WikiAnesthesia - User contributions [en]

Mitral valve repair or replacement

2026-03-03T15:00:17Z

Zining2023: References section completed

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity and mechanism of lesion (MS vs MR, primary vs secondary)
-LV size and systolic function
-Pulmonary HTN, RV function
-Chronic atrial fibrillation
-Thromboembolism risk (LA thrombus)
-Concomitant procedures (CABG, MAZE, multi valves)
| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbances
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -RV failure
-SAM
-Atrial fibrillation
-Low cardiac output syndrome
-Bleeding
}}

Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement (SMVR) is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

== Overview ==

=== Indications ===

* Symptomatic severe primary (degenerative) MR
*Symptomatic severe MS
* Severe secondary (functional) MR with persistent symptoms despite GDMT
* Severe MR with LV dilation or LV dysfunction
*Recurrent MR after primary repair
* Endocarditis with structural destruction
* Concomitant need during CABG or other valve surgery
Unlike Transcatheter mitral valve repair/replacement, SMVR allows:

* Complete annular debridement
* Abscess debridement
* Annular enlargement
* Leaflet resection and chordal reconstruction
* Preservation of subvalvular apparatus
* Concomitant procedures like MAZE, left atrial appendage excision, tricuspid repair, or CABG
* Durability advantage in primary MR in low risk patients

Transcatheter mitral valve repair/replacement (TMVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

=== Surgical procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches exists<ref>{{Citation|last=Yandrapalli|first=Srikanth|title=Minimally Invasive Mitral Valve Surgery|date=2025|url=http://www.ncbi.nlm.nih.gov/books/NBK567730/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=33620807|access-date=2026-03-03|last2=Sharma|first2=Sanjeev|last3=Kaplan|first3=Jason}}</ref>

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

Left atriotomy (via interatrial groove or transseptal approach) is performed and mitral valve is directly inspected to determine mechanism of pathology.

Repair techniques include annuloplasty ring placement, leaflet resection, chordal replacement, or commissurotomy (MS).

Replacement involves native valve excision (preserving posterior leaflet, if possible, to maintain ventricular geometry). Mechanical or bioprosthetic valve is then implanted. Sutures are placed circumferentially around the annulus. Preservation of subvalvular apparatus reduces postoperative LV dysfunction.

Concomitant MAZE procedure frequently performed in patients with chronic atrial fibrillation and involves surgical ablation lines created in atria. This can be combined with left atrial appendage ligation or excision.

De-airing is critical due to open left atrium and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior sternotomy may limit neck mobility
|-
|Neurologic
| -History of stroke, TIA, cognitive baseline
|-
|Cardiovascular
| -Severity assessment (MS vs MR)
-LV size and systolic function

-LA size

-RV function

-Pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
|<nowiki>-Dysphagia, esophageal/GI tract surgeries (TEE)</nowiki>
|-
|Hematologic
|<nowiki>-Anticoagulation use, blood products available</nowiki>
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
|<nowiki>-DM</nowiki>
|-
|Other
|<nowiki>-Endocarditis (longer CPB)</nowiki>
|}
'''Echocardiography'''

Severe Mitral Stenosis - Valve area < 1.0 cm2, mean gradient > 10mmHg, PAP > 50mmHg

Severe Mitral Regurgitation - EROA > 0.4cm2, regurgitant volume > 60mL, regurgitant fraction > 50%, vena contracta > 7mm

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors/ARBs and DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Arterial line (usually before induction)
* Central access (usually double stick with multi lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe mitral stenosis - standard IV induction acceptable with caution

* Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension (maintain preload)
* Avoid sudden decrease in SVR
* Tachycardia shortens diastole -> worsens LV filling -> pulmonary congestion
* Loss of atrial contraction in MS can cause dramatic decrease in cardiac output

Severe mitral regurgitation - standard IV induction typically well tolerated

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Maintain forward flow
* Bradycardia -> increase regurgitant time -> decrease forward flow
* Increased SVR -> increased regurgitant fraction -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (LA is opened)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

MAZE procedure

* Longer cross-clamp and CPB time
* Higher early conduction abnormalities and postoperative pacing requirements
* Left atrial appendage often ligated or excised

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)
*Pulmonary vasodilators

Common issues:

* Systolic anterior motion (SAM)
* Pulmonary HTN
*RV dysfunction
* Residual gradient
* Paravalvular leak
*Atrial arrhythmias

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Mean gradient appropriate
** Systolic anterior motion (SAM)
* Air
** LA, LV apex, LVOT, ascending aorta
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
** Afterload mismatch (chronic MR patients may develop acute LV dysfunction after repair due to sudden increase in afterload)
* RV function
** RV dilation
** TAPSE
** Septal shift
** Elevated PAP

Hypotension causes:

* SAM - LVOT obstruction, MR
* Vasoplegia - good EF, low SVR
* Ischemia/stunning or afterload mismatch - poor EF, LV function
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Atrial arrhythmias (large left atrium, surgical manipulation, MAZE procedure)
* Heart block (requiring pacing)
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LV dysfunction, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke/neurological deficits (air embolism from LA opening)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|last=Bartels|first=Karsten|title=Hensley's Practical Approach to Cardiothoracic Anesthesia: EBook Without Multimedia|date=2024|publisher=Wolters Kluwer Health|others=Amanda A. Fox, Andrew D. Shaw, Kimberly Howard-Quijano, Robert H. Thiele|isbn=978-1-9752-0910-0|edition=7th ed|location=Philadelphia}}</ref>
!
!Minimally invasive
!MVR+MAZE
!MVR+CABG
!Redo
!Commando
|-
|Unique considerations
| -Peripheral cannulation
-Lung isolation
| -Possible LAA closure
| -Higher ischemic risk
-More inotropes need
|Blood in room before incision
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Higher
|Higher, longer
|Higher, longer
|Very high
|Extremely high
|-
|EBL
|Lower
|Similar
|Higher
|Higher
|Very high
|-
|Potential complications
|<nowiki>-Full sternotomy conversion</nowiki>

-Less wound complications
| -Atrial arrhythmia
-Heart block
|LCOS, bleeding
| -Re-entry injury
-Transfusion
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==

[[Category:Surgical procedures]]

Mitral valve repair or replacement

2026-03-03T14:10:16Z

Zining2023: Procedural variants section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity and mechanism of lesion (MS vs MR, primary vs secondary)
-LV size and systolic function
-Pulmonary HTN, RV function
-Chronic atrial fibrillation
-Thromboembolism risk (LA thrombus)
-Concomitant procedures (CABG, MAZE, multi valves)
| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbances
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -RV failure
-SAM
-Atrial fibrillation
-Low cardiac output syndrome
-Bleeding
}}

Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement (SMVR) is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

== Overview ==

=== Indications ===

* Symptomatic severe primary (degenerative) MR
*Symptomatic severe MS
* Severe secondary (functional) MR with persistent symptoms despite GDMT
* Severe MR with LV dilation or LV dysfunction
*Recurrent MR after primary repair
* Endocarditis with structural destruction
* Concomitant need during CABG or other valve surgery
Unlike Transcatheter mitral valve repair/replacement, SMVR allows:

* Complete annular debridement
* Abscess debridement
* Annular enlargement
* Leaflet resection and chordal reconstruction
* Preservation of subvalvular apparatus
* Concomitant procedures like MAZE, left atrial appendage excision, tricuspid repair, or CABG
* Durability advantage in primary MR in low risk patients

Transcatheter mitral valve repair/replacement (TMVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest

=== Surgical procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

Left atriotomy (via interatrial groove or transseptal approach) is performed and mitral valve is directly inspected to determine mechanism of pathology.

Repair techniques include annuloplasty ring placement, leaflet resection, chordal replacement, or commissurotomy (MS).

Replacement involves native valve excision (preserving posterior leaflet, if possible, to maintain ventricular geometry). Mechanical or bioprosthetic valve is then implanted. Sutures are placed circumferentially around the annulus. Preservation of subvalvular apparatus reduces postoperative LV dysfunction.

Concomitant MAZE procedure frequently performed in patients with chronic atrial fibrillation and involves surgical ablation lines created in atria. This can be combined with left atrial appendage ligation or excision.

De-airing is critical due to open left atrium and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior sternotomy may limit neck mobility
|-
|Neurologic
| -History of stroke, TIA, cognitive baseline
|-
|Cardiovascular
| -Severity assessment (MS vs MR)
-LV size and systolic function

-LA size

-RV function

-Pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
|<nowiki>-Dysphagia, esophageal/GI tract surgeries (TEE)</nowiki>
|-
|Hematologic
|<nowiki>-Anticoagulation use, blood products available</nowiki>
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
|<nowiki>-DM</nowiki>
|-
|Other
|<nowiki>-Endocarditis (longer CPB)</nowiki>
|}
'''Echocardiography'''

Severe Mitral Stenosis - Valve area < 1.0 cm2, mean gradient > 10mmHg, PAP > 50mmHg

Severe Mitral Regurgitation - EROA > 0.4cm2, regurgitant volume > 60mL, regurgitant fraction > 50%, vena contracta > 7mm

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors/ARBs and DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Arterial line (usually before induction)
* Central access (usually double stick with multi lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe mitral stenosis - standard IV induction acceptable with caution

* Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension (maintain preload)
* Avoid sudden decrease in SVR
* Tachycardia shortens diastole -> worsens LV filling -> pulmonary congestion
* Loss of atrial contraction in MS can cause dramatic decrease in cardiac output

Severe mitral regurgitation - standard IV induction typically well tolerated

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Maintain forward flow
* Bradycardia -> increase regurgitant time -> decrease forward flow
* Increased SVR -> increased regurgitant fraction -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (LA is opened)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

MAZE procedure

* Longer cross-clamp and CPB time
* Higher early conduction abnormalities and postoperative pacing requirements
* Left atrial appendage often ligated or excised

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)
*Pulmonary vasodilators

Common issues:

* Systolic anterior motion (SAM)
* Pulmonary HTN
*RV dysfunction
* Residual gradient
* Paravalvular leak
*Atrial arrhythmias

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Mean gradient appropriate
** Systolic anterior motion (SAM)
* Air
** LA, LV apex, LVOT, ascending aorta
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
** Afterload mismatch (chronic MR patients may develop acute LV dysfunction after repair due to sudden increase in afterload)
* RV function
** RV dilation
** TAPSE
** Septal shift
** Elevated PAP

Hypotension causes:

* SAM - LVOT obstruction, MR
* Vasoplegia - good EF, low SVR
* Ischemia/stunning or afterload mismatch - poor EF, LV function
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Atrial arrhythmias (large left atrium, surgical manipulation, MAZE procedure)
* Heart block (requiring pacing)
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LV dysfunction, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke/neurological deficits (air embolism from LA opening)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Minimally invasive
!MVR+MAZE
!MVR+CABG
!Redo
!Commando
|-
|Unique considerations
| -Peripheral cannulation
-Lung isolation
| -Possible LAA closure
| -Higher ischemic risk
-More inotropes need
|Blood in room before incision
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Higher
|Higher, longer
|Higher, longer
|Very high
|Extremely high
|-
|EBL
|Lower
|Similar
|Higher
|Higher
|Very high
|-
|Potential complications
|<nowiki>-Full sternotomy conversion</nowiki>

-Less wound complications
| -Atrial arrhythmia
-Heart block
|LCOS, bleeding
| -Re-entry injury
-Transfusion
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==

[[Category:Surgical procedures]]

Mitral valve repair or replacement

2026-03-03T13:17:05Z

Zining2023: Finished postop management section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity and mechanism of lesion (MS vs MR, primary vs secondary)
-LV size and systolic function
-Pulmonary HTN, RV function
-Chronic atrial fibrillation
-Thromboembolism risk (LA thrombus)
-Concomitant procedures (CABG, MAZE, multi valves)
| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbances
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -RV failure
-SAM
-Atrial fibrillation
-Low cardiac output syndrome
-Bleeding
}}

Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement (SMVR) is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

== Overview ==

=== Indications ===

* Symptomatic severe primary (degenerative) MR
*Symptomatic severe MS
* Severe secondary (functional) MR with persistent symptoms despite GDMT
* Severe MR with LV dilation or LV dysfunction
*Recurrent MR after primary repair
* Endocarditis with structural destruction
* Concomitant need during CABG or other valve surgery
Unlike Transcatheter mitral valve repair/replacement, SMVR allows:

* Complete annular debridement
* Abscess debridement
* Annular enlargement
* Leaflet resection and chordal reconstruction
* Preservation of subvalvular apparatus
* Concomitant procedures like MAZE, left atrial appendage excision, tricuspid repair, or CABG
* Durability advantage in primary MR in low risk patients

Transcatheter mitral valve repair/replacement (TMVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest

=== Surgical procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

Left atriotomy (via interatrial groove or transseptal approach) is performed and mitral valve is directly inspected to determine mechanism of pathology.

Repair techniques include annuloplasty ring placement, leaflet resection, chordal replacement, or commissurotomy (MS).

Replacement involves native valve excision (preserving posterior leaflet, if possible, to maintain ventricular geometry). Mechanical or bioprosthetic valve is then implanted. Sutures are placed circumferentially around the annulus. Preservation of subvalvular apparatus reduces postoperative LV dysfunction.

Concomitant MAZE procedure frequently performed in patients with chronic atrial fibrillation and involves surgical ablation lines created in atria. This can be combined with left atrial appendage ligation or excision.

