Aortic valve repair or replacement - Revision history

Zining2023: Minor formating, fixes

2026-03-02T16:54:24Z

Minor formating, fixes

← Older revision		Revision as of 09:54, 2 March 2026
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	!System		!System
	!Considerations		!Considerations
			\|-
			\|Airway
			\| -Prior sternotomy may limit neck mobility
	\|-		\|-
	\|Neurologic		\|Neurologic
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	-Diastolic dysfunction (preload sensitivity)		-Diastolic dysfunction (preload sensitivity)

	-~~pulmonary~~ HTN (RV risk post bypass)		-Pulmonary HTN (RV risk post bypass)

	-CAD (concomitant CABG)		-CAD (concomitant CABG)
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	* Continue beta blockers, statins, antianginals		* Continue beta blockers, statins, antianginals
	* Hold ACE inhibitors, DOACs per protocol		* Hold ACE inhibitors/ARBs and DOACs per protocol

	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

Zining2023: Added positioning

2026-03-02T14:21:30Z

Added positioning

← Older revision		Revision as of 07:21, 2 March 2026
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	* Avoid sudden increase in SVR		* Avoid sudden increase in SVR
	* Bradycardia -> increase regurgitant time -> decrease forward flow		* Bradycardia -> increase regurgitant time -> decrease forward flow

			=== Positioning ===

			* Supine
			* Arms tucked

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

Zining2023: Added surgical procedure section in overview

2026-03-02T14:16:51Z

Added surgical procedure section in overview

← Older revision		Revision as of 07:16, 2 March 2026
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	=== Surgical Procedure ===		=== 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 ==		== Preoperative management ==

Zining2023: Fix formatting to match other wiki pages

2026-03-02T14:03:09Z

Fix formatting to match other wiki pages

← Older revision		Revision as of 07:03, 2 March 2026
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	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.		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:~~		== Overview ==

			=== Indications ===
	* Symptomatic severe AS		* Symptomatic severe AS
	* Severe AR with LV dilation or dysfunction		* Severe AR with LV dilation or dysfunction
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	* High or prohibitive surgical risk		* 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>		* 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 ==		== Preoperative management ==

Zining2023: formating variants

2026-02-17T21:55:25Z

formating variants

← Older revision		Revision as of 14:55, 17 February 2026
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	\|Potential complications		\|Potential complications
	\| -Stroke risk (retrograde perfusion)		\| -Stroke risk (retrograde perfusion)
	-~~Conversion to full~~ sternotomy		-Full sternotomy conversion
	\|MI, LCOS, AF, bleeding		\|MI, LCOS, AF, bleeding
	\| -Severe hemorrhage		\| -Severe hemorrhage
	-Graft injury		-Graft injury
	\|Stroke, coronary ischemia~~, massive~~ hemorrhage		\| -Stroke, coronary ischemia
	\|Pacemaker dependence~~, very~~ high bleeding, vasoplegia~~, mortality~~ risk		-Massive hemorrhage
			\| -Pacemaker dependence
			-Very high bleeding, vasoplegia

			-Mortality risk
	\|}		\|}

Zining2023: formating variants

2026-02-17T21:53:39Z

formating variants

← Older revision		Revision as of 14:53, 17 February 2026
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	\|-		\|-
	\|Unique considerations		\|Unique considerations
	\|Peripheral cannulation~~, retrograde~~ perfusion~~, possible~~ lung isolation		\|<nowiki>-Peripheral cannulation</nowiki>
	\|Higher ischemic burden~~, more~~ inotropes~~, transfusion~~
			-Retrograde perfusion

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

			-Transfusion
	\|Blood in room before incision		\|Blood in room before incision
	\|Coronary button reimplantation risk~~, large~~ aortic manipulation~~, possible~~ circulatory arrest		\| -Coronary button reimplantation risk
	\|Prolonged bypass, vasoplegia~~, massive~~ transfusion~~, mechanical~~ circulatory support		-Large aortic manipulation

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

			-Mechanical circulatory support
	\|-		\|-
	\|CPB complexity/time		\|CPB complexity/time
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	\|-		\|-
	\|Potential complications		\|Potential complications
	\|Stroke risk (retrograde perfusion)~~, conversion~~ to full sternotomy		\| -Stroke risk (retrograde perfusion)
			-Conversion to full sternotomy
	\|MI, LCOS, AF, bleeding		\|MI, LCOS, AF, bleeding
	\|Severe hemorrhage~~, graft~~ injury		\| -Severe hemorrhage
			-Graft injury
	\|Stroke, coronary ischemia, massive hemorrhage		\|Stroke, coronary ischemia, massive hemorrhage
	\|Pacemaker dependence, very high bleeding, vasoplegia, mortality risk		\|Pacemaker dependence, very high bleeding, vasoplegia, mortality risk

