Mod3: TRANSCATHETER VALVE REPLACEMENT Flashcards
TRANSCATHETER VALVE REPLACEMENT
Minimally invasive valvular replacement therapy accomplished without the use of CPB
TRANSCATHETER VALVE REPLACEMENT
TRANSCATHETER VALVE REPLACEMENTS
Where are they performed? by whom? using which type of anesthesia?
Usually performed in Cath Lab
By an Interventional Cardiologist
Under GA or moderate sedation
TRANSCATHETER VALVE REPLACEMENT
T/F: Currently, therapy for Transcatheter Aortic Valve Replacement (TAVR) is considered routine therapy and has been highly successful
True
Transcatheter valve replacement (TAVR) = preferred treatment for patients with severe aortic stenosis
TRANSCATHETER VALVE REPLACEMENT
T/F: Transcatheter Mitral valve replacement and Tricuspid valve replacement still in early developmental stages
True
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
There are three types of approaches for a TAVR:
Transvenous approach
Transarterial approach
Transapical approach
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
TAVR approach where the guidewire inserted through femoral vein sheath into right atrium; and the the valve is advanced across septum into the left atrium
Transvenous TAVR
A second device is inserted into the femoral artery and it smears the gidewire
The puncture site is dilated and the diseased valve is valvuloplastied
The prostetic valve is loaded unto the guidewire, compressed and deployed across the septum during rapid ventricular pacing
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
TAVR approach where the guidewire is inserted through femoral artery into the aortic position where valve is deployed?
Transarterial TAVR
Has replaced the transvenous approach
The guidewire is inserted through femoral artery into the aortic and across the aortic valve
The diseased valve is valvuloplastied
The prostetic valve is deployed and positioned during rapid ventricular pacing
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
TAVR approach where LV apex is exposed by a cardiothoracic surgeon through an anterolateral intercostal incision
Transapical TAVR
LV apex is exposed by a cardiothoracic surgeon through an anterolateral intercostal incision
A guide wire is inserted into the aortic valve and the compressed valve is deployed into position
TAVR PATIENT SELECTION
Potential TAVR recipients must satisfy three criteria:
They must have Severe symptomatic aortic stenosis
They must be either High-risk for surgical candidate or deemed inoperable
They must also not have any contraindications to TAVR placement
TAVR PATIENT SELECTION
Current “gold standard” for assessing the severity of aortic stenosis is:
TEE
TAVR PATIENT SELECTION
What’s the current definition for Aortic stenosis?
AVA equal to or less than 1 cm2 or
A mean aortic valve gradient of equal to or > 40 mmHg
TAVR PATIENT SELECTION
TAVR placement is indicated in certain patients who are either high risk for traditional aortic valve replacement or have been deemed inoperable. What are the two surgical risk quantifiers currently used
The EuroScore and the STS Predicted risk of mortality
TAVR PATIENT SELECTION
Surgical risk quantified using the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of which value indicates high surgical risk?
<15%
TAVR PATIENT SELECTION
Surgical risk quantified using the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) of which value indicates high surgical risk?
<10%
TAVR PATIENT SELECTION
While the EuroScore and the STS have been usefull for predicting mortality risk, they do share some important limitations, including:
They do not take intoconsideration a pt’s hx of chronic lung disease, hx of liver cirrhosis, previous cardiac surgery, etc.
TAVR PATIENT SELECTION
TAVRs are typically done on older adults that are how old?
over 70 years of age
TAVR PATIENT SELECTION
Why should Futility and Frailty be assessed?