De-airing is critical due to open left atrium and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior sternotomy may limit neck mobility
|-
|Neurologic
| -History of stroke, TIA, cognitive baseline
|-
|Cardiovascular
| -Severity assessment (MS vs MR)
-LV size and systolic function

-LA size

-RV function

-Pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
|<nowiki>-Dysphagia, esophageal/GI tract surgeries (TEE)</nowiki>
|-
|Hematologic
|<nowiki>-Anticoagulation use, blood products available</nowiki>
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
|<nowiki>-DM</nowiki>
|-
|Other
|<nowiki>-Endocarditis (longer CPB)</nowiki>
|}
'''Echocardiography'''

Severe Mitral Stenosis - Valve area < 1.0 cm2, mean gradient > 10mmHg, PAP > 50mmHg

Severe Mitral Regurgitation - EROA > 0.4cm2, regurgitant volume > 60mL, regurgitant fraction > 50%, vena contracta > 7mm

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors/ARBs and DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Arterial line (usually before induction)
* Central access (usually double stick with multi lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe mitral stenosis - standard IV induction acceptable with caution

* Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension (maintain preload)
* Avoid sudden decrease in SVR
* Tachycardia shortens diastole -> worsens LV filling -> pulmonary congestion
* Loss of atrial contraction in MS can cause dramatic decrease in cardiac output

Severe mitral regurgitation - standard IV induction typically well tolerated

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Maintain forward flow
* Bradycardia -> increase regurgitant time -> decrease forward flow
* Increased SVR -> increased regurgitant fraction -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (LA is opened)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

MAZE procedure

* Longer cross-clamp and CPB time
* Higher early conduction abnormalities and postoperative pacing requirements
* Left atrial appendage often ligated or excised

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)
*Pulmonary vasodilators

Common issues:

* Systolic anterior motion (SAM)
* Pulmonary HTN
*RV dysfunction
* Residual gradient
* Paravalvular leak
*Atrial arrhythmias

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Mean gradient appropriate
** Systolic anterior motion (SAM)
* Air
** LA, LV apex, LVOT, ascending aorta
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
** Afterload mismatch (chronic MR patients may develop acute LV dysfunction after repair due to sudden increase in afterload)
* RV function
** RV dilation
** TAPSE
** Septal shift
** Elevated PAP

Hypotension causes:

* SAM - LVOT obstruction, MR
* Vasoplegia - good EF, low SVR
* Ischemia/stunning or afterload mismatch - poor EF, LV function
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Atrial arrhythmias (large left atrium, surgical manipulation, MAZE procedure)
* Heart block (requiring pacing)
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LV dysfunction, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke/neurological deficits (air embolism from LA opening)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Mitral valve repair or replacement

2026-03-02T17:31:53Z

Zining2023: Finished intraop section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity and mechanism of lesion (MS vs MR, primary vs secondary)
-LV size and systolic function
-Pulmonary HTN, RV function
-Chronic atrial fibrillation
-Thromboembolism risk (LA thrombus)
-Concomitant procedures (CABG, MAZE, multi valves)
| considerations_intraoperative = -Hemodynamic goals (MS vs MR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbances
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -RV failure
-SAM
-Atrial fibrillation
-Low cardiac output syndrome
-Bleeding
}}

Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement (SMVR) is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

== Overview ==

=== Indications ===

* Symptomatic severe primary (degenerative) MR
*Symptomatic severe MS
* Severe secondary (functional) MR with persistent symptoms despite GDMT
* Severe MR with LV dilation or LV dysfunction
*Recurrent MR after primary repair
* Endocarditis with structural destruction
* Concomitant need during CABG or other valve surgery
Unlike Transcatheter mitral valve repair/replacement, SMVR allows:

* Complete annular debridement
* Abscess debridement
* Annular enlargement
* Leaflet resection and chordal reconstruction
* Preservation of subvalvular apparatus
* Concomitant procedures like MAZE, left atrial appendage excision, tricuspid repair, or CABG
* Durability advantage in primary MR in low risk patients

Transcatheter mitral valve repair/replacement (TMVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest

=== Surgical procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

Left atriotomy (via interatrial groove or transseptal approach) is performed and mitral valve is directly inspected to determine mechanism of pathology.

Repair techniques include annuloplasty ring placement, leaflet resection, chordal replacement, or commissurotomy (MS).

Replacement involves native valve excision (preserving posterior leaflet, if possible, to maintain ventricular geometry). Mechanical or bioprosthetic valve is then implanted. Sutures are placed circumferentially around the annulus. Preservation of subvalvular apparatus reduces postoperative LV dysfunction.

Concomitant MAZE procedure frequently performed in patients with chronic atrial fibrillation and involves surgical ablation lines created in atria. This can be combined with left atrial appendage ligation or excision.

De-airing is critical due to open left atrium and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior sternotomy may limit neck mobility
|-
|Neurologic
| -History of stroke, TIA, cognitive baseline
|-
|Cardiovascular
| -Severity assessment (MS vs MR)
-LV size and systolic function

-LA size

-RV function

-Pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
|<nowiki>-Dysphagia, esophageal/GI tract surgeries (TEE)</nowiki>
|-
|Hematologic
|<nowiki>-Anticoagulation use, blood products available</nowiki>
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
|<nowiki>-DM</nowiki>
|-
|Other
|<nowiki>-Endocarditis (longer CPB)</nowiki>
|}
'''Echocardiography'''

Severe Mitral Stenosis - Valve area < 1.0 cm2, mean gradient > 10mmHg, PAP > 50mmHg

Severe Mitral Regurgitation - EROA > 0.4cm2, regurgitant volume > 60mL, regurgitant fraction > 50%, vena contracta > 7mm

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors/ARBs and DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Arterial line (usually before induction)
* Central access (usually double stick with multi lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe mitral stenosis - standard IV induction acceptable with caution

* Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension (maintain preload)
* Avoid sudden decrease in SVR
* Tachycardia shortens diastole -> worsens LV filling -> pulmonary congestion
* Loss of atrial contraction in MS can cause dramatic decrease in cardiac output

Severe mitral regurgitation - standard IV induction typically well tolerated

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Maintain forward flow
* Bradycardia -> increase regurgitant time -> decrease forward flow
* Increased SVR -> increased regurgitant fraction -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (LA is opened)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

MAZE procedure

* Longer cross-clamp and CPB time
* Higher early conduction abnormalities and postoperative pacing requirements
* Left atrial appendage often ligated or excised

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Mean gradient appropriate
** Systolic anterior motion (SAM)
* Air
** LA, LV apex, LVOT, ascending aorta
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
** Afterload mismatch (chronic MR patients may develop acute LV dysfunction after repair due to sudden increase in afterload)
* RV function
** RV dilation
** TAPSE
** Septal shift
** Elevated PAP

Hypotension causes:

* SAM - LVOT obstruction, MR
* Vasoplegia - good EF, low SVR
* Ischemia/stunning or afterload mismatch - poor EF, LV function
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Mitral valve repair or replacement

2026-03-02T16:58:07Z

Zining2023: Finished preop management

Aortic valve repair or replacement

2026-03-02T16:54:24Z

Zining2023: Minor formating, fixes

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

== Overview ==

=== Indications ===
* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

=== Surgical Procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches (upper hemi-sternotomy or right anterior thoracotomy) exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

A transverse or oblique aortotomy is made in the ascending aorta above the sinotubular junction. Native valve leaflets are excised and annular calcifications are debrided. Caution near membranous septum to avoid conduction system injury. Circumferential annular sutures are then placed and passed through sewing ring of prosthesis (mechanical or bioprosthetic). The valve is seated and secured. If annulus is small, annular enlargement procedures may be performed to reduce prosthesis-patient mismatch. Aortotomy is then closed.

De-airing is performed using aortic root vents and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior sternotomy may limit neck mobility
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-Pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors/ARBs and DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Full sternotomy conversion
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
| -Stroke, coronary ischemia
-Massive hemorrhage
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Mitral valve repair or replacement

2026-03-02T15:28:39Z

Zining2023: Finished surgical procedure overview section

Mitral valve repair or replacement

2026-03-02T15:12:13Z

Zining2023: Added TMVR comparison in indications section

Mitral valve repair or replacement

2026-03-02T14:58:24Z

Zining2023: Completed infobox

Mitral valve repair or replacement

2026-03-02T14:52:30Z

Zining2023: General description and indications

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Mitral valve repair or replacement is performed for severe mitral regurgitation (MR), mitral stenosis (MS), or mixed disease. Repair is preferred when possible because it preserves annular-ventricular continuity, maintains LV geometry, improves long-term survival, and avoids prosthetic complications. Replacement is performed when repair is not durable or technically feasible (severe calcifications, rheumatic disease, extensive endocarditis).

== Overview ==

=== Indications ===

* Symptomatic severe primary MR
* Severe secondary MR with persistent symptoms despite GDMT
* Severe MS with symptoms or pulmonary hypertension
* Endocarditis with structural destruction
* Concomitant need during CABG or other valve surgery

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Aortic valve repair or replacement

2026-03-02T14:21:30Z

Zining2023: Added positioning

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

== Overview ==

=== Indications ===
* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

=== Surgical Procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches (upper hemi-sternotomy or right anterior thoracotomy) exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

A transverse or oblique aortotomy is made in the ascending aorta above the sinotubular junction. Native valve leaflets are excised and annular calcifications are debrided. Caution near membranous septum to avoid conduction system injury. Circumferential annular sutures are then placed and passed through sewing ring of prosthesis (mechanical or bioprosthetic). The valve is seated and secured. If annulus is small, annular enlargement procedures may be performed to reduce prosthesis-patient mismatch. Aortotomy is then closed.

De-airing is performed using aortic root vents and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Positioning ===

* Supine
* Arms tucked

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Full sternotomy conversion
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
| -Stroke, coronary ischemia
-Massive hemorrhage
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Aortic valve repair or replacement

2026-03-02T14:16:51Z

Zining2023: Added surgical procedure section in overview

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

== Overview ==

=== Indications ===
* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

=== Surgical Procedure ===
Most commonly performed via median sternotomy, but minimally invasive approaches (upper hemi-sternotomy or right anterior thoracotomy) exists.

After systemic heparinization (ACT > 480 seconds), cardiopulmonary bypass is established with aortic and right atrial (or bicaval) cannulation. Aortic cross-clamp is applied, and myocardial protection is achieved through cold blood cardioplegia delivered either through aortic root (antegrade) and/or coronary sinus (retrograde).

A transverse or oblique aortotomy is made in the ascending aorta above the sinotubular junction. Native valve leaflets are excised and annular calcifications are debrided. Caution near membranous septum to avoid conduction system injury. Circumferential annular sutures are then placed and passed through sewing ring of prosthesis (mechanical or bioprosthetic). The valve is seated and secured. If annulus is small, annular enlargement procedures may be performed to reduce prosthesis-patient mismatch. Aortotomy is then closed.

De-airing is performed using aortic root vents and TEE guidance before cross-clamp removal. After reperfusion and rewarming, patient is weaned from CPB.

Temporary epicardial pacing wires are routinely placed due to risk of conduction disturbances. After protamine administration and hemostasis, chest closure is performed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Full sternotomy conversion
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
| -Stroke, coronary ischemia
-Massive hemorrhage
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Aortic valve repair or replacement

2026-03-02T14:03:09Z

Zining2023: Fix formatting to match other wiki pages

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

== Overview ==

=== Indications ===
* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

=== Surgical Procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Full sternotomy conversion
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
| -Stroke, coronary ischemia
-Massive hemorrhage
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Laryngeal papillomatosis removal

2026-02-26T19:52:51Z

Zining2023:

{{Infobox surgical procedure
| anesthesia_type = General
(Topical/Local in select patients)
| airway = Shared airway
ETT (microcuff) or jet ventilation or intermittent apnea
| lines_access = PIV
| monitors = Standard ASA
| considerations_preoperative = -Severity of airway obstruction (stridor, retractions)
-Voice changes or feeding difficulties
-Location and bulk of papillomas
-Recent URI
-Prior airway history
| considerations_intraoperative = -Shared airway with surgeon
-Airway bleeding/edema
-Airway fire prevention (laser precautions)
-Smoke protection (N95, smoke evacuator)
| considerations_postoperative = -Laryngospasm risk
-Airway edema
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy (SML) - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Stridor at rest (inspiratory vs biphasic)
-Retractions, work of breathing

-Voice quality (hoarseness suggests glottic involvement)

-Prior tracheostomy

-Prior anesthesia records
|-
|Neurologic
| -N/a
|-
|Cardiovascular
| -Tachycardia from distress
-Exercise intolerance
|-
|Pulmonary
| -Baseline oxygenation
-Reactive airway disease history

-Lower airway involvement
|-
|Gastrointestinal
| -NPO guidelines
-Feeding difficulties
|-
|Hematologic
| -Low bleeding risk
|-
|Renal
| -N/a
|-
|Endocrine
| -N/a
|-
|Other
| -OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator)
-No isolation precautions outside OR
|}
===Labs and studies===
Usually none. Consider imaging if distal airway involvement suspected

===Operating room setup===
Airway equipment

* Multiple small ETTs available (consider microcuff for pediatric patients)
* LMA as rescue
* Suction immediately available
* Laser-safe ETT if laser planned
* Backup rigid bronchoscope
* Jet ventilation equipment if used
* Difficult airway cart immediately available
* Tracheostomy equipment if used

Laser precautions (airway fire precautions)

* N95 mask with laser safe eyewear<ref>{{Cite web|title=Hygiene measures for HP viruses in the operating room|url=https://www.hartmann-science-center.com/en/hygiene-knowledge/hygiene-measures/pathogen-specific-hygiene-measures/hygiene-measures-for-hpv-in-the-operating-room|access-date=2026-02-26|website=www.hartmann-science-center.com|language=en}}</ref>
* Smoke evacuator with ULPA filter
* Laser-safe ETT
* ETT cuff inflated with saline +/- methylene blue
* Saline available on field
* FiO2 < 30%, avoid nitrous

===Patient preparation and premedication===

* Standard premedication acceptable if minimal obstruction
* Avoid heavy sedation if airway obstruction presents
* Glycopyrrolate may improve visualization
* Dexamethasone to reduce airway edema

===Regional and neuraxial techniques===
Not routinely used

* Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
* Office-based laser procedures in adults may use topical anesthesia with minimal sedation

==Intraoperative management==
===Monitoring and access===
Standard ASA monitors with 1 PIV often sufficient

===Induction and airway management===
Mild to moderate obstruction

* Standard IV induction with short acting paralytic (if paralysis for ETT is needed)
* Adults with partial obstruction typically tolerate paralysis and positive pressure ventilation
* Shared decision-making regarding airway plan (possibly mask ventilation until ENT intubates with SML)

