Cardio-anesthesiology considerations for the trans-catheter aortic valve implantation (TAVI) procedure

Comparison of anesthesia management in transcatheter aortic valve implantation: a retrospective cohort study

BACKGROUND AND OBJECTIVES

We aimed to investigate the effects of two different anesthetic techniques in our patients who underwent transcatheter aortic valve implantation (TAVI).

METHODS

In this study, 303 patients who underwent TAVI procedure with a diagnosis of severe aortic stenosis between January 1, 2012 and December 31, 2018 were retrospectively evaluated. The patients were divided according to the type of anesthesia given during each procedure as; general anesthesia (GA), local anesthesia (LA).

RESULTS

LA was preferred in 245 (80.8%) of 303 patients who underwent TAVI, while GA was preferred in 58 patients (19.1%). Median ages ​​of our patients who received LA and GA were 83 and 84, respectively. The procedure and anesthesia durations of the patients in the GA group were longer than the LA group (p< 0.00001, p < 0.00001, respectively). Demographic and pre-operative clinical data were similar in comparison between two groups (p > 0.05) except for peripheral artery disease. Hypertension was the most common comorbidity in both groups. While the number of inotrope use was significantly higher in patients who received GA (p < 0.00001), no significant differences were found between LA and GA patients in terms of major complications and mortality (p > 0.05). Intensive care and hospital stays were significantly shorter in the LA group (p = 0.001, p = 0.023, respectively).

CONCLUSION

The anesthetic technique of TAVI procedure did not have a significant effect on outcomes including; complications, mortality and success of the procedure. LA provides shorter duration of procedure and hospital stay.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

Long-Term Outcomes and Valve Performance in Patients Undergoing Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is an established method for treating patients with aortic valve stenosis. We sought to determine the long-term clinical outcomes and performance of a self-expanding bioprosthesis beyond 5 years. Consecutive patients scheduled for TAVI were included in the analysis. Primary end points were all-cause and cardiovascular mortality, structural valve deterioration (SVD) and bioprosthetic valve failure (BVF), based on the VARC-2 criteria and consensus statement by ESC/EAPCI. The study prospectively evaluated 273 patients (80.61 ± 7.00 years old, 47% females) who underwent TAVI with CoreValve/Evolut-R (Medtronic Inc.). The median follow-up duration was 5 years (interquartile range: 2.9 to 6; longest: 8 years). At 1, 5, and 8 years, estimated survival rates were 89.0%, 61.1%, and 56.0%, respectively, while cardiovascular mortality was 8% at the end of follow-up. Regarding valve performance, 5% of patients had early BVF and 1% had late BVF. Concerning SVD, 16 patients (6% of the total population) had moderate SVD (91% had an increase in mean gradient), with no severe SVD cases. Five patients with SVD died during follow-up. Actual analysis of the 8-year cumulative incidence of function of moderate SVD was 5.9% (2.5% to 16.2%). At multivariate analysis, the factor that emerged as an independent predictor for future SVD, was smaller bioprosthetic valve size (HR 0.58, 95% CI 0.41 to 0.82, p = 0.002). Long-term evaluation beyond 5 years after TAVI with a self-expanding bioprosthesis demonstrated low rates of cardiovascular mortality and structural valve deterioration. Valve size was an independent predictor for SVD.

Trans-femoral TAVI: Successful hemostasis of a totally calcified femoral artery ("calcium tube") with the Manta© device

We describe a case of trans-femoral trans-catheter aortic valve implantation (TF-TAVI) wherein the use of a novel collagen plug-based device (i.e. Manta© device) was very successful in arterial 16 French sheath hemostasis despite an extremely hostile peripheral vessel anatomy due to calcification.

When the pressure drops: A case of vasoplegia during a structural heart intervention

A 67-year-old male underwent general anesthesia for left atrial appendage occlusion. During the procedure, the patient developed catecholamine refractory hypotension requiring the administration of several vasopressin boluses to maintain adequate perfusion pressure. At the conclusion of the procedure, mild venous bleeding necessitated the administration of protamine. This led to a further decrease in the patient's blood pressure. Tamponade and continued volume loss were quickly ruled out leading to a diagnosis of vasoplegia syndrome (VS). The patient was appropriately treated with a vasopressin infusion with normalization of blood pressure and no significant morbidity or adverse outcome. With the use of general anesthesia during structural heart interventions on the rapid rise, we discuss the two common causes for vasoplegia along with evidence-based treatments and possible prevention strategies.

Relationships Between Intraoperative Hemodynamic Parameters and Delayed Hemodynamic Recovery After Valve Deployment in Transcatheter Aortic Valve Replacement

OBJECTIVE

To determine the relationships between intraoperative hemodynamic parameters and delayed hemodynamic recovery after valve deployment and identify the predictive factors of delayed hemodynamic recovery by focusing on intraoperative hemodynamics in patients with transcatheter aortic valve replacement (TAVR).

DESIGN

A retrospective study.

SETTING

A single university hospital.

PARTICIPANTS

Sixty-four patients who underwent elective TAVR between 2015 and 2017.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

The 64 patients were divided into the following 2 groups according to the time for recovery: systolic arterial pressure exceeded 90 mmHg and central venous oxygen saturation (ScvO₂) exceeded 65%-delayed recovery (DR) (n = 36) group, and early recovery (ER) (n = 28) group. ScvO₂ in the DR group was not lower than that in the ER group after induction of anesthesia. However, ScvO₂ in the DR group gradually decreased and was lower than that in the ER group before valve deployment, despite improvement in blood pressure through the administration of vasopressor agents.

CONCLUSION

ScvO₂ monitoring during TAVR is useful to predict delayed recovery greater than 60 seconds after valve deployment in TAVR.

Assessment and pathophysiology of pain in cardiac surgery

Analysis of the problem of surgical pain is important in view of the fact that the success of surgical treatment depends largely on proper pain management during the first few days after a cardiosurgical procedure. Postoperative pain is due to intraoperative damage to tissue. It is acute pain of high intensity proportional to the type of procedure. The pain is most intense during the first 24 hours following the surgery and decreases on subsequent days. Its intensity is higher in younger subjects than elderly and obese patients, and preoperative anxiety is also a factor that increases postoperative pain. Ineffective postoperative analgesic therapy may cause several complications that are dangerous to a patient. Inappropriate postoperative pain management may result in chronic pain, immunosuppression, infections, and less effective wound healing. Understanding and better knowledge of physiological disorders and adverse effects resulting from surgical trauma, anesthesia, and extracorporeal circulation, as well as the development of standards for intensive postoperative care units are critical to the improvement of early treatment outcomes and patient comfort.