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Evaluate the patient as you would any high-risk candidatefor cardiac surgery
Consider the anesthetic implications present in mostTAVR patients
Multiple co-morbid conditions
Advanced age
Frailty
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Routine ECG
Pulse oximetry
Capnography
Invasive and noninvasive blood pressure Large-bore peripheral and central venous access
TEE
Foley catheter
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Important Considerations Pulmonary artery catheter
Frequent MR/MS, pulmonary hypertension, RV failure, low cardiacoutput
Systolic and/or diastolic dysfunction
EEG monitor Frequent difficult anesthetic depth titration
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General anesthesia preferred by most anesthesiologists No adequate published data providing superiority of any particular
anesthetic technique
Advantages to general anesthesia
Maintains patient immobility to permit stable valve positioning and
deployment Maximizes patient comfort during TEE and direct repair of the vascular
access site, if necessary
Facilitates patient management should complications that require CPBand/or sternotomy occur
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Short-acting agents used most frequently Facilitates fast-tracking
Supine position
Pressure-points padded
Radiolucent external defibrillator pads Warming devices
Blankets, forced-air heating
Fluids
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Assess adequacy of cardiovascular function Maintain euvolemia
Improve cardiac output
May require > 1 liter IV fluid
Guidance
Adequate LV filling on TEE
Consider trends of CVP and PCWP
Consider urine output > 1 cc/kg/hr
Beware of over-hydration
Systolic and diastolic dysfunction
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If cardiac index remains low despite volume Consider inotropic support
Dobutamine
especially if HR is low
Milrinone
If cardiac index remains low despite inotropic support Consider mechanical support
IABP
Cardiopulmonary bypass
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Heparin dose
Maintain ACT > 250 seconds 1 - 1.5 mg/kg unfractionated heparin
Emergent CPB
Bolus additional heparin to maintain ACT > 400 seconds
Systemic blood pressure maintained at a level to ensurecoronary and cerebral perfusion
Vasopressors
Phenylephrine, norepinephrine, vasopressin, ephedrine
Vasodilators
Nitroglycerin, short-acting calcium channel blocker
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Rapid ventricular burst pacing
Induces an instantaneous, reversible fall in cardiac output Reduces ejection of balloon and valve from aortic annulus during inflation
Pacemaker settings
Ventricular rate
Start rapid pacing at 180 bpm
Rate should be adjusted (typical pacing rates range between 160 and220 bpm) and the pacing sequence should be repeated until
sustained 1:1 capture, SBP of 50 mmHg or below is achieved, and
pulse pressure < 10 mmHg
20 MA
Asynchronous Atrial off
Pacemaker operator should only act on the direction of the primaryimplanting physician
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Backup pacemaker available Primary pacemaker fails
Treat bradycardia
Faster solution than trying to reset primary pacemaker
Backup pacemaker settings
Ventricular rate80 bpm
MA > threshold
Synchronous
Atrial off
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Assess cardiovascular stability prior to rapid burst pacing Rule-out a serious or prolonged cause of ventricular dysfunction
Ensure balloon-manipulation hypotension is transient
Consider removing balloon and further optimization
Consider a bolus dose of phenylephrine or norepinephrineto achieve faster recovery of blood pressure and coronaryperfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing
Allow sufficient hemodynamic recovery before initiating
another episode of rapid pacing
Minimize the number and duration of rapid burst pacingepisodes
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Refractory hemodynamic instability after BAV Echocardiographic findings key
Acute aortic insufficiency
May not be tolerated, particularly in patients without preexisting aorticinsufficiency
Treat with immediate valve deployment
Stunned myocardium after pacing-induced subendocardialischemia
Optimize coronary perfusion
Aortic rupture/dissection
Emergent CPB
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Rapid ventricular burst pacing Pacemaker settings same as BAV
Consider a bolus dose of phenylephrine or norepinephrineto achieve faster recovery of blood pressure and coronaryperfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing
