Why early stroke recognition matters after a heart valve procedure

TAMPA, Fla. - Making sure patients have the best outcomes possible is the primary focus for AdventHealth Tampa Nurse Practitioner Deana Harbach. She is the structural heart program coordinator at the AdventHealth Tampa Pepin Heart Institute and is a co-author on new stroke research, published this fall in the national journal Circulation.

"Part of providing good quality outcomes for heart patients is a commitment to collecting and analyzing data," Harbach said.

As one of only two nurse practitioners nationwide on the Transcatheter Valve Therapy National Data Registry (TVTR) steering committee, an oversight board for structural transcatheter cases, Harbach joined an impressive group of colleagues who conducted the study.

It looked at the reporting of hospital stroke rates after Transcatheter Aortic Valve Replacement (TAVR), a minimally invasive heart procedure performed to treat severe aortic stenosis.

CSCs better at recognizing strokes

The study shows that hospitals designated as Comprehensive Stroke Centers (CSC) do a better job of reporting post-TAVR strokes to the national data registry than other facilities.

"Comprehensive Stroke Centers seem to have a recognition of stroke earlier, and they're able to send for imaging to be able to diagnose that," Harbach said. "So they're reporting a higher number, but it's because they're recognizing it."

AdventHealth Tampa is among only three-percent of hospitals nationwide designated as a CSC, which means it provides the highest level of stroke care. While AdventHealth Tampa is a designated CSC, it was not among the institutions included in the study.

Earning CSC certification is a demanding and rigorous process, which requires staff training in stroke recognition, access to 24/7 advanced neuroimaging and immediate availability of specialized personnel, including vascular neurologists, neurosurgeons and critical care medicine teams.

Harbach says the higher level of training and expert personnel at CSCs makes it possible to recognize a stroke earlier, which leads to better outcomes for patients.

During a TAVR procedure, a doctor replaces a patient's stiff, narrowed aortic valve with a replacement valve inserted through a catheter.

Strokes are a potential complication, because during the procedure, tiny pieces of calcium or tissue can sometimes break loose and travel to the brain, causing a blockage and stroke.

The national rate for post-TAVR strokes within 30 days of the procedure ranges from 1.5 to 2.5%.

"When someone is having a stroke, getting the right care quickly can make all the difference. Time is key," Harbach said. "The recognition of stroke after TAVR can be very, very subtle, where a patient might just seem sleepy. So having a comprehensive stroke team and having those nurses trained to be able to recognize that is crucial. That can lead to interventions, especially when you're having disabling strokes."

Research findings

The research, conducted by the TVTR board, reviewed more than 500,000 TAVRs performed at more than 800 sites nationwide from January 2016 to June 2023. It looked at how many strokes were reported within 30 days of the procedure, in-hospital and after discharge.

A total of nearly 11,000 post-TAVR strokes were reported, which is just over 2%. Of those, about 4,800 or .9% were disabling strokes.

"One of the most important findings was that Comprehensive Stroke Center designation was independently associated with higher reported rates of in-hospital and disabling strokes following TAVR," Harbach said.

Adding context to that finding, she said that CSCs handle a higher volume of TAVR cases and have specially trained professionals with skills to recognize stroke symptoms, which skews the numbers.

"If your operators are doing more volume and you have a hospital that has a designated CSC that is neuro-focused and you have higher trained nursing staff and physicians to recognize that, your reporting is going to be higher," Harbach said.

Although the study showed that hospitals with CSC designation had a higher rate of stroke reporting, ultimately, CSCs were not associated with higher reported mortality, renal failure or bleeding rates.

"You're recognizing things more frequently than say a smaller hospital that doesn't have the resources or education that you need in order to recognize things sooner," Harbach said. "So that can lead to earlier interventions."

The research helps to level the playing field on performance metrics, providing clarity for why CSCs report higher stroke rates but don't see impact on overall outcomes.

"The common denominator is that the more volume your operators are doing the better outcomes that you have; the more recognition of stroke the more recognition of any kind of bad outcome- you're reporting it, you're seeing it, because you're doing more," Harbach said.

For more information on TAVRs, visit the AdventHealth Pepin Heart Institute and the AdventHealth Heart, Lung and Vascular Institute page on the TAVR procedure.