Transcatheter aortic valve replacement
Anesthesia type |
MAC vs. GA |
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Airway |
Natural airway vs. ETT |
Lines and access |
2 large bore PIV + art line (left preferred) |
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 |
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Neurologic | |
Cardiovascular | |
Pulmonary | |
Gastrointestinal | |
Hematologic | |
Renal | |
Endocrine | |
Other |
Labs and studies
Type and cross ~2 units for risk of major bleeding
Operating room setup
Often done in remote anesthesia setting, so have emergency drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.
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. Fibrilliation will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if prolonged.
Emergence
Postoperative management
Disposition
Pain management
Potential complications
- Complete heart block, stroke, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks
- 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
Procedure variants
Variant 1 | Variant 2 | |
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Unique considerations | ||
Position | ||
Surgical time | ||
EBL | ||
Postoperative disposition | ||
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Potential complications |
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:
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