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Introduction ⬇

Although surgery remains the treatment of choice for valvular heart disease, balloon valvuloplasty provides an alternative to valve replacement in patients with critical stenoses.1 This technique enlarges the orifice of a heart valve that has been narrowed by a congenital defect, calcification, rheumatic fever, or aging. It evolved from percutaneous transluminal coronary angioplasty and uses the same balloon-tipped catheters for dilatation. Balloon valvuloplasty may be considered as a bridge to surgery or transcatheter aortic valve implantation.1 It may be indicated for patients for whom surgery poses a high risk and for those who refuse surgery.

Balloon valvuloplasty is performed in a cardiac catheterization laboratory under local anesthesia, light sedation, moderate sedation, or general anesthesia.2,3,4 The practitioner inserts a balloon-tipped catheter through the patient’s femoral vein or artery using a sheath, threads it into the heart, and repeatedly inflates it against the leaflets of the diseased valve. This process increases the size of the orifice, improving valvular function and helping prevent complications from decreased cardiac output. (See How balloon valvuloplasty works.)

After balloon valvuloplasty, you should monitor the patient closely for complications, provide supportive care, and teach the patient and family about postprocedure care.

Equipment ⬆ ⬇

Equipment

Before and During Balloon Valvuloplasty

Antiseptic solution • local anesthetic • vital signs monitoring equipment • gloves • gown • caps • masks • valvuloplasty or balloon-tipped catheter • sheath • IV catheter insertion supplies • prescribed IV solution and tubing • cardiac monitor and electrodes • oxygen source • oxygen delivery device • sterile label • prescribed sedative • emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with mask, intubation equipment) • heparin (or other anticoagulant) for injection5 • contrast medium • introducer kit for balloon catheter • introducer kit for balloon catheter • sterile gown • sterile gloves • sterile drapes • sterile dressings • pulse oximeter and probe • prescribed antiplatelet or antithrombotic medications • Optional: disposable head clippers, pulmonary artery (PA) catheter, Doppler ultrasound blood flow detector, sterile scissors, suture material.

After Balloon Valvuloplasty

Gloves • stethoscope • vital signs monitoring equipment • pulse oximeter and probe • prescribed IV solution • IV administration set • cardiac monitor and electrodes • pulmonary artery monitoring system • oxygen source • oxygen delivery device • Doppler ultrasound blood flow detector • disinfectant pad • facility-approved disinfectant • Optional: prescribed medications, electronic infusion device (preferably a smart pump with dose-error reduction software and interoperability with the electronic health record),6 supplies for arterial blood gas (ABG) analysis, additional personal protective equipment (gown, mask with face shield or mask and goggles), prescribed analgesic, labels, bedpan.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. Make sure that emergency equipment is readily available and functioning properly.

Implementation ⬆ ⬇

Implementation

Before Balloon Valvuloplasty

  • Verify the practitioner’s orders.
  • Check the patient’s medical record for allergies to the prescribed contrast medium, prescribed medications, local anesthetic, or latex, and for any other contraindications to the procedure.
  • If required by your facility, confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.7,8,9,10
  • Gather and prepare the necessary equipment and supplies.
  • Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are available and matched correctly to the patient’s identifiers.11,12
  • Verify that the ordered laboratory and imaging studies have been completed and that the results are in the patient’s medical record. Notify the practitioner of critical test results within your facility’s established timeframe so that the patient can be treated promptly.13 Ensure that results of coagulation studies, complete blood count, serum electrolyte studies, and blood typing and crossmatching are available.11,12
  • Review baseline hemodynamic parameters and patient medications for contraindications to the procedure.14
  • Perform hand hygiene.15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers.21
  • Provide privacy.22,23,24,25
  • Reinforce the practitioner’s explanation of the procedure, taking into account the patient’s and family’s (if appropriate) communication and learning needs, to increase understanding, allay fears, and enhance cooperation.26 Include the procedure risks and alternatives, and answer the patients questions.
  • Provide reassurance that, although awake during the procedure, the patient will receive a sedative and a local anesthetic beforehand for comfort.
  • Teach the patient what to expect to ease anxiety and enhance cooperation. For example, inform the patient that the hair in the groin area will be clipped and the skin cleaned with an antiseptic; a brief stinging sensation will be felt when the local anesthetic is injected; and there may be pressure as the catheter moves along the vessel. Describe the warm, flushed feeling that the patient will likely experience from injection of the contrast medium.
  • Explain that the procedure may last up to 4 hours, and that the patient may feel discomfort from lying on a hard table for that long.
  • If the procedure isn’t an emergency, confirm the patient’s nothing-by-mouth status before the procedure; minimum fasting recommendations are 2 hours for clear liquids, 6 or more hours for a light meal or nonhuman milk, and 8 or more hours for fried or fatty foods or meat.27
  • Have the patient void.
  • Raise the bed to waist level before providing care to prevent caregiver back strain.28
  • Perform hand hygiene.15,16,17,18,19,20
  • Obtain vital signs and oxygen saturation level using pulse oximetry to serve as a baseline for comparison during and after the procedure.
  • Perform a neurovascular assessment on all extremities. Assess the presence or absence and quality of all distal pulses. Assess faint or nonpalpable pulses using a Doppler ultrasound blood flow detector, as indicated. (See the "Doppler ultrasound device use" procedure.)10
  • Perform hand hygiene.15,16,17,18,19,20
  • Put on gloves to comply with standard precautions.29,30,31
  • Insert an IV catheter, as ordered, to provide access for medications and to infuse prescribed IV fluid. (See the "IV catheter insertion and removal" procedure.)
  • Clip hair from the insertion site, as needed; clean the site with antiseptic solution and allow it to dry completely.32
  • Administer an antiplatelet or antithrombotic agent, as ordered, following safe medication administration practices.14,33,34,35,36