Severe airway obstruction

# Inhalational induction (sevoflurane)
#* Maintain spontaneous respirations
#* Avoid sudden loss of upper airway tone
#* More challenging in adults
# TIVA with spontaneous ventilation
#* Propofol + low dose remifentanil, consider ketamine
#* Avoid neuromuscular blockade until secured
# Awake vocal cord intubation (adults)
#* Topical anesthesia
#* Minimal sedation

Airway techniques

# Endotracheal tube
#* Most common method with continuous ventilation
#* Appropriately downsized ETT (microcuff in pediatric)
# Intermittent apnea
#* Advance surgical instruments between ventilation (either mask or withdrawn ETT)
#* Reintubate/ventilate between passes
# Jet ventilation
#* Subglottic obtains best uninterrupted surgical view
#* Monitor pressure and other risks

===Positioning===
HOB likely away from anesthesia machine and towards surgeons

===Maintenance and surgical considerations===

* TIVA with propofol +/- remifentanil commonly used
* Balanced volatile more challenging due to shared airway
* Avoid nitrous oxide (increased combustion risk of airway fire)
* Ensure adequate anesthetic depth to prevent coughing or reflex movement during airway manipulation as SML can be very stimulating

Laser precautions

* Fire triad: oxidizer (O2 or N2O), ignition source (laser), fuel (ETT cuff/tube)
* Use laser-resistant ETT
* Maintain FiO2 < 30% (lowest safe possible)
* Inflate cuff with saline +/- methylene blue
* Smoke evacuator with ULPA filter
* Saline immediately available on field

Airway fire emergency protocol<ref>{{Cite journal|date=2008-05-01|title=Practice Advisory for the Prevention and Management of Operating Room Fires|url=https://doi.org/10.1097/01.anes.0000299343.87119.a9|journal=Anesthesiology|volume=108|issue=5|pages=786–801|doi=10.1097/01.anes.0000299343.87119.a9|issn=0003-3022}}</ref>

* Stop oxygen and laser
* Remove ETT
* Flood airway with saline
* Ventilate with room air
* Reassess tube and airway injury (e.g. bronchoscopy)

===Emergence===
Goal

* Smooth
* Avoid coughing and bucking
* Prevent laryngospasm (especially in pediatric)

Strategies

* Deep extubation
* IV or topical lidocaine to blunt cough reflex
* Dexamethasone to reduce edema
* Racemic epinephrine and reintubation equipment readily available

==Postoperative management==
===Disposition===
PACU for mild disease

Observation or admission if

* Significant edema
* Severe preoperative obstruction
* Long case

===Pain management===
Typically mild

* Acetaminophen
* NSAIDs
* Opioids rarely required

===Potential complications===
Immediate

* Laryngospasm
* Airway edema
* Stridor
* Bleeding
* Airway fire

Delayed

* Recurrence (common)
* Subglottic stenosis (from repeated procedures)
* Distal airway spread
<ref>{{Citation|title=Copyright|date=2010|url=https://doi.org/10.1016/b978-0-443-06959-8.00105-9|work=Miller's Anesthesia|pages=iv|publisher=Elsevier|isbn=978-0-443-06959-8|access-date=2026-02-26}}</ref><ref>{{Cite book|title=Anesthesiologist's manual of surgical procedures|date=2020|publisher=Wolters Kluwer|isbn=978-1-4963-7125-6|editor-last=Jaffe|editor-first=Richard A.|edition=6th ed|location=Philadelphia|editor-last2=Schmiesing|editor-first2=Clifford A.|editor-last3=Golianu|editor-first3=Brenda|editor-last4=Ovid Technologies, Inc}}</ref>

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Microdebrider
!Cold instruments
!Laser excision
!Office-based laser
|-
|Unique considerations
|Less fire risk
Tolerate higher FiO2
|Spontaneous ventilation
or intermittent apnea preferred
|Laser precautions
|Often local/topical anesthesia
Minimal sedation
|-
|Advantages
|Shorter operating time
|No thermal injury
|Precision
Hemostasis
|Avoids GA
|-
|Potential complications
|Bleeding
Mucosal trauma
|Bleeding
Airway edema
|Airway fire
Thermal injury
|Laryngospasm
|}

==References==

[[Category:Surgical procedures]]

Mitral valve repair or replacement

2026-02-26T19:14:48Z

Zining2023: Created template

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Provide a brief summary here.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T19:12:07Z

Zining2023: Finished procedure variants and references section

{{Infobox surgical procedure
| anesthesia_type = General
(Topical/Local in select patients)
| airway = Shared airway
ETT (microcuff) or jet ventilation or intermittent apnea
| lines_access = PIV
| monitors = Standard ASA
| considerations_preoperative = -Severity of airway obstruction (stridor, retractions)
-Voice changes or feeding difficulties
-Location and bulk of papillomas
-Recent URI
-Prior airway history
| considerations_intraoperative = -Shared airway with surgeon
-Airway bleeding/edema
-Airway fire prevention (laser precautions)
-Smoke protection (N95, smoke evacuator)
| considerations_postoperative = -Laryngospasm risk
-Airway edema
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy (SML) - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Stridor at rest (inspiratory vs biphasic)
-Retractions, work of breathing

-Voice quality (hoarseness suggests glottic involvement)

-Prior tracheostomy

-Prior anesthesia records
|-
|Neurologic
| -N/a
|-
|Cardiovascular
| -Tachycardia from distress
-Exercise intolerance
|-
|Pulmonary
| -Baseline oxygenation
-Reactive airway disease history

-Lower airway involvement
|-
|Gastrointestinal
| -NPO guidelines
-Feeding difficulties
|-
|Hematologic
| -Low bleeding risk
|-
|Renal
| -N/a
|-
|Endocrine
| -N/a
|-
|Other
| -OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator)
-No isolation precautions outside OR
|}
===Labs and studies===
Usually none. Consider imaging if distal airway involvement suspected

===Operating room setup===
Airway equipment

* Multiple small ETTs available (consider microcuff for pediatric patients)
* LMA as rescue
* Suction immediately available
* Laser-safe ETT if laser planned
* Backup rigid bronchoscope
* Jet ventilation equipment if used
* Difficult airway cart immediately available
* Tracheostomy equipment if used

Laser precautions (airway fire precautions)

* N95 mask with laser safe eyewear<ref>{{Cite web|title=Hygiene measures for HP viruses in the operating room|url=https://www.hartmann-science-center.com/en/hygiene-knowledge/hygiene-measures/pathogen-specific-hygiene-measures/hygiene-measures-for-hpv-in-the-operating-room|access-date=2026-02-26|website=www.hartmann-science-center.com|language=en}}</ref>
* Smoke evacuator with ULPA filter
* Laser-safe ETT
* ETT cuff inflated with saline +/- methylene blue
* Saline available on field
* FiO2 < 30%, avoid nitrous

===Patient preparation and premedication===

* Standard premedication acceptable if minimal obstruction
* Avoid heavy sedation if airway obstruction presents
* Glycopyrrolate may improve visualization
* Dexamethasone to reduce airway edema

===Regional and neuraxial techniques===
Not routinely used

* Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
* Office-based laser procedures in adults may use topical anesthesia with minimal sedation

==Intraoperative management==
===Monitoring and access===
Standard ASA monitors with 1 PIV often sufficient

===Induction and airway management===
Mild to moderate obstruction

* Standard IV induction with short acting paralytic (if paralysis for ETT is needed)
* Adults with partial obstruction typically tolerate paralysis and positive pressure ventilation
* Shared decision-making regarding airway plan (possibly mask ventilation until ENT intubates with SML)

Severe airway obstruction

# Inhalational induction (sevoflurane)
#* Maintain spontaneous respirations
#* Avoid sudden loss of upper airway tone
#* More challenging in adults
# TIVA with spontaneous ventilation
#* Propofol + low dose remifentanil
#* Avoid neuromuscular blockade until secured
# Awake vocal cord intubation (adults)
#* Topical anesthesia
#* Minimal sedation

Airway techniques

# Endotracheal tube
#* Most common method with continuous ventilation
#* Appropriately downsized ETT (microcuff in pediatric)
# Intermittent apnea
#* Advance surgical instruments between ventilation (either mask or withdrawn ETT)
#* Reintubate/ventilate between passes
# Jet ventilation
#* Subglottic obtains best uninterrupted surgical view
#* Monitor pressure and other risks

===Positioning===
HOB likely away from anesthesia machine and towards surgeons

===Maintenance and surgical considerations===

* TIVA with propofol +/- remifentanil commonly used
* Balanced volatile more challenging due to shared airway
* Avoid nitrous oxide (increased combustion risk of airway fire)
* Ensure adequate anesthetic depth to prevent coughing or reflex movement during airway manipulation as SML can be very stimulating

Laser precautions

* Fire triad: oxidizer (O2 or N2O), ignition source (laser), fuel (ETT cuff/tube)
* Use laser-resistant ETT
* Maintain FiO2 < 30% (lowest safe possible)
* Inflate cuff with saline +/- methylene blue
* Smoke evacuator with ULPA filter
* Saline immediately available on field

Airway fire emergency protocol<ref>{{Cite journal|date=2008-05-01|title=Practice Advisory for the Prevention and Management of Operating Room Fires|url=https://doi.org/10.1097/01.anes.0000299343.87119.a9|journal=Anesthesiology|volume=108|issue=5|pages=786–801|doi=10.1097/01.anes.0000299343.87119.a9|issn=0003-3022}}</ref>

* Stop oxygen and laser
* Remove ETT
* Flood airway with saline
* Ventilate with room air
* Reassess tube and airway injury (e.g. bronchoscopy)

===Emergence===
Goal

* Smooth
* Avoid coughing and bucking
* Prevent laryngospasm (especially in pediatric)

Strategies

* Deep extubation
* IV or topical lidocaine to blunt cough reflex
* Dexamethasone to reduce edema
* Racemic epinephrine and reintubation equipment readily available

==Postoperative management==
===Disposition===
PACU for mild disease

Observation or admission if

* Significant edema
* Severe preoperative obstruction
* Long case

===Pain management===
Typically mild

* Acetaminophen
* NSAIDs
* Opioids rarely required

===Potential complications===
Immediate

* Laryngospasm
* Airway edema
* Stridor
* Bleeding
* Airway fire

Delayed

* Recurrence (common)
* Subglottic stenosis (from repeated procedures)
* Distal airway spread
<ref>{{Citation|title=Copyright|date=2010|url=https://doi.org/10.1016/b978-0-443-06959-8.00105-9|work=Miller's Anesthesia|pages=iv|publisher=Elsevier|isbn=978-0-443-06959-8|access-date=2026-02-26}}</ref><ref>{{Cite book|title=Anesthesiologist's manual of surgical procedures|date=2020|publisher=Wolters Kluwer|isbn=978-1-4963-7125-6|editor-last=Jaffe|editor-first=Richard A.|edition=6th ed|location=Philadelphia|editor-last2=Schmiesing|editor-first2=Clifford A.|editor-last3=Golianu|editor-first3=Brenda|editor-last4=Ovid Technologies, Inc}}</ref>

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Microdebrider
!Cold instruments
!Laser excision
!Office-based laser
|-
|Unique considerations
|Less fire risk
Tolerate higher FiO2
|Spontaneous ventilation
or intermittent apnea preferred
|Laser precautions
|Often local/topical anesthesia
Minimal sedation
|-
|Advantages
|Shorter operating time
|No thermal injury
|Precision
Hemostasis
|Avoids GA
|-
|Potential complications
|Bleeding
Mucosal trauma
|Bleeding
Airway edema
|Airway fire
Thermal injury
|Laryngospasm
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T18:45:32Z

Zining2023: Finished maintenance and emergence sections

{{Infobox surgical procedure
| anesthesia_type = General
(Topical/Local in select patients)
| airway = Shared airway
ETT (microcuff) or jet ventilation or intermittent apnea
| lines_access = PIV
| monitors = Standard ASA
| considerations_preoperative = -Severity of airway obstruction (stridor, retractions)
-Voice changes or feeding difficulties
-Location and bulk of papillomas
-Recent URI
-Prior airway history
| considerations_intraoperative = -Shared airway with surgeon
-Airway bleeding/edema
-Airway fire prevention (laser precautions)
-Smoke protection (N95, smoke evacuator)
| considerations_postoperative = -Laryngospasm risk
-Airway edema
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy (SML) - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Stridor at rest (inspiratory vs biphasic)
-Retractions, work of breathing

-Voice quality (hoarseness suggests glottic involvement)

-Prior tracheostomy

-Prior anesthesia records
|-
|Neurologic
| -N/a
|-
|Cardiovascular
| -Tachycardia from distress
-Exercise intolerance
|-
|Pulmonary
| -Baseline oxygenation
-Reactive airway disease history

-Lower airway involvement
|-
|Gastrointestinal
| -NPO guidelines
-Feeding difficulties
|-
|Hematologic
| -Low bleeding risk
|-
|Renal
| -N/a
|-
|Endocrine
| -N/a
|-
|Other
| -OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator)
-No isolation precautions outside OR
|}
===Labs and studies===
Usually none. Consider imaging if distal airway involvement suspected

===Operating room setup===
Airway equipment

* Multiple small ETTs available (consider microcuff for pediatric patients)
* LMA as rescue
* Suction immediately available
* Laser-safe ETT if laser planned
* Backup rigid bronchoscope
* Jet ventilation equipment if used
* Difficult airway cart immediately available
* Tracheostomy equipment if used

Laser precautions (airway fire precautions)

* N95 mask with laser safe eyewear
* Smoke evacuator with ULPA filter
* Laser-safe ETT
* ETT cuff inflated with saline +/- methylene blue
* Saline available on field
* FiO2 < 30%, avoid nitrous

===Patient preparation and premedication===

* Standard premedication acceptable if minimal obstruction
* Avoid heavy sedation if airway obstruction presents
* Glycopyrrolate may improve visualization
* Dexamethasone to reduce airway edema

===Regional and neuraxial techniques===
Not routinely used

* Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
* Office-based laser procedures in adults may use topical anesthesia with minimal sedation

==Intraoperative management==
===Monitoring and access===
Standard ASA monitors with 1 PIV often sufficient

