Periprocedural considerations of transcatheter aortic valve implantation for anesthesiologists

Carbon Footprint of Total Intravenous and Inhalation Anesthesia in the Transcatheter Aortic Valve Replacement Procedure

OBJECTIVES

To quantify and compare the emissions for deep sedation with total intravenous anesthesia (TIVA) and general anesthesia with inhaled agents during the transcatheter aortic valve replacement procedure.

DESIGN

A retrospective study.

SETTING

A tertiary hospital in Boston, Massachusetts.

PARTICIPANTS

The anesthesia records of 604 consecutive patients who underwent the transcatheter aortic valve replacement procedure between January 1, 2018, and March 31, 2022, were reviewed and analyzed.

INTERVENTIONS

Data were examined and compared in the following 2 groups: general anesthesia with inhaled agents and deep sedation with TIVA.

MEASUREMENTS AND MAIN RESULTS

The gases, drugs, airway management devices, and anesthesia machine electricity were collected and converted into carbon dioxide emissions (CO2e). The carbon emissions of intravenous medications were converted with the CO2e data for anesthetic pharmaceuticals from the Parvatker et al. study. For inhaled agents, inhaled anesthetics and oxygen/air flow rate were collected at 15-minute intervals and calculated using the anesthetic gases calculator provided by the Association of Anesthetists. The airway management devices were converted based on life-cycle assessments. The electricity consumed by the anesthesia machine during general anesthesia was estimated from the manufacturer's data (Dräger, GE) and local Energy Information Administration data. The data were analyzed in the chi-squared test or Wilcoxon rank-sum test. There were no significant differences in the patients' demographic characteristics, such as age, sex, weight, height, and body mass index. The patients who received general anesthesia with inhaled agents had statistically higher total CO2e per case than deep sedation with TIVA (16.188 v 1.518 kg CO2e; p < 0.001), primarily due to the inhaled agents and secondarily to airway management devices. For deep sedation with TIVA, the major contributors were intravenous medications (71.02%) and airway management devices (16.58%). A subgroup study of patients who received sevoflurane only showed the same trend with less variation.

CONCLUSIONS

The patients who received volatile anesthesia were found to have a higher CO2e per case. This difference remained after a subgroup analysis evaluating those patients only receiving sevoflurane and after accounting for the differences in the duration of anesthesia. Data from this study and others should be collectively considered as the healthcare profession aims to provide the best care possible for their patients while limiting the harm caused to the environment.

Optimizing Anesthetic Selection in Transcatheter Aortic Valve Replacement: Striking a Delicate Balance between Efficacy and Minimal Intervention

Patients with severe calcific native aortic valve stenosis (AS) who require valve replacement have two options, surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). TAVR was approved in late 2011 for extremely high-risk patients and was subsequently approved for high-risk (2012), intermediate-risk (2016), and low-risk (2019) patients. In 2019, TAVR procedures surpassed SAVR procedures for the first time in the United States. The approach to anesthesia for this procedure has also evolved. Initially, general anesthesia (GA) was preferred, but currently, conscious sedation (CS) is favored. This review aims to clarify the indications and contraindications for both approaches, as well as the advantages of one approach over the other. Recent studies show that conscious sedation has better outcomes in terms of all-cause mortality, procedure complications such as stroke, myocardial infarction, infection requiring antibiotics, acute kidney injury, and the need for inotropes or vasopressors.

Cerebral regional oxygen saturation as a predictive parameter for preoperative heart failure and delayed hemodynamic recovery in transcutaneous aortic valve implantation: a retrospective cohort study

This study aimed to investigate the relationship of perioperative cerebral regional oxygen saturation (rSO2) with various preoperative clinical variables and hemodynamic changes during transfemoral transcatheter aortic valve implantation (TAVI) under general anesthesia. We retrospectively analyzed cerebral rSO2 values from left-hemisphere measurements obtained using near-infrared spectroscopy (O3™ regional oximetry) at five time points: pre-induction, the start of the procedure, the start of valve deployment, time of lowest cerebral rSO2 value during valve deployment, and the end of the procedure. This study included 91 patients (60 with balloon-expandable valves and 31 with self-expandable valves). The baseline cerebral rSO2 values were correlated with B-type natriuretic peptide, hemoglobin, fractional shortening, ejection fraction, left ventricular mass index, left ventricular end-systolic diameter, STS risk of mortality, and STS morbidity or mortality. The patients who took longer to recover their systolic blood pressure to 90 mmHg after valve deployment with a balloon-expandable valve (group B) had lower cerebral rSO2 values during deployment compared to patients with faster recovery with balloon-expandable valve (group A) and with self-expandable valve (group C). Baseline cerebral rSO2 is associated with preoperative variables related to cardiac failure and function, and a significant decline during valve deployment may indicate a risk of prolonged hypotension during TAVI.

Identifying Patients without a Survival Benefit following Transfemoral and Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) offers a novel treatment option for patients with severe symptomatic aortic valve stenosis, particularly for patients who are unsuitable candidates for surgical intervention. However, high therapeutical costs, socio-economic considerations, and numerous comorbidities make it necessary to target and allocate available resources efficiently. In the present study, we aimed to identify risk factors associated with futile treatment following transfemoral (TF) and transapical (TA) TAVR. Five hundred and thirty-two consecutive patients (82 ± 9 years, female 63%) who underwent TAVR between June 2009 and December 2016 at the Vienna Heart Center Hietzing were retrospectively analyzed to identify predictors of futility, defined as all-cause mortality at one year following the procedure for the overall patient cohort, as well as the TF and TA cohort. Out of 532 patients, 91 (17%) did not survive the first year after TAVR. A multivariate logistic model identified cerebrovascular disease, home oxygen dependency, wheelchair dependency, periinterventional myocardial infarction, and postinterventional renal replacement therapy as the factors independently associated with an increased one-year mortality. Our findings underscore the significance of a precise preinterventional evaluation, as well as illustrating the subtle differences in baseline characteristics in the TF and TA cohort and their impact on one-year mortality.