They are possible contraindications to TAVR
Frailty is a distinct clinical syndrome that significantly increase the risk of adverse event
Futility implies that despite successfull procedure, the risk of mortality or mobidity at one year is > 50%
TAVR PATIENT SELECTION
The distinct clinical syndrome, characterized by decreased muscle mass, increased energy expenditure, and malnutrition, all of which significantly increase the risk of adverse event is known as:
Frailty
TAVR PATIENT SELECTION
Situation that implies that a patient’s condition is so advanced that meaningful improvement will not be achieved despite technically successful intervention is also known as:
Futility
In other words, despite successfull procedure, their risk of mortality or mobidity at one year is > 50%
TAVR PATIENT SELECTION
T/F: >50% compromise of >3 major organs is contraindication for TAVR
True
TAVR PATIENT SELECTION
T/F: Mortality and Morbidity at 1 year >50% as determined by STS PROM is contraindication for TAVR
True
TAVR SURGICAL CONSIDERATIONS
Pre procedural planning includes
Selecting the bioprostehtic valve and size
TAVR SURGICAL CONSIDERATIONS
There are currently two systems used for implantation
The Sapien valve
Medtronic Core valve
TAVR SURGICAL CONSIDERATIONS
What’s the major difference between the Sapien valve and the Medtronic CoreValve?
There is a higher rate of permanent pacemaker requirements post procedure with the Medtronic CoreValve
15-47% Medtronic CoreValve, compared to
4-21% with Sapien valve
TAVR SURGICAL CONSIDERATIONS
Why do most facilities stick to one type of valve?
Operator experience is also an important factor when selecting between the two valves
so most facilities stick to one type of valve
.
TAVR SURGICAL CONSIDERATIONS
Valve size depends on:
Pts’ aortic annulus
This should be measure prior to the procedure with at TEE
TAVR SURGICAL CONSIDERATIONS
Selecting the vascular site should be patient specific. why?
Pts should undergo vascular screening to evaluate the peripheral vasculature for size, how tortuous it is and calcification of ilio-femoral vessels
Peripheral vasculature screening for luminal diameter, tortuosity, and calcification of iliofemoral arteries.
TAVR SURGICAL CONSIDERATIONS
All patients assessed for feasibility of femoral approach
True
TAVR SURGICAL CONSIDERATIONS
If the peripheral vasculature is unfavorable, what do you do?
an alternative site should be chosen.
may consider transapical TAVR
TAVR SURGICAL CONSIDERATIONS
In the event of emergency, what should be discussed with the surgical team?
A “Bail-out” plan
TAVR SURGICAL CONSIDERATIONS
What must the “Bail out” plan include?
Cardiothoracic surgeon and CPB on standby
TAVR SURGICAL CONSIDERATIONS
What is the typical Bail out until a sternotomy can be made?
ECMO
However, depending on what the adverse event is, TAVR are typically catastrophic
TAVR ANESTHETIC CONSIDERATIONS
Which should be on stanby during TAVR
Cardiothoracic surgeon
Cardiopulmonary bypass machine
Perfusionist
TAVR ANESTHETIC CONSIDERATIONS
T/F: External defibrillator pads should be placed on the pt and the pacemaker should be readily available
True
TAVR ANESTHETIC CONSIDERATIONS
What should be available for pts with AICD implanted?
Magnet
TAVR ANESTHETIC CONSIDERATIONS
Monitors for TAVR procedures include:
5-lead EKG
Pulse oximetry
Temperature monitoring
Radial arterial line ?
Central venous catheter/Introducer with pacing Swan-Ganz Catheter
TAVR ANESTHETIC CONSIDERATIONS
Why are Foley Catheters not typically inserted?
Procedures last 2 hours or less
TAVR ANESTHETIC CONSIDERATIONS
TTE versus TEE: what determines which is used?
Moderate sedation vs. General anesthesia
TAVR ANESTHETIC CONSIDERATIONS
The primary goal for anesthesia during TAVR procedures includes
Hemodynamic stability
Avoiding on-table patient moving
Achieving early extubation if general anesthesia is used
TAVR ANESTHETIC CONSIDERATIONS
TAVR is Multidisciplinary approach that requires
OPEN COMMUNICATION
TAVR ANESTHETIC CONSIDERATIONS
It’s important to assess the patient’s ability to both lay flat and still for the procedure; why?
Because coughing and movement can lead to catastrophic events especially if they occur while the valve is being deployed
Movement during valve deployment can lead to poor valve seating, paravalvular leak, or aortic dissection
TAVR ANESTHETIC CONSIDERATIONS
So why not intubate all pts to prevent on-table movement?
