Controversies and Complications in the Perioperative Management of Transcatheter Aortic Valve Replacement

Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone

Background:

Transcatheter aortic valve implantation (TAVI) is a valid option for patients with severe aortic stenosis judged to be at high surgical risk. For this procedure, there is no agreement on the appropriate type of anesthesia. Sedation offers several advantages, but general anesthesia (GA) leads to less paravalvular leaks (PVLs) probably because of the transesophageal echocardiography (TEE) guidance. The objective was to compare the incidence of PVL among patients receiving conscious sedation (TAVI-S) and patients receiving GA (TAVI-GA). We made the hypothesis that a referral center does not necessitate TAVI-GA to reduce the incidence of moderate-to-severe PVL.

Aim:

The primary outcome was the incidence of moderate-to-severe PVL at 30 days after the implantation.

Design and Setting:

This study design was a retrospective observational trial in a university hospital.

Methods:

The TAVI-S group underwent the procedure under conscious sedation. In the TAVI-GA group, an endotracheal tube and a TEE probe were inserted. After the valve deployment, PVL was assessed by hemodynamic and fluoroscopic measurements in the TAVI-S group. TEE was also used in the TAVI-GA group to evaluate the presence of PVL. When PVL was moderate or severe according to the Valve Academic Research Consortium criteria.

Results:

TAVI-S and TAVI-GA were accomplished in 168 (67.5%) and 81 (32.5%) patients, respectively. Our results show no difference between the two groups regarding the incidence and grade of PVL.

Conclusion:

Performing TAVI under GA with TEE guidance is not associated with a lower incidence of moderate and severe PVL.

Complications after transcatheter aortic valve implantation using transfemoral and transapical approach in general anaesthesia

Background

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat degenerative heart valve disease. The implantation requires a highly specific and interdisciplinary management approach. Currently, TAVI is performed with the patient under local or general anaesthesia.

Methods

This study was a retrospective analysis of all TAVI procedures performed at the University Hospital of Regensburg between January 2009 and July 2015. All pre-, intra and postoperative data focusing on perioperative complications were recorded.

Results

A total of 853 transfemoral- and transapical-TAVI patients were included in the study. All patients underwent general anaesthesia. The ASA classifications were primarily 3–4. The average logistic EuroScores for the transfemoral- and transapical-TAVI patients were 18 ± 12% and 21 ± 15% (p = 0.002), respectively. The anaesthesia coverage time was 170 ± 49 min., including 37 ± 12 minutes for anaesthetic management. Overall, 458 complications were recorded; with pneumonia, acute renal failure, indication for a permanent pacemaker and non-extubation in the operating theatre the most frequently recorded complications.

Conclusion

In the present study, we showed that our patients’ outcomes are comparable to those reported in the available literature. Compared to TF, TA patients show an overall worse physical condition as well as a higher perioperative morbidity and mortality. Consequently TA patients need additional care and should only be operated in appropriately experienced medical centres.

A Pilot Analysis of the Association Between Types of Monitored Anesthesia Care Drugs and Outcomes in Transfemoral Aortic Valve Replacement Performed Without General Anesthesia

OBJECTIVE

The types of agents used for monitored anesthesia care (MAC) and their possible differential effects on outcomes have received less study despite increased use over general anesthesia (GA) in transfemoral aortic valve replacements (TAVRs). In this pilot analysis of patients undergoing TAVR using MAC, the authors described the anesthetic agents used and sought to investigate the possible association of anesthetic agent choice with outcomes and the extent to which total weight and time-adjusted doses of anesthetics declined with increasing 10-year age increments.

DESIGN

Retrospective observational study.

SETTING

Tertiary teaching hospital.

PARTICIPANTS

Ninety-three participants scheduled to undergo TAVR, with a primary plan of conscious sedation between November 2014 and June 2016, were included.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Types of MAC were divided into 4 primary groups, but 2 groups were focused: propofol (n = 39) and dexmedetomidine plus propofol (n = 34). Conversion to GA occurred in 6 participants (6.45%) and was not associated with the type of sedation received. The authors also compared patients who received dexmedetomidine with those who did not in accordance with their a priori analytic plan. There were no associations between the use of dexmedetomidine and postoperative delirium or intensive care unit/hospital length of stay. No significant trends in medication dose adjustments were seen across increasing 10-year age increments.

CONCLUSIONS

A wide breadth of MAC medications is in use among TAVR patients and does not support differences in outcomes. Despite recommendations to reduce anesthetic drug dosing in the elderly, no significant trends in dose reduction with increasing age were noted.