===Induction and airway management===
Mild to moderate obstruction

* Standard IV induction with short acting paralytic (if paralysis for ETT is needed)
* Adults with partial obstruction typically tolerate paralysis and positive pressure ventilation
* Shared decision-making regarding airway plan (possibly mask ventilation until ENT intubates with SML)

Severe airway obstruction

# Inhalational induction (sevoflurane)
#* Maintain spontaneous respirations
#* Avoid sudden loss of upper airway tone
#* More challenging in adults
# TIVA with spontaneous ventilation
#* Propofol + low dose remifentanil
#* Avoid neuromuscular blockade until secured
# Awake vocal cord intubation (adults)
#* Topical anesthesia
#* Minimal sedation

Airway techniques

# Endotracheal tube
#* Most common method with continuous ventilation
#* Appropriately downsized ETT (microcuff in pediatric)
# Intermittent apnea
#* Advance surgical instruments between ventilation (either mask or withdrawn ETT)
#* Reintubate/ventilate between passes
# Jet ventilation
#* Subglottic obtains best uninterrupted surgical view
#* Monitor pressure and other risks

===Positioning===
HOB likely away from anesthesia machine and towards surgeons

===Maintenance and surgical considerations===

* TIVA with propofol +/- remifentanil commonly used
* Balanced volatile more challenging due to shared airway
* Avoid nitrous oxide (increased combustion risk of airway fire)
* Ensure adequate anesthetic depth to prevent coughing or reflex movement during airway manipulation as SML can be very stimulating

Laser precautions

* Fire triad: oxidizer (O2 or N2O), ignition source (laser), fuel (ETT cuff/tube)
* Use laser-resistant ETT
* Maintain FiO2 < 30% (lowest safe possible)
* Inflate cuff with saline +/- methylene blue
* Smoke evacuator with ULPA filter
* Saline immediately available on field

Airway fire emergency protocol

* Stop oxygen and laser
* Remove ETT
* Flood airway with saline
* Ventilate with room air
* Reassess tube and airway injury (e.g. bronchoscopy)

===Emergence===
Goal

* Smooth
* Avoid coughing and bucking
* Prevent laryngospasm (especially in pediatric)

Strategies

* Deep extubation
* IV or topical lidocaine to blunt cough reflex
* Dexamethasone to reduce edema
* Racemic epinephrine and reintubation equipment readily available

==Postoperative management==
===Disposition===
PACU for mild disease

Observation or admission if

* Significant edema
* Severe preoperative obstruction
* Long case

===Pain management===
Typically mild

* Acetaminophen
* NSAIDs
* Opioids rarely required

===Potential complications===
Immediate

* Laryngospasm
* Airway edema
* Stridor
* Bleeding
* Airway fire

Delayed

* Recurrence (common)
* Subglottic stenosis (from repeated procedures)
* Distal airway spread

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T18:03:36Z

Zining2023: Finished induction and airway management

{{Infobox surgical procedure
| anesthesia_type = General
(Topical/Local in select patients)
| airway = Shared airway
ETT (microcuff) or jet ventilation or intermittent apnea
| lines_access = PIV
| monitors = Standard ASA
| considerations_preoperative = -Severity of airway obstruction (stridor, retractions)
-Voice changes or feeding difficulties
-Location and bulk of papillomas
-Recent URI
-Prior airway history
| considerations_intraoperative = -Shared airway with surgeon
-Airway bleeding/edema
-Airway fire prevention (laser precautions)
-Smoke protection (N95, smoke evacuator)
| considerations_postoperative = -Laryngospasm risk
-Airway edema
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy (SML) - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Stridor at rest (inspiratory vs biphasic)
-Retractions, work of breathing

-Voice quality (hoarseness suggests glottic involvement)

-Prior tracheostomy

-Prior anesthesia records
|-
|Neurologic
| -N/a
|-
|Cardiovascular
| -Tachycardia from distress
-Exercise intolerance
|-
|Pulmonary
| -Baseline oxygenation
-Reactive airway disease history

-Lower airway involvement
|-
|Gastrointestinal
| -NPO guidelines
-Feeding difficulties
|-
|Hematologic
| -Low bleeding risk
|-
|Renal
| -N/a
|-
|Endocrine
| -N/a
|-
|Other
| -OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator)
-No isolation precautions outside OR
|}
===Labs and studies===
Usually none. Consider imaging if distal airway involvement suspected

===Operating room setup===
Airway equipment

* Multiple small ETTs available (consider microcuff for pediatric patients)
* LMA as rescue
* Suction immediately available
* Laser-safe ETT if laser planned
* Backup rigid bronchoscope
* Jet ventilation equipment if used
* Difficult airway cart immediately available
* Tracheostomy equipment if used

Laser precautions (airway fire precautions)

* N95 mask with laser safe eyewear
* Smoke evacuator with ULPA filter
* Laser-safe ETT
* ETT cuff inflated with saline +/- methylene blue
* Saline available on field
* FiO2 < 30%, avoid nitrous

===Patient preparation and premedication===

* Standard premedication acceptable if minimal obstruction
* Avoid heavy sedation if airway obstruction presents
* Glycopyrrolate may improve visualization
* Dexamethasone to reduce airway edema

===Regional and neuraxial techniques===
Not routinely used

* Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
* Office-based laser procedures in adults may use topical anesthesia with minimal sedation

==Intraoperative management==
===Monitoring and access===
Standard ASA monitors with 1 PIV often sufficient

===Induction and airway management===
Mild to moderate obstruction

* Standard IV induction with short acting paralytic (if paralysis for ETT is needed)
* Adults with partial obstruction typically tolerate paralysis and positive pressure ventilation
* Shared decision-making regarding airway plan (possibly mask ventilation until ENT intubates with SML)

Severe airway obstruction

# Inhalational induction (sevoflurane)
#* Maintain spontaneous respirations
#* Avoid sudden loss of upper airway tone
#* More challenging in adults
# TIVA with spontaneous ventilation
#* Propofol + low dose remifentanil
#* Avoid neuromuscular blockade until secured
# Awake vocal cord intubation (adults)
#* Topical anesthesia
#* Minimal sedation

Airway techniques

# Endotracheal tube
#* Most common method with continuous ventilation
#* Appropriately downsized ETT (microcuff in pediatric)
# Intermittent apnea
#* Advance surgical instruments between ventilation (either mask or withdrawn ETT)
#* Reintubate/ventilate between passes
# Jet ventilation
#* Subglottic obtains best uninterrupted surgical view
#* Monitor pressure and other risks

===Positioning===
HOB likely away from anesthesia machine and towards surgeons

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==
===Disposition===
PACU for mild disease

Observation or admission if

* Significant edema
* Severe preoperative obstruction
* Long case

===Pain management===
Typically mild

* Acetaminophen
* NSAIDs
* Opioids rarely required

===Potential complications===
Immediate

* Laryngospasm
* Airway edema
* Stridor
* Bleeding
* Airway fire

Delayed

* Recurrence (common)
* Subglottic stenosis (from repeated procedures)
* Distal airway spread

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T15:22:44Z

Zining2023: Finished postop management section

{{Infobox surgical procedure
| anesthesia_type = General
(Topical/Local in select patients)
| airway = Shared airway
ETT (microcuff) or jet ventilation or intermittent apnea
| lines_access = PIV
| monitors = Standard ASA
| considerations_preoperative = -Severity of airway obstruction (stridor, retractions)
-Voice changes or feeding difficulties
-Location and bulk of papillomas
-Recent URI
-Prior airway history
| considerations_intraoperative = -Shared airway with surgeon
-Airway bleeding/edema
-Airway fire prevention (laser precautions)
-Smoke protection (N95, smoke evacuator)
| considerations_postoperative = -Laryngospasm risk
-Airway edema
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Stridor at rest (inspiratory vs biphasic)
-Retractions, work of breathing

-Voice quality (hoarseness suggests glottic involvement)

-Prior tracheostomy

-Prior anesthesia records
|-
|Neurologic
| -N/a
|-
|Cardiovascular
| -Tachycardia from distress
-Exercise intolerance
|-
|Pulmonary
| -Baseline oxygenation
-Reactive airway disease history

-Lower airway involvement
|-
|Gastrointestinal
| -NPO guidelines
-Feeding difficulties
|-
|Hematologic
| -Low bleeding risk
|-
|Renal
| -N/a
|-
|Endocrine
| -N/a
|-
|Other
| -OR precautions to possible viral aerosolization and laser plum (N95, smoke evacuator)
-No isolation precautions outside OR
|}
===Labs and studies===
Usually none. Consider imaging if distal airway involvement suspected

===Operating room setup===
Airway equipment

* Multiple small ETTs available (consider microcuff for pediatric patients)
* LMA as rescue
* Suction immediately available
* Laser-safe ETT if laser planned
* Backup rigid bronchoscope
* Jet ventilation equipment if used
* Difficult airway cart immediately available
* Tracheostomy equipment if used

Laser precautions (airway fire precautions)

* N95 mask with laser safe eyewear
* Smoke evacuator with ULPA filter
* Laser-safe ETT
* ETT cuff inflated with saline +/- methylene blue
* Saline available on field
* FiO2 < 30%, avoid nitrous

===Patient preparation and premedication===

* Standard premedication acceptable if minimal obstruction
* Avoid heavy sedation if airway obstruction presents
* Glycopyrrolate may improve visualization
* Dexamethasone to reduce airway edema

===Regional and neuraxial techniques===
Not routinely used

* Superior laryngeal nerve block or transtracheal block may be used in rare awake adults cases
* Office-based laser procedures in adults may use topical anesthesia with minimal sedation

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==
===Disposition===
PACU for mild disease

Observation or admission if

* Significant edema
* Severe preoperative obstruction
* Long case

===Pain management===
Typically mild

* Acetaminophen
* NSAIDs
* Opioids rarely required

===Potential complications===
Immediate

* Laryngospasm
* Airway edema
* Stridor
* Bleeding
* Airway fire

Delayed

* Recurrence (common)
* Subglottic stenosis (from repeated procedures)
* Distal airway spread

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T15:17:22Z

Zining2023: Finished preop section

Laryngeal papillomatosis removal

2026-02-26T14:56:17Z

Zining2023: Finished infobox

Laryngeal papillomatosis removal

2026-02-26T14:15:47Z

Zining2023: Overview citation

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree<ref>{{Cite journal|last=Primov-Fever|first=Adi|last2=Madgar|first2=Ory|date=2019-12|title=Surgery for adult laryngeal papillomatosis|url=https://linkinghub.elsevier.com/retrieve/pii/S1043181019300661|journal=Operative Techniques in Otolaryngology-Head and Neck Surgery|volume=30|issue=4|pages=264–268|doi=10.1016/j.otot.2019.09.008|issn=1043-1810}}</ref>

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T14:10:55Z

Zining2023: Finish overview with indications and surgical procedure

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===

* Airway obstruction (symptomatic)
* Voice dysfunction (interfering with communication or quality)
* Recurrent disease debulking
* Distal airway spread into subglottic or lower

Urgency ranges from elective to emergent depending on obstruction severity

Surgery is palliative, not curative, and does not remove HPV from the tissue

===Surgical procedure===
Principles:

* Preserve healthy mucosa to minimize scarring and voice disruption
* Avoid overly aggressive resection to reduce webbing and dysphonia

Suspension microlaryngoscopy - surgeon visualizes the larynx with laryngoscope and removes papillomas using:

* Microdebrider
** Rotating blade with suction to remove papillomas with minimal manipulation of surrounding tissue
** Rapidly debulk lesions with shorter operative time and less injury to surrounding tissue than lasers
* Cold instruments
** Traditional excision via forceps or scissors
** Useful for small or focal lesions and biopsy
* Laser resection
** CO2 historically used with precision and hemostasis
** Photoangiolytic lasers (KTP, pulsed dye) more favored with potentially lower scar formation
** Requires airway fire precautions

Office-based flexible endoscopic laser under topical sedation is possible in cooperative adults with limited disease

Tracheotomy possible in severe, airway-compromising disease unresponsive to repeated microlaryngoscopy, but carries risk of distal viral spread along tracheobronchial tree

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Laryngeal papillomatosis removal

2026-02-26T13:52:36Z

Zining2023: Page creation and brief overview

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}Laryngeal papillomatosis or recurrent respiratory papillomatosis (RRP) is a benign but chronic, recurrent disease caused by human papillomavirus (HPV) types 6 and 11. Lesions most commonly occur on vocal cords but can involve any part of the larynx and occasionally subglottic or tracheal region. Papillomas grow exophytically and interfere with phonation and airway patency.

It affects both children (juvenile-onset) and adults (adult-onset), with more aggressive disease and higher recurrence rates typically see in children. There is no cure and recurrence is common, so patient often require multiple procedures over their lifetime. The goal of surgery is to relieve airway obstruction and improve voice quality.

==Overview==
===Indications===
===Surgical procedure===

==Preoperative management==
===Patient evaluation===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
===Labs and studies===
===Operating room setup===
===Patient preparation and premedication===
===Regional and neuraxial techniques===

==Intraoperative management==
===Monitoring and access===

===Induction and airway management===

===Positioning===

===Maintenance and surgical considerations===

===Emergence===

==Postoperative management==
===Disposition===

===Pain management===

===Potential complications===

==Procedure variants==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

==References==

[[Category:Surgical procedures]]

Bladder exstrophy repair

2026-02-23T17:44:54Z

Zining2023: Finished postop management and references

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (often recommended)
| monitors = Standard ASA
Temperature
Arterial BP (if placed)
| considerations_preoperative = -Neonate/infant physiology
-Associated congenital anomalies
| considerations_intraoperative = -Large fluid shifts and blood loss risk
-Hypothermia prevention
-Pelvic osteotomies need
-Regional analgesia (caudal/epidural)
| considerations_postoperative = -Ventilatory support (neonate or prolonged case)
-Epidural analgesia management
-Wound dehiscence risk
-Electrolyte abnormalities
}}

Bladder exstrophy is a rare congenital anomaly characterized by failure of lower abdominal wall and anterior bladder closure, resulting in exposure of posterior bladder wall through the abdominal wall. The defect results from failure of mesenchymal migration and premature rupture of cloacal membrane during embryologic development.

