Salvaging catastrophe in transcatheter aortic valve implantation: rehearsal, preassigned roles, and emergency preparedness

Tam, Derrick Y.; Jones, Philip M.; Kiaii, Bob; Diamantouros, Pantelis; Teefy, Patrick; Bainbridge, Daniel; Cleland, Andrew; Fernandes, Philip; Chu, Michael

doi:10.1007/s12630-015-0393-0

Cited by 13 publications

(8 citation statements)

References 14 publications

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“…By the time of ECMO institution, these patients had already suffered from structural damage (coronary occlusion, annular rupture, aortic dissection, valvular malposition and/or left ventricular disruption after transapical approach) and the increased mortality was probably related to the impact of such conditions. 36…”

Section: Discussionmentioning

confidence: 99%

“…Needless to say, the heart team should be composed of all of the individuals involved in the care of the patient: the referring cardiologist, the interventional cardiologist, the cardiac surgeon, the cardiac anaesthesiologist, the perfusionist and the OR and catheter-lab nurses. 36 For centres without an in-house cardiac surgery back-up unit, a remote consultation during the case decision-making and a hub-and-spoke network to manage emergency transport and surgery if appropriate might represent an additional asset for patient safety.…”

Section: Discussionmentioning

confidence: 99%

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In-hospital outcomes after emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature

et al. 2019

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Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has been used to deal with life-threatening complications as well as back-up or active cardiovascular support during high-risk procedures in patients undergoing transcatheter aortic valve implantation (TAVI). PubMed and MEDLINE electronic databases were searched in order to identify studies with emergency or prophylactic V-A ECMO application in association with TAVI procedures. From November 2012 to November 2017, 14 relevant studies were identified that included 5,115 TAVI patients of whom 102 (2%) required V-A ECMO (22 prophylactically, 66 as an emergency and 14 without a reported indication). The reason for emergency V-A ECMO institution was detailed in 64 patients: left ventricle free wall rupture (n = 14), haemodynamic instability (n = 12), ventricular arrhythmias (n = 7), aortic annulus rupture (n = 6), coronary obstruction (n = 6), low left ventricular output (ejection fraction <35%) (n = 5), uncontrollable bleeding (n = 5), severe aortic regurgitation (n = 4), prosthesis embolisation (n = 3), aortic dissection (n = 1) and respiratory failure (n = 1). Femoral arterial and vein cannulation was the most common access technique for V-A ECMO institution. Major bleeding (n = 7) and vascular access complications (n = 7) were reported after ECMO institution. The overall in-hospital survival was 73% (61% in the emergency vs. 100% in the prophylactic group). V-A ECMO support should be available at any centre performing TAVI and provides effective mechanical circulatory support in an emergency setting. We present an algorithm to aid decisions about prophylactic circulatory assistance with V-A ECMO and it should form part of the heart team discussion before a TAVI procedure is undertaken.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

In-hospital outcomes after emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature

et al. 2019

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“…Given that TAVR patients are often frail and decompensated, early signs of hemodynamic instability during anesthetic induction may be predictive of subsequent problems and dictate additional measures to be initiated for stabilization (38).…”

Section: Use Of Ecmo As Prophylactic Measurementioning

confidence: 99%

Use of extracorporeal membranous oxygenator in transcatheter aortic valve replacement

Makdisi¹,

Makdisi²,

Wang³

2016

Ann. Transl. Med.

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The superiority of transcatheter aortic valve replacement (TAVR) compared with medical therapy for patients with aortic stenosis (AS) who are not suitable candidates for surgery had been proven. Cardiopulmonary bypass (CPB) is rarely used in TAVR. Reports of early use of extracorporeal membranous oxygenator (ECMO) have promising outcomes. ECMO offers the option of cardiac support rescue in case of intraoperative hemodynamic instability and can be instituted in advance when hemodynamic instability is expected. Here we review the English literature about the use of ECMO in TAVR procedures, and discuss the indications and rationale for its use as well as its advantages.

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“…To maintain the patient's blood pressure, we used a high dose of inotropic agents. There have been reports using supplementary circulation such as PCPS at the time of a sudden change in preventive or intraoperative disorder [3][4][5][6], but we could not identify any report describing the introduction of PCPS after a sudden change in the condition of a patient with AS and the urgent implementation of TAVI. We believe that the emergent TAVI following PCPS is rare and that most Japanese anesthesiologists are not familiar with this type of perioperative management.…”

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confidence: 94%

Anesthetic management for a patient with aortic stenosis who underwent transcatheter aortic valve implantation after introduction of percutaneous cardiopulmonary support

2018

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The patient was a 74-year-old male with a height of 155 cm and a body weight of 41 kg. At the age of 63, he underwent off-pump coronary artery bypass grafting due to a previous myocardial infarction. The patient had been hospitalized several times due to heart failure secondary to aortic stenosis (AS) since approximately 71 years of age. On transthoracic echocardiography, the patient's left ventricle showed diffuse hypokinesis and an ejection fraction of 27%. The aortic valve was highly calcified and showed mobility restrictions together with the tricuspid valve; moderate to severe AS was also present.While planning the surgery, the heart team at our institution considered the patient's cardiovascular dysfunction and history of open-chest surgery and decided that conventional aortic valve replacement would be a high-risk procedure. Therefore, we planned to perform transcatheter aortic valve implantation (TAVI). However, the patient had to wait for insurance approval for a self-expandable valve (CoreValve®). He underwent balloon aortic valvuloplasty (BAV) three times while awaiting insurance approval for the CoreValve®. The last BAV was performed 3 months before hospitalization, which controlled his heart failure until insurance approval. His condition seemed to be stable, but in the process, he developed orthostatic breathing and low output syndrome (LOS) and was transferred from the general ward to the intensive care unit (ICU). Tracheal intubation was performed by an ICU physician. The patient was administered 3 mg of midazolam and 40 mg rocuronium intravenously. We believed his condition to be a result of overhydration due to his decreased urine output after hospitalization. Despite administering intravenous dopamine, dobutamine, and noradrenaline at high doses, the patient's vital signs were unstable. Therefore, it became necessary to perform an emergency TAVI after introducing percutaneous cardiopulmonary support (PCPS). The patient was inserted a PCPS catheter from the right femoral artery and right femoral vein and then started thigh-femoral PCPS. Because the patient's vital signs were stable, he was then transferred to the operating room. General anesthesia was maintained by inhalation of 2% desflurane, with sufficient administration of rocuronium. Just before surgery, 100 μg of fentanyl was administered. A self-expanding 29-mm TAVI valve CoreValve® was placed on top of the aortic valve. Although the patient's arterial pressure decreased during the CoreValve® expansion, it quickly recovered after full expansion. The perioperative course is shown in Fig. 1.On transthoracic echocardiography, the patient's left ventricular function did not change compared with the preoperative condition, but the mobility of the implanted artificial valve was good.Since TAVI became covered by health insurance, it has gained wide clinical use in our country. It is anticipated that TAVI will become more popular in the future [1].

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Salvaging catastrophe in transcatheter aortic valve implantation: rehearsal, preassigned roles, and emergency preparedness

Cited by 13 publications

References 14 publications

In-hospital outcomes after emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature

In-hospital outcomes after emergency or prophylactic veno-arterial extracorporeal membrane oxygenation during transcatheter aortic valve implantation: a comprehensive review of the literature

Use of extracorporeal membranous oxygenator in transcatheter aortic valve replacement

Anesthetic management for a patient with aortic stenosis who underwent transcatheter aortic valve implantation after introduction of percutaneous cardiopulmonary support

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