Circulatory Arrest due to Retrograde Embolization of a Transapically Implanted Aortic Valve Prosthesis with Subsequent Inversion and Left Ventricular Outflow Occlusion

An 82-year-old man required aortic valve replacement because of aortic stenosis. A transapical approach was chosen to reduce surgical mortality. Initially, echocardiography and fluoroscopy confirmed correct valve positioning. Shortly thereafter, progressive paravalvular leakage, embolization of the valve prosthesis into the ventricle, and subsequent inversion of the prosthesis with complete left ventricular outflow occlusion were observed by echocardiography. Left ventricular outflow occlusion resulted in immediate circulatory arrest. We immediately converted to on-pump surgical aortic valve replacement. Cardiac output was restored once the valve was replaced. The patient fully recovered. This case report highlights the importance of periprocedural transesophageal echocardiography, which instantly detected the malpositioned valve and guided emergency management of this severe complication.

Anaesthetic management of percutaneous aortic valve implants: Results of 100 cases

INTRODUCTION

Transfemoral transcatheter aortic-valve implantation represents a therapeutic alternative for patients with severe aortic stenosis who cannot undergo surgery due to high surgical risk.

OBJECTIVE

The aim of this study is to describe the anaesthetic procedure for transfemoral transcatheter aortic-valve implantation and the results on 100 patients with symptomatic severe aortic stenosis.

MATERIAL AND METHODS

A series of cases are presented with prospective data collected on 100 consecutive patients. The anaesthetic procedure consisted of continuous remifentanil and propofol infusions, for sedation or general anaesthetic.

RESULTS

Almost two-thirds (65%) of the cases ended on sedation, and 35% on general anaesthetic (19% out of this total were elective and 16% were due to complications during the procedure). Complications occurred in 34% of the cases, with both vascular and complete atrioventricular block being the most frequent. Mortality within the first 24h was 5%.

CONCLUSIONS

Implantation of transfemoral aortic prosthesis under remifentanil-propofol sedation can be considered a valid therapeutic alternative for patients with severe symptomatic aortic stenosis, and with a high surgical risk, and therefore not considered for conventional surgery.

The Anesthetic Management of Transcatheter Aortic Valve Implantation

An increasing number of patients with a high risk for surgery because of advanced age and associated comorbidities that significantly increase the perioperative risk successfully undergo transcatheter aortic valve implantation (TAVI). TAVI is commonly performed under general or local anesthesia or local anesthesia plus mild sedation to achieve a conscious sedation. The anesthetic regimen generally depends on the patient’s clinical profile and the procedural technical characteristics, but the center’s experience and internal organization likely play an important role in anesthetic decision making. The large variation in anesthetic management among various centers and countries likely depends on the different composition of the operating team and institutional organization. Therefore, a tight interaction among the various members of the TAVI team, including the cardiac anesthetist, provides the proper anesthetic management using the chosen procedural technique.

Predictors of Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement

OBJECTIVE

Determine predictors of permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR).

DESIGN

A retrospective chart review of patients undergoing TAVR at the authors' institution. Extracted data included patient demographics, electrocardiogram, procedural, and echocardiographic data. Multivariate regression was performed to identify associations with PPM implantation.

SETTING

Single-center academic hospital.

PARTICIPANTS

Patients undergoing TAVR.

INTERVENTIONS

This study was retrospective. No interventions were performed on patients.

MEASUREMENTS AND MAIN RESULTS

Baseline electrocardiogram, Society of Thoracic Surgeons score, age, and echocardiographic parameters were not predictors of PPM implantation. However, multiple deployments was a risk factor, and degree of paravalvular leak trended toward significance. Ten patients required placement of a 2nd valve, or valve-in-valve (VIV). Of the 10 patients with VIV, 5 (50%) required a PPM, compared with 8 (14%) of 56 patients with a single valve (OR 6.0, p = 0.02). PPM implantation occurred in 5 (42%) patients with no leak, 8 (19%) patients with trace leak, and no patients with mild or moderate leak (p = 0.085). In patients with no or trace leak, VIV increased the likelihood of PPM from 17.4% to 62.5% (OR 7.9, p = 0.006). For the 42 patients with trace leak, VIV increased the likelihood of PPM from 11.4% to 57.1% (OR 10.33, p = 0.005).

CONCLUSIONS

The authors found VIV placement, and likely degree of paravalvular leak, to be predictors of PPM placement. VIV and the degree of leak may be useful markers for postoperative prophylactic pacemaker placement.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.