A discrepancy between CT angiography and transesophageal echocardiographic measurements of the annular size affect long-term survival following trans-catheter aortic valve replacement

Introduction: Accurate measurement of the aortic valve annulus is critical for proper valve sizing for the transcatheter aortic valve replacement (TAVR) procedure. While computed tomography angiography (CTA) is the widely-accepted standard, two-dimensional (2D) and three-dimensional(3D) transesophageal echocardiography (TEE) is commonly performed to measure the size of the aortic valve and to verify appropriate seating of prostheses.

Methods: Patients undergoing TAVR between 2013-2015 were examined. 2D- and 3D-TEEmeasurements were compared to CTA taken as standard. Patients were followed for at least one year. The presence and effect of discrepancy (defined as a difference of more than 10%) between CTA and TEE measurements on survival were examined.

Results: One hundred eighty-five patients (70 men) were included. 2D- and 3D-TEE measurements underestimated the annulus size by -1.49 and -1.32 mm, respectively. Discrepancies > 10% between TEE and CTA methods in estimating the aortic annulus size were associated with a decrease in post implant survival. The peak pressure gradient across the aortic prosthesis measured one year after the implant was higher in patients with an initial discrepancy between 3D-TEE and CTA measurements. In a multivariate cox-regression model, the discrepancy between CTA and 2D-TEE readings and the smaller size of the aortic annular area were the predictors of long-term survival.

Conclusion: Both 2D and 3D-TEE underestimate the aortic annulus measurements compared to CTA, with 2D-TEE being relatively more precise than 3D-TEE technology. The presence of a discrepancy between echocardiographic and CTA measurements of the aortic annulus is associated with a lower survival rate.

Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed With General Anesthesia Using a Supraglottic Airway Versus Monitored Anesthesia Care

OBJECTIVE

Compare general anesthesia with a supraglottic airway versus monitored anesthesia care for transfemoral transcatheter aortic valve replacement (TF-TAVR) in patients with aortic stenosis. The authors hypothesized that the supraglottic airway group would have similar operating room and procedure times, postanesthesia care unit (PACU) and hospital stays, and similar rates of intraprocedural and postprocedural complications compared with the monitored anesthesia care group.

STUDY DESIGN

Retrospective chart review with 1:1 propensity score matching of supraglottic airway to monitored anesthesia care patients.

SETTING

Tertiary care academic medical center.

PARTICIPANTS

TF-TAVR patients between 2017 and 2019.

INTERVENTIONS

Supraglottic airway or monitored anesthesia care.

MEASUREMENTS AND MAIN RESULTS

One hundred forty-eight supraglottic airway patients were matched with 148 monitored anesthesia care patients. Monitored anesthesia care patients had slightly shorter operating room (p < 0.001) and procedure times (p = 0.015). No difference was observed in hospital length of stay (p = 0.34). Fewer patients in the supraglottic airway group required a PACU stay >2 hours (p < 0.001). Use of intraprocedural vasopressors (p < 0.001) and fentanyl dosage (p < 0.001) was higher in the supraglottic airway group. No differences were observed in postoperative complications or procedural success rates.

CONCLUSIONS

In this, the first study to compare these 2 modalities, supraglottic airway use was demonstrated to be a safe, feasible alternative to monitored anesthesia care during TF-TAVR and did not increase organ-specific morbidity, 30-day mortality, hospital length of stay, or PACU length of stay. Even though supraglottic airway was associated with slight increases in procedure and operating room times, these were not clinically significant.

Expert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist

Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. To optimize care and improve access for patients with valvular heart disease the Expert Consensus Systems of Care Document by Nishimura et al.¹ was recently published. The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.

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.

Transthoracic echocardiography is adequate for intraprocedural guidance of transcatheter aortic valve implantation

Background

While transcatheter aortic valve implantation (TAVI) has traditionally been supported intraprocedurally by transoesophageal echocardiography (TOE), transthoracic echocardiography (TTE) is increasingly being used. We evaluated echocardiographic imaging characteristics and clinical outcomes in patients who underwent TTE during TAVI (TTE-TAVI).

Methods and results

A select team of dedicated sonographers and interventional echocardiographers performed TTE-TAVI in 278 patients, all of whom underwent TAVI through transfemoral access. We implanted the Medtronic EVOLUT R valve in 258 patients (92.8%). TTE images were acquired immediately pre-procedure by a dedicated sonographer in the cardiac catheterization laboratory with the patient in the supine position. TTE was then performed post deployment of TAVI. In the procedure, TTE image quality was fair or better in 249 (89.6%) cases. Color-flow Doppler was adequate or better in 275 (98.9%) cases. In 2 cases, paravalvular regurgitation (PVL) could not be assessed confidently by echocardiography due to poor image quality; in those cases, PVL was assessed by fluoroscopy, aortic root injection and invasive hemodynamics. Both TTE and invasive hemodynamics were used in the assessment of need for post-deployment stent ballooning (n = 23, 8.3%). TTE adequately recognized new pericardial effusion in 3 cases. No case required TOE conversion for image quality. There was only 1 case of intraprocedural TTE failing to recognize moderate PVL, without clinical implication. In 99% of patients, TTE-TAVI adequately assessed PVL compared with 24-h and 1-month follow-up TTE.

Conclusions

With the current generation of TAVI, TTE-TAVI is adequate intraprocedurally when performed by specialized sonographers and dedicated cardiologists in a highly experienced TAVI center.