Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients

Abstract

Purpose: To describe both the evolution and the main associated complications in the anesthetic management of the initial 40 patients at our centre who underwent percutaneous retrograde aortic valve replacement, a novel technique utilizing a catheterguided femoral artery approach. Clinical features:With institutional Research Ethics Board approval, we retrospectively reviewed the medical records of the first 40 patients who underwent percutaneous retrograde aortic valve replacement between January 2005 and March 2006. Information obtained included patient characteristics, anesthetic management, details of the procedure, and complications. All procedures were scheduled to be performed in the cardiac catheterization laboratory. The first four patients received monitored anesthesia care, and the subsequent 36 underwent general anesthesia. There were no anesthesia-related adverse events. The prosthetic valve was placed successfully in 33/40 patients (83%). Median anesthetic time was 3.5 hr (range, 1.25-7.25 hr). Thirty-two/40 patients required vasopressor support. The most common, serious procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing, hemorrhage from vascular injury secondary to the placement and removal of the large-bore sheath in the ilio-femoral artery, aortic rupture, and prosthetic valve maldeployment; 30-day mortality was 13% (n = 5/40). Conclusions:Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges. Careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome. Serious complications, including major hemorrhage from vascular injury as well as arrhythmia and myocardial ischemia following rapid ventricular pacing, must be anticipated and managed in an expeditious fashion.

Anesthetic management of transcatheter aortic valve implantation

“…Less invasive cardiac output monitoring systems can be useful alternatives to PAC in this setting [47]. Avoidance of hypothermia is important during TA-TAVI, temperature monitoring is essential, and the use of external warming systems and intravenous fluid warmers are required [42]. The cell-saver may be considered for blood conservation during TA-TAVI.…”

Postoperative delirium following transcatheter aortic valve implantation: a historical cohort study

“…The objectives of the present study, therefore, were to investigate and compare the rates of postoperative delirium in patients who had undergone TF and TA TAVI at our hospital, a tertiary/quaternary cardiac centre that pioneered the use of these procedures, 15,16 as well as to identify risk factors for delirium.…”

Transcatheter Aortic Valve Replacement

“…Theoretical immediate postvalvuloplasty or postdeployment complications include obstruction of the coronary ostia, dislodgment of the valve-stent, pericardial tamponade, and hemodynamically significant ventricular arrhythmias. 21,36,37,[63][64][65]83 The need for mechanical circulatory support via CPB is rare (<5%). 28 Anesthesiologists should have clear preprocedural communication with the cardiologist, surgeon, and perfusionist, with a focus on emergent cannulation strategy.…”

“…Thus, different regimens vary regarding the use of clopidogrel, which is given as a bolus of 75 to 300 mg preoperatively and is continued for 3 to 6 months after the procedure. 36,[62][63][64][65] Prophylactic antibiotics are continued for 3 to 7 days following the procedure, though without substantial support in the literature.…”

“…Aspirin in a dose of 75 to 300 mg is usually started before the procedure and is continued indefinitely afterward. 36,[62][63][64][65] No clear guidelines exist about the need and duration of an antiplatelet medication regimen. Thus, different regimens vary regarding the use of clopidogrel, which is given as a bolus of 75 to 300 mg preoperatively and is continued for 3 to 6 months after the procedure.…”