Catheter-based Cardiac Surgery
Figure 1. Paraprosthetic and central (wire-related) aortic regurgitation after implantation of an Edwards SAPIEN valve (TEE, midesophageal aortic valve, long-
axis view). Ao ¼ aorta; LA ¼ left atrium; LVOT ¼ left ventricular outflow tract; TEE ¼ transesophageal echocardiography. From Klein AA, Skubas NJ, Ender J:
Controversies and complications in the perioperative management of transcatheter aortic valve replacement. Anesth Analg 2014; 119:784–98. Copyright r
2014, International Anesthesia Research Society.
allows delivery via either a 16 or 19 Fr sheath. TA approaches
utilize a 26 Fr delivery sheath. The CoreValve system is dif-
ferent altogether, and utilizes a self-expandable system that
deforms when cold and regains its shape when warmed in the
patient. Sizes available include 22 and 26 mm devices that are
delivered via 18 or 19 Fr sheaths.34 There is more published
experience in the United States with the SAPIEN compared
with the CoreValve, thus much of this discussion will reflect
that experience.
Patient selection and preoperative evaluation for TAVR
varies from the typical patient for whom a multi-
disciplinary team discussion and selection process is typi-
cally employed (largely on the basis of a process developed
in the PARTNER trial).30,31,35 In addition to the usual
preoperative evaluation for AVR (i.e., symptomatic AV
stenosis), TAVR patient selection includes the following
criteria for most centers: adequately sized aortic annulus;
elevated Society of Thoracic Surgeons risk score (typically
more than 9 to 10%), denial of surgery by two surgeons, or
both; advanced lung disease; functional coronary vessels/
grafts; degree of frailty; functional status; and the usual
comorbidities of diabetes, renal disease, and coronary ar-
tery disease. Exclusion criteria may include advanced liver
disease, advanced dementia, severe mitral valve disease,
severe LV failure, nonrevascularized severe coronary ar-
tery disease, pulmonary hypertension, severe arrhythmias
(atrial fibrillation), and severe chronic obstructive pulmo-
nary disease.34,35 The next phase of diagnostics includes
evaluation of the aortic annulus, typically via transthoracic
echocardiography or TEE, in addition to computerized
tomography and angiography. Additional critical details
are evaluation of the femoral and iliac vessels to determine
degree of tortuosity, caliber, and atherosclerotic burden to
determine the feasibility of the TF approach.34,35 Pre-
Copyright r 2015 American Society of Anesthesiologists. All rights reserved.
125
anesthetic evaluation should also focus on degree of lung
disease to predict extubation after the procedure, airway
anatomy, overall cardiac functional status, neurological
status, and any history of previous anesthetic difficulties.
TEE is routinely used, so any esophageal pathology that
might preclude use of TEE should be noted.
The procedural specifics for the SAPIEN valve typically
include placement of standard monitors, adequate intra-
venous (IV) access, and arterial line, followed by induction
of general anesthesia and intubation with a single-lumen
endotracheal tube. Frequently, this is followed by central
access including placement of a pulmonary artery catheter
and the TEE probe. The surgical team, consisting of a
cardiothoracic surgeon and an interventional cardiologist,
then obtains appropriate femoral access. A temporary
pacing wire is placed in the RV, followed by heparinization
to an activated clotting time goal of 250 to 300 seconds.
Repeat imaging by TEE is routinely done to verify size
estimates of the AV annulus. A trial of rapid ventricular
pacing (RVP) is undertaken to verify adequate capture, but
this also gives the anesthesiologist a sense of how the pa-
tient will respond once RVP is terminated. Often, there is a
1- or 2-minute period of hypotension after RVP, which
may require vasopressors such as phenylephrine or epi-
nephrine. Often it is helpful to elevate the systolic blood
pressure slightly above baseline (to 130 to 140 mmHg)
before RVP. Once the delivery sheaths are placed, AV bal-
loon valvuloplasty is performed. Next, the device is in-
serted retrograde through the aorta and positioned across
the AV annulus with confirmation by TEE and fluoros-
copy. RVP from 160 to 200 bpm is then initiated to reduce
LV ejection, typically reducing the systolic blood pressure
to 60 to 80 mmHg and pulse pressures to 20 to 30 mmHg.