NURSING ALERT Aspirin reduces the frequency of ischemic complications after percutaneous coronary intervention (PCI). Although the minimum effective aspirin dosage in the setting of PCI hasn’t been established, it’s recommended that 325 mg of aspirin be given at least 2 hours (preferably 24 hours) before PCI.14

  • Administer a sedative, as ordered, following safe medication administration practices.33,34,35,36
  • Remove and discard your gloves.29
  • Perform hand hygiene.15,16,17,18,19,20
  • Provide hand-off communication about the patient’s history, condition, and care to the person who will assume responsibility for the patient’s care during the procedure. Allow time for questions, as necessary, to avoid miscommunications that can cause patient care errors during transitions of care.37
  • Document the procedure.38,39,40,41

During Balloon Valvuloplasty

  • Receive hand-off communication from the person who was responsible for the patient’s care. Ask questions, as necessary, to avoid miscommunications that can cause patient care errors during transitions of care.37 As part of the hand-off process, trace each tubing and catheter from the patient to its point of origin using a standardized line recognition process.37,42,43
  • Perform hand hygiene.15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers.21
  • Conduct a preprocedural verification to make sure that all relevant documentation, related information, and equipment are available and correctly matched with the patient’s identifiers.11,12
  • Put on a cap and mask.
  • Perform hand hygiene.15,16,17,18,19,20
  • Put on a gown, and gloves to comply with standard precautions.29,30,31
  • Attach the patient to the cardiac monitoring equipment. Make sure that the alarm limits are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff.44,45,46,47
  • Administer supplemental oxygen, as ordered.
  • The practitioner will put on a cap and mask, a sterile gown, and sterile gloves, and will then open the sterile supplies. Assist as necessary.
  • Confirm that the correct procedure has been identified for the correct patient at the correct site.11,12
  • Label all medications, medication containers, and other solutions on and off the sterile field.48,49
  • Using maximal barrier precautions, the practitioner will drape the patient and prepare and anesthetize the catheter insertion site (usually at the femoral artery). The practitioner may insert a PA catheter if one isn’t already in place.50
  • Conduct a time-out immediately before starting the procedure to ensure that the correct patient, site, positioning, and procedure are identified and, as applicable, that all relevant information and necessary equipment are available.51
  • The practitioner will then insert a sheath into the site and thread a valvuloplasty or balloon-tipped catheter up into the heart.
  • The practitioner will inject a contrast medium to visualize the heart valves and assess the stenosis; the practitioner will also inject heparin or another anticoagulant5 to prevent the catheter from clotting.13,50
  • Using low pressure, the practitioner will repeatedly inflate the balloon on the valvuloplasty catheter for a short time, usually 15 to 30 seconds, gradually increasing the time and pressure. If these actions don’t reduce the stenosis, the practitioner may use a larger balloon.
  • Monitor the patient during the procedure. Assess the insertion site frequently for bleeding, and monitor International Normalized Ratio, prothrombin time, partial thromboplastin time, activated clotting time, and platelet count, as ordered.5,50 Assess the patient’s vital signs and oxygen saturation levels continually during the procedure, especially for aortic valvuloplasty.

NURSING ALERT During balloon inflation, the aortic outflow tract is completely obstructed, causing blood pressure to fall dangerously low. Ventricular ectopy also is common during balloon positioning and inflation. Start treatment for ectopy when signs or symptoms develop or when ventricular tachycardia is sustained. Carefully assess the patient’s respiratory status; changes in rate and pattern can be the first sign of a complication such as an embolism.

