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Ascension St. Mary’s is making great strides in improving patient safety and outcomes. Aiming to reduce contrast usage during TAVR procedures and reduce the TAVR-related pacemaker rate, the group looked at an alternate technique for determining TAVR deployment. “The traditional TAVR deployment angle is a visual illusion angle, not an anatomical one. The nadir of the non-coronary cusp, the most inferior and most posterior of the three cusps, can function as a very useful target for proper deployment and depth,” explained the hospital’s Dr. Safwan Kassas.

Reducing the implant depth of the balloon-expandable valve related to the nadir of the non-coronary cusp can lower the procedural risk that the patient will need a pacemaker because it lowers the pressure on the adjacent conduction system. It also requires less contrast use and, as such, results in reduced kidney injury. 

“It is important to note that the non-coronary cusp technique used for balloon-expandable TAVR valve is very different from the cusp overlap technique used by the self-expanding TAVR valves,” said Dr. Kassas.

The site performed a verification process through a previously initiated safety study to ensure that the safety of this approach was comparable to the traditional deployment approach. They reviewed the new method's procedural safety and 30-day outcomes against the historical control.

The new approach significantly reduced procedural contrast use from an average of 80 - 100 CC per procedure as reported in some of the national TAVR registries to an average of 15 CC per procedure.  The TAVR-related pacemaker rate was reduced to 4.6% of the 150 most recent TAVR procedures, down from the 8-10% reported rate for the balloon-expandable TAVR valve.

Dr. Kassas, along with Dr. Christopher Liakonis, and Registered Nurse Brandi Horgan, has presented this project during prior TCT and ACC meetings. The team continues to introduce this approach through their proctoring activities in other hospitals. They hope to publish a full paper describing their reasoning for the approach, their technique, and the potential benefits to patients in the future.

Ascension St. Mary’s team was also interested in safely and efficiently improving cath lab time and better-utilizing cath lab and anesthesia staff. Brandi Horgan and Drs. Kassas, and Liakonis along with Dr. Zaker Quershi (head of the anesthesia department at St. Mary’s hospital) developed a collaborative project to establish a TAVR-related sedation protocol. 

The protocol was co-written and approved by the structural cardiology, cardiac surgery, and anesthesia departments. It identifies patients who are at high risk for mechanical, vascular, or pulmonary complications. Those patients have their sedation provided by a member of the anesthesia staff while those not considered to be at high risk have their sedation administered by an experienced and dedicated structural cath lab nurse. Approximately 68% of patients met the criteria for cath lab nurse-administered sedation. 

It was imperative to prove the accuracy and reliability of the protocol to identify high-risk patients.  A site-initiated study tested the safety and reliability of the protocol by looking at safety endpoints and conversion rates. 

Following a strict protocol, cath lab nurse-administered sedation during TAVR procedures is safe and leads to better cath lab efficiency and utilization of resources. The technique can also potentially lead to improved cost-effectiveness for TAVR procedures.

In line with MISHC's mission of collaborating for improved quality of care and patient outcomes, Ascension St. Mary’s hopes to increase other sites’ awareness of the benefits of both projects.