure, recovery and follow-up care. Use the page at the back of this booklet to note important dates and to record any questions you may have for your doctor. Also included with this booklet is a card for you to carry in your wallet or purse. Please carry the card with you at all times. If you need to go to the hospital or see a doctor who is not your regular doctor, show the card to them so that they can call our offi ce about any change in your medical condition. What will happen during the TAVR procedure? Transcatheter means that a catheter (a small, fl exible and hollow tube) is used to place a new aortic valve in the heart. A small opening is made in a large artery at the top of the leg or through the front of the chest, and then the catheter is used to place the new valve in the right position. Unlike open heart surgery, there is no need to open the chest for this procedure. The TAVR procedure is usually done one of two ways. Both approaches use small catheters to place the artifi cial valve in the correct position. As technology changes, your doctor may decide to use a different approach. We have checked off ( ) which approach the doctor will use: Transfemoral TAVR: A small opening is made in a large artery, usually in your groin (called the femoral artery). The doctor threads a catheter through the artery and up into the heart. Described in more detail on page 10. Transapical or alternate surgical approach: A small opening is made in your chest between your ribs. The catheter is inserted through the chest wall and into the heart. Described in more detail on page 10. Other approach: How long will I be on the waiting list? How long a patient remains on the waiting list depends on many factors, including: their overall health as well as the size and shape of their heart valve. When the TAVR nurse contacts you and you agree to be placed on the waiting list, she will tell you how long you will probably be on the waiting list. In most cases, patients are notifi ed of their procedure date a week or two following their TAVR assessment offi ce visit. Who will look after my health while I am on the waiting list? You will continue to be watched and treated by your family doctor or heart doctor while waiting for your TAVR. Summa s team of heart specialists is responsible for your care when you come into the hospital for your TAVR procedure. When you go home, you will continue to see your regular family doctor. 2 3
What if my health changes while I am on the waiting list? Getting ready for the TAVR: Over time, as your aortic valve continues to stiffen, it gets harder for the heart to pump blood through the valve. It s a bit like when a door doesn t open wide anymore and you have to push harder to open it. While you are waiting for the TAVR procedure, here are some things you should do: As the valve opening gets narrower, you might feel more tired or more short of breath than you did a few months ago. It is normal to have small changes in the way you feel while you are waiting for your new valve. If your health does not change too much, your regular doctor will keep watching over you and treating you while you wait. If your health suddenly gets worse, however, we need to know this. Follow your doctor s instructions. Ask a family member to call our office. The number is on your wallet card. Keep active. Stay as active as you can. Ask your doctor about how much you should do. Exercise every day, even if only for a short while. Slow down if you get short of breath, have chest pain or feel faint. Talk with your doctor about what kind of exercise is best for you. Ask about driving. We usually recommend that you do not drive until your valve is replaced. Everyone is different, however. Ask your family doctor about whether or not it is safe for you to drive during this time. Eat healthy. It is important that you eat well during your wait for the TAVR. Your doctor may have asked you to limit the amount of liquids and salt you should have. Continue to follow your doctor s recommendations. If you are admitted to a hospital, give the nurse or doctor your wallet card. Have them call us at the Heart Valve Clinic Office at (330) 375-4798 or use our toll-free number We will call your regular doctor and follow your care indirectly. We may change the date of your TAVR. If the doctors no longer feel that TAVR is best for you, we will recommend other possible treatments for your heart condition. 4 Take your medicines. Continue to take the medicines that your doctor has prescribed. See your dentist. If you have your own teeth and have not seen a dentist in the last six months, make an appointment. If you need dental work done, have it done before your TAVR procedure. Dental work done right after your TAVR procedure could cause the new valve to become infected. See any other recommended doctors. Your TAVR nurse or doctor may have asked you to see other special doctors or therapists or a dietitian to help you get well after your TAVR. Call and make appointments to see them before the procedure. Plan ahead. Plan ahead for your return home. Plan how you will get home. Plan for any extra help you may need at home once you are discharged from the hospital. (See the section on Going Home ). When your procedure date is booked: Write this date on the checklist at the end of this booklet. We may call to move your procedure date closer if there are any cancellations. We may need to call and postpone your TAVR procedure because of other surgeries or emergencies. We will try to give you as much notice as possible for any changes, but sometimes these changes occur unexpectedly. Plan now for the care you wish to receive if your health worsens. Think about your personal and financial affairs. Talk to your family now about your future healthcare wishes in case you cannot speak for yourself later. Write down your questions and concerns. Contact the TAVR Clinic office with these questions. It is better to get answers to your questions now, rather than the morning of your TAVR procedure. 5
