Difference between revisions of "Transcatheter aortic valve replacement"

From WikiAnesthesia
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| monitors = Standard, ABP
| monitors = Standard, ABP
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative =  
| considerations_intraoperative = Hypotension during induced fibrillation
| considerations_postoperative =  
| considerations_postoperative =  
}}
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<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.
<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 ==
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=== 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 Cross 2 units of pRBCs
Type and cross ~2 units for risk of major bleeding


=== 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 a remote anesthesia setting.  
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<!-- 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 ==
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=== 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. --> ===
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=== 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. --> ===
For MAC cases, can consider starting with remifentanil 0.02mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.


=== 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. Fibrilliation will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if prolonged.
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===  


== Postoperative management ==
== Postoperative management ==
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=== 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, 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
* 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<!-- 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 08:25, 8 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)

Monitors

Standard, ABP

Primary anesthetic considerations
Preoperative
Intraoperative

Hypotension during induced fibrillation

Postoperative
Article quality
Editor rating
In development
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
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
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. 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)