Download The Utility of Atrioventricular Pacing via Pulmonary Artery Catheter

CASE REPORT
The Utility of Atrioventricular Pacing via Pulmonary Artery Catheter During
Transcatheter Aortic Valve Replacement
William J. Vernick, MD,§ Wilson Y. Szeto, MD,† Robert H. Li, MD,‡ Pavan Atluri, MD,† John G. Augoustides, MD,
FASE, FAHA,§ Jeremy D. Kukafka, MD,§ Prakash A. Patel, MD,§ and Jack T. Gutsche, MD*
T
HE DEVELOPMENT OF TRANSCATHETER aortic
valve replacement (TAVR) has led to the treatment of
calcific aortic stenosis in patients whose condition might
otherwise be considered inoperable if relegated to traditional
aortic valve surgery. Although the ability to replace a patient’s
aortic valve in this manner represents an important advancement in the treatment of aortic valve disease, there remain
many challenges associated with successfully performing the
procedure.
One of these challenges is the ability to maintain hemodynamic stability during valve positioning and then recover
stability after its deployment. Several factors can complicate
this mission. The most obvious relate to the patient’s underlying aortic valve pathology as well as other concomitant
cardiac disease. During valve positioning, the interposition of
the deployment system across an already compromised aortic
valve will further limit the native valve’s effective orifice area
and also can promote regurgitation. Mechanical or functional
mitral regurgitation also may occur during this process,
producing additional strain on the myocardium. The cardiovascular system is further burdened by the need for cardiac
“stand-still” during valve deployment. This is achieved by
inducing rapid ventricular pacing (V-pacing). Hemodynamic
recovery after this may be difficult, particularly if the pacing
runs are protracted or successive. Delayed recovery can
promote further myocardial ischemia, initiating a downward
spiral that may prove intractable without significant intervention, including the need for mechanical circulatory
support.
Management can be complicated further by the development
of conduction abnormalities (CA) after TAVR. This association
has been well documented, but most of the literature has
discussed them in regard to postoperative management, particularly the potential need for permanent pacemaker (PPM)
placement.1–4 However, CAs typically present during or
immediately after valve deployment5 and their acute hemodynamic effects have, in contrast, largely been ignored in
published reports. This may be an important omission because
the acute loss of atrioventricular (AV) synchrony may be
tolerated poorly given the common association of ventricular
hypertrophy and diastolic dysfunction in patients with aortic
stenosis. In addition, because of the percutaneous nature of the
procedure there are limited intraoperative rhythm management
options available should the CA be associated with hemodynamic instability.
Because of these concerns, all patients undergoing TAVR at
this institution have percutaneous right atrial (RA) and right
ventricular (RV) endocardial pacing wires placed via a specialized pulmonary artery catheter (PAC), unless they already
have a PPM or have pre-existing atrial fibrillation (Fig 1). What
follows is the discussion of a case that exemplifies the
important benefits of this technique.
CASE
A 91-year-old woman with progressive dyspnea on exertion
secondary to critical aortic stenosis presented for TAVR. The patient’s
medical history also was significant for coronary artery disease with
drug-eluting stents placed 2 years earlier, non–insulin-dependent
diabetes mellitus, and temporal arteritis. Preoperative echocardiography
revealed normal left ventricular function but with severe concentric
hypertrophy, moderate mitral valve stenosis and regurgitation, and
moderate-to-severe tricuspid regurgitation. The baseline electrocardiogram (ECG) was notable for sinus rhythm at 76 beats/min with an
incomplete right bundle-branch block (RBBB) and a PR interval of 156
ms. A transaortic surgical approach was chosen because of the presence
of a small and tortuous aorta with significant atheroma as well as the
patient’s small body size, the combination of which limited both
transapical and transfemoral deployment.
After the induction of general anesthesia, a thermodilution PAC
with two additional ports allowing the introduction of endocardial
pacing wires into both the RA and RV (A-V Paceport Catheter,
Edwards Lifesciences Corp., Irvine, CA) was inserted through a
9- French introducer sheath that had been placed into the right internal
jugular vein (IJV). In order to properly position the pacing wires, the
PAC was advanced while the pressure waveforms of both the catheter
tip and the RV Paceport orifice were simultaneously monitored. Once
the catheter tip entered the pulmonary artery (PA), it was further
advanced until an RV pressure waveform was seen from the RV
Paceport orifice, which indicated that this port had crossed the tricuspid
From the *Department of Anesthesia and Critical Care, PennPresbyterian Medical Center, Philadelphia, PA; †Department of Cardiac Surgery, Penn-Presbyterian Medical Center, Philadelphia, PA;
‡Department of Cardiology, Penn-Presbyterian Medical Center,
Philadelphia, PA; and §Department of Anesthesia and Critical Care,
Hospital of the University of Pennsylvania, Philadelphia, PA.