During this time, respirations are usually held as well to
126
Table 5. Summary of Key Anesthesia Management
Points for TAVR34
Intervention/
Procedure Anesthetic Management Points*
TAVR General anesthesia—but possible with local
anesthesia and sedation
Arterial line þ TEE monitoring
Adequate IV access required; central access and
possible PAC
Type and cross-match with products immediately
available
Cardiothoracic surgeon participation/availability
Perfusion standby
Cardiac anesthesiologist†
*All cases should have standard ASA monitoring in place. Specific anesthesia
planning should be based on individual medical conditions and may be altered
from these recommendations.
†There is current debate surrounding whether cardiothoracic anesthesiolo-
gists should staff these cases, and the decision may depend on whether
cardiology versus anesthesiology is performing TEE.
ASA ¼ American Society of Anesthesiologists; IV ¼ intravenous; PAC ¼ pulmo-
nary artery catheter; TAVR ¼ transcatheter aortic valve replacement; TEE ¼
transesophageal echocardiography.
reduce patient motion and to allow for the most ideal de-
ployment conditions. Immediately after deployment, at-
tention is focused on resolution of hemodynamics as well
as evaluation by TEE and fluoroscopy for proper seating of
the prosthetic valve, degree of paravalvular leak (if any),
pericardial effusion, and any evidence of compromise of
coronary flow. Occasionally, repeat balloon stenting of the
valve is employed to treat paravalvular leak, which re-
quires additional RVP.
The overall procedure is very similar for the TA
approach, with the obvious exception of the need for
minithoracotomy and direct cannulation of the LV apex.
TAVR management by the TA approach follows the same
induction and monitoring plans as for TF and, like TF, uses
a single-lumen endotracheal tube and two-lung ven-
tilation. The LV apex is exposed surgically and punctured
with a needle, a finder wire is then placed into the LV (with
visual confirmation by TEE), and the valvuloplasty sheath
is introduced, all followed by the deployment sheath. RVP
is utilized as in the TF procedure, and the same consid-
erations apply. Advantages include no risk of iliac or aortic
intervention, which can be critical in patients with severe
atherosclerosis, as well as an ideal placement angle for the
device.34 Disadvantages include pain associated with the
need for a thoracotomy, risk of myocardial damage, and
risk of severe bleeding from the LV apex. Initial results
seemed to demonstrate some differences in outcomes be-
tween TA and TF; however, recent larger-scale and longer-
term studies appear to indicate that procedural success,
short-term and long-term mortality, and stroke outcomes
are similar between these two groups.34
Copyright r 2015 American Society of Anesthesiologists. All rights reserved.
We i t z e l
Factors key to success for anesthesia
management include identifying specific risk
areas for each patient and planning how best
to counteract them with the knowledge of the
planned procedure.
Anesthetic planning for any procedure must take into
account a working knowledge of known or possible com-
plications. The list of complications for TAVR includes
peripheral vascular injury, paravalvular leak, rupture of
the annulus, heart block, coronary artery occlusion or
compromise leading to ischemia, stroke, bleeding, device
malposition, and low-output cardiac syndrome after
RVP.32–35 Factors key to success for anesthesia manage-
ment include identifying specific risk areas for each patient
and planning how best to counteract them with the
knowledge of the planned procedure (Table 5). Also crit-
ical is TEE imaging of the device and device placement,
which may be done by the anesthesia team or a cardiology
team, depending on the scenario. Discussion is encouraged
regarding management with general anesthesia versus IV
sedation for TAVR, especially since a number of studies
using IV sedation have been published. A recent meta-
analysis that spans seven nonrandomized studies, includ-
ing more than 1,500 patients, indicates that the 30-day
mortality did not differ between the general anesthesia
versus IV sedation groups.36 One obvious challenge to IV
sedation includes lack of TEE capability, as these are
lengthy procedures and the patient will not tolerate the
TEE probe for that duration. Reported advantages of IV
sedation include reduced hospital stay, reduced ventilator-
associated pneumonia, and shorter overall procedure
times. Given the lack of randomized trials, the authors
were hesitant to make sweeping conclusions, but suggest
that either approach may be appropriate on the basis of
patient, provider, and system preferences. Finally, dis-
cussion with the patient and the care team should include
the backup plan should there be a severe complication.
Often, sternotomy, cardiopulmonary bypass, and SAVR
comprise the backup plan, but some patients and surgeons
may refuse this option.
CONCLUSIONS
Catheter-based cardiac surgery represents an ever-growing
frontier for anesthesiologists. As techniques improve, pa-
tient volumes will likely follow, and a working knowledge
of these complex procedures is required for appropriate
anesthetic planning (Supplemental Digital Content 5,
http://links.lww.com/ASA/A566).
Catheter-based Cardiac Surgery
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