Many facilities have adopted Fast-track protocols for these pts
And because the TAVR pt population tends to be high risk population with multiple commorbidities, standardizing general anesthesia would lead to longer length of stay and more complications
TAVR ANESTHETIC CONSIDERATIONS
General anesthesia with a regular endotracheal tube is typically done for which TAVR approach?
The trans-apical approach
TAVR ANESTHETIC CONSIDERATIONS
Which anesthesia technique is widely accepted for trans-femoral cases?
Moderate sedation with incision site localization
TAVR ANESTHETIC CONSIDERATIONS
When General Anesthesia is chosen, which drugs are used? What’s the ultimate goal?
Volatile anesthetics with vasopressors for BP control
Watch opioid administration
(There is not a lot of post op pain a/w the procedure)
Goal is early extubation
TAVR ANESTHETIC CONSIDERATIONS
What’s the goal of Moderate Sedation?
Keep patient comfortable
Limit movement
Keep pt arousable, so they can alert providers of any chest discomfort
TAVR ANESTHETIC CONSIDERATIONS
Chest discomfort during TAVR procedure could be indicative of:
Acute ischemic episode
Aortic dissection,
Rupture aortic annulus
TAVR ANESTHETIC CONSIDERATIONS
Benefits of keeping patients comfortable, but arousable include:
Monitor neurologic status, procedural complications
They can alert providers of acute chest discomfort
Better hemodynamic control
Reduced length of stay
TAVR ANESTHETIC CONSIDERATIONS
Which drug are used for Moderate Sedation?
Propofol** infusion versus Precedex infusion
Minimal opioid administration
TAVR ANESTHETIC CONSIDERATIONS
How is BP maintained during TAVR?
Vasopressors IVP or infusions as necessary
TAVR ANESTHETIC CONSIDERATIONS
Why should IVP drugs that are short acting be used for Blood pressure management?
Because Blood pressure management should be precise control
TAVR ANESTHETIC CONSIDERATIONS
The use of which drugs is acceptable for the management of hypertension during TAVR?
Nicardipine
NTG (small doses)
TAVR ANESTHETIC CONSIDERATIONS
The use of which drugs is acceptable for the management of hypotension during TAVR?
Phenylepherine
Norepinepherine
Epinepherine
TAVR ANESTHETIC CONSIDERATIONS
There are times where rapid ventricular pacing (160-200 bmp) will be required. Why is this done?
To produce a functional asystole that will momentarily minimize LV outflow
This will facilitate balloon valvuloplasty and proper valve positioning
Done to reduce left ventricular stroke volume and the risk of device migration during deployment
TAVR ANESTHETIC CONSIDERATIONS
What are the possible negative effects of the reduced left ventricular stroke caused by Rapid ventricular pacing (160-200 bmp)?
Significant hypotension can occur since SV and thus CO reduced
Can induce ventricular arrhythmias. Treat with Lidocaine or cardioversion if necessary
Ventricular pacing can lead to ventricular dyssynchrony
TAVR ANESTHETIC CONSIDERATIONS
After the valve is placed, what could cause myocardial stunning? How is it treated?
Improved blood flow through valve
Consider treating Myocardial stunning with low-dose inotropic agents
TAVR ANESTHETIC CONSIDERATIONS
How is Anticoagulation achieved for the procedure?
Heparin 100 units/kg for ACT of 300 s for procedure.
TAVR ANESTHETIC CONSIDERATIONS
Why should the surgical team be consulted prior to heparin reversal with Protamine?
May only want partial reversal of Heparin with Protamine
Consult with surgical team
TAVR COMPLICATIONS
Complications of TAVR include:
Paravalvular leaking
Need for post-procedure pacing versus permanent pacemaker placement
Ruptured aortic annulus
Acute ischemia
Aortic dissection
Stroke
Respiratory insufficiency
Bleeding
Perforation of femoral artery
TAVR COMPLICATIONS
What can increase the risk for complication a/w TAVR?
Pts commordidities
This is why proper pt selection an screening is important
A full pt’s picture should be used to guide decision during TAVR therapy
TAVR COMPLICATIONS
Paravalvular leaking - incidence?
