• Print This
• Select Text Size:
• Comments
• 

Nurses at Miami Children’s Hospital’s Congenital Heart Institute helped ensure a good outcome for the recipient of the world’s first non-surgical tricuspid valve replacement, placed in January in the facility’s cardiac catheterization lab.

“It was very exciting but very fulfilling,” says Casey Krotts, RN, BSN, nurse manager of the cardiac catheterization lab. “It’s more worthwhile when you know they don’t have another option, and you are doing something really good.”

The 9-year-old patient, Charlie Anderson from Gainesville, was born with Ebstein’s anomaly, a rare congenital defect in which the tricuspid value is displaced and severely deformed. He had undergone five open-heart surgeries, the first when he was only a few weeks old. It’s not unusual for valves to need replacement as a child matures into adulthood, says Ruby Whalen, RN, CCRC, nurse clinician and research nurse for cardiology at Miami Children’s. However, Charlie had experienced more than his share of health problems.

Over time, he suffered a stroke, shortness of breath, and exercise intolerance. He couldn’t play. The child’s North Florida physician contacted Miami Children’s after running out of options.

“By the time he came to us, he was a poor surgical candidate,” Whalen says. “Being able to save him another surgery by putting the valve in during a cardiac catheterization procedure was very important to him.”

A new approach

Whalen screened the patient and educated him and his parents about the procedure, including the fact it had never been performed before. The hospital obtained institutional review board approval and secured permission for a compassionate use of the Melody Transcatheter Pulmonary Valve and Ensemble Transcatheter Delivery System from manufacturer Medtronic and the U.S. Food and Drug Administration,
a process that took more than a month.

Miami Children’s is participating in a clinical trial, investigating use of the valve, made from the internal jugular of a cow, for pulmonary valve replacements. Eleven children have received it for that purpose.

Preparation was thorough. “When we introduce a new procedure, the nurses are provided with in-services on the device, how the procedure is performed, how the device will change the patient’s pathophysiology, what to anticipate post-cath and potential complications,” Whalen says. “The nurses are provided with written information and often get to see a sample of the device.”

In Charlie's case, a clinical specialist from Medtronic also attended the implant surgery in case the physician had technical questions about the device.

On the table

In the cath lab, two nurses assisted with proper positioning so the cameras could take clear images of the anatomy, Whalen says. In Charlie's case, the cameras were taking pictures inside of his heart, especially on the right side. If his arms or other body parts were in the way, the images the physician relied on for proper catheter and valve position would not have been clear. The implantable valve position has to be accurate within hundredths of a millimeter, so proper positioning and clear, accurate images are vital to the success of the procedure.

Unlike most adult cardiac catheterizations, interventional caths in pediatrics, especially in patients with complex congenital heart disease, are lengthy and most often done under general anesthesia, Whalen says. They average three or four hours.

Patients are lying on a relatively hard table; the mattress has to be thin to allow the cameras to penetrate and obtain accurate images. The cath lab nurses are responsible for a baseline assessment of skin integrity before the procedure and to ensure that pressure points, such as elbows/arms, heels, coccyx, legs, and neck are protected with foam and cushions, Whalen says. At the end of the cath, the nurses again perform an assessment of skin integrity before the patient is transferred from the cath lab.

The nurses also kept the family updated during the four-hour procedure. “In Charlie’s case, because he had previously undergone multiple caths, the main concerns of the family were his physical status and [whether] the doctor could implant the valve,” Whalen says.

Cardiologist Evan Zahn, MD, inserted the catheter into the internal jugular vein in the neck, due to a lack of femoral access, probably related to many prior femoral sticks. The procedure progressed smoothly and at the end, a nurse held pressure on the site for more than 30 minutes.

Follow-up care

Charlie was monitored with one-to-one nursing care in the immediate post-cath phase, Whalen says. He was connected to telemetry that monitored his heart rate and rhythm, respiratory rate, O2 sats, both at the bedside and remotely. Chief among their concerns were signs of bleeding from the catheter insertion sites (neck and leg) and his hemodynamic status.

Nurses who care for post-cath patients are trained in signs and symptoms of potential device migration. These might include chest pain, changes in heart rhythm (ECG), drop in blood pressure, and other signs of shock.

“A lot of the post-cath nursing care for this or any other procedure is anticipatory, proactive, understanding the disease, what to expect after,” Whalen says.
Charlie continues to do well. He takes aspirin but has not needed a heavier-duty anticoagulant. He will follow up with his regular cardiologist and at Miami Children’s at three, six and 12 months. In between, Whalen will call and check on his progress.

“Being on the cutting edge of something that could really improve the quality of life for children by saving them open-heart surgery, even one, is quite a feat,” Whalen says. “It offers good hope for these families.”

Debra Anscombe Wood, RN, is a Nursing Spectrum contributing writer.

---

To comment, e-mail editorFL@nursingspectrum.com.

Reader Comments

You must adhere to the Terms of Service and Community Rules for Nurse.com when posting comments. Please do not post disparaging or offensive remarks. You may use links in your post.

Be the first to comment!