Valvular Heart Disease: A Guide for Cardiovascular Nurses and Allied Health Professionals

Contents
Introduction
Valvular Heart Disease
Experts Needed: Opportunities for Clinical Leadership
A Unique Resource for a New Field of Practice
A Team of International “Practice-Close” Leaders
About the Contributors
Part I: Understanding Valvular Heart Disease
	1: Acquired Valvular Heart Disease: Overview of Patient Population
		1.1	 Objectives
		1.2	 Challenges Associated with the Care of Patients with Valvular Heart Disease
		1.3	 Acquired Valvular Heart Disease Pathologies
			1.3.1	 Aortic Stenosis
				1.3.1.1	 Age and Gender
				1.3.1.2	 Etiology and Risk Factors
				1.3.1.3	 Comorbid Conditions
			1.3.2	 Aortic Regurgitation
				1.3.2.1	 Age and Gender
				1.3.2.2	 Etiology and Risk Factors
				1.3.2.3	 Comorbid Conditions
			1.3.3	 Mitral Regurgitation
				1.3.3.1	 Age and Gender
				1.3.3.2	 Etiology and Risk Factors
				1.3.3.3	 Comorbid Conditions
			1.3.4	 Mitral Stenosis
				1.3.4.1	 Age and Gender
				1.3.4.2	 Etiology and Risk Factors
				1.3.4.3	 Comorbid Conditions
			1.3.5	 Tricuspid Regurgitation
				1.3.5.1	 Age and Gender
				1.3.5.2	 Etiology and Risk Factors
				1.3.5.3	 Comorbid Conditions
		1.4	 Key Takeaways
		References
	2: Anatomy and Pathophysiology of Valvular Heart Disease
		2.1	 Objectives
		2.2	 Background
		2.3	 Anatomy and Physiology
			2.3.1	 Normal Anatomy
				2.3.1.1	 Semilunar Valves
					Pulmonary Valve
					Aortic Valve
				2.3.1.2	 Atrioventricular Valves
					Tricuspid Valve
					Mitral Valve
			2.3.2	 Normal Physiology
		2.4	 Etiologies and Pathogenesis of Acquired VHD
			2.4.1	 Rheumatic heart disease
				2.4.1.1	 Epidemiology
				2.4.1.2	 Pathogenesis
				2.4.1.3	 Presentation
			2.4.2	 Non-rheumatic Valve Disease
				2.4.2.1	 Infective Endocarditis
					Epidemiology
					Pathogenesis
					Presentation
				2.4.2.2	 Degenerative Valve Disease
					Epidemiology
					Pathogenesis
				2.4.2.3	 Calcific Valve Disease
					Epidemiology
					Pathogenesis
		2.5	 Aortic Valve Disease
			2.5.1	 Aortic Stenosis
				2.5.1.1	 Etiology and Pathoanatomy
				2.5.1.2	 Pathophysiology
				2.5.1.3	 Clinical Manifestations
				2.5.1.4	 Physical Assessment
			2.5.2	 Aortic Regurgitation
				2.5.2.1	 Etiology and Pathoanatomy
				2.5.2.2	 Pathophysiology
				2.5.2.3	 Clinical Manifestations
			2.5.3	 Physical Assessment
		2.6	 Mitral Valve Disease
			2.6.1	 Mitral Stenosis
				2.6.1.1	 Etiology and Pathoanatomy
				2.6.1.2	 Pathophysiology
				2.6.1.3	 Clinical Manifestations
				2.6.1.4	 Physical Assessment
			2.6.2	 Mitral Regurgitation
				2.6.2.1	 Etiology and Pathoanatomy
					Primary Mitral Regurgitation
					Secondary mitral regurgitation
				2.6.2.2	 Pathophysiology
					Clinical Manifestations
				2.6.2.3	 Physical Assessment
		2.7	 Tricuspid Valve Disease
			2.7.1	 Tricuspid Regurgitation
			2.7.2	 Etiology and Pathoanatomy
			2.7.3	 Pathophysiology
			2.7.4	 Clinical Manifestations
			2.7.5	 Physical Assessment
			2.7.6	 Tricuspid Stenosis
		2.8	 Summary
		2.9	 Key Takeaways
		References
Part II: Valvular Heart Disease Program Structure
	3: The Heart Team: A Gold Standard of Care