Hold ventilation during valve deployment
Decreases ventricular ejection
Decreases motion artifact
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Successful valve deployment typically results in a rapidreturn or increase in cardiac output and blood pressure
Sustained significant hypertension
Nitroglycerin, short-acting calcium channel blocker
Refractory hemodynamic instability
Echocardiographic findings key
Aortic insufficiency
Severe paravalvular leak
Balloon dilatation of valve
Severe transvalvular leak
Valve-in-a-valve*
* No testing has been performed to determine the long-term durability in this configuration
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Myocardial ischemia Stunned myocardium after pacing-induced subendocardial ischemia
Optimize coronary perfusion
Coronary artery obstruction
PCI, IABP, CPB, mechanical ventricular assistance
Acute aortic or ventricular rupture/dissection CPB
AV block
Pacemaker
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Refractory hemodynamic instability Vascular-access bleeding
Fluid replacement
Balloon occlusion of vascular injury site and repair of artery
Reverse anticoagulation
Protamine
Administer when no more interventions are anticipated
Dosage strategies
Heparin-level based
Fixed ratio from heparin dose
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Extubate when meets standard criteria Immediate extubation in the OR is appropriate for most
Minimum patient core temperature > 36 C
Patient awake and able to follow simple commands
Patient able to protect airway and has a normal respiratory pattern and
rate, with oxygen saturation > 90% Full reversal of neuromuscular blockade if utilized
Patient is not bleeding significantly
Patient is hemodynamically stable
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Pain management Typically minimal postoperative pain unless extensive vascular
access issues
Medications
Consider dexmedetomidine
Analgesia and sedation without delirium
Narcotics
Judicious doses
Delirium frequent in elderly population
Non-narcotic analgesics
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1. Fassl J, Augoustides JGT: Transcatheter Aortic Valve Implantation - Part 2: Anesthesia Management. J Cardiothorac Vasc Anesth 24:691-
699, 20102. Guinot P, Depoix J, Etchegoyen L, et al: Anesthesia and Perioperative Management of Patients Undergoing Transcatheter Aortic Valve
Implantation: Analysis of 90 Consecutive Patients With Focus on Perioperative Complications. J Cardiothorac Vasc Anesth 24:752-761,2010
3. Ree RM, Bowering JB, Schwarz SK: Case series: Anesthesia for retrograde percutaneous aortic valve replacementExperience with thefirst 40 patients. Can J Anaesth 55:761-768, 2008
4. Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encounteredand proposed solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009
5. Fassl J, Kodavatiganti R, Ingerski MS: Anesthesia management for retrograde aortic valve replacement. Can J Anaesth 56:336, 2009
6. Fassl J, Seeberger M, Augoustides JGT: Transcatheter Aortic Valve Implantation: Is General Anesthesia Superior to Conscious Sedation? J
Cardiothorac Vasc Anesth 25:576-577, 20117. Covello D, Maj G, Landoni G, et al: Anesthetic Management of Percutaneous Aortic Valve Implantation: Focus on Challenges Encountered
and Proposed Solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009
8. Bergmann L, Kottenberg E, Heine T, et al: [Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventionalmanagement and hemodynamic observations]. Herz 34:381-387, 2009
9. Frederic T. Billings IV, Susheel K. et al: Transcatheter Aortic Valve Implantation: Anesthetic Considerations. Anesth Analg 108:1453-1462,2009
10. Cheung A: Transcatheter aortic valve replacement. Anesthesiol Clin 26:465-479, 2008
11. Klein AA: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 103:792-799, 2009
12. Heinze H: Percutaneous aortic valve replacement: Overview and suggestions for anesthestic management. J Clin Anesth 22:373-8, 2010
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SOP4407EL25 Rev. A Issued 07/28/2011 ECN:78281
For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for
full prescribing information, including indications, contraindications, warnings, precautions and adverse events.
Edwards Lifesciences, Edwards and the stylized E logo are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their
respective owners.
2011 Edwards Lifesciences Corporation. All rights reserved.
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