Difference between revisions of "Transcatheter aortic valve replacement"
From WikiAnesthesia
Chris Rishel (talk | contribs) m (Text replacement - "|Respiratory" to "|Pulmonary") |
|||
| (7 intermediate revisions by 3 users not shown) | |||
| Line 2: | Line 2: | ||
| anesthesia_type = MAC vs. GA | | anesthesia_type = MAC vs. GA | ||
| airway = Natural airway vs. ETT | | airway = Natural airway vs. ETT | ||
| lines_access = 2 large bore PIV + art line (left preferred) | | lines_access = 2 large bore PIV + art line (left preferred - clarify with proceduralist since sometime arterial line placed by them) | ||
| monitors = Standard, ABP | | monitors = Standard, ABP | ||
| considerations_preoperative = | | considerations_preoperative = | ||
| considerations_intraoperative = | | considerations_intraoperative = Hypotension during induced fibrillation | ||
| considerations_postoperative = | | considerations_postoperative = | ||
}} | }} | ||
<ref>{{Cite journal|last=Clegg|first=Stacey D.|last2=Krantz|first2=Mori J.|date=2012-07|title=Transcatheter Aortic Valve Replacement: What's in a Name?|url=http://dx.doi.org/10.1016/j.jacc.2012.03.049|journal=Journal of the American College of Cardiology|volume=60|issue=3|pages=239|doi=10.1016/j.jacc.2012.03.049|issn=0735-1097}}</ref>TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy. | |||
There are many techniques | |||
== Preoperative management == | == Preoperative management == | ||
| Line 20: | Line 22: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Preoperative neurological deficits/previous CVA with residual deficit | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Symptoms of AS and functional status, LV EF | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Coexisting pulmonary disease | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| Line 45: | Line 47: | ||
=== 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. --> === | ||
Type and Screen usually sufficient or type and cross ~2 units - check with local site for usual practice | |||
=== 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. --> === | ||
* Often done in remote anesthesia setting, so have emergency cardiac drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function. | |||
* Heparin/protamine prepared | |||
* Infusion and bolus pressors ready for BP swings with rapid pacing. | |||
=== 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. --> === | ||
Typically on antiplatelet medications, which should be taken the morning of surgery as well. | |||
=== Regional and neuraxial techniques | === Regional and neuraxial techniques === | ||
N/A | |||
== Intraoperative management == | == Intraoperative management == | ||
| Line 64: | Line 71: | ||
=== 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. --> === | ||
For MAC, a very small bolus of propofol is adequate prior to starting maintenance infusions. | |||
=== 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. --> === | ||
| Line 69: | Line 77: | ||
=== 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. --> === | ||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | * For MAC cases, can consider starting with remifentanil 0.02 mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect. | ||
* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient). | |||
* Venous access is obtained for transvenous pacing. Rapid pacing will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if persistent following completion of rapid pacing. | |||
**Pacing may also be performed through native pacemaker if already present in patient. | |||
*For MAC cases, assess neurological status following deployment of valve. | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | |||
== 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. -->=== | ||
<blockquote>Usually cardiology floor with telemetry</blockquote> | |||
=== 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. -->=== | ||
Pain control is not usually difficult. Most patients have difficulty with back pain/aches due to laying flat for several hours after groin access. | |||
=== 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. --> === | ||
Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture | * Complete heart block, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks | ||
*Stroke - risk can be minimized with use of sentinel device | |||
* Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma | |||
* Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture | |||
*Pericardial effusion/tamponade | |||
*Obstruction of coronary arteries: dependent on coronary heights (<12 mm for both right and left coronaries have been established as a risk factor), but more likely to happen for valve-in-valve procedures | |||
== 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). --> == | ||
| Line 96: | Line 112: | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | |Valve-in-Valve TAVR | ||
| | | | ||
|- | |- | ||
| Line 120: | Line 136: | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
| | |Same as above but slightly higher risk of coronary artery obstruction | ||
| | | | ||
|} | |} | ||
Latest revision as of 11:20, 11 August 2022
Transcatheter aortic valve replacement
| Anesthesia type |
MAC vs. GA |
|---|---|
| Airway |
Natural airway vs. ETT |
| Lines and access |
2 large bore PIV + art line (left preferred - clarify with proceduralist since sometime arterial line placed by them) |
| Monitors |
Standard, ABP |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
Hypotension during induced fibrillation |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
[1]TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.
There are many techniques
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Preoperative neurological deficits/previous CVA with residual deficit |
| Cardiovascular | Symptoms of AS and functional status, LV EF |
| Pulmonary | Coexisting pulmonary disease |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Type and Screen usually sufficient or type and cross ~2 units - check with local site for usual practice
Operating room setup
- Often done in remote anesthesia setting, so have emergency cardiac drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.
- Heparin/protamine prepared
- Infusion and bolus pressors ready for BP swings with rapid pacing.
Patient preparation and premedication
Typically on antiplatelet medications, which should be taken the morning of surgery as well.
Regional and neuraxial techniques
N/A
Intraoperative management
Monitoring and access
2 PIVs: one for infusion. one for push line.
If doing MAC: do not need to place an invasive A-line. Cardiologists will place a femoral and radial A-line that will monitor aortic and LV pressures; these can be used intra-op by the anesthesia team to monitor BP. Can use a non-invasive a-line such as a clear-sight if available.
If doing GA, place arterial line prior to induction.
Induction and airway management
For MAC, a very small bolus of propofol is adequate prior to starting maintenance infusions.
Positioning
Supine, arms tucked
Maintenance and surgical considerations
- For MAC cases, can consider starting with remifentanil 0.02 mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.
- Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).
- Venous access is obtained for transvenous pacing. Rapid pacing will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if persistent following completion of rapid pacing.
- Pacing may also be performed through native pacemaker if already present in patient.
- For MAC cases, assess neurological status following deployment of valve.
Emergence
Postoperative management
Disposition
Usually cardiology floor with telemetry
Pain management
Pain control is not usually difficult. Most patients have difficulty with back pain/aches due to laying flat for several hours after groin access.
Potential complications
- Complete heart block, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks
- Stroke - risk can be minimized with use of sentinel device
- Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma
- Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture
- Pericardial effusion/tamponade
- Obstruction of coronary arteries: dependent on coronary heights (<12 mm for both right and left coronaries have been established as a risk factor), but more likely to happen for valve-in-valve procedures
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | Valve-in-Valve TAVR | |
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications | Same as above but slightly higher risk of coronary artery obstruction |
References
- ↑ Clegg, Stacey D.; Krantz, Mori J. (2012-07). "Transcatheter Aortic Valve Replacement: What's in a Name?". Journal of the American College of Cardiology. 60 (3): 239. doi:10.1016/j.jacc.2012.03.049. ISSN 0735-1097. Check date values in:
|date=(help)
Top contributors: Olivia Sutton, Jessica, Tony Wang, David Leon, William Hsu and Chris Rishel