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

2026-02-17T21:50:29Z

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

← Older revision		Revision as of 14:50, 17 February 2026
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	* Acute RV failure (air to RCA)		* Acute RV failure (air to RCA)

	=== Post-bypass ~~TEE evaluation~~ ===		=== Post-bypass considerations ===
	Valve assessment		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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
			Often wean to extubation in ICU

	== Postoperative management ==		== Postoperative management ==
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	{\| class="wikitable wikitable-horizontal-scroll"		{\| 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>
	!		!
	!~~Mechanical~~		!Minimally invasive
	~~!Bioprosthetic~~
	!AVR+CABG		!AVR+CABG
	!~~Minimally invasive AVR~~		!Redo
			!Bentall
			!Commando
	\|-		\|-
	\|Unique considerations		\|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
	\|-		\|-
	\|~~Position~~		\|CPB complexity/time
	\|		\|Moderate
	\|		\|Higher, longer clamp
	\|		\|Higher
	\|		\|Higher, prolonged clamp
	\|-		\|Very high, prolonged CPB
	\|~~Surgical time~~
	\|
	\|
	\|
	\|
	\|-		\|-
	\|EBL		\|EBL
	\|		\|Moderate
	\|		\|Higher
	\|		\|High
	\|		\|High
	\|-		\|Very high
	~~\|Postoperative disposition~~
	\|
	\|
	\|
	\|
	\|-
	~~\|Pain management~~
	\|
	\|
	\|
	\|
	\|-		\|-
	\|Potential complications		\|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 ==		== References ==
	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
			<references />

Zining2023: CPB portion

2026-02-17T21:13:56Z

CPB portion

← Older revision		Revision as of 14:13, 17 February 2026
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	'''Echocardiography'''		'''Echocardiography'''

	Severe Aortic Stenosis - AVA < 1cm2, mean pressure gradient > 40mmHg, peak velocity > 4m/~~sSevere~~ Aortic Regurgitation - vena contracta > 6mm, pressure half-time < 200ms, holodiastolic flow reversal in the descending aorta > 20cm/s		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'''		'''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%		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<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
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	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

	* Pre-Op: Erector Spinae Plane Block ~~-- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology~~		* Pre-Op: Erector Spinae Plane Block
	* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence		* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence

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

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	Severe aortic stenosis - slow, controlled induction		Severe aortic stenosis - slow, controlled induction

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

	Severe aortic regurgitation - standard induction acceptable		Severe aortic regurgitation - standard induction acceptable

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

	=== ~~Positioning~~<!-- Describe ~~any unique positioning~~ considerations, including potential ~~intraoperative position changes~~. ~~If none, this section may be removed~~. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
			Cardiopulmonary bypass:

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

	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		Complications during cross-clamp removal:

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

			=== Post-bypass TEE evaluation ===
			Valve assessment

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Zining2023: Induction goals

2026-02-17T18:16:22Z

Induction goals

← Older revision		Revision as of 11:16, 17 February 2026
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	* Have at least 5-8 channels for infusions		* Have at least 5-8 channels for infusions
	** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)		** Epinephrine, norepinephrine, carrier, insulin (some institutions use phenylephrine in place of norepi)
	** Consider ketamine, dexmedetomidine, cefazolin		** Consider TXA, ketamine, dexmedetomidine, cefazolin
	* Drugs:		* Drugs:
	** Emergency medications (bolus):		** Emergency medications (bolus):
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	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
			Severe aortic stenosis - slow, controlled induction

			* maintain SVR
			* avoid tachycardia
			* avoid hypotension
			* Hypotension -> decrease coronary perfusion -> ischemia -> collapse

			Severe aortic regurgitation - standard induction acceptable

			* avoid bradycardia
			* avoid sudden increase in SVR
			* Bradycardia -> increase regurgitant time -> decrease forward flow

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

Zining2023: Monitoring and access, starting procedure variants

2026-02-17T18:02:38Z

Monitoring and access, starting procedure variants

← Older revision		Revision as of 11:02, 17 February 2026
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	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

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

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
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	\|+		\|+
	!		!
	!~~Variant 1~~		!Mechanical
	!~~Variant 2~~		!Bioprosthetic
			!AVR+CABG
			!Minimally invasive AVR
	\|-		\|-
	\|Unique considerations		\|Unique considerations
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|Position		\|Position
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|Surgical time		\|Surgical time
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|EBL		\|EBL
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|Postoperative disposition		\|Postoperative disposition
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|Pain management		\|Pain management
			\|
			\|
	\|		\|
	\|		\|
	\|-		\|-
	\|Potential complications		\|Potential complications
			\|
			\|
	\|		\|
	\|		\|