Each author with particular expertise and members of the cardiovascular team in their respective institutions were asked to comment on what they felt was important to this case or an overall approach to patients having severe aortic stenosis who are considering transcatheter aortic valve replacement (TAVR) based on their unique and specific expertise and viewpoints. The "What Matters Most" to Them!

Jesse Fitzpatrick, MD (Fellow-in-Training)

• "I struggle with how to approach patient-centered discussions in older adults about invasive procedures like TAVR. Risk assessment calculators with information on both hard outcomes (i.e., death, hospitalization) and quality of life metrics (i.e., ambulatory status, independence, metrics of life satisfaction) would be beneficial to me and my patients."
• "Palliative care is routinely involved in the care of heart failure patients undergoing advanced therapy evaluation, though often not proactively engaged for other cardiac conditions. As a fellow, I would appreciate training on how best to utilize the expertise of our palliative care colleagues."

Seema Pursnani, MD (Expertise in Multimodal Imaging)

• "Once a mutual decision has been made to move forward with TAVR evaluation between the patient and our Heart Team, a planning CT scan is essential to determine valve type and sizing, vascular access route, and in coronary artery assessment. If femoral artery access is not feasible, additional discussion regarding an alternative access route (usually trans-carotid) is essential as the risk-benefit profile may change substantially."
• "If a patient has pre-existing renal disease, we need to discuss with the patient the possibility of worsening renal function and need for renal replacement therapy from contrast dye exposure from a CT scan, along with additional contrast dye use during possible invasive coronary angiography and during the TAVR procedure itself."

Wayne Batchelor, MD (Expertise in Structural Heart Disease/Interventional)

• "It is crucial to clearly articulate in layman's terms the risk versus benefit of available transcatheter therapies, in particular how procedures will impact symptoms and prognosis."
• "I believe that it is also important to understand when to leverage experts in geriatrics and palliative care so that older, more frail patients undergo the proper baseline evaluations with appropriately recommended co-interventions so that we are treating the patient and not just the valve."

Victoria Vaughan Dickson, PhD, RN (Expertise in Nursing)

• "Shared decision making is an integral component of patient-centered care and involves the active participation of patients in health care decisions that have multiple acceptable options. The basic tenet of shared decision making is that clinicians are experts in medical evidence, while patients are experts in what matters most to them."
• "Engaging in shared decision making that includes a discussion of patient preferences, patient goals of care, and values, can strengthen the patient provider relationship and ideally result in better outcomes including greater satisfaction and patient engagement in care."

Gwen Bernacki, MD (Expertise in Geriatric Cardiology and Palliative Care)

• "Both aging and palliative care experts uniformly seek to find what matters most to patients, emphasizing the patient-centered care reliance on eliciting patient values, goals, and preferences. Refining the patient's goals in the presence of a confirmed healthcare proxy is especially important in the setting of cognitive impairment/anticipated delirium and in this case would help inform care."
• "Palliative care specialists focus on relieving symptom burden, enhancing comfort, and maintaining or improving quality of life among patients with serious illness. Palliative care can be, and often is, provided in parallel with life-prolonging care for patients of all ages. Geriatricians are aging specialists who specialize in the care and treatment of older adults, recognizing geriatric syndromes, enhancing mobility, and maximizing function."

Ashok Krishnaswami, MBBS, FACC (Expertise in Geriatric Cardiology)

• "It is imperative when caring for the older adult with cardiovascular diseases that a comprehensive assessment of the baseline clinical status is undertaken. This considers underlying geriatric conditions in multiple domains: medical/surgical (multimorbidity, nutrition, dominant disease states, polypharmacy), physical (frailty, fall risk, activities of daily living, instrumental activities of daily living), cognitive (dementia, mild cognitive dysfunction, depression), social (support system, living situation, finances)."¹
• "It is also important to address and discuss possible health trajectories based on baseline clinical status."
• "Understanding and taking into account each individual's unique patient-centered outcome – the "What Matters Most" – as a function of the treatment burden willing to be endured is essential. For example, a patient-centered outcome could be a statement such as 'Doc, I would like to be able to walk half-mile 3-4 time a week with my spouse'. The denominator in this would be the ask of what treatment burden are they willing to go through to maintain or improve physical function."

References

1. Krishnaswami AS, Bernacki GM, Bhatt DL. Geriatric and palliative care specialists as valued members of the multi-disciplinary heart team. Am J Med 2022;Feb 5:[Epub ahead of print].

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Computed Tomography, Nuclear Imaging, Sleep Apnea

Keywords: Aged, Quality of Life, Activities of Daily Living, Transcatheter Aortic Valve Replacement, Palliative Care, Frail Elderly, Patient Participation, Benchmarking, Cardiovascular Diseases, Coronary Angiography, Coronary Vessels, Decision Making, Shared, Depression, Femoral Artery, Geriatricians, Multimorbidity, Patient Preference, Personal Satisfaction, Polypharmacy, Psychosocial Support Systems, Aging, Delirium, Patient-Centered Care, Dementia, Heart Failure, Prognosis, Renal Replacement Therapy, Multimodal Imaging, Hospitalization, Risk Assessment, Aortic Valve Stenosis, Patient Care Planning, Geriatrics, Cognition, Tomography, X-Ray Computed

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