Journal Reading

Transcatheter aortic valve replacement under monitored

anesthesia care versus
general anesthesia with intubation
Tomy Resky Sandriya / 30101407340
Co-Ass Bagian Ilmu Anestesi / FK Unissula
RS K.R.M.T Wongsonegoro
Pembimbing: dr. Donni Indra K., Sp.An FAKV
Introduction

Aortic Stenosis

Echocardiographic

T-AVR

Monitored anesthesia care

General anesthesia with intubation

Aortic Stenosis
• Chronic progressive disease that produces obstruction to the left
ventricular stroke volume leading symptoms of chest pain,
breathlessness, syncope and pre-syncope and fatigue.

Calcific Aotic Valvular Disease (CAVD)

Bicuspid Aortic Valve (BAV)

Rheumatic Aortic Stenosis

Pathophysiology
Relative
Obstructed ischemia,
LV
Increase
LV angina,
LV
pressure Hyper arrhythmias,
trophy LV failure

Relative ischemia 
hypotension
Symptom
• There are usually no symptoms until aortic stenosis is moderately
severe (when the aortic orifice is reduced to one-third of its normal
size). At this stage, exercise-induced syncope, angina and dyspnoea
develop.
Sign
Echocardiographic
• Echocardiography is the key diagnostic tool. It confirms the presence
of aortic stenosis, that can assess:
• The degree of valve calcification
• LV function and wall thickness
• Detects the presence of other associated valve disease or aortic pathology
• Provides prognostic information
• Doppler echocardiography is the preferred technique for assessing
the severity of aortic stenosis.
Cont’s
Degree of AS
Management of AS Medical Therapy

• No medical therapy for aortic stenosis

can improve the outcome
• RCT  statin consistently do not affect
the progression of AS
• Patient with symptoms heart failure who
are unsuitable candidates for SAVR or
TAVR , or waiting surgical or catheter
intervention should be medically treated
according CHF guideline.
• Principle of medical therapy  avoid
hypotention, maintenance of sinus
rhythm.
SAVR or TAVR?
Transcatheter Aortic Valve Replacement

Trans-
Femoral
T-AVR
Trans-
Apical
TAVR trans-femoral
TAVR trans-apical
Method
• Prospective cohort study was approved by the Instutional Review Board of
the MedStar Health Reseach Institute.
• 137 patient form April 2007 to January 2011  symtompmatic severe AS.
• All patient screened and assessed by angiographic, echocardiographic, and
chest CT-scan before T-AVR procedure.
• Include 92 consecutive patients undergoing T-AVR guided by TEE using the
Edward SAPIEN transcatheter via transfemoral
• 43 patient had transapical approach and were exclude, and 2 patient was
aborted due to inability to advance the dilators beyond the common iliac.
 N= 70; 76.1%
Provide by a cardiac anesthesiologist.
Sedation : Propofol(200mg)/Ketamine(50mg) or
Monitored Dexmedetomidine 0.3-0.7 mcg/kg/h.
Very low dose Versed or Fentanyl was
anesthesia administered as needed.
TEE monitoring.
Percutaneus access of femoral artery.
Group

General N= 22; 23.9%

anesthesia
All patient received 1% lidocaine subcutaneously at the
arterial and venous access sites.
Provide by the anesthesiologist.
TEE monitoring, inserted after ETT and
sedation.
Surgical access of femoral artery.
Baseline characteristic of sample
Procedural time
Hospital stay
ICU stay
Discussion
• Procedure time done under MAC
was significantly less as compared to
GA.
• ICU and total hospital stay were
shorter in MAC group.
• Local anesthesia in endovascular
aortic aneursm repair was
associated with shorter procedure
time and hospital stay as compared
to GA.
Cont
• Shorter procedural time is interpreted because surgical access on GA
takes longer than it does percutaneously on MCA.
• All procedures were supervised by cardiac anesthesiologist.
• Conversion rate from MAC to GA is 10%, Behan et al  11.1%, covello
et al  7.1 %.
• These conversion rate reflect the necessity of having a cardiovascular
anesthesiologist present throughout the procedure.
• Most of the patient with GA could potentially be etubated in the cath
lab.
Thank You