By Najah Ali Khan, MD
Ms. A., a 63-year-old Spanish-speaking woman, has progressive dyspnea and fatigue caused by prosthetic valve aortic stenosis. Five years earlier, she underwent surgical aortic valve replacement (SAVR), followed by a STEMI complicated by cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) support and months of recovery. This traumatic experience left her fearful of doctors and procedures.
We met in person at the fellows’ integrative clinic in San Diego. I used the Spanish version of the ACC CardioSmart decision aid, “For Patients With Severe Aortic Stenosis: Deciding Between TAVR and SAVR.” While Ms. A. is conversational in English, she prefers reading in Spanish, which immediately put her at ease.
Building Trust
Ms. A., a single mother with two adult children and several grandchildren, works 10-hour days at a desk job but struggles with dyspnea during simple activities like walking with family. She missed caring for her grandchildren the most.
The decision aid’s visuals of a stenosed valve helped her understand the source of her symptoms. Presenting information visually and in her preferred language empowered her to actively participate in decision-making and foster a partnership.
Understanding Risks vs. Benefits
The decision aid opened dialogue about her concerns. We compared transcatheter aortic valve replacement (TAVR) and repeat SAVR. The aid highlighted TAVR’s less invasive nature and quicker recovery, which appealed to her desire to return quickly to work and family. However, the aid also addressed SAVR’s durability, helping her confront fears about future interventions.
Initially, Ms. A. shut down at the mention of SAVR, haunted by her past trauma. With the decision aid, she weighed her goal of minimizing health risks and maintaining independence against her fears. The aid helped her process that while TAVR offered a shorter recovery, its lower durability might require another procedure, conflicting with her goal of reducing interventions.
Social Determinants of Health – Family Support
In the “Making Your Decision” section, Ms. A. reflected on her goals and aligned them with medical expectations. Initially favoring TAVR, she wanted to consult her family. Recognizing her family’s role as her support system, I sent her home with the decision aid to discuss the options with them.
At her follow-up visit, Ms. A. returned with renewed clarity. After reviewing the decision aid with her family, she realized her long-term goal of avoiding repeat interventions outweighed her fear of SAVR. Her family reassured her about SAVR’s durability and the importance of prioritizing a lasting solution over a quicker recovery. Confident in her decision, Ms. A. opted for SAVR, knowing it aligned with her aspirations to stay active with her grandchildren and support her family.
Empowering Patients and Overcoming Challenges
Ms. A.’s emotional trauma initially made discussing SAVR difficult, unable to consider all options objectively. Additionally, cultural nuances required effort to explain complex medical terms. For instance, discussing valve durability and future interventions involved adapting explanations into relatable analogies. Her deep sense of family responsibility further complicated matters, as she struggled to balance caregiving with prioritizing her health.
Despite these challenges, the decision aid transformed an intimidating process into one of clarity and empowerment. The 45 minutes we spent together gave Ms. A. confidence to voice her concerns, ultimately leading her to an informed, values-based decision. In fact, when referred to the surgical and interventional cardiology teams, she felt more in control of the discussion. Later, at a multidisciplinary meeting, she requested I serve as her advocate, trusting I best understood her goals based on our initial meeting with the decision aid.
Outcomes and Reflections
Ms. A. underwent SAVR successfully and returned for a follow-up visit two weeks later. She shared she had taken her grandchildren to the park a week after surgery. This encounter reaffirmed the transformative power of shared decision-making. By prioritizing Ms. A.’s story and goals, we empowered her to make a decision rooted in her values. Moving forward, we can:
- Integrate Family Involvement Earlier: Inviting family to initial consultations may enhance patient comfort and engagement.
- Add Cultural Relevance: Tailor decision aids with culturally relevant visuals or testimonials. Stories of Spanish-speaking patients who underwent TAVR or SAVR could alleviate fears.
- Foster Multidisciplinary Collaboration: Encourage teamwork among cardiologists, surgeons, and allied professionals to ensure cohesive care.
Ms. A.’s journey is a powerful reminder that effective cardiovascular care extends beyond clinical decisions – it’s about understanding the person behind the condition. Each interaction offers an opportunity to bridge barriers, build trust, and deliver care that is as individualized as it is evidence-based.
Najah Ali Khan, MD, is a second-year cardiology fellow at Scripps Prebys Cardiovascular Institute in La Jolla, CA.