Surgical repair is typically performed in neonatal period (primary closure) or later in staged reconstruction.

== Overview ==

=== Indications ===
Surgical repair indicated in all cases of classic bladder exstrophy with goals to

* Protect exposed bladder mucosa from infection and trauma
* Prevent progressive renal damage
* Restore urinary continence
* Reconstruct genital and abdominal anatomy

Timing

* Ideally within first year of life, preferably before 9 months (now the new norm)
* Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies
* Delayed or staged reconstruction can be performed in older infants or failed primary closure

=== Surgical procedure ===

* Bladder plate mobilization and closure (exposed bladder plate is dissected and mobilized to allow posterior wall approximation)
* Bladder neck and urethra reconstruction (if part of staged repair)
* Abdominal wall closure (rectus muscles and fascia are mobilized and reapproximated)
* Pelvic osteotomies (commonly done to reduce tension and allow pubic approximation, which increase surgical time, blood loss, and postop pain)
* Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage)
* Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair)
<ref>{{Cite journal|last=Mathews|first=Ranjiv I.|last2=Schaeffer|first2=Anthony J.|last3=Gearhart|first3=John P.|date=2024-06|title=Classic Bladder Exstrophy - Timing of initial closure and technical highlights|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC11649320/|journal=African Urology|volume=4|issue=se1|pages=S11–S15|doi=10.36303/auj.0150|issn=2710-2750|pmc=11649320|pmid=39687281}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Neonatal airway considerations
-Syndromic features possible

-Prematurity possible

-Appropriate ETT size
|-
|Neurologic
| -Developmental abnormalities possible
|-
|Cardiovascular
| -Congenital heart disease screening
-Neonatal physiology (HR dependence)
|-
|Pulmonary
| -Prematurity related lung disease
-Postoperative apnea risk
|-
|Gastrointestinal
| -NPO considerations in neonate
-Aspiration risk
|-
|Hematologic
| -T&C
-Anticipate moderate to significant blood loss
|-
|Renal
| -Urinary tract anomalies
-Monitor electrolytes
|-
|Endocrine
| -Neonatal glucose (hypoglycemia risk)
|-
|Other
| -Hypothermia risk
-Latex allergy precautions
|}

=== Labs and studies ===

* T&C
* CBC
* BMP, electrolytes
* Echocardiogram if cardiac anomaly suspected

=== Operating room setup ===

* Blood products available
* Fluid warmer
* Forced-air warming device
* Pediatric airway equipment
* Consider arterial line setup
* Caudal/epidural kit

=== Patient preparation and premedication ===

* Multidisciplinary planning per institution (urology + orthopedic if osteotomies)

=== Regional and neuraxial techniques ===
Caudal or Lumbar Epidural strongly considered for

* Intra/postoperative opioid-sparing pain control
* Reduction in movement to protect repair
* Sometimes tunneled as epidural will be in place for days to weeks

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Core temperature montoring
* PIV x2 preferred
* Arterial line commonly used
* Foley/suprapubic catheter placed by surgeon with UOP monitoring

=== Induction and airway management ===

* Standard inhalational or IV induction
* Neonatal dosing considerations
* Avoid hypotension
* Standard pediatric airway considerations

=== Maintenance and surgical considerations ===

* Balanced anesthesia with volatile or TIVA
* Temperature management (large exposed viscera, long case)
* Blood loss replaced promptly (neonates tolerate anemia poorly)
* Fluid balance (neonates sensitive to hypo and hypervolemia)
* Glucose monitoring (neonates have limited glycogen stores)
* Osteotomies may increase bleeding and stimulation
* Continuous epidural infusions commonly used

=== Emergence ===
Extubation if

* Hemodynamically stable
* Normothermic
* Adequate ventilation

Consider postoperative ventilation if

* Premature infants
* Prolonged case
* Significant blood loss
* Severe edema

== Postoperative management ==

=== Disposition ===
NICU or PICU (PACU uncommon for primary repairs)

=== Pain management ===
Pain often significant (especially with osteotomy) and adequate analgesia is critical to prevent movement that compromise repair

* Epidural analgesia
* Scheduled acetaminophen
* Opioids for breakthrough pain

=== Potential complications ===

* Wound dehiscence
* Bladder outlet obstruction
* Urinary leakage
* Pelvic instability (if osteotomy)
* Bleeding
* Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=A practice of anesthesia for infants and children|date=2019|publisher=Elsevier|isbn=978-0-323-42974-0|editor-last=Coté|editor-first=Charles J.|edition=Sixth edition|location=Philadelphia, PA|editor-last2=Lerman|editor-first2=Jerrold|editor-last3=Anderson|editor-first3=Brian J.}}</ref><ref>{{Cite book|last=Davis|first=Peter J.|title=Smith's anesthesia for infants and children|last2=Cladis|first2=Franklyn P.|last3=Motoyama|first3=Etsuro K.|date=2011|publisher=Mosby|isbn=978-0-323-06612-9|edition=8th ed|location=St. Louis, Mo}}</ref><ref>{{Cite book|title=Campbell-Walsh-Wein urology|date=2026|publisher=Elsevier|isbn=978-0-323-88405-1|editor-last=Dmochowski|editor-first=Roger R.|location=Philadelphia, PA|editor-last2=Kavoussi|editor-first2=Louis R.|editor-last3=Peters|editor-first3=Craig A.|editor-last4=Campbell|editor-first4=Meredith F.|editor-last5=Walsh|editor-first5=Patrick C.|editor-last6=Wein|editor-first6=Alan J.}}</ref>
!
!Modern staged repair (MSRE)
!Complete primary repair (CPRE)
|-
|Surgical timing
|Stage 1 (before 9 months for primary closure +/- osteomy)
Stage 2 (before 2 years for epispadias repair in males)

Stage 3 (childhood for bladder neck reconstruction)
|Neonatal period
|-
|EBL
|Moderate
|High
|-
|Unique consideration
|Repeated anesthesia exposure
|Prolonged case
High blood loss

More fluid shifts
|}

== References ==

[[Category:Surgical procedures]]

Bladder exstrophy repair

2026-02-23T17:17:23Z

Zining2023: Finished intraop section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (often recommended)
| monitors = Standard ASA
Temperature
Arterial BP (if placed)
| considerations_preoperative = -Neonate/infant physiology
-Associated congenital anomalies
| considerations_intraoperative = -Large fluid shifts and blood loss risk
-Hypothermia prevention
-Pelvic osteotomies need
-Regional analgesia (caudal/epidural)
| considerations_postoperative = -Ventilatory support (neonate or prolonged case)
-Epidural analgesia management
-Wound dehiscence risk
-Electrolyte abnormalities
}}

Bladder exstrophy is a rare congenital anomaly characterized by failure of lower abdominal wall and anterior bladder closure, resulting in exposure of posterior bladder wall through the abdominal wall. The defect results from failure of mesenchymal migration and premature rupture of cloacal membrane during embryologic development.

Surgical repair is typically performed in neonatal period (primary closure) or later in staged reconstruction.

== Overview ==

=== Indications ===
Surgical repair indicated in all cases of classic bladder exstrophy with goals to

* Protect exposed bladder mucosa from infection and trauma
* Prevent progressive renal damage
* Restore urinary continence
* Reconstruct genital and abdominal anatomy

Timing

* Ideally within first year of life, preferably before 9 months
* Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies
* Delayed or staged reconstruction can be performed in older infants or failed primary closure

=== Surgical procedure ===

* Bladder plate mobilization and closure (exposed bladder plate is dissected and mobilized to allow posterior wall approximation)
* Bladder neck and urethra reconstruction (if part of staged repair)
* Abdominal wall closure (rectus muscles and fascia are mobilized and reapproximated)
* Pelvic osteotomies (commonly done to reduce tension and allow pubic approximation, which increase surgical time, blood loss, and postop pain)
* Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage)
* Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Neonatal airway considerations
-Syndromic features possible

-Prematurity possible

-Appropriate ETT size
|-
|Neurologic
| -Developmental abnormalities possible
|-
|Cardiovascular
| -Congenital heart disease screening
-Neonatal physiology (HR dependence)
|-
|Pulmonary
| -Prematurity related lung disease
-Postoperative apnea risk
|-
|Gastrointestinal
| -NPO considerations in neonate
-Aspiration risk
|-
|Hematologic
| -T&C
-Anticipate moderate to significant blood loss
|-
|Renal
| -Urinary tract anomalies
-Monitor electrolytes
|-
|Endocrine
| -Neonatal glucose (hypoglycemia risk)
|-
|Other
| -Hypothermia risk
-Latex allergy precautions
|}

=== Labs and studies ===

* T&C
* CBC
* BMP, electrolytes
* Echocardiogram if cardiac anomaly suspected

=== Operating room setup ===

* Blood products available
* Fluid warmer
* Forced-air warming device
* Pediatric airway equipment
* Consider arterial line setup
* Caudal/epidural kit

=== Patient preparation and premedication ===

* Multidisciplinary planning per institution (urology + orthopedic if osteotomies)

=== Regional and neuraxial techniques ===
Caudal or Lumbar Epidural strongly considered for

* Intra/postoperative opioid-sparing pain control
* Reduction in movement to protect repair
* Sometimes tunneled as epidural will be in place for days to weeks

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA
* Core temperature montoring
* PIV x2 preferred
* Arterial line commonly used
* Foley/suprapubic catheter placed by surgeon with UOP monitoring

=== Induction and airway management ===

* Standard inhalational or IV induction
* Neonatal dosing considerations
* Avoid hypotension
* Standard pediatric airway considerations

=== Maintenance and surgical considerations ===

* Balanced anesthesia with volatile or TIVA
* Temperature management (large exposed viscera, long case)
* Blood loss replaced promptly (neonates tolerate anemia poorly)
* Fluid balance (neonates sensitive to hypo and hypervolemia)
* Glucose monitoring (neonates have limited glycogen stores)
* Osteotomies may increase bleeding and stimulation
* Continuous epidural infusions commonly used

=== Emergence ===
Extubation if

* Hemodynamically stable
* Normothermic
* Adequate ventilation

Consider postoperative ventilation if

* Premature infants
* Prolonged case
* Significant blood loss
* Severe edema

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Bladder exstrophy repair

2026-02-23T17:04:32Z

Zining2023: Finished patient evaluation preop section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (often recommended)
| monitors = Standard ASA
Temperature
Arterial BP (if placed)
| considerations_preoperative = -Neonate/infant physiology
-Associated congenital anomalies
| considerations_intraoperative = -Large fluid shifts and blood loss risk
-Hypothermia prevention
-Pelvic osteotomies need
-Regional analgesia (caudal/epidural)
| considerations_postoperative = -Ventilatory support (neonate or prolonged case)
-Epidural analgesia management
-Wound dehiscence risk
-Electrolyte abnormalities
}}

Bladder exstrophy is a rare congenital anomaly characterized by failure of lower abdominal wall and anterior bladder closure, resulting in exposure of posterior bladder wall through the abdominal wall. The defect results from failure of mesenchymal migration and premature rupture of cloacal membrane during embryologic development.

Surgical repair is typically performed in neonatal period (primary closure) or later in staged reconstruction.

== Overview ==

=== Indications ===
Surgical repair indicated in all cases of classic bladder exstrophy with goals to

* Protect exposed bladder mucosa from infection and trauma
* Prevent progressive renal damage
* Restore urinary continence
* Reconstruct genital and abdominal anatomy

Timing

* Ideally within first year of life, preferably before 9 months
* Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies
* Delayed or staged reconstruction can be performed in older infants or failed primary closure

=== Surgical procedure ===

* Bladder plate mobilization and closure (exposed bladder plate is dissected and mobilized to allow posterior wall approximation)
* Bladder neck and urethra reconstruction (if part of staged repair)
* Abdominal wall closure (rectus muscles and fascia are mobilized and reapproximated)
* Pelvic osteotomies (commonly done to reduce tension and allow pubic approximation, which increase surgical time, blood loss, and postop pain)
* Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage)
* Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Neonatal airway considerations
-Syndromic features possible

-Prematurity possible

-Appropriate ETT size
|-
|Neurologic
| -Developmental abnormalities possible
|-
|Cardiovascular
| -Congenital heart disease screening
-Neonatal physiology (HR dependence)
|-
|Pulmonary
| -Prematurity related lung disease
-Postoperative apnea risk
|-
|Gastrointestinal
| -NPO considerations in neonate
-Aspiration risk
|-
|Hematologic
| -T&C
-Anticipate moderate to significant blood loss
|-
|Renal
| -Urinary tract anomalies
-Monitor electrolytes
|-
|Endocrine
| -Neonatal glucose (hypoglycemia risk)
|-
|Other
| -Hypothermia risk
-Latex allergy precautions
|}

=== Labs and studies ===

* T&C
* CBC
* BMP, electrolytes
* Echocardiogram if cardiac anomaly suspected

=== Operating room setup ===

* Blood products available
* Fluid warmer
* Forced-air warming device
* Pediatric airway equipment
* Consider arterial line setup
* Caudal/epidural kit

=== Patient preparation and premedication ===

* Multidisciplinary planning per institution (urology + orthopedic if osteotomies)

=== Regional and neuraxial techniques ===
Caudal or Lumbar Epidural strongly considered for

* Intra/postoperative opioid-sparing pain control
* Reduction in movement to protect repair
* Sometimes tunneled as epidural will be in place for days to weeks

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Bladder exstrophy repair

2026-02-23T16:08:23Z

Zining2023: Finished surgical infobox

Bladder exstrophy repair

2026-02-23T16:02:57Z

Zining2023: Created page and finished overview indications and procedure description

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Bladder exstrophy is a rare congenital anomaly characterized by failure of lower abdominal wall and anterior bladder closure, resulting in exposure of posterior bladder wall through the abdominal wall. The defect results from failure of mesenchymal migration and premature rupture of cloacal membrane during embryologic development.

Surgical repair is typically performed in neonatal period (primary closure) or later in staged reconstruction.