Address correspondence and reprint requests to William J. Vernick,
MD, Department of Anesthesia and Critical Care, Dulles 6, Hospital of
the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA
19104. Tel.: þ(215) 662-7270. E-mail: [email protected].
edu
© 2014 Elsevier Inc. All rights reserved.
1053-0770/2602-0033$36.00/0
http://dx.doi.org/10.1053/j.jvca.2013.10.023
Key words: TAVR, aortic stenosis, pacemaker, pacing swan,
CoreValve Revalving System, Medtronic
Journal of Cardiothoracic and Vascular Anesthesia, Vol ], No ] (Month), 2014: pp ]]]–]]]
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VERNICK ET AL
A
B
D
E
C
Fig 1. A fluoroscopic 39-degree left anterior oblique image taken
at the conclusion of transcatheter aortic valve replacement (TAVR) is
shown in a patient with a Thermodilution A-V Paceport catheter
(Edwards Lifesciences, Irvine, CA). (A) The aortic root enhanced by
contrast injection. (B) The deployed TAVR seen within the aortic
root. (C) The A-V Paceport catheter within the right side of the heart.
(D) Flex-Tip Transluminal A-Pacing probe within the right atrium. (E)
The Chandler Transluminal V-Pacing probe within the right ventricle.
valve. A flexible-tipped pacing wire (Chandler Transluminal V-Pacing
Probe, Edwards Lifesciences Corp., Irvine CA) then was inserted
through the RV Paceport while connected to a Medtronic 5388
Dual Chamber Temporary Pacemaker (Medtronic Inc., Minneapolis,
MN). The pacing wire was advanced 4.5 cm until ventricular capture
occurred at 2.5 mA. Next, the atrial wire (Flex-Tip Transluminal
A-Pacing Probe, Edwards Lifesciences Corp., Irvine CA) was passed
through the RA Paceport. Using transesophageal echocardiography
(TEE), the wire was visualized advancing into the right atrial
appendage (5 cm beyond the port) (Fig 2). Consistent atrial
pacing (A-pacing) using an atrial sensing mode at 5 mA confirmed
proper positioning.
The case proceeded in usual fashion for transaortic access, which
uses an upper “mini-sternotomy” followed by cannulation of the
ascending aorta. During aortic balloon valvuloplasty, rapid V-pacing
at 170 beats/min was instituted via the RV pacing wire. Upon
discontinuation of rapid V-pacing, maintenance of AV synchrony with
A-pacing alone was achieved and a rapid restoration of the patient’s
hemodynamics occurred. After insertion of the valve delivery system
into the ascending aorta with subsequent positioning of the valve within
the native aortic root, deployment of a 23-mm Edwards SAPIEN valve
(Edwards Lifesciences Corp., Irvine, California) was facilitated again
by rapid V-pacing at 170 beats/min. Isolated A-pacing, however, was
now complicated by complete heart block with no observable ventricular escape rhythm seen. Immediate and successful AV-pacing then
was employed, ensuring a successful resuscitation (Fig 3). Valve
positioning and function were deemed to be excellent.
After removal of the valve delivery system from the ascending
aorta, significant bleeding occurred and a limited aortic repair was
required. This period of acute hypovolemia was well tolerated. The
remainder of the procedure was uneventful. The patient’s ECG upon
arrival to the intensive care unit was dramatically different from the
preoperative ECG and was notable for second-degree heart block,
Mobitz type I (Fig 4). AV pacing was employed for the first several
hours after surgery, with gradual recovery of normal sinus rhythm over
the next several hours. The patient was extubated later that same day of
surgery. The postoperative day 1 ECG displayed to normal sinus
rhythm with a PR interval near baseline (158 ms).
DISCUSSION
The development of a new CA after TAVR is a common
occurrence. For example, the CoreValve registry (CoreValve
Revalving System, Medtronic Inc., Minneapolis, MN)
described new or worsening AV conduction delay in 77% of
patients.6 Although the rates appear highest with the CoreValve, CAs are not unique to this deployment system. The
SAPIEN valve has been associated with new CAs in up to
15.2% of patients7 and an even higher incidence of new left
bundle-branch block (14.5% compared with 29.5%).3 Most of
these abnormalities occur during or shortly after surgery5 and
may be associated with hemodynamic instability. However,
because of the procedure’s inherent percutaneous nature,
LA
C
A
D
B
RA
Fig 2. The picture on the left is a transesophageal echocardiographic bicaval image. The A-V Paceport catheter is shown entering the right
atrium (RA) from the superior vena cava and is marked by A. The Flex-Tip Transluminal A-Pacing probe is shown exiting the A-V Paceport
catheter and is marked B. The picture on the right is a 3D reconstruction, which more clearly shows the A-Pacing probe (C) exiting the A-V
Paceport catheter and then directed toward the right atrial appendage (D). Abbreviation: LA, Left atrium.