		3.1	 Objectives
		3.2	 Introduction
		3.3	 The Pre-Procedure Heart Team
			3.3.1	 Team Members
				3.3.1.1	 Valve Program Clinician
				3.3.1.2	 Interventional Cardiologists and Cardiac Surgeons
				3.3.1.3	 Cardiac Imaging Specialists
				3.3.1.4	 Advanced Practice Nurses
				3.3.1.5	 Geriatric Medicine and Palliative Approach Specialists
			3.3.2	 Strategies to Strengthen the Impact of the Pre-Procedure Heart Team
		3.4	 The Peri-Procedure Heart Team
			3.4.1	 Team Members
				3.4.1.1	 Procedural Cardiologists and Cardiac Surgeons
				3.4.1.2	 Nursing and Allied Health Professional Team
				3.4.1.3	 Anesthesiology Services
			3.4.2	 Strategies to Strengthen the Impact of the Peri-Procedure Heart Team
		3.5	 The Post-Procedure Heart Team
			3.5.1	 Team Members
				3.5.1.1	 Critical Care and Cardiac Telemetry Nurses
				3.5.1.2	 Nurse Practitioners and Advanced Practice Providers
				3.5.1.3	 Specialized Medical Services: Electrophysiology
			3.5.2	 Strategies to Strengthen the Impact of the Post-Procedure Heart Team
		3.6	 Conclusion
		3.7	 Key Takeaways
		References
	4: Processes of Care and Evaluation Pathway for Patients with Valvular Heart Disease
		4.1	 Evaluation Pathway: Structure and Processes
		4.2	 Patient Pathway
		4.3	 Diagnostic Testing and Evaluations
			4.3.1	 History and Physical Examination
			4.3.2	 Transthoracic Echocardiogram
			4.3.3	 Transesophageal Echocardiogram
			4.3.4	 Dobutamine Stress Echocardiogram
			4.3.5	 Electrocardiogram
			4.3.6	 Computerized Tomography Scan
			4.3.7	 Coronary Angiography
			4.3.8	 Carotid Ultrasound
			4.3.9	 Pulmonary Function Testing
			4.3.10	 Blood Work
			4.3.11	 Dental Clearance
			4.3.12	 Functional and Cognitive Assessments
				4.3.12.1	 5 Meter Walk Test (5MWT)
				4.3.12.2	 6-Minute Walk Test (6MWT)
				4.3.12.3	 Kansas City Cardiomyopathy Questionnaire (KCCQ-12)
				4.3.12.4	 Mini Mental State Examination (MMSE)
				4.3.12.5	 Surgical and Procedural Risk Evaluation
			4.3.13	 Anesthesia Assessment
		4.4	 Putting It All Together: Making Balanced Treatment Decisions
		References
Part III: Assessing Valvular Heart Disease
	5: Imaging Modalities in the Diagnosis and Treatment of Acquired Heart Valve Disease
		5.1	 Background
		5.2	 Diagnostic and Imaging Modalities
			5.2.1	 Electrocardiogram (ECG)
			5.2.2	 Chest Radiography (CXR)
			5.2.3	 Echocardiography
				5.2.3.1	 Transthoracic Echocardiogram (TTE)
				5.2.3.2	 Transesophageal Echocardiography (TEE)
				5.2.3.3	 Nursing Considerations
				5.2.3.4	 Three-Dimensional Echocardiography (3DE)
			5.2.4	 Cardiac Catheterization
			5.2.5	 Multidetector Computed Tomography (MDCT)
				5.2.5.1	 Nursing Considerations
			5.2.6	 Cardiac Magnetic Resonance
				5.2.6.1	 Nursing Considerations
			5.2.7	 Exercise Testing
				5.2.7.1	 Nursing Considerations
				5.2.7.2	 Serial Testing of Patients with VHD
		5.3	 Mitral Regurgitation
			5.3.1	 Preprocedural/Procedural Imaging
			5.3.2	 Procedural Considerations
				5.3.2.1	 Edge to Edge
				5.3.2.2	 Minimally Invasive and Robotic Mitral Valve Surgery
				5.3.2.3	 After Edge-to-Edge Repair
		5.4	 Mitral Stenosis
		5.5	 Aortic Regurgitation
			5.5.1	 Intraprocedural Imaging