== Overview ==

=== Indications ===
Surgical repair indicated in all cases of classic bladder exstrophy with goals to

* Protect exposed bladder mucosa from infection and trauma
* Prevent progressive renal damage
* Restore urinary continence
* Reconstruct genital and abdominal anatomy

Timing

* Ideally within first year of life, preferably before 9 months
* Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies
* Delayed or staged reconstruction can be performed in older infants or failed primary closure

=== Surgical procedure ===

* Bladder plate mobilization and closure (exposed bladder plate is dissected and mobilized to allow posterior wall approximation)
* Bladder neck and urethra reconstruction (if part of staged repair)
* Abdominal wall closure (rectus muscles and fascia are mobilized and reapproximated)
* Pelvic osteotomies (commonly done to reduce tension and allow pubic approximation, which increase surgical time, blood loss, and postop pain)
* Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage)
* Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair)

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Pericardial Window

2026-02-22T23:37:26Z

Zining2023: References section completed

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (if tamponade physiology or instability)
Central line only if necessary (do not delay drainage)
| monitors = Standard ASA
Invasive arterial BP
+/- CVP
TEE
| considerations_preoperative = -Determine presence and severity of tamponade physiology
-Identify etiology (malignancy, uremia, infection, post-cardiac surgery, trauma)
-Assess degree of sympathetic compensation
-Evaluate anticoagulation
| considerations_intraoperative = -Avoid loss of sympathetic tone
-Avoid reductions in preload
-Avoid sudden increases in intrathoracic pressure
-Surgeon scrubbed and ready before induction if unstable
| considerations_postoperative = -Hemodynamic instability after decompression
-Acute RV failure
-Re-expansion pulmonary edema
-Reaccumulation of effusion
}}A pericardial window creates a surgical communication between the pericardial space and pleural or peritoneal cavity to allow continuous drainage of pericardial fluid. It is indicated for symptomatic effusions, cardiac tamponade, purulent pericarditis, recurrent malignant effusions, and failed percutaneous drainage.

From an anesthesia standpoint, the central issue is tamponade physiology, not the surgical incision itself.

== Overview ==

=== Indications ===

* Cardiac tamponade
* Symptomatic moderate-to-large effusion
* Recurrent effusion after percutaneous drainage
* Malignant effusion
* Purulent pericarditis

Unlike percutaneous pericardiocentesis, a pericardial window provides:

* Ongoing drainage
* Lower recurrence rates
* Ability to obtain pericardial biopsy
* Direct visualization of bleeding or loculations<ref>{{Cite journal|last=Adler|first=Yehuda|last2=Charron|first2=Philippe|last3=Imazio|first3=Massimo|last4=Badano|first4=Luigi|last5=Barón-Esquivias|first5=Gonzalo|last6=Bogaert|first6=Jan|last7=Brucato|first7=Antonio|last8=Gueret|first8=Pascal|last9=Klingel|first9=Karin|last10=Lionis|first10=Christos|last11=Maisch|first11=Bernhard|date=2015-11-07|title=2015 ESC Guidelines for the diagnosis and management of pericardial diseases|url=https://academic.oup.com/eurheartj/article/36/42/2921/2293375|journal=European Heart Journal|language=en|volume=36|issue=42|pages=2921–2964|doi=10.1093/eurheartj/ehv318|issn=0195-668X|pmc=7539677|pmid=26320112}}</ref>

=== Surgical procedure ===
Most common approach for urgent tamponade is via subxiphoid. A small infraxiphoid incision is made and the retrosternal space is entered bluntly. The anterior pericardium is identified, opened sharply, and a segment of pericardium is excised to create a window. Fluid is evacuated, often sent for cytology, culture, or pathology, and a drain is left in the pericardial space.

In a left anterior thoracotomy or VATS approach, the chest is entered through the left pleural space. The pericardium is opened anterior to the phrenic nerve, and a segment is resected so that fluid drains directly into the pleural cavity. A chest tube is placed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior mediastinal radiation or malignancy (difficult airway, limited neck mobility)
-Orthopnea (tamponade may not tolerate supine positioning)
|-
|Neurologic
| -Altered mental status from low cardiac output
-Syncope or presyncope (suggests severe tamponade physiology)
|-
|Cardiovascular
| -Assess tamponade physiology (Beck's triad, tachycardia, narrow pulse pressure, pulsus paradoxus, electrical alternans)
-Echo findings (RA systolic collapse, RV diastolic collapse, dilated IVC with minimal variation, large effusion with swinging heart)

-Assess underlying cardiomyopathy or recent cardiac surgery
|-
|Pulmonary
| -Dyspnea at rest, orthopnea
-Pleural effusion
|-
|Gastrointestinal
| -NPO status uncertain in urgent cases
-Hepatic congestion or ascites
|-
|Hematologic
| -Anticoagulation usage
-Thrombocytopenia (malignancy, chemotherapy)

-Coagulopathy
|-
|Renal
| -Uremia?
-AKI from low cardiac output
|-
|Endocrine
| -hypothyroidism can cause pericardial effusion
|-
|Other
| -etiologies include TB, autoimmune diseases
|}

=== Labs and studies ===

* CBC/CMP
* Coags
* T&S (consider crossmatch if unstable)
* EKG (low voltage, electrical alternans)
* CXR (enlarged cardiac silhouette if chronic effusion)
* TTE/TEE

=== Operating room setup ===
For tamponade physiology:

* Arterial line before induction
* Large-bore IV access
* Vasopressors ready and spiked
** Epinephrine
** Norepinephrine
** Phenylephrine
* Atropine and glycopyrrolate available
* Emergency pericardiocentesis tray accessible
* Defibrillator immediately available
* TEE

If stable, non-tamponade effusion:

* Arterial line may be optional

Avoid delay to drainage in unstable patients

=== Patient preparation and premedication ===
In tamponade:

* Avoid sedative premedication
* Even small doses of benzodiazepines or opioids may cause collapse
* Maintain spontaneous ventilation until surgical access if severe physiology

Goal:

* Maintain preload
* Maintain heart rate
* Maintain SVR
* Avoid myocardial depression

If unstable:

* Transport to OR with monitoring
* Consider awake arterial line
* Surgeon prepped and ready before induction

Standard premedication acceptable in stable, non-tamponade effusions

=== Regional and neuraxial techniques ===
Neuraxial anesthesia is contraindicated in tamponade physiology as sympathectomy leads to drop in preload and SVR, causing potential CV collapse

* Even in stable effusions, neuraxial techniques are generally avoided.
* Subxiphoid approach typically does not require regional analgesia.
* Paravertebral or erector spinae blocks may be considered for thoracotomy approach post-drainage once hemodynamics stabilize.

* Avoid blocks before decompression in unstable patients.

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* Arterial line (preferably pre-induction, can be optional in stable, non-tamponade effusions)
* Large bore IV access
* Central line (do not delay drainage if urgent tamponade physiology)
* TEE (may be used if diagnosis unclear or persistent hemodynamic instability after drainage

=== Induction and airway management ===
Physiologic goals:

* Maintain preload (avoid hypotension)
* Maintain heart rate (avoid bradycardia)
* Maintain contractility (avoid myocardial depression)
* Maintain SVR (avoid vasodilation)
* Avoid positive pressure ventilation before decompression (if severe)

Severe tamponade:

* Surgeon prepped and ready before induction
* Maintain spontaneous ventilation until pericardium opened (if feasible)
* Slow, titrated induction:
** Ketamine (maintains sympathetic tone)
** Etomidate (minimal myocardial depression)
** Titrate narcotics carefully (large bolus can cause bradycardia)
** Avoid large propofol bolus
* Apneic time should be minimized

* Avoid high PEEP and large tidal volumes

If patient arrests:

* Immediate surgical decompression is definitive therapy
* Epinephrine
* CPR (may be ineffective until decompression)

Stable patients:

* Standard IV induction acceptable
* Controlled ventilation tolerated

=== Maintenance and surgical considerations ===
Preserve physiologic goals above until pericardial decompression is achieved. Low-dose volatile anesthesia often used with readily available vasopressors.

Hemodynamic changes may occur immediately upon opening pericardium and evacuation of fluid:

* Increased venous return
* Improved cardiac output
* Reflex hypertension (abrupt BP changes)
* Arrhythmias

Once tamponade physiology resolves:

* Standard anesthetic maintenance
* Normal ventilation
* Persistent hypotension should prompt for evaluation for potential complications below or other etiology

=== Emergence ===
Consider OR extubation if patient is hemodynamically stable with no significant respiratory compromise. Patients with persistent hemodynamic instability, high vasopressor requirements, pulmonary dysfunction, or major comorbidities should remain intubated.

== Postoperative management ==

=== Disposition ===
ICU admission recommended for:

* Tamponade physiology
* Hemodynamic instability
* Malignant effusion
* Post-cardiac surgery effusion
* Significant cardiopulmonary comorbidities

Step-down/telemetry for stable elective effusion

=== Pain management ===
Subxiphoid approach - mild to moderate pain comparable to laparoscopic upper abdominal incision

* Acetaminophen, low dose opioid, consider NSAIDs

Thoracotomy/VATS approach - moderate to severe pain, especially with chest tube placement

* Multimodal including acetaminophen, opioids, regional anesthesia.

=== Potential complications ===

* Recurrent effusion
* Bleeding
* Pneumothorax
* Myocardial injury
* Arrhythmias
* Re-expansion pulmonary edema
* Persistent hypotension
* Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Subxiphoid
!Thoracotomy
!VATS
!Post-cardiac
surgery
!Pericardioperitoneal
|-
|Unique considerations
|Tamponade
Maintain spontaneous ventilation
|OLV
|OLV
|Adhesions
Graft injury risk
|Drain into abdomen
|-
|Timing
|Emergent/Urgent
|Urgent/Elective
|Elective
|Urgent
|Elective
|-
|EBL
|Low
|Moderate
|Low
|High
|Low
|-
|Potential complications
|Incomplete drainage
|Pain, PTX
|Conversion to open
|Bleeding
|Abdominal complications
|}

== References ==

[[Category:Surgical procedures]]

Pericardial Window

2026-02-22T23:30:57Z

Zining2023: Finished procedural variants section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (if tamponade physiology or instability)
Central line only if necessary (do not delay drainage)
| monitors = Standard ASA
Invasive arterial BP
+/- CVP
TEE
| considerations_preoperative = -Determine presence and severity of tamponade physiology
-Identify etiology (malignancy, uremia, infection, post-cardiac surgery, trauma)
-Assess degree of sympathetic compensation
-Evaluate anticoagulation
| considerations_intraoperative = -Avoid loss of sympathetic tone
-Avoid reductions in preload
-Avoid sudden increases in intrathoracic pressure
-Surgeon scrubbed and ready before induction if unstable
| considerations_postoperative = -Hemodynamic instability after decompression
-Acute RV failure
-Re-expansion pulmonary edema
-Reaccumulation of effusion
}}A pericardial window creates a surgical communication between the pericardial space and pleural or peritoneal cavity to allow continuous drainage of pericardial fluid. It is indicated for symptomatic effusions, cardiac tamponade, purulent pericarditis, recurrent malignant effusions, and failed percutaneous drainage.

From an anesthesia standpoint, the central issue is tamponade physiology, not the surgical incision itself.

== Overview ==

=== Indications ===

* Cardiac tamponade
* Symptomatic moderate-to-large effusion
* Recurrent effusion after percutaneous drainage
* Malignant effusion
* Purulent pericarditis

Unlike percutaneous pericardiocentesis, a pericardial window provides:

* Ongoing drainage
* Lower recurrence rates
* Ability to obtain pericardial biopsy
* Direct visualization of bleeding or loculations

=== Surgical procedure ===
Most common approach for urgent tamponade is via subxiphoid. A small infraxiphoid incision is made and the retrosternal space is entered bluntly. The anterior pericardium is identified, opened sharply, and a segment of pericardium is excised to create a window. Fluid is evacuated, often sent for cytology, culture, or pathology, and a drain is left in the pericardial space.

In a left anterior thoracotomy or VATS approach, the chest is entered through the left pleural space. The pericardium is opened anterior to the phrenic nerve, and a segment is resected so that fluid drains directly into the pleural cavity. A chest tube is placed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior mediastinal radiation or malignancy (difficult airway, limited neck mobility)
-Orthopnea (tamponade may not tolerate supine positioning)
|-
|Neurologic
| -Altered mental status from low cardiac output
-Syncope or presyncope (suggests severe tamponade physiology)
|-
|Cardiovascular
| -Assess tamponade physiology (Beck's triad, tachycardia, narrow pulse pressure, pulsus paradoxus, electrical alternans)
-Echo findings (RA systolic collapse, RV diastolic collapse, dilated IVC with minimal variation, large effusion with swinging heart)

-Assess underlying cardiomyopathy or recent cardiac surgery
|-
|Pulmonary
| -Dyspnea at rest, orthopnea
-Pleural effusion
|-
|Gastrointestinal
| -NPO status uncertain in urgent cases
-Hepatic congestion or ascites
|-
|Hematologic
| -Anticoagulation usage
-Thrombocytopenia (malignancy, chemotherapy)

-Coagulopathy
|-
|Renal
| -Uremia?
-AKI from low cardiac output
|-
|Endocrine
| -hypothyroidism can cause pericardial effusion
|-
|Other
| -etiologies include TB, autoimmune diseases
|}

=== Labs and studies ===

* CBC/CMP
* Coags
* T&S (consider crossmatch if unstable)
* EKG (low voltage, electrical alternans)
* CXR (enlarged cardiac silhouette if chronic effusion)
* TTE/TEE

=== Operating room setup ===
For tamponade physiology:

* Arterial line before induction
* Large-bore IV access
* Vasopressors ready and spiked
** Epinephrine
** Norepinephrine
** Phenylephrine
* Atropine and glycopyrrolate available
* Emergency pericardiocentesis tray accessible
* Defibrillator immediately available
* TEE

If stable, non-tamponade effusion:

* Arterial line may be optional

Avoid delay to drainage in unstable patients

=== Patient preparation and premedication ===
In tamponade:

* Avoid sedative premedication
* Even small doses of benzodiazepines or opioids may cause collapse
* Maintain spontaneous ventilation until surgical access if severe physiology

Goal:

* Maintain preload
* Maintain heart rate
* Maintain SVR
* Avoid myocardial depression

If unstable:

* Transport to OR with monitoring
* Consider awake arterial line
* Surgeon prepped and ready before induction

Standard premedication acceptable in stable, non-tamponade effusions

=== Regional and neuraxial techniques ===
Neuraxial anesthesia is contraindicated in tamponade physiology as sympathectomy leads to drop in preload and SVR, causing potential CV collapse

* Even in stable effusions, neuraxial techniques are generally avoided.
* Subxiphoid approach typically does not require regional analgesia.
* Paravertebral or erector spinae blocks may be considered for thoracotomy approach post-drainage once hemodynamics stabilize.