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ATRIOVENTRICULAR PACING DURING TRANSCATHETER VALVE REPLACEMENT
undergoing TAVR at this institution, except in those who present
with atrial fibrillation or have an in-situ PPM. Ideally, it would be
possible to clearly identify those patients at high risk for CAs
before deciding in whom to use this approach. Unfortunately,
despite the high incidence of CAs after TAVR, the only consistent
predictor of high-grade AV block is the preoperative presence of
an RBBB.8 It is worth noting that the baseline incomplete RBBB
in this patient may have represented a risk factor.
The long-term outcome associated with the development of
CAs after TAVR remains unclear.5 Their acute consequences
have been even less well studied in the literature and are likely
not accurately represented by 1-year survival data. Perioperative
hemodynamic instability may be multifactorial, and practitioners may not necessarily attribute it to a new CA. In addition,
the hemodynamic consequences related to loss of AV synchrony often can be mitigated through escalating doses of
vasoactive medications. Thus, a more focused study would be
required in order to determine the isolated effect of CAs. As of
now, there is no literature to support the prophylactic use of an
AV-pacing catheter for management of CAs after TAVR, but
such a trial currently is underway at this institution. This study
will examine beyond traditional outcome measures by comparing both the time to hemodynamic recovery after valve
deployment as well as the degree of pharmacologic and
mechanical support needed to achieve this recovery. The current
extensive but anecdotal experience suggests that the ability to
Fig 3. The hemodynamic data after transcatheter valve implantation. Notice the successful AV-pacing. The temporary disconnection
of the ventricular pacing wire is indicated by A., displaying the
underlying heart block without a ventricular escape beat.
options for cardiac rhythm intervention are limited. In most
centers, either the native rhythm must be tolerated or V-pacing
via a temporary transvenous wire is employed.
The presented case, in which complete heart block without an
escape rhythm occurred immediately after valve deployment,
highlights the ability to preserve AV synchrony through use of an
AV-pacing catheter. This catheter is used in all patients
92 yr
Female Unknown
0in
0lb
Room:SICU.
Loc:11
Vent. rate
49 BPM
PR interval
* ms
QRS duration
114 ms
QT/QTc
486/439 ms
P-R-T axes
55 -72 55
SINUS RHYTHM WITH 2ND-DEGREE A-V BLOCK (MOBITZ I)
LEFT AXIS DEVIATION
RIGHT BUNDLE-BRANCH BLOCK
ABNORMAL ECG
Technician
Test ind:Shortness of breath
I
aVR
V1
V4
II
aVL
V2
V5
V3
V6
III
aVF
V1
Fig 4. Electrocardiogram on arrival to the intensive care unit immediately after transcatheter aortic valve replacement. Second-degree heart
block, Mobitz type I, was now present.
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VERNICK ET AL
ensure AV synchrony not only speeds recovery after valve
deployment but also helps avoid overly aggressive resuscitation
and associated hypertension, which may be particularly problematic with transapical or transaortic approaches.
In this presented case, a trial of V-pacing alone was not
attempted, and, therefore, the authors did not prove that AV
pacing in this patient was necessary for an acceptable hemodynamic recovery. With that said, maintaining AV synchrony
likely provided a superior hemodynamic profile compared with
V-pacing alone, particularly in light of the concomitant moderate
mitral stenosis and the degree of ventricular hypertrophy.
Although it can be argued that the acute relief of aortic stenosis
may limit the importance of AV synchrony after TAVR, it must
be recognized that regression of left ventricular hypertrophy after
aortic valve replacement is a much more gradual process.9,10
Although the placement of an AV-pacing catheter in those
who do not suffer from an acute CA may not be absolutely
necessary, there also does not appear to be a significant
downside, particularly if a standard PAC is going to be inserted
anyway. In addition, the avoidance of bradycardia through A
pacing may be beneficial. The potential for tachyarrhythmias or
direct injury as a result of the endocardial wires does exist, but
in the authors’ experience these events have not occurred and
the system has been used effectively, reliably, and safely. The
added disposable costs related to the equipment, the additional
time needed to place the pacing wires, and any increased risks
associated with its use are typically offset by avoidance of the
separate temporary transvenous wire used for rapid ventricular
pacing wire, which, unlike our approach, requires an additional
introducer sheath to be placed.
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