		5.6	 Aortic Stenosis
			5.6.1	 Stress Echo
			5.6.2	 Transcatheter Aortic Valve Replacement
		5.7	 Tricuspid Regurgitation
			5.7.1	 Intraoperative Assessment
		5.8	 Tricuspid Stenosis
		5.9	 Summary
		References
	6: Measuring Function, Frailty and Quality of Life in People with Heart Valve Disease
		6.1	 Introduction
			6.1.1	 Clinical Case
		6.2	 Functionality
		6.3	 Frailty
			6.3.1	 Understanding Frailty
			6.3.2	 Measuring Frailty
			6.3.3	 Frailty in Patients with Symptomatic Aortic Stenosis
			6.3.4	 Frailty and Implications for Treatment
		6.4	 Quality of Life
			6.4.1	 Measuring Quality of Life
			6.4.2	 Integrating the Measurement of Quality of Life in Clinical Care
		6.5	 Conclusion
		References
	7: Making a High-Quality Treatment Decision: Shared Decision-Making
		7.1	 Background
		7.2	 Shared Decision-Making
			7.2.1	 Creating the Foundation
				7.2.1.1	 A Disruptive Practice
				7.2.1.2	 Conceptual and Education Foundations
			7.2.2	 Shaping Meaningful Conversation
				7.2.2.1	 Addressing Health Disparities
				7.2.2.2	 Unique Considerations in Valvular Heart Disease
				7.2.2.3	 Multiple Treatment Options
				7.2.2.4	 Goals and Preferences
		7.3	 Eliciting Patient Goals
			7.3.1	 Choices for a Life Time
			7.3.2	 Opening the Conversation
			7.3.3	 Patient Decision Aids
		7.4	 Influencing Change
			7.4.1	 The Right Competencies
		7.5	 Conclusion
		References
Part IV: Valvular Heart Disease Treatment Options
	8: Surgical Treatment for Patients with Valvular Heart Disease
		8.1	 Heart Valve Surgery: An Introduction
		8.2	 The Multiple Moving Parts of the Careful Preparation for Heart Valve Surgery
			8.2.1	 Before Heart Valve Surgery: Nursing Procedures and Observations in the Operating Room
			8.2.2	 Role of Nurses in the Peri-Operative Heart Valve Surgery Team
			8.2.3	 Preparing Patients for Heart Valve Surgery
		8.3	 An Overview of Heart Valve Surgery Procedures
			8.3.1	 Before the Valve: The Preliminary Steps of Heart Valve Surgery
				8.3.1.1	 Exposing the Heart
				8.3.1.2	 Bypassing Cardiovascular Circulation
				8.3.1.3	 Stopping the Heart
				8.3.1.4	 Anesthesia
				8.3.1.5	 Choosing the Right Valve for the Right Patient
			8.3.2	 During Heart Valve Surgery: Nursing Procedures and Observations in the Operating Room
		8.4	 Understanding the Different Types of Heart Valve Surgeries
			8.4.1	 Aortic Valve Surgery
				8.4.1.1	 Aortic Valve Replacement
				8.4.1.2	 Aortic Valve Repair
			8.4.2	 Mitral Valve Surgery
				8.4.2.1	 Mitral Valve Repair
				8.4.2.2	 Mitral Valve Replacement
				8.4.2.3	 Tricuspid and Pulmonary Valve Surgery
			8.4.3	 Heart Valve Surgery and Coronary Artery Disease
		8.5	 Once the New Heart Valve Is in Place: Final Surgical Steps
			8.5.1	 Cardiac Imaging
			8.5.2	 Completing the Surgery
			8.5.3	 Invasive Equipment for Safe Early Recovery
		8.6	 Conclusion
		References
	9: Transcatheter Treatment Options for Acquired Valvular Heart Disease
		9.1	 Introduction
		9.2	 Treatment of Aortic Valve Disease
			9.2.1	 Transcatheter Aortic Valve Replacement
				9.2.1.1	 Contraindications to TAVR
				9.2.1.2	 Evaluation and Assessment
				9.2.1.3	 TAVR Devices
