Management of the Patient for Transcatheter Aortic Valve Implantation in the Perioperative Period

Abstract

Aortic stenosis is a prevalent valvular disease among aging patients, and surgical correction is the most definitive treatment. Yet many elderly patients are deemed to be "inoperable" or at excessive risk to undergo open surgical aortic valve replacement (AVR). Transcatheter aortic valve implantation (TAVI), either through a transfemoral or transapical approach, has become a potential option for these high-risk patients. Although TAVI technology will continue to be developed and perfected, most studies at this time reveal that symptoms are improved and that 1-year morbidity and mortality are similar to those for open surgical AVR. Anesthetic management for patients undergoing TAVI involves maintaining hemodynamic stability during periods of rapidly changing conditions and providing echocardiographic guidance and assessment. Postoperative care includes a variety of challenges such as managing pain control, monitoring for potential complications, and providing hemodynamic management.

Transcatheter aortic valve replacement

“…Further, a transfemoral transcatheter valve is more difficult to position than a valve inserted via a more direct approach. 38,39,41,42,46,48 Some studies have reported a higher incidence of neurologic events with the transfemoral route, which is probably because the sheath has to pass through the curved aortic arch, but others could not support these findings. 40,49,50 Introducing the valve through the left-ventricular apex is performed via a left anterior thoracotomy through the fifth or sixth intercostal space.…”

“…25 Of the two most commonly used valves, only the SAPIEN can be inserted transapically. 48,51 The transapical approach is feasible in the majority of patients, with exception of a few in whom a left-ventricular aneurysm or adhesions might prohibit this access route. 46 is a major advantage for the large group of patients with peripheral vascular disease.…”

“…46 Therefore, the transapical access route might be less ideal for patients with severe pulmonary comorbidities. 48 Bleeding and tamponade, myocardial injury, ventricular aneurysm formation, and damage to the mitral valve are rare but possible risks that must be considered. Barbash et al 52 assessed the degree of apical ventricular dysfunction after transapical TAVR and concluded that 30% of patients showed apical dysfunction that was associated with a nonsignificant trend toward a reduced ejection fraction.…”

“…47 Most studies comparing the transfemoral and transapical approach did not show a significant difference regarding mortality. 48,49,53,54 When reviewing data on the comparison of these two access routes, it must be noted that most centers have a "femoral-first" approach. Subsequently, the patient subgroups undergoing transfemoral and transapical TAVR usually show significant differences with regard to their baseline characteristics.…”

“…While most studies suggest that the choice of access route itself does not have a significant impact on mortality, 42,48,49,53 both procedures have specific advantages and risks. More precise decisive algorithms need to be defined to individually choose the ideal access route for each patient.…”