* Avoid blocks before decompression in unstable patients.

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* Arterial line (preferably pre-induction, can be optional in stable, non-tamponade effusions)
* Large bore IV access
* Central line (do not delay drainage if urgent tamponade physiology)
* TEE (may be used if diagnosis unclear or persistent hemodynamic instability after drainage

=== Induction and airway management ===
Physiologic goals:

* Maintain preload (avoid hypotension)
* Maintain heart rate (avoid bradycardia)
* Maintain contractility (avoid myocardial depression)
* Maintain SVR (avoid vasodilation)
* Avoid positive pressure ventilation before decompression (if severe)

Severe tamponade:

* Surgeon prepped and ready before induction
* Maintain spontaneous ventilation until pericardium opened (if feasible)
* Slow, titrated induction:
** Ketamine (maintains sympathetic tone)
** Etomidate (minimal myocardial depression)
** Titrate narcotics carefully (large bolus can cause bradycardia)
** Avoid large propofol bolus
* Apneic time should be minimized

* Avoid high PEEP and large tidal volumes

If patient arrests:

* Immediate surgical decompression is definitive therapy
* Epinephrine
* CPR (may be ineffective until decompression)

Stable patients:

* Standard IV induction acceptable
* Controlled ventilation tolerated

=== Maintenance and surgical considerations ===
Preserve physiologic goals above until pericardial decompression is achieved. Low-dose volatile anesthesia often used with readily available vasopressors.

Hemodynamic changes may occur immediately upon opening pericardium and evacuation of fluid:

* Increased venous return
* Improved cardiac output
* Reflex hypertension (abrupt BP changes)
* Arrhythmias

Once tamponade physiology resolves:

* Standard anesthetic maintenance
* Normal ventilation
* Persistent hypotension should prompt for evaluation for potential complications below or other etiology

=== Emergence ===
Consider OR extubation if patient is hemodynamically stable with no significant respiratory compromise. Patients with persistent hemodynamic instability, high vasopressor requirements, pulmonary dysfunction, or major comorbidities should remain intubated.

== Postoperative management ==

=== Disposition ===
ICU admission recommended for:

* Tamponade physiology
* Hemodynamic instability
* Malignant effusion
* Post-cardiac surgery effusion
* Significant cardiopulmonary comorbidities

Step-down/telemetry for stable elective effusion

=== Pain management ===
Subxiphoid approach - mild to moderate pain comparable to laparoscopic upper abdominal incision

* Acetaminophen, low dose opioid, consider NSAIDs

Thoracotomy/VATS approach - moderate to severe pain, especially with chest tube placement

* Multimodal including acetaminophen, opioids, regional anesthesia.

=== Potential complications ===

* Recurrent effusion
* Bleeding
* Pneumothorax
* Myocardial injury
* Arrhythmias
* Re-expansion pulmonary edema
* Persistent hypotension
* Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Subxiphoid
!Thoracotomy
!VATS
!Post-cardiac
surgery
!Pericardioperitoneal
|-
|Unique considerations
|Tamponade
Maintain spontaneous ventilation
|OLV
|OLV
|Adhesions
Graft injury risk
|Drain into abdomen
|-
|Timing
|Emergent/Urgent
|Urgent/Elective
|Elective
|Urgent
|Elective
|-
|EBL
|Low
|Moderate
|Low
|High
|Low
|-
|Potential complications
|Incomplete drainage
|Pain, PTX
|Conversion to open
|Bleeding
|Abdominal complications
|}

== References ==

[[Category:Surgical procedures]]

Pericardial Window

2026-02-22T23:19:14Z

Zining2023: Finished intraop section

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (if tamponade physiology or instability)
Central line only if necessary (do not delay drainage)
| monitors = Standard ASA
Invasive arterial BP
+/- CVP
TEE
| considerations_preoperative = -Determine presence and severity of tamponade physiology
-Identify etiology (malignancy, uremia, infection, post-cardiac surgery, trauma)
-Assess degree of sympathetic compensation
-Evaluate anticoagulation
| considerations_intraoperative = -Avoid loss of sympathetic tone
-Avoid reductions in preload
-Avoid sudden increases in intrathoracic pressure
-Surgeon scrubbed and ready before induction if unstable
| considerations_postoperative = -Hemodynamic instability after decompression
-Acute RV failure
-Re-expansion pulmonary edema
-Reaccumulation of effusion
}}A pericardial window creates a surgical communication between the pericardial space and pleural or peritoneal cavity to allow continuous drainage of pericardial fluid. It is indicated for symptomatic effusions, cardiac tamponade, purulent pericarditis, recurrent malignant effusions, and failed percutaneous drainage.

From an anesthesia standpoint, the central issue is tamponade physiology, not the surgical incision itself.

== Overview ==

=== Indications ===

* Cardiac tamponade
* Symptomatic moderate-to-large effusion
* Recurrent effusion after percutaneous drainage
* Malignant effusion
* Purulent pericarditis

Unlike percutaneous pericardiocentesis, a pericardial window provides:

* Ongoing drainage
* Lower recurrence rates
* Ability to obtain pericardial biopsy
* Direct visualization of bleeding or loculations

=== Surgical procedure ===
Most common approach for urgent tamponade is via subxiphoid. A small infraxiphoid incision is made and the retrosternal space is entered bluntly. The anterior pericardium is identified, opened sharply, and a segment of pericardium is excised to create a window. Fluid is evacuated, often sent for cytology, culture, or pathology, and a drain is left in the pericardial space.

In a left anterior thoracotomy or VATS approach, the chest is entered through the left pleural space. The pericardium is opened anterior to the phrenic nerve, and a segment is resected so that fluid drains directly into the pleural cavity. A chest tube is placed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior mediastinal radiation or malignancy (difficult airway, limited neck mobility)
-Orthopnea (tamponade may not tolerate supine positioning)
|-
|Neurologic
| -Altered mental status from low cardiac output
-Syncope or presyncope (suggests severe tamponade physiology)
|-
|Cardiovascular
| -Assess tamponade physiology (Beck's triad, tachycardia, narrow pulse pressure, pulsus paradoxus, electrical alternans)
-Echo findings (RA systolic collapse, RV diastolic collapse, dilated IVC with minimal variation, large effusion with swinging heart)

-Assess underlying cardiomyopathy or recent cardiac surgery
|-
|Pulmonary
| -Dyspnea at rest, orthopnea
-Pleural effusion
|-
|Gastrointestinal
| -NPO status uncertain in urgent cases
-Hepatic congestion or ascites
|-
|Hematologic
| -Anticoagulation usage
-Thrombocytopenia (malignancy, chemotherapy)

-Coagulopathy
|-
|Renal
| -Uremia?
-AKI from low cardiac output
|-
|Endocrine
| -hypothyroidism can cause pericardial effusion
|-
|Other
| -etiologies include TB, autoimmune diseases
|}

=== Labs and studies ===

* CBC/CMP
* Coags
* T&S (consider crossmatch if unstable)
* EKG (low voltage, electrical alternans)
* CXR (enlarged cardiac silhouette if chronic effusion)
* TTE/TEE

=== Operating room setup ===
For tamponade physiology:

* Arterial line before induction
* Large-bore IV access
* Vasopressors ready and spiked
** Epinephrine
** Norepinephrine
** Phenylephrine
* Atropine and glycopyrrolate available
* Emergency pericardiocentesis tray accessible
* Defibrillator immediately available
* TEE

If stable, non-tamponade effusion:

* Arterial line may be optional

Avoid delay to drainage in unstable patients

=== Patient preparation and premedication ===
In tamponade:

* Avoid sedative premedication
* Even small doses of benzodiazepines or opioids may cause collapse
* Maintain spontaneous ventilation until surgical access if severe physiology

Goal:

* Maintain preload
* Maintain heart rate
* Maintain SVR
* Avoid myocardial depression

If unstable:

* Transport to OR with monitoring
* Consider awake arterial line
* Surgeon prepped and ready before induction

Standard premedication acceptable in stable, non-tamponade effusions

=== Regional and neuraxial techniques ===
Neuraxial anesthesia is contraindicated in tamponade physiology as sympathectomy leads to drop in preload and SVR, causing potential CV collapse

* Even in stable effusions, neuraxial techniques are generally avoided.
* Subxiphoid approach typically does not require regional analgesia.
* Paravertebral or erector spinae blocks may be considered for thoracotomy approach post-drainage once hemodynamics stabilize.

* Avoid blocks before decompression in unstable patients.

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* Arterial line (preferably pre-induction, can be optional in stable, non-tamponade effusions)
* Large bore IV access
* Central line (do not delay drainage if urgent tamponade physiology)
* TEE (may be used if diagnosis unclear or persistent hemodynamic instability after drainage

=== Induction and airway management ===
Physiologic goals:

* Maintain preload (avoid hypotension)
* Maintain heart rate (avoid bradycardia)
* Maintain contractility (avoid myocardial depression)
* Maintain SVR (avoid vasodilation)
* Avoid positive pressure ventilation before decompression (if severe)

Severe tamponade:

* Surgeon prepped and ready before induction
* Maintain spontaneous ventilation until pericardium opened (if feasible)
* Slow, titrated induction:
** Ketamine (maintains sympathetic tone)
** Etomidate (minimal myocardial depression)
** Titrate narcotics carefully (large bolus can cause bradycardia)
** Avoid large propofol bolus
* Apneic time should be minimized

* Avoid high PEEP and large tidal volumes

If patient arrests:

* Immediate surgical decompression is definitive therapy
* Epinephrine
* CPR (may be ineffective until decompression)

Stable patients:

* Standard IV induction acceptable
* Controlled ventilation tolerated

=== Maintenance and surgical considerations ===
Preserve physiologic goals above until pericardial decompression is achieved. Low-dose volatile anesthesia often used with readily available vasopressors.

Hemodynamic changes may occur immediately upon opening pericardium and evacuation of fluid:

* Increased venous return
* Improved cardiac output
* Reflex hypertension (abrupt BP changes)
* Arrhythmias

Once tamponade physiology resolves:

* Standard anesthetic maintenance
* Normal ventilation
* Persistent hypotension should prompt for evaluation for potential complications below or other etiology

=== Emergence ===
Consider OR extubation if patient is hemodynamically stable with no significant respiratory compromise. Patients with persistent hemodynamic instability, high vasopressor requirements, pulmonary dysfunction, or major comorbidities should remain intubated.

== Postoperative management ==

=== Disposition ===
ICU admission recommended for:

* Tamponade physiology
* Hemodynamic instability
* Malignant effusion
* Post-cardiac surgery effusion
* Significant cardiopulmonary comorbidities

Step-down/telemetry for stable elective effusion

=== Pain management ===
Subxiphoid approach - mild to moderate pain comparable to laparoscopic upper abdominal incision

* Acetaminophen, low dose opioid, consider NSAIDs

Thoracotomy/VATS approach - moderate to severe pain, especially with chest tube placement

* Multimodal including acetaminophen, opioids, regional anesthesia.

=== Potential complications ===

* Recurrent effusion
* Bleeding
* Pneumothorax
* Myocardial injury
* Arrhythmias
* Re-expansion pulmonary edema
* Persistent hypotension
* Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Pericardial Window

2026-02-22T16:38:48Z

Zining2023: Finished postop disposition, pain, complications

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV x2
Arterial line (if tamponade physiology or instability)
Central line only if necessary (do not delay drainage)
| monitors = Standard ASA
Invasive arterial BP
+/- CVP
TEE
| considerations_preoperative = -Determine presence and severity of tamponade physiology
-Identify etiology (malignancy, uremia, infection, post-cardiac surgery, trauma)
-Assess degree of sympathetic compensation
-Evaluate anticoagulation
| considerations_intraoperative = -Avoid loss of sympathetic tone
-Avoid reductions in preload
-Avoid sudden increases in intrathoracic pressure
-Surgeon scrubbed and ready before induction if unstable
| considerations_postoperative = -Hemodynamic instability after decompression
-Acute RV failure
-Re-expansion pulmonary edema
-Reaccumulation of effusion
}}A pericardial window creates a surgical communication between the pericardial space and pleural or peritoneal cavity to allow continuous drainage of pericardial fluid. It is indicated for symptomatic effusions, cardiac tamponade, purulent pericarditis, recurrent malignant effusions, and failed percutaneous drainage.

From an anesthesia standpoint, the central issue is tamponade physiology, not the incision itself.

== Overview ==

=== Indications ===

* Cardiac tamponade
* Symptomatic moderate-to-large effusion
* Recurrent effusion after percutaneous drainage
* Malignant effusion
* Purulent pericarditis

Unlike percutaneous pericardiocentesis, a pericardial window provides:

* Ongoing drainage
* Lower recurrence rates
* Ability to obtain pericardial biopsy
* Direct visualization of bleeding or loculations

=== Surgical procedure ===
Most common approach for urgent tamponade is via subxiphoid. A small infraxiphoid incision is made and the retrosternal space is entered bluntly. The anterior pericardium is identified, opened sharply, and a segment of pericardium is excised to create a window. Fluid is evacuated, often sent for cytology, culture, or pathology, and a drain is left in the pericardial space.

