Download Transcatheter aortic valve implantation: anesthetic

Transcatheter aortic valve implantation: anesthetic management and
considerations
Bianco, Juan Carlos, Guardabassi Diego, Battellini Roberto R, Falconi Mariano,
Agatiello Carla R., Berrocal Daniel H.
Introduction: Aortic stenosis (AS) is the most common form of adult valvular heart
disease.1 Many patients with severe AS and multiple comorbidity conditions are not
candidate for surgical replacement of the aortic valve, which is currently the goldstandard treatment. Transcatheter aortic-valve implantation (TAVI) has been
suggested as a less invasive treatment for high-risk patients with AS. Objective:
The aim of this study is to report the anesthetic considerations and management in
the first nineteen TAVI with the CoreValve Revalving™ system. Methods:
Patients with severe AS who had been refused surgery because of comorbidity
were enrolled. Nineteen high-risk surgical patients underwent TAVI between march
2009 and august 2011, under general anesthesia. The induction and maintenance
of anesthesia was done avoiding bradycardia or tachycardia, maintaining systemic
vascular resistant and preserving preload. A general anesthetic was tailored to
achieve extubation after procedure completion, whereas IV access and
pharmacological support allowed for sudden hemodynamic changes, emergent
sternotomy and initiation of cardiopulmonary bypass. Aortic balloon valvuloplasty
was performed first under rapid ventricular pacing and then retrograde CoreValve
was implanted.
Transesophageal echocardiography (TEE) was performed to confirm the
diagnosis, determine ventricular function, annulus size, aortic pathology, and mitral
regurgitation. It evaluated the Corevalve function, measured aortic regurgitation
and assessed for aortic dissection, pericardial effusion and myocardial ischemia.
Result: Patients were 79 ± 7 years (63%male), with multiple comorbidities
(EuroSCORE = 22,16 ± 9,74%). Patients who survived to the procedure (94,7%)
were extubated and transfer to intensive care unit without vasoactive or inotropic
infusions. The most common in-hospital complications were third degree
atrioventricular block (42,11%) and need for permanent pacemaker (26,32%). One
patient underwent aortic valve replacement after TAVI because of symptomatic
severe perivalvular leak. No patient required intraoperative transfusions. After a
mean follow up of 317+-263 days, the rate of survival was 89,47%. Early hospital
discharge was not always possible because of the comorbilities, been an average
of 8,1 ± 6,9 days. Conclusion: Corevalve TAVI procedure in high risk patients
appeared feasible and safe. Anesthesiologists have to manage critical patients with
severe cardiac and noncardiac comorbilities applying the expertise to a novel
procedure.
References
1. Eur Heart J. 2003;24(13):1231-43