What to bring to the hospital: Bring items you might need during your hospital stay, such as: Toothbrush Toothpaste Dentures Comb or brush Glasses Hearing aid(s) Reading materials Your cane or walker (if you use one) Bring only a few personal items and clothing. It is best if your family can keep your clothes until the day you leave the hospital. Do not bring a lot of cash or valuables. A wedding ring is ok. You may be moved twice during your stay. We do not want to lose any of your belongings in these moves. For valuable belongings you need to keep with you, it may be a good idea to have insurance on them for loss or damage. These items could include glasses, dentures, hearing aids, watches, as well as your own wheelchair or walker. We will help you label your valuables with your name and room number once you are in the hospital. How long will I stay in the hospital? Most people stay in the hospital three to seven days following a TAVR procedure. Some patients need more time to recover. It is diffi cult to tell in advance how long you will need. It depends on your overall general health, how the procedure went and your plan for getting home. Most people recover faster if they do not stay in the hospital longer than needed. Our plan is for you to go home as soon as we feel it is safe for you to leave. If you need more time in a hospital to recover, we may transfer you to another facility that can provide specialized care of this type. The day before the procedure: You will come into the hospital to be admitted the evening before the procedure (see the map at the end of this booklet). We may start an IV (intravenous) access line and get blood samples for testing. We may possibly need urine samples as well. Please bring a list of your medicines to the hospital. You will meet the doctors who will be with you during the procedure the next day. These will include your surgeon, heart doctor and anesthesiologist (the doctor who gives you medicine to sleep during the procedure). At this time, we will ask you to sign the consent form agreeing to have the procedure done. Some people fi nd it hard to read and take in the information on the form right before the procedure. Please feel free to ask us to read it to you. We will update your medications and health history and instruct you on further preparations for the procedure. Please feel free to ask questions and talk about your concerns. Tell us about any of your health problems we might not have asked about during your previous visit. We especially want to know if you have any allergies not mentioned, or any history of frequent bladder infections or, for men, an enlarged prostate gland which makes urinating diffi cult. The TAVR Procedure What happens before the procedure? The evening before: While in the admissions area, we check you in. We take you to the Surgical Cardiovascular Intensive Care Unit (SCVICU) located on the fi rst fl oor. Upon arrival in the SCVICU, we will: Ask that you change into a hospital gown Start an intravenous (IV) line in one of the veins of your arm Attach you to a heart monitor What happens during the procedure? The morning of: You are taken to the procedure room, where your anesthesiologist gives you medicines to let you relax and sleep during the procedure. With general anesthesia medicines are given that cause all of your muscles to completely relax, including the muscles you use to breathe. Once you are asleep, the doctor puts a breathing tube down your throat and into your lungs to protect your lungs from any fl uid accidentally getting into them. The tube also allows the doctor to give you oxygen and help you breathe. While you are sleeping, we may put a urinary catheter (a small hollow tube) into your bladder to drain urine if needed. Ask you to sign a form giving us your consent to the procedure Introduce your anesthesiologist who will give the medicine to make you sleep during the procedure Have you speak with your surgeon and other specialists who will be in the operating room with you Answer questions you and your family may still have The whole TAVR procedure may take anywhere from 90 minutes to three hours. The actual placement of the new heart valve usually takes 30 to 45 minutes. 6 7
How is the procedure done? This depends on what approach you are having: If you are having a transfemoral TAVR (usually through the groin): A small opening is made in the femoral artery in your groin A catheter (a small flexible and hollow tube) is threaded through the artery and up into the heart The doctor uses a special X-ray machine to guide the catheter and new valve into position The doctor may insert a small wire and attach it to a pacemaker in case there is a need to control your heart rhythm while the valve is put in place Once the valve is secured in place, the catheter and wire are removed A dressing is placed over the skin opening If you are having a transapical or other surgical approach TAVR (usually through the chest wall): A small incision is made in the left side of your chest The catheter is inserted through the chest and into the heart The doctor uses a special X-ray machine to guide the catheter and new valve into position The doctor may insert a small wire and attach it to a pacemaker in case there is a need to control your heart beat while the valve is placed The pacemaker wire may be left in place until your heart s rhythm returns to normal. We can use the wires to connect to energy to reset the heart rhythm, if needed. Once the heart rhythm returns to normal, the wire is removed A dressing is placed over the skin opening What happens right after the procedure? You are transported from the procedure room back to the Surgical Cardiovascular Intensive Care Unit (SCVICU) For most people who receive general anesthesia, the breathing tube is removed in the procedure room, shortly after you return to the SCVICU or as soon as it is safe