‘Minimalist approach’ enhances patient recovery

UCHealth’s approach to valve replacements catches eye of national training program.
May 25th, 2016

The less-invasive approach to heart valve replacement keeps improving, and UCHealth is leading the charge.

“Everything we do has potential risks,” said Dr. Justin Strote, cardiologist with UCHealth Heart Center at Medical Center of the Rockies. “In the case of transcatheter aortic valve replacement (TAVR), we have been able to eliminate some of those risks while maintaining great outcomes.”

Since its approval by the FDA in late 2011, TAVR has been used mostly in patients who have a heart-valve condition called aortic stenosis but are too high of a risk for the traditional open-heart surgery required for aortic valve replacement, or AVR. TAVR is a less-invasive procedure in which a team of cardiologists works together to place a collapsible artificial valve into the heart through a patient’s artery.

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Erin Yeater carries the the Edwards SAPIEN 3 transcatheter heart valve. The valve will be implanted in the heart through a catheter inserted into the femoral artery

Although less invasive than open-heart surgery, TAVR has, like open-heart surgery, also relied on general anesthesia, a central line (large IV placed in the neck), and a urinary catheter, and patients’ average hospital stay has been about six days.

But for the past year,  UCHealth’s heart teams at MCR and University of Colorado Hospital have adopted a new philosophy — a minimalist approach — that’s benefiting patients with fewer days in the hospital and faster recovery times.

“This minimalist approach leans even more toward the less invasive,” said Dr. Brad Oldemeyer, cardiologist with UCHealth Heart Center at MCR. “We’ve been able to eliminate central lines, general anesthesia and urinary catheters. … and 70 percent of our [MCR] patients are out of the hospital within 24 hours.”

UCH specialists now perform the majority of TAVR procedures without general anesthesia, and both UCH and MCR plan soon to investigate whether the less-invasive TAVR procedure is the best treatment for patients who are at low risk for open surgery, a new option for this patient population.

When the heart pumps, the aortic valve opens to let a burst of oxygenated blood through, then it closes again until the heart’s next beat. But in people with aortic stenosis, the valve doesn’t open all the way. This causes blood to be held back, increasing pressure in the heart’s left ventricle and backing up blood into the lungs. In severe cases, the brain and body don’t get enough blood, which is what causes symptoms like breathlessness, fatigue and loss of consciousness.

“The mortality rate [for people with severe aortic stenosis] is 50 percent in two years without valve replacement,” Oldemeyer said.

Fort Collins resident Frank Gibson, 82, had been diagnosed with aortic stenosis, and recently it became clear that it needed to be addressed. His age and weak pumping heart steered him away from open-heart surgery and toward TAVR. After his multidisciplinary team at MCR consulted with the anesthesiologist, it was determined that Gibson also was a safe candidate for the center’s minimalist approach.

“We must ensure that we can take a minimalist approach safely and that the patient can be comfortable,” Strote said.

The streamlined process starts even before the patient arrives. The behind-the-scenes prep work by the staff ensures the patient’s procedure begins on time.

“Their prep work was excellent,” Gibson said of his experience. “I remember extensively the interviews I had with all the doctors that day. They explained with great care what was going to happen.”

During a TAVR procedure, the multi-physician team consisting of interventional cardiologists, cardiac surgeons and a cardiologist specializing in ultrasound of the heart work together to guide a catheter, via a wire, through blood vessels and up to the heart. This is done through a small incision in either the upper thigh or below the rib cage. When it has reached the heart, the device is positioned inside the diseased valve using ultrasound and X-ray imaging. The artificial valve is then expanded inside the original valve by inflating a temporary balloon. The new valve fills the space within seconds and goes to work.

When UCHealth’s heart teams began performing TAVR about four years ago, patients were always put under general anesthesia, which can cause nausea, sore throat and achy muscles, as well as confusion and fatigue, according to the American Society of Anesthesiologists.

With the minimalist approach, patients undergo conscious sedation. Although they may not remember much, they can answer surgeons’ questions about their comfort level during surgery.

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Dr. Brad Oldemeyer, an interventional cardiologist, discusses imaging with Mike Thompson and Erin Yeater during a recent TAVR procedure at Medical Center of the Rockies. The procedure replaces a patient’s aortic valve to increase blood flow and thus help to lengthen patients’ lives.

“They rolled me into the [operating] room, and that’s all I remember until after the procedure was over,” Gibson said. “But I have not had a trace of pain. … There is no reason whatsoever to get uptight about this procedure.”

Like most patients who undergo the new minimalist approach, Gibson was walking around his room within about four hours and took to the halls a few hours later.

Being able to have the patient get out of bed sooner helps them gain strength faster, Strote explained. Patients also recover in a progressive care unit instead of the intensive care unit, which also seems to help with recovery — not to mention lowering medical expenses for the patient, he said.

Gibson was home enjoying his ministry studies and model trains about 24 hours after arriving at MCR.

“We should be in the cheering section for what science is able to do,” Gibson said. “I’m very grateful for what science has been able to do in medicine, and in my case, I’ve come through quite appreciative and with high praises for those involved in my experience.”

UCHealth’s philosophy change has attracted national attention as well. The UCHealth Heart Center at MCR recently became one of only four programs in North America to be asked to train others in the minimalist approach. Last month, more than a dozen physicians from three different medical institutions spent several days at MCR learning about and watching how the UCHealth Heart Center team administers their program. These trainings are expected to continue on a quarterly basis, Strote said.

“TAVR has always been a good procedure,” Strote said. “But to now see these patients sitting up and feeling quite good — well, that’s pretty impressive.”

About the author

Kati Blocker has always been driven to learn and explore the world around her. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Even better, she gets to share their stories with the world.

As a journalism major at the University of Wyoming, Kati wrote for her college newspaper. She also studied abroad in Swansea, Wales, while simultaneously writing for a Colorado metaphysical newspaper.

After college, Kati was a reporter for the Montrose Daily Press and the Telluride Watch, covering education and health care in rural Colorado, as well as city news and business.

When she's not writing, Kati is creating her own stories with her husband Joel and their two young children.