Transcatheter aortic valve replacement

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
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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.

Postoperative management

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