Paula Guest

Paula Guest, RN, is St. Mary's valve clinic coordinator. She has spent the past six months training and planning for the new Trans Aortic Valve Replacement Clinic.

Just four letters — T, A, V, R — are generating a buzz of excitement at St. Mary’s Medical Center.

St. Mary’s is set this week to begin performing the cutting-edge, life-changing heart procedure called TAVR. TAVR is short for Transcatheter Aortic Valve Replacement.

The procedure uses a wide-ranging team of medical specialists who take part in the tightly choreographed implantation of an artificial valve inside a patient’s heart — without a patient having to undergo open-heart surgery.

TAVR requires only a tiny incision, or sometimes just a needle stick, in the femoral artery of the groin or, less commonly, in the chest. A valve is threaded through a catheter in the artery. It is put in place using multiple imaging modalities so physicians have a clear view into the heart. The tight choreography of the procedure also very briefly involves rapidly increasing the heart rate so the valve can be properly placed.

“Every step in the approximately 45-minute procedure must be done in careful sequence,” said Cindy Shanklin, RN, clinical nurse manager of cardiac services at St. Mary’s.

“Everyone’s awareness and attention to every detail is very important,” Shanklin added. “Following every step is very crucial to the procedure.”

TAVR is designed to help certain patients with aortic stenosis — a narrowing of the aortic valve that can impede delivery of blood from the heart to the body. An important part of the TAVR program at St.

Mary’s will be identifying which of those patients with stenosis meet the criteria to undergo TAVR. Guidelines currently limit the use of TAVR to patients with moderate to severe stenosis. TAVR patients usually have other health problems that would make open-heart surgery too risky. The majority of TAVR patients are in their 70s or 80s.

Many patients with serious heart problems will still be helped by open-heart surgery. But for those who are cleared for TAVR, the procedure has many obvious benefits over major surgery. There is no zipperlike scar down the chest. Recovery time is much shorter. There is less pain. There are none of the potential complications related to being on a heart-lung machine.

The hospital stay is only about two days.

Because St. Mary’s has opted to offer this cutting-edge treatment to a service area that spans western Colorado and eastern Utah, patients also now have convenience.

They will no longer have to travel to Denver or Salt Lake City to undergo a TAVR procedure.

Furthermore, thanks to the new Valve Clinic within the Cardiovas- cular & Thoracic Clinic, patients are included on a nationwide registry: Heart problems can be identified more often before the development of heart valve disease.

Initially, St. Mary’s expects to do about 40 TAVR procedures a year. Patients who are identified as potential TAVR candidates by their cardiologists or their primary care physicians will have to go through stringent screening. They will be tested with electrocardiograms and echocardiograms. They will have their chests, abdomens and pelvises scanned to make sure the blood vessels are open enough for the catheter and valve. They will have blood tests that will show the functioning of many organs and processes in the body. They will go through education about TAVR to learn the risks as well as the benefits of the procedure and to learn about post-procedure care and restrictions.

Six patients have already gone through that screening and are scheduled to have the TAVR procedure at St. Mary’s before the end of the year. The first is scheduled for Dec. 7.

“The patients are excited to be able to access this advanced procedure at St. Mary’s,” said Paula Guest, RN and Valve Clinic coordinator. She is coordinating the TAVR program at St. Mary’s and has spent the past six months in training and planning sessions.

The early TAVR procedures will be done in St. Mary’s largest cardiac catheter procedure lab. It has been outfitted with the specialized surgical and monitoring equipment needed for TAVR and will serve as the TAVR room until a special hybrid TAVR operating room is completed in St. Mary’s new Center for Heart and Vascular Health. That center is currently under construction and will be completed in January 2019. The hybrid OR used for TAVR is slated to be finished and in use next spring before the rest of the center opens.

The room where TAVR will be done is called a hybrid because the guidelines for TAVR require both surgical and procedural equipment be in one room. Even though TAVR is done like other cardiac catheter procedures, the cardiovascular surgical team is on standby. The room can instantly become an operating theater in the rare instance the TAVR valve placement can’t be completed and it is necessary to do the procedure through open-heart surgery.

The Hybrid OR is much larger because of the extra equipment needed, and also because of the personnel. There will be 12 to 18 medical professionals in the room during a TAVR procedure. At the center of it all, interventional cardiologist Dr. Charlie Brunson will be the one threading the valve into the heart, assisted by cardiac and thoracic surgeon Dr. Leonard Lapkin.

Physicians and technicians specializing in X-ray and angiographic and electrocardiographic ultrasound images will be part of the team. There will also be an anesthesiologist, cardiac cath lab staff, cardiovascular surgery staff and representatives of the company that makes the heart valves. The crowd will include observers who have been key in putting the TAVR program together at St. Mary’s.

Guest will be one of the observers and Shanklin will be one of the nurses assisting in the procedure.

Both are looking forward to that “moment of intensity” when the first valve has been seated in the proper place and the balloon is withdrawn.

“When all the choreographed steps have been completed,” Shanklin said, “it is going to be an awesome moment — for the patient as well as the entire hospital.

This is going to be exciting for the hospital because the whole facility had a hand in getting this thing up and going.”

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