Difference between revisions of "Aortic valve repair or replacement"

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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type =  
| anesthesia_type = General
| airway =  
| airway = ETT
| lines_access =  
| lines_access = PIV, Arterial line, Central line, +/- PA catheter
| monitors =  
| monitors = Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS
| considerations_preoperative =  
| considerations_preoperative = -Severity of lesion (AS vs AR)
| considerations_intraoperative =  
-Symptoms (syncope, angina, dyspnea)
| considerations_postoperative =  
-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
}}
}}


Provide a brief summary of this surgical procedure and its indications here.
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 ==
== Preoperative management ==
Line 20: Line 56:
|-
|-
|Neurologic
|Neurologic
|
| -Syncope history (critical AS)
-Carotid disease (stroke risk)
|-
|-
|Cardiovascular
|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)
|-
|-
|Respiratory
|Pulmonary
|
| -Restrictive lung physiology (HF/sternotomy)
-COPD (prolonged vent weaning)
|-
|-
|Gastrointestinal
|Gastrointestinal
|
| -Dysphagia, esophageal/GI tract surgeries (TEE)
|-
|-
|Hematologic
|Hematologic
|
| -Anticoagulation use, blood products available
|-
|-
|Renal
|Renal
|
| -Baseline Cr, kidney disease (CPB AKI risk)
|-
|-
|Endocrine
|Endocrine
|
| -DM
|-
|-
|Other
|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<!-- 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. --> ===
* CBC, CMP, PT/PTT
* T&C pRBC FFP
* TTE/TEE, cardiac cath, EKG, CXR


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* 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<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Continue beta blockers, statins, antianginals
* Hold ACE inhibitors, 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. --> ===
* Pre-Op: Erector Spinae Plane Block
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence


== Intraoperative management ==
== Intraoperative management ==


=== 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 (in severe LV dysfunction, pulmonary HTN, or RV dysfunction)
* 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. --> ===
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


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Avoid bradycardia (goal HR 80-100)
* Avoid sudden increase in SVR
* Bradycardia -> increase regurgitant time -> decrease forward flow


=== 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. --> ===
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<!-- 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 ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* Cardiac ICU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
* Parasternal block
* Multimodal analgesia


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* 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<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==


{| 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>
!
!
!Variant 1
!Minimally invasive
!Variant 2
!AVR+CABG
!Redo
!Bentall
!Commando
|-
|-
|Unique considerations
|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
|-
|-
|Position
|CPB complexity/time
|
|Moderate
|
|Higher, longer clamp
|-
|Higher
|Surgical time
|Higher, prolonged clamp
|
|Very high, prolonged CPB
|
|-
|-
|EBL
|EBL
|
|Moderate
|
|Higher
|-
|High
|Postoperative disposition
|High
|
|Very high
|
|-
|Pain management
|
|
|-
|-
|Potential complications
|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 ==
== References ==
[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />

Latest revision as of 13:55, 17 February 2026

Aortic valve repair or replacement
Anesthesia type

General

Airway

ETT

Lines and access

PIV, Arterial line, Central line, +/- PA catheter

Monitors

Standard ASA, arterial line BP, CVP +/- PAP, TEE, NIRS

Primary anesthetic 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)

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

Postoperative

-Vasoplegia -Low cardiac output syndrome -Conduction abnormalities -Bleeding -Early vs delayed extubation

Article quality
Editor rating
Unrated
User likes
0

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[1]

Preoperative management

Patient evaluation

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

[2][3]
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)

-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

  1. ↑ Otto, Catherine M.; Nishimura, Rick A.; Bonow, Robert O.; Carabello, Blase A.; Erwin, John P.; Gentile, Federico; Jneid, Hani; Krieger, Eric V.; Mack, Michael; McLeod, Christopher; O’Gara, Patrick T. (2021-02-02). "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". Circulation. 143 (5). doi:10.1161/CIR.0000000000000923. ISSN 0009-7322.
  2. ↑ Kaplan, Joel A.; Augoustides, John G. T.; Gutsche, Jacob T., eds. (2024). Kaplan's cardiac anesthesia: perioperative and critical care (8th edition ed.). Philadelphia, PA: Elsevier. ISBN 978-0-323-82924-3. |edition= has extra text (help)
  3. ↑ Bartels, Karsten; Shaw, Andrew D.; Fox, Amanda; Thiel, Robert H.; Howard-Quijano, Kimberly, eds. (2025). Hensley's practical approach to cardiothoracic anesthesia (Seventh edition ed.). Philadelphia: Wolters Kluwer Health. ISBN 978-1-9752-0910-0. |edition= has extra text (help)

Top contributors: Zining Chen, Olivia Sutton and Chris Rishel

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