15-20%
TAVR COMPLICATIONS
Paravalvular leaking - Causes?
Valve malpositioning
Under expansion of the annulus
Heavy annular calcification
TAVR COMPLICATIONS
Need for post-procedure pacing versus permanent pacemaker placement - Cause?
AV block
TAVR COMPLICATIONS
Need for post-procedure pacing versus permanent pacemaker placement - Research notes higher incidence with which type of valve?
CoreValve versus Sapien Valve
TAVR COMPLICATIONS
Ruptured aortic annulus - risk factor?
Highly calcified aortic annulus
TAVR COMPLICATIONS
Acute ischemia - Mechanisms?
Pre-existing CAD + Rapid ventricular pacing
=> decrease in myocardial O2 supply
also
Poorly positioned prosthetic valve
TAVR COMPLICATIONS
Aortic dissection
!!!
TAVR COMPLICATIONS
Stroke - causes?
Embolic lesions
Calcification from aortic valve and aortic arch
TAVR COMPLICATIONS
Respiratory insufficiency - Factors?
Prolonged mechanical intubation
Reintubation
Existing pulmonary comorbidities directly associated with pulmonary complications
TAVR COMPLICATIONS
Bleeding at the site d/t?
Use of sheaths in groins
TAVR COMPLICATIONS
Bleeding - Other cause?
Full reversal of heparin not always done
TAVR COMPLICATIONS
How could bleeding be reduced at suture sites?
Adequate blood pressure control
TAVR COMPLICATIONS
How is perforation of femoral artery treated
Requires stenting of femoral vessels
TAVR POSTPROCEDURE CONSIDERATIONS
T/F: If General anesthesia was used, pts are typically stable enough for intra-op extubation
True
TAVR POSTPROCEDURE CONSIDERATIONS
If transported to the ICU, early extubation is a/w?
Lower in-hospital mortality
TAVR POSTPROCEDURE CONSIDERATIONS
Why should pain control be optimize?
Pain requirements not high for procedure
Patients must lay flat for ~4 hours post procedure
While there isn’t a lot of pain a/w TAVR, these pt are typically older and have other issues like osteoporosis
TAVR POSTPROCEDURE CONSIDERATIONS
It’s important to understand that TAVR pts must be heparinized during the procedure. What’s a post consideration for heparin?
Full reversal of the heparin w/ Protamine may not have been done
TAVR POSTPROCEDURE CONSIDERATIONS
Why must the pt lay flat for 4 hours after the procedure?
Because large sheaths were inserted into the pt’s groin; so the risk of bleeding is higher
Patients must lay flat for ~4 hours post procedure so that uninterrupted clots can form at the insertion site
This may be difficult for pts w/ osteoporosis or back pain
The pain should be controlled
TAVR POSTPROCEDURE CONSIDERATIONS
Why should patients have continuous cardiac monitoring for a few days post procedure?
Because the majority of AV blocks will occur within 3-7 days following implantation
This is especially important in patients more susceptible to AV conduction issues
TAVR POSTPROCEDURE CONSIDERATIONS
What’s the incidence of permanent pacemaker following TAVR?
10-50%.
TAVR POSTPROCEDURE CONSIDERATIONS
Which pts are more susceptible to AV conduction issues and therefore require continuous cardiac monitoring for a few days post procedure?
> 75 years of age
Oversizing of implanted valve
Small annulus
Pre-existing bradycardia (<55 bpm)
AMERICAN HEART ASSOCIATION
Scientific Statement on Minimally Invasive Procedures
- The American Heart Association has been carefully monitoring minimally invasive procedures and their outcomes
- While all the surgeries appear promising, the conclusion of the AHA is that they need much more study before they are recommended over conventional methods
- If these surgeries can be refined to the point where they are no more invasive than angioplasty, they will end up having a distinct advantage over angioplasty
- Based on the preceding, at this point in time, minimally invasive surgeries are considered experimental and are NOT recommended over more conventional, time tested techniques
- This may change as more data is collected, but at this time no recommendation can be made for or against them