to remove it. Usually we remove the tube fairly soon after the procedure. If you wake up with the tube in place, do not worry. We tell you what to do and how to communicate with us. If you are someone who suffers from claustrophobia and you worry about waking up with the breathing tube in place, please let us know at your first clinic visit or during one of the question-and-answer discussions. We can give you medications to help you relax and remain calm should you wake up with the breathing tube in place During the first 24 hours of recovery, here s what you can expect: Equipment: You will be attached to a heart monitor You will have an intravenous (IV) line in your arm and maybe one in your neck or groin You may have a urinary catheter in place to drain urine from the bladder You may have a chest tube or pacemaker wires still in place Our goal is to remove all of this equipment as soon as possible, often the same day as your procedure or early the next morning. If you have a chest tube, we usually take it out the day after your procedure. Positioning: If you have the Transfemoral TAVR (usually through the groin), you must lie flat for the first four hours. We will remind you to keep both of your legs straight. This is to make sure you don t start to bleed through the small opening made in your groin. A nurse will check your groin area frequently. If you have the transapical or alternate surgical approach TAVR (usually through the chest wall), you may have your head raised slightly. Activity: At first, we keep you lying in bed. We will help you turn from side to side often. We begin to increase your activity as soon as it is safe. Increasing your activity is important to your recovery. Our goal is to get you sitting in bed, then in a chair and then walking the day after your procedure. Nutrition: Once the effects of the anesthesia are gone and you feel well enough, we will see how well you swallow. If you are doing ok, you can start drinking clear fluids and progress to eating normally. Pain and discomfort: We give you medication to help relieve pain. If you had a Transfemoral TAVR (usually through the groin area), you may have pain in the groin area. Sometimes, people get a bruise, and it can get quite large. The bruise will slowly go away. Most people do not feel a lot of pain after this procedure. If you had a Transapical or alternate surgical approach TAVR (usually through the chest wall), you may have pain in the chest area. Let us know if you feel pain. We give you medication to ease the pain so you can move around comfortably and heal more quickly. 8 9
Do not worry about taking too much pain medication. It is best to take as much as you need to keep your pain under control. As you recover, you will not need as much pain medication. Equipment: To help us keep a close watch on your heart, we may leave you on a heart monitor for the fi rst few days or until you leave the hospital. Dressing care: Your nurse will change and remove your dressing as necessary. Activity: We will get you to gradually increase your level of activity. It is very important that you try to be as active as possible to prepare for when you leave the hospital. Nutrition: Your appetite will probably be smaller than usual for a few days. It is important to drink enough liquids and eat enough food to help you recover as soon as possible. Talk to your nurse about any concerns or special needs you have. Visitors: Visiting hours are generally from noon to 8:00 p.m. We ask that you be considerate of other patients and speak quietly during visits. Length of stay: It is diffi cult to predict how long you will stay on the cardiac unit. People who have a Transfemoral TAVR (through the groin area) are usually ready to leave the hospital about three to four days after their procedure. Some patients leave a little later than this. People who have a Transapical TAVR (through the chest wall) usually need more recovery time because it takes longer for the wound in the chest to heal. They are usually ready to leave the hospital about fi ve to seven days after their procedure. Tests: Before you leave the hospital, you will have a chest X-ray and another echocardiogram (an ultrasound test of your heart) to check the valve s position. You also may have some more blood tests. Plan Now for Going Home Start planning for your return home the moment you know you will be having the TAVR procedure. Planning is one of the most important things you and your family can do to help us make your procedure a success Before you come to the hospital, you and your family Key points to plan for: Getting home: You must make your own arrangements for your trip home from the hospital. This includes road transport, fl ights and accommodation reservations and payment. Even if you were brought to the hospital by ground or air ambulance you must arrange for your return home. Ambulance services cannot be used to return people to their homes. We suggest you arrange to have someone travel with you for the trip home. Help at home: You will need help when you fi rst go home. It is hard to predict how much help you will need, and for how long. It is best to plan ahead so that you are sure to have the help you need at home. Most people who have TAVR say it takes them a month or two to fully recover. We suggest you arrange to have someone stay with you for the fi rst week (or longer) to help you as you recover. If you are from outside of the greater Akron area, we will work with our healthcare team to coordinate your return home We need to make sure you are prepared to go home before you go into the hospital suggest you stay one night close to the hospital before your trip home. If you do not have family or friends to help, you may qualify for home health services. If support at home is a concern, ask to speak to one of Summa s social workers to get more information about home health services before you come to the hospital. 10 11
CAV-14-21831/CS/EF/7-14/200