Clinical Connection - Summer 2023

INSIDE

2 Transcatheter aortic valve replacement program

3 Digital health

SUMMER

Transcatheter aortic valve replacement program

By Ahmad Edris, MD, Montage Medical Group

SEVERE AORTIC STENOSIS

Asignificant portion of patients with symptomatic, severe aortic stenosis remain untreated despite data showing that aortic valve replacement (AVR) can improve survival and quality of life (1). Reasons for surgical non-treatment includes patient comorbidities or high operative risk, advanced age or limited life expectancy, patient or family refusal, or perceived asymptomatic status. Many patients with severe aortic stenosis who are thought to be asymptomatic decrease their activity level slowly over time as their valve disease progresses, adapting to their condition and believing that a decline in functional ability is due to age alone. These patients ultimately present to the hospital at the end-stage of their disease when they develop congestive heart failure.

REFERENCES

y Tang L, et al. Contemporary reasons and clinical outcomes for patients with severe, symptomatic aortic non undergoing aortic valve replacement. Circ Cardiovasc Interv 2018;11:e007220

y Leon MB et al. Transcatheter or surgical aortic valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609-20.

y Mack MJ et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 2019;380(18):1695-1705

y Popma JJ et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 2019;380(18):1706-1715

TRANSCATHETER AORTIC VALVE REPLACEMENT

Transcatheter aortic valve replacement (TAVR) has emerged as a transformative, minimally invasive therapy that serves an unmet need. It provides a safe alternative for patients that would not have been able to be treated in the past. TAVR has been rigorously studied in several randomized clinical trials and has robust data showing the benefit of TAVR in appropriately selected patients using self-expanding and balloon-expandable valves (2-4). Many of the initial obstacles and complications encountered with TAVR have been addressed and have led to steady improvements in outcomes due to better patient selection, meticulous procedural planning using multimodality imaging, device development leading to fewer complications, and accumulating operator and site experience. This has resulted in the expansion of TAVR to even low-risk patients with favorable anatomy. Although TAVR was initially performed using general anesthesia and transesophageal echocardiographic guidance, the procedure has been simplified to conscious or moderate anesthesia care (minimalist approach) where patients are awake for the procedure allowing for more rapid recovery and next day discharge home.

MULTIDISCIPLINARY HEART TEAM

What is fundamental to the success of any program is the multidisciplinary heart team made up of interventional cardiologists, cardiovascular surgeons, imaging cardiologists, and a structural heart coordinator RN, which evaluate each patient with extensive testing to ensure the best individualized treatment option for each

Evolut™ PRO Valve (Medtronic) SAPIEN 3 Ultra™ (Edwards)

Digital health

By Jill Tiongco, MD, Montage Medical Group

patient. Community Hospital of the Monterey Peninsula has developed a team of physicians and clinical staff to take care of the full spectrum of patients regardless of complexity. We offer the latest generation selfexpanding and balloon expandable TAVR valves and tailor valve choice to patient anatomy, providing a level of care comparable to leading university hospital programs.

RESOURCES

Better outcomes are observed when patients are referred earlier in the disease process. Ideally, the patient should be referred when they have been identified or diagnosed as having “moderate aortic stenosis”. To refer a patient for TAVR evaluation, please contact Dr. Ahmad Edris, Interventional Cardiology and Structural Heart Disease Program Director, Montage Medical Group, at (831) 647-1123. For information about the Structural Heart Program and patient education resources, please contact Elizabeth Vitanza, Structural Heart Coordinator, Tyler Heart Institute, at (831) 625-4536.

Zoom, Zoom, Zoom — the term feels like the new “Xerox” or ”Post-It.” It’s a brand name that’s now a household term to mean virtual meetings or virtual physician visits. For many, this represents the visceral experience around technology and the speed with which it has transformed the practice of medicine.

Traditionally, physicians would ask for patient information, evaluate, analyze, prescribe, share, and teach. Now, patients are at the front and center driving innovation. This is not surprising since one in three Americans have used a wearable fitness tracker, about 85 percent of American adults

use smartphones, and there are about 300 million smartphone users in the United States. Imagine all those tracked steps, heart rates, and blood pressure readings. We’ve gone from reviewing written records in a clinic visit to getting a smartphone notification when there’s a shift or trend in our health.

Not so long ago, patients would need to bring a paper prescription to the pharmacy. With electronic prescribing, patients or caregivers can just head to the pharmacy after a text notification that it is ready. Before, paper forms were necessary to access medical records for patients’ perusal or care team use (be it their caregivers,

family members, specialists, etc.). Fast forward to 2018 when we deployed MyChart. With this patientbeloved app, there is real-time access to medical information, a portal to have virtual visits, and a one-stop shop to request and confirm appointments, check in, and pay for bills. And with the push of a button, patients can choose to share information to other care team providers.

We are also innovating ways to provide easier access beyond the walls of the doctors’ office. An example of this is our eVisits. These are generally designed for what we refer to as “low touch, low acuity” care. More information and a link to e-visits are available at montagehealth.org/evisit. We are also deploying e-consults, also known as electronic inter-professional consults.

Providers can use e-consults to get recommendations for certain conditions from specialists in other locations. This can expedite care decisions for patients if the condition does not require the specialist to see the patient in person.

What else does the ongoing journey of digital health have in store for us? In many corners of the world, technology is used to provide care to patients directly in their homes. Our goal is to do so with patient-appropriate technology that engages and enables. We have started this journey, and very soon, through participating Montage Medical Group physicians, remote patient monitoring programs will help patients better manage their hypertension, diabetes, and congestive heart failure from home.

In the future, we shouldn’t be surprised when more care services beyond

virtual doctor visits are provided closer to home. As stated by Montage Health Digital Health Director Meg Dingae, “Our vision is to improve lives with the most seamless, exceptional, consistent, and accessible digital health program possible that engages community members, patients, providers, and staff throughout the entire health journey.”

Our mission is to meet patients where they are, leverage technologies to improve connection, and build the program with the voice of the community. This is because the heart of digital health lives in how we transform the way our patients receive the care they deserve. For any questions, please contact Jill Tiongco, MD, FAMIA at jill.tiongco@montagehealth.org.

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