  • After completion of valvuloplasty, a series of angiograms is taken to evaluate the effectiveness of the treatment. Assist as necessary.
  • The practitioner may then suture the sheath in place and cover the insertion site with a sterile dressing. The sutures typically remain in place until the effects of the anticoagulant have worn off.
  • Continue to closely monitor the patient.
  • Discard used supplies in appropriate receptacles.52
  • Remove and discard your gloves and other personal protective equipment.52
  • Perform hand hygiene.15,16,17,18,19,20
  • Document the procedure.38,39,40,41

After Balloon Valvuloplasty

  • Receive hand-off communication from the person who was responsible for the patient’s care during the procedure. Ask questions as necessary to avoid miscommunications that can cause patient care errors during transitions of care.37 As part of the hand-off process, trace each tubing and catheter from the patient to its point of origin using a standardized line reconciliation process.37,42,43
  • Verify the practitioner’s orders.
  • Reconcile the patient’s medications at the care transition to reduce the risk for medication errors, including omissions, duplications, dosing errors, and drug interactions.53,54
  • Gather and prepare the necessary equipment and supplies.
  • Perform hand hygiene.15,16,17,18,19,20
  • Confirm the patient’s identity using at least two patient identifiers.21
  • Provide privacy.22,23,24,25
  • Explain the procedure to the patient and family (if appropriate) according to their communication and learning needs to increase understanding, allay fears, and enhance cooperation.26
  • Raise the patient’s bed to waist level before providing care to prevent caregiver back strain.28
  • Put on gloves and other personal protective equipment as needed to comply with standard precautions.29,30
  • Attach the patient to a cardiac monitor and pulse oximeter. Make sure that the alarm limits are set appropriately for the patient’s current condition and that the alarms are turned on, functioning properly, and audible to staff.44,45,46,47
  • Obtain the patient’s vital signs to serve as a baseline for comparison, and continue to monitor them frequently at an interval determined by your facility and the patient’s condition to promptly recognize changes in the patient’s condition. Note that there’s no evidence-based research to indicate best practice for the frequency of vital signs monitoring.55
  • Assess the sheath insertion site for bleeding, hematoma, and ecchymosis. If the sheath remains in place, refer to the "Arterial and venous sheath removal" procedure when removal is indicated. If the sheath was removed and a compression device remains in place over the insertion site, make sure that the device was applied properly.
  • Ensure that the patient is positioned properly; positioning will depend on the presence of a sheath or the time since sheath removal. Follow facility guidelines, the manufacturer’s guidelines, or the practitioner’s orders.56
  • If the patient is receiving IV heparin,14 nitroglycerin, or another medicated infusion, administer the medication using an electronic infusion device57 following safe medication administration practices to prevent life-threatening dosing errors.33,34,35,58 Make sure that the electronic infusion device alarm limits are set appropriately and that the alarms are turned on, functioning properly, and audible to staff.44,45,46 Trace the tubing from the patient to its point of origin to make sure that it’s connected to the proper port.43 Route the tubing in a standardized direction if the patient has other tubing and catheters that have different purposes. If multiple IV lines will be used, label the tubing at the distal end (near the patient connection) and proximal end (near the source container) to reduce the risk of misconnection.44 If required by your facility, have another nurse perform an independent double-check to verify the patient’s identity and to ensure that the correct medication is hanging in the prescribed concentration, the medication’s indication corresponds with the patient’s diagnosis, the dosage calculations are correct and the dosing formula used to derive the final dose is correct, the route of administration is safe and proper for the patient, the pump settings are correct, and the infusion line is attached to the correct port.59,60 Compare the results of the independent double-check with the other nurse (if required) and, if no discrepancies exist, continue infusing the medication. If discrepancies exist, rectify them before continuing the infusion.60
  • Assess the patient’s cardiac status; continue to monitor the patient’s heart rate and rhythm, and auscultate regularly for murmurs, which may indicate worsening valvular insufficiency. Notify the practitioner if you detect a new or worsening murmur.
  • Administer oxygen, if ordered, as prescribed. Assess the patient’s respiratory status, including oxygen saturation level using pulse oximetry; continue to monitor respiratory status for changes, because changes in respiratory rate and pattern can be the first sign of a complication such as an embolism. Monitor ABG results, as ordered.
  • Monitor the patient’s arterial pressure, pulmonary artery pressure, and other hemodynamic parameters, as indicated.
  • Continue to monitor the insertion site for bleeding and to assess peripheral pulses distal to the insertion site as well as the color, sensation, temperature, and capillary refill time of the affected extremity. Use a Doppler ultrasound blood flow detector to assess pedal pulses because they may be difficult to assess, especially if the sheath remains in place. Compare findings bilaterally.
  • Administer IV fluids, as prescribed, to help the kidneys excrete the contrast medium used during the procedure. Closely monitor intake and output, and watch for signs of fluid overload, such as distended neck veins, atrial and ventricular gallops, dyspnea, pulmonary congestion, tachycardia, hypertension, and hypoxemia.
  • Assess for signs and symptoms of complications of the procedure, such as embolism (dyspnea, tachypnea, altered mental status, and tachycardia), hemorrhage (including retroperitoneal bleeding), myocardial ischemia (chest pain caused by obstruction of blood flow during valvuloplasty), and cardiac tamponade (decreased or absent peripheral pulses, pale or cyanotic skin, hypotension, and paradoxical pulse). Immediately report signs and symptoms of any of these complications.
  • Encourage the patient to perform deep-breathing exercises to prevent atelectasis, which can occur with immobility. Note that this step is especially important in older adult patients.
  • Screen for and assess the patient’s pain using facility-defined criteria that are consistent with the patient’s age, condition, and ability to understand. Treat the patient’s pain as needed and ordered using nonpharmacologic, pharmacologic, or a combination of approaches. Base the treatment plan on evidence-based practices and the patient’s clinical condition, past medical history, and pain management goals.61
  • Administer pain medications, as needed and prescribed, following safe medication administration practices.33,34,35,58
  • Assist the patient during meals, bedpan use, and position changes that are appropriate to the patient’s activity limitations.
  • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment.61
  • Return the patient’s bed to the lowest position to prevent falls and maintain patient safety.64
  • Discard used supplies in appropriate receptacles.52
  • Remove and discard your gloves and any other personal protective equipment worn.52
  • Perform hand hygiene.15,16,17,18,19,20
  • Clean and disinfect your stethoscope using a disinfectant pad.63,64
  • Perform hand hygiene.15,16,17,18,19,20
  • Put on gloves and other personal protective equipment, as needed.52
  • Clean and disinfect reusable equipment according to the manufacturer’s instructions to prevent the spread of infection.63,64
  • Remove and discard your gloves and other personal protective equipment.52
  • Perform hand hygiene.15,16,17,18,19,20
  • Document the procedure.38,39,40,41

