Aortic valve repair or replacement

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
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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.

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

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)

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications