Menachem M. Weiner Assistant Professor of Anesthesiology
Icahn School of Medicine at Mount Sinai
Anesthetic care and considerations
Intraoperative events
TEE
Perioperative complications
•Most common valvular disease
•Degenerative disease- Senile calcification
•Rheumatic disease
•Congenital (e.g. Bicuspid)
Severe Aortic Stenosis
• Angina
• CHF
• Syncope
Otto et al. Circulation. 1997;95:2262-70.
Parameter
Preload
Afterload
Contractilty
Heart rate Maintain
Sinus Rhythm
Table 10.
Summary of recommendations for AS: Choice of surgical or transcatheter intervention
Recommendations COR LOE
Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk I A
For patients in whom TAVR or high-risk surgical AVR is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care I C
TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo I B
TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk IIa B
Percutaneous aortic balloon dilation may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe AS IIb C
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS
III: No Benefit B
2014 AHA/ACC guideline for the management of patients with valvular heart disease : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Alfirevic A, Mehta AR, Svensson LG. Transcatheter aortic valve replacement. Anesthesiol Clin. 2013;31:355-81.
• Preparation
• Hemodynamics *monitoring/management
• GA or MAC
• TEE (TTE)
• Complications
Communication
Surgical team
CPB readiness
IABP
Ethical dilemma
Invasive arterial access
Central venous access
PAC
Vasopressors
Transvenous pacemaker
Anesthesia induction
Balloon valvuloplasty
Between valvuloplasty and deployment
Valve deployment
Complications of deployment
General anesthesia
? Extubation
MAC
Midazalam
Propofol
Dexmedetomidine
Fentanyl
Remifentanyl
Mount Sinai Cocktail
General anesthesia
Advantages TEE monitoring throughout procedure Secured airway at all times Ability to suspend mechanical ventilation Better pain control
Disadvantages Airway manipulation and potential damage Potential for prolonged intubation Hemodynamic instability throughout the procedure
MAC Advantages Avoidance of airway manipulation Quicker emergence and recovery, shorter hospital stay Neurologic monitoring
Disadvantages Inability to use TEE Procedural need for lying in one position for prolonged period of time Intolerance to decrease in CBF with RVP Unprotected airway (with increase chance for sudden instability) Inability to suspend ventilation Local anesthetic toxicity Escalation in sedation reaching general anesthesia levels
Confirm diagnosis and prosthesis size
Exclude unfavorable anatomy
Guide wires and valve into place
Examine for AI after BAV
Examine for procedural success
Transvalvular vs. Paravalvular AI
Diagnose complications
Aortic regurgitation
Vascular injury
Electrophysiological
Pericardial hemorrhage
Valve malpositioning
Stroke
Mitral valve disruption
Aortic dissection/ Annular Rupture
Death
• TAVR is now main stream
• Need to know anesthetic considerations • Avoid tachycardia and decreased CPP • Maintain systemic pressure during RVP • Limit cardiac ejection during BAV and valve implant • Extubate safely
• Advance planning
• Younger/lower risk patients