Special Considerations ⬆ ⬇

Special considerations
  • Be aware that using heparin and a large-bore catheter can lead to arterial hemorrhage. Monitor the patient closely.
  • If the patient is receiving heparin, monitor partial thromboplastin time or activated clotting time and maintain the infusion according to your facility’s protocol or the practitioner’s order.50,57 Notify the practitioner of critical test results within your facility’s established time frame so that the patient can receive prompt treatment.13
  • The Joint Commission has issued a sentinel event alert concerning medical device alarm safety because alarm-related events have been associated with permanent loss of function and death. Among the major contributing factors were improper alarm settings, alarm settings turned off inappropriately, and alarm signals that are inaudible to staff. Make sure that alarm limits are set appropriately and that alarms are turned on, functioning properly, and audible. Follow facility guidelines for preventing alarm fatigue.44
  • The Joint Commission has issued a sentinel event alert related to managing risk during transition to the new International Organization for Standardization tubing standards that were designed to prevent dangerous tubing misconnections, which can lead to serious patient injury and death. During the transition, trace each tubing and catheter from the patient to its point of origin before connecting or reconnecting any device or infusion, at any care transition (such as a new setting or service), and as part of the hand-off process; route tubes and catheters serving different purposes in different standardized directions; label the tubing at both the distal and proximal ends (when there are different access sites or several bags hanging); use tubing and equipment only as intended; and store medications for different delivery routes in separate locations.42
  • The Joint Commission has issued a sentinel event alert concerning inadequate hand-off communication because of the potential for patient harm that can result when a receiver receives inaccurate, incomplete, untimely, misinterpreted, or otherwise inadequate information. To improve hand-off communication, standardize the critical information communicated by the sender. At a minimum, include the sender contact information; illness assessment; patient summary, including events leading up to the illness or admission, hospital course, ongoing assessment, and care plan; to-do action list; contingency plans; allergy list; code status; medication list; and dated laboratory test results and vital signs. Provide face-to-face communication whenever possible in an interruption-free location using facility-approved, standardized tools and methods (for example, forms, templates, checklists, protocols, and mnemonics). Provide ample time and opportunity for questions, and include the multidisciplinary team members and the patient and family when appropriate.65

Complications ⬆ ⬇

Complications

Complications include bleeding and hematoma at the insertion site, vessel damage, arrhythmias, stroke, valvular rupture, ventricular rupture, valve regurgitation, infection, and an allergic reaction to the contrast medium.66

Documentation ⬆ ⬇

Documentation

Document the patient’s vital signs and oxygen saturation levels before and during the procedure, assessment findings, diagnostic test results, complications and resulting interventions, and the patient’s tolerance of the procedure. Record any teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

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