Difference between revisions of "Aortic valve repair or replacement"
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Zining Chen (talk | contribs) (Small addition to Preop management) |
Zining Chen (talk | contribs) (Completed preop and postop management) |
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| -Endocarditis (longer CPB) | | -Endocarditis (longer CPB) | ||
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'''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 | |||
'''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. --> === | |||
* 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 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 -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology | |||
* Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence | |||
== Intraoperative management == | == Intraoperative management == | ||
| Line 122: | Line 147: | ||
=== 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). --> == | ||
Revision as of 09:58, 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 | |
| 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/sSevere 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 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
- Emergency medications (bolus):
- 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 -- check departmental policy as institutions vary on candidacy for pre-op block based on vessel pathology
- Intra-op: Parasternal Intercostal Block - after sternal wound closure and prior to emergence
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
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
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ 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.
Top contributors: Zining Chen, Olivia Sutton and Chris Rishel