				9.2.1.4	 Limitations
				9.2.1.5	 Evolving Applications
				9.2.1.6	 Procedural Approaches
				9.2.1.7	 Procedure
				9.2.1.8	 Post-Procedure
		9.3	 Transcatheter Mitral and Tricuspid Valve Therapies
			9.3.1	 Mitral Regurgitation
				9.3.1.1	 Evaluation
				9.3.1.2	 Transcatheter Mitral Valve Leaflet Repair
				9.3.1.3	 Transcatheter Annuloplasty Techniques
				9.3.1.4	 Transcatheter Chordal Repair
				9.3.1.5	 Transcatheter Mitral Valve Replacement (TMVR)
			9.3.2	 Tricuspid Regurgitation
				9.3.2.1	 Transcatheter Tricuspid Valve Repair
		9.4	 Conclusion
		References
Part V: Nursing Care for Patients with Valvular Heart Disease
	10: Safe Recovery after Valvular Heart Surgery
		10.1	 Introduction
		10.2	 Postsurgical Clinical Pathways
			10.2.1	 Enhanced Recovery after Surgery
				10.2.1.1	 ERAS in the Preoperative Phase
				10.2.1.2	 ERAS Across the Peri- and Postoperative Phase
		10.3	 Identification and Management of Complications Following Valve Surgery
			10.3.1	 Postoperative Complications
			10.3.2	 Pulmonary Complications
			10.3.3	 Cerebrovascular Incidents
			10.3.4	 Bleeding and Pericardial Effusion
			10.3.5	 Surgical Site Complications
			10.3.6	 Infection
			10.3.7	 Atrial Fibrillation and Rhythm Issues
			10.3.8	 Cardiac Arrest
			10.3.9	 Gastrointestinal Issues
			10.3.10 Postoperative Central Nervous System Dysfunction
		10.4	 Postoperative Continued Care
			10.4.1	 Nursing Priorities
				10.4.1.1	 Management of Respiratory Status and Safe Extubation
				10.4.1.2	 Pain Control
				10.4.1.3	 Warming
				10.4.1.4	 Wound Care
				10.4.1.5	 Activity
				10.4.1.6	 Nutrition
			10.4.2	 Steps for a Safe Discharge
				10.4.2.1	 Discharge Planning
				10.4.2.2	 Site Care
				10.4.2.3	 Diet Considerations
				10.4.2.4	 Activity and Self-Care
				10.4.2.5	 Emotional Well-being
				10.4.2.6	 Medications
				10.4.2.7	 Cardiac Rehabilitation
				10.4.2.8	 Outpatient Follow-Up
		10.5	 Conclusion
		References
	11: Safe Recovery After Transcatheter Heart Valve Procedures
		11.1	 Introduction
		11.2	 Essential Elements of Care
			11.2.1	 Anesthesia, Sedation, and Pain Management
			11.2.2	 Post-Procedure Monitoring
				11.2.2.1	 Cardiac/Hemodynamic Status
				11.2.2.2	 Cardiac Rhythm
				11.2.2.3	 Vascular Access
				11.2.2.4	 Neurologic Status
				11.2.2.5	 Renal Function
			11.2.3	 Activity Progression
		11.3	 Time for Discharge
			11.3.1	 Medication Regimen
			11.3.2	 Endocarditis Prophylaxis
			11.3.3	 Diagnostic Testing
			11.3.4	 Activity Progression
		11.4	 Tools for Success
		References
	12: Transitions of Care and Long-Term Follow-Up after Heart Valve Procedures
		12.1	 Introduction
		12.2	 At Discharge
		12.3	 Follow-Up Care Immediately after Discharge
			12.3.1	 Usually 2–7 Days After Discharge
		12.4	 Early Assessment after Heart Valve Surgery and Transcather Procedures
			12.4.1	 Usually 4–6 Weeks Postoperatively
		12.5	 Long-Term Follow-Up Care
			12.5.1	 Usually 6 and 12 Months: Then as Recommended
		12.6	 The Role of Cardiac Rehabilitation
		12.7	 Special Consideration for Postoperative Care of VHD Patients
			12.7.1	 Frailty
			12.7.2	 Health-Related Quality of Life
		References