In a left anterior thoracotomy or VATS approach, the chest is entered through the left pleural space. The pericardium is opened anterior to the phrenic nerve, and a segment is resected so that fluid drains directly into the pleural cavity. A chest tube is placed.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
| -Prior mediastinal radiation or malignancy (difficult airway, limited neck mobility)
-Orthopnea (tamponade may not tolerate supine positioning)
|-
|Neurologic
| -Altered mental status from low cardiac output
-Syncope or presyncope (suggests severe tamponade physiology)
|-
|Cardiovascular
| -Assess tamponade physiology (Beck's triad, tachycardia, narrow pulse pressure, pulsus paradoxus, electrical alternans)
-Echo findings (RA systolic collapse, RV diastolic collapse, dilated IVC with minimal variation, large effusion with swinging heart)

-Assess underlying cardiomyopathy or recent cardiac surgery
|-
|Pulmonary
| -Dyspnea at rest, orthopnea
-Pleural effusion
|-
|Gastrointestinal
| -NPO status uncertain in urgent cases
-Hepatic congestion or ascites
|-
|Hematologic
| -Anticoagulation usage
-Thrombocytopenia (malignancy, chemotherapy)

-Coagulopathy
|-
|Renal
| -Uremia?
-AKI from low cardiac output
|-
|Endocrine
| -hypothyroidism can cause pericardial effusion
|-
|Other
| -etiologies include TB, autoimmune diseases
|}

=== Labs and studies ===

* CBC/CMP
* Coags
* T&S (consider crossmatch if unstable)
* EKG (low voltage, electrical alternans)
* CXR (enlarged cardiac silhouette if chronic effusion)
* TTE/TEE

=== Operating room setup ===
For tamponade physiology:

* Arterial line before induction
* Large-bore IV access
* Vasopressors ready and spiked
** Epinephrine
** Norepinephrine
** Phenylephrine
* Atropine and glycopyrrolate available
* Emergency pericardiocentesis tray accessible
* Defibrillator immediately available
* TEE

If stable, non-tamponade effusion:

* Arterial line may be optional

Avoid delay to drainage in unstable patients

=== Patient preparation and premedication ===
In tamponade:

* Avoid sedative premedication
* Even small doses of benzodiazepines or opioids may cause collapse
* Maintain spontaneous ventilation until surgical access if severe physiology

Goal:

* Maintain preload
* Maintain heart rate
* Maintain SVR
* Avoid myocardial depression

If unstable:

* Transport to OR with monitoring
* Consider awake arterial line
* Surgeon prepped and ready before induction

Standard premedication acceptable in stable, non-tamponade effusions

=== Regional and neuraxial techniques ===
Neuraxial anesthesia is contraindicated in tamponade physiology as sympathectomy leads to drop in preload and SVR, causing potential CV collapse

* Even in stable effusions, neuraxial techniques are generally avoided.
* Subxiphoid approach typically does not require regional analgesia.
* Paravertebral or erector spinae blocks may be considered for thoracotomy approach post-drainage once hemodynamics stabilize.

* Avoid blocks before decompression in unstable patients.

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===
ICU admission recommended for:

* Tamponade physiology
* Hemodynamic instability
* Malignant effusion
* Post-cardiac surgery effusion
* Significant cardiopulmonary comorbidities

Step-down/telemetry for stable elective effusion

=== Pain management ===
Subxiphoid approach - mild to moderate pain comparable to laparoscopic upper abdominal incision

* acetaminophen, low dose opioid, consider NSAIDs

Thoracotomy/VATS approach - moderate to severe pain, especially with chest tube placement

* Multimodal including acetaminophen, opioids, regional anesthesia.

=== Potential complications ===

* Recurrent effusion
* Bleeding
* Pneumothorax
* Myocardial injury
* Arrhythmias
* Re-expansion pulmonary edema
* Persistent hypotension
* Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Pericardial Window

2026-02-22T16:29:48Z

Zining2023: Finished preop considerations table

Pericardial Window

2026-02-22T16:09:20Z

Zining2023: Finished preop management, except patient eval

Pericardial Window

2026-02-22T15:46:54Z

Zining2023: Overview section completed

Pericardial Window

2026-02-22T15:35:53Z

Zining2023: Created page. Completed basic description and infobox

Aortic valve repair or replacement

2026-02-17T21:55:25Z

Zining2023: formating variants

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

Indications:

* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Full sternotomy conversion
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
| -Stroke, coronary ischemia
-Massive hemorrhage
| -Pacemaker dependence
-Very high bleeding, vasoplegia

-Mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Aortic valve repair or replacement

2026-02-17T21:53:39Z

Zining2023: formating variants

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

Indications:

* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|<nowiki>-Peripheral cannulation</nowiki>

-Retrograde perfusion

-Possible lung isolation
| -Higher ischemic burden
-More inotropes

-Transfusion
|Blood in room before incision
| -Coronary button reimplantation risk
-Large aortic manipulation

-Possible circulatory arrest
| -Prolonged bypass, vasoplegia
-Massive transfusion

-Mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
| -Stroke risk (retrograde perfusion)
-Conversion to full sternotomy
|MI, LCOS, AF, bleeding
| -Severe hemorrhage
-Graft injury
|Stroke, coronary ischemia, massive hemorrhage
|Pacemaker dependence, very high bleeding, vasoplegia, mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Aortic valve repair or replacement

2026-02-17T21:50:29Z

Zining2023: Completed Intraop management, bypass section, TEE, variants, citations

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative = -Severity of lesion (AS vs AR)
-Symptoms (syncope, angina, dyspnea)
-LV function and size (hypertrophy)
-Coronary disease (concomitant CABG)
-Pulmonary HTN
-Rhythm (atrial fibrillation)
| considerations_intraoperative = -Hemodynamic goals (AS vs AR)
-Full heparinization before CPB
-Myocardial protection and de-airing
-Conduction disturbance after valve replacement
-Weaning from CPB: LV/RV function, valve seating, gradients
| considerations_postoperative = -Vasoplegia
-Low cardiac output syndrome
-Conduction abnormalities
-Bleeding
-Early vs delayed extubation
}}

Aortic valve repair or replacement is performed for aortic stenosis (AS), aortic regurgitation (AR), or mixed disease. It is performed with sternotomy under cardiopulmonary bypass (CPB). Surgical aortic valve replacement (SAVR) involves excision of the native valve and implantation of a mechanical or bioprosthetic prosthesis.

Indications:

* Symptomatic severe AS
* Severe AR with LV dilation or dysfunction
* Endocarditis with structural destruction
* Concomitant CABG requirement
* Root/ascending aortic pathology

Unlike Transcatheter aortic valve replacement, SAVR allows:

* Complete annular debridement
* Abscess repair
* Annular enlargement
* Root replacement
* Concomitant multivessel CABG
* Durability advantage in younger patients

Transcatheter aortic valve replacement (TAVR) is preferred in:

* Elderly patients
* High or prohibitive surgical risk
* Frailty or hostile chest<ref>{{Cite journal|last=Otto|first=Catherine M.|last2=Nishimura|first2=Rick A.|last3=Bonow|first3=Robert O.|last4=Carabello|first4=Blase A.|last5=Erwin|first5=John P.|last6=Gentile|first6=Federico|last7=Jneid|first7=Hani|last8=Krieger|first8=Eric V.|last9=Mack|first9=Michael|last10=McLeod|first10=Christopher|last11=O’Gara|first11=Patrick T.|date=2021-02-02|title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines|url=https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923|journal=Circulation|language=en|volume=143|issue=5|doi=10.1161/CIR.0000000000000923|issn=0009-7322}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|Cardiovascular
| -AVA, mean gradient, velocity (severity)
-LVEF, LVH vs LV dilation (pressure or volume overload)

-Diastolic dysfunction (preload sensitivity)

-pulmonary HTN (RV risk post bypass)

-CAD (concomitant CABG)

-Rhythm (atrial fibrillation)
|-
|Pulmonary
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|Gastrointestinal
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|Hematologic
| -Anticoagulation use, blood products available
|-
|Renal
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|Endocrine
| -DM
|-
|Other
| -Endocarditis (longer CPB)
|}
'''Echocardiography'''

Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/s

Severe Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s

'''Conduction System Risk'''

AV node and bundle of His lie near membranous septum, so sutures placed in annulus can damage conduction tissue. This is higher risk with pre-existing RBBB, heavy annular calcification, and endocarditis with abscess.

Permanent pacemaker rate: ~3-8%

=== Labs and studies ===

* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR

=== Operating room setup ===

* Have at least 5-8 channels for infusions
** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
** Consider TXA, ketamine, dexmedetomidine, cefazolin
* Drugs:
** Emergency medications (bolus):
*** epinephrine, atropine
*** Other bolus vasopressors (e.g. vasopressin, phenylephrine, norepinephrine)
*** +/- esmolol, nicardipine, and nitroprusside
** Heparin, protamine, calcium
** +/- Magnesium
* Perfusion technician should be available along with cell saver
* Fluid warmer
* Triple transducers primed and zeroed
* Internal defibrillator/pacer available in room
* TEE machine with appropriately sized probe

=== Patient preparation and premedication ===

* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, DOACs per protocol

=== Regional and neuraxial techniques ===

* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

== Intraoperative management ==

=== Monitoring and access ===

* Arterial line (usually before induction)
* Central access (usually double stick with single lumen and cordis)
* +/- PA catheter (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* TEE

=== Induction and airway management ===
Severe aortic stenosis - slow, controlled induction

* Maintain SVR
*Maintain sinus rhythm
* Avoid tachycardia (goal HR 60-80)
* Avoid hypotension
*Avoid high PEEP initially
* Hypotension/decrease SVR -> decrease coronary perfusion -> ischemia -> acute LV failure

Severe aortic regurgitation - standard induction acceptable

* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow

=== Maintenance and surgical considerations ===
Cardiopulmonary bypass:

* Full heparinization (ACT > 480sec)
* Aortic cross clamp
* Cardioplegia (antegrade +/- retrograde)
* Venting LV
* De-airing critical (air embolism risk)

Complications during cross-clamp removal:

* Air embolism
* Ventricular arrhythmia
* Acute RV failure (air to RCA)

=== Post-bypass considerations ===
Be ready for:

* Inotropes (epinephrine, milrinone, dobutamine)
* Vasopressors (norepinephrine, vasopressin)
* Pacing (temporary wires placed)

Common issues:

* LV dysfunction
* RV dysfunction
* Residual gradient
* Paravalvular leak
* Complete heart block

TEE assessment:

* Valve assessment
** Proper seating
** Paravalvular leak
** Central regurgitation
** Leaflet mobility
** Mean gradient appropriate
* Air
** LV apex, LVOT, Non-coronary cusp, Pulmonary veins
** Air in coronaries -> immediate ST changes and RV dysfunction
* LV function
** Global function
** New RWMA
* RV function
* Aorta
** Aortic root
** Cannulation sites
** Dissection flap
** Hematoma

Hypotension causes:

* Vasoplegia - good EF, low SVR
* Ischemia/stunning - poor EF
* RV failure - high CVP, dilated RV
* Prosthesis mismatch - high gradient across valve
* Air embolism - ST changes

=== Emergence ===
Often wean to extubation in ICU

== Postoperative management ==

=== Disposition ===

* Cardiac ICU

=== Pain management ===

* Parasternal block
* Multimodal analgesia

=== Potential complications ===

* Complete heart block (AV node lies near membranous septum and can be damaged during annular suturing)
* Atrial fibrillation
* Vasoplegia (CPB induced inflammatory state with low SVR despite normal EF)
* Low cardiac output syndrome (can be from ischemia, LVH stiffness, afterload mismatch, prosthesis-patient mismatch)
* Bleeding/re-exploration
* Stroke (aortic manipulation, calcified debris, air embolism)
* Acute kidney injury

Mechanical valve is more durable but carries higher bleeding risk and requires lifelong anticoagulation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+<ref>{{Cite book|title=Kaplan's cardiac anesthesia: perioperative and critical care|date=2024|publisher=Elsevier|isbn=978-0-323-82924-3|editor-last=Kaplan|editor-first=Joel A.|edition=8th edition|location=Philadelphia, PA|editor-last2=Augoustides|editor-first2=John G. T.|editor-last3=Gutsche|editor-first3=Jacob T.}}</ref><ref>{{Cite book|title=Hensley's practical approach to cardiothoracic anesthesia|date=2025|publisher=Wolters Kluwer Health|isbn=978-1-9752-0910-0|editor-last=Bartels|editor-first=Karsten|edition=Seventh edition|location=Philadelphia|editor-last2=Shaw|editor-first2=Andrew D.|editor-last3=Fox|editor-first3=Amanda|editor-last4=Thiel|editor-first4=Robert H.|editor-last5=Howard-Quijano|editor-first5=Kimberly}}</ref>
!
!Minimally invasive
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|Unique considerations
|Peripheral cannulation, retrograde perfusion, possible lung isolation
|Higher ischemic burden, more inotropes, transfusion
|Blood in room before incision
|Coronary button reimplantation risk, large aortic manipulation, possible circulatory arrest
|Prolonged bypass, vasoplegia, massive transfusion, mechanical circulatory support
|-
|CPB complexity/time
|Moderate
|Higher, longer clamp
|Higher
|Higher, prolonged clamp
|Very high, prolonged CPB
|-
|EBL
|Moderate
|Higher
|High
|High
|Very high
|-
|Potential complications
|Stroke risk (retrograde perfusion), conversion to full sternotomy
|MI, LCOS, AF, bleeding
|Severe hemorrhage, graft injury
|Stroke, coronary ischemia, massive hemorrhage
|Pacemaker dependence, very high bleeding, vasoplegia, mortality risk
|}

== References ==
[[Category:Surgical procedures]]
<references />

Aortic valve repair or replacement

2026-02-17T21:13:56Z

Zining2023: CPB portion

Aortic valve repair or replacement

2026-02-17T18:16:22Z

Zining2023: Induction goals

Aortic valve repair or replacement

2026-02-17T18:02:38Z

Zining2023: Monitoring and access, starting procedure variants

Aortic valve repair or replacement

2026-02-17T17:58:01Z

Zining2023: Completed preop and postop management

Aortic valve repair or replacement

2026-02-17T16:46:29Z

Zining2023: Small addition to Preop management

Aortic valve repair or replacement

2026-02-17T16:15:08Z

Zining2023: Patient evaluation table

Aortic valve repair or replacement

2026-02-17T15:50:38Z

Zining2023: Completed general description and infobox