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8361 Exam I > Mod3: TRANSCATHETER VALVE REPLACEMENT > Flashcards

Mod3: TRANSCATHETER VALVE REPLACEMENT Flashcards

1
Q

TRANSCATHETER VALVE REPLACEMENT

Minimally invasive valvular replacement therapy accomplished without the use of CPB

A

TRANSCATHETER VALVE REPLACEMENT

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2
Q

TRANSCATHETER VALVE REPLACEMENTS

Where are they performed? by whom? using which type of anesthesia?

A

Usually performed in Cath Lab

By an Interventional Cardiologist

Under GA or moderate sedation

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3
Q

TRANSCATHETER VALVE REPLACEMENT

T/F: Currently, therapy for Transcatheter Aortic Valve Replacement (TAVR) is considered routine therapy and has been highly successful

A

True

Transcatheter valve replacement (TAVR) = preferred treatment for patients with severe aortic stenosis

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4
Q

TRANSCATHETER VALVE REPLACEMENT

T/F: Transcatheter Mitral valve replacement and Tricuspid valve replacement still in early developmental stages

A

True

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5
Q

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

There are three types of approaches for a TAVR:

A

Transvenous approach

Transarterial approach

Transapical approach

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6
Q

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

A

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

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7
Q

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

TAVR approach where the guidewire is inserted through femoral artery into the aortic position where valve is deployed?

A

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

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8
Q

TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

TAVR approach where LV apex is exposed by a cardiothoracic surgeon through an anterolateral intercostal incision

A

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

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9
Q

TAVR PATIENT SELECTION

Potential TAVR recipients must satisfy three criteria:

A

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

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10
Q

TAVR PATIENT SELECTION

Current “gold standard” for assessing the severity of aortic stenosis is:

A

TEE

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11
Q

TAVR PATIENT SELECTION

What’s the current definition for Aortic stenosis?

A

AVA equal to or less than 1 cm2 or

A mean aortic valve gradient of equal to or > 40 mmHg

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12
Q

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

A

The EuroScore and the STS Predicted risk of mortality

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13
Q

TAVR PATIENT SELECTION

Surgical risk quantified using the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of which value indicates high surgical risk?

A

<15%

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14
Q

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?

A

<10%

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15
Q

TAVR PATIENT SELECTION

While the EuroScore and the STS have been usefull for predicting mortality risk, they do share some important limitations, including:

A

They do not take intoconsideration a pt’s hx of chronic lung disease, hx of liver cirrhosis, previous cardiac surgery, etc.

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16
Q

TAVR PATIENT SELECTION

TAVRs are typically done on older adults that are how old?

A

over 70 years of age

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17
Q

TAVR PATIENT SELECTION

Why should Futility and Frailty be assessed?

A

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%

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18
Q

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:

A

Frailty

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19
Q

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:

A

Futility

In other words, despite successfull procedure, their risk of mortality or mobidity at one year is > 50%

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20
Q

TAVR PATIENT SELECTION

T/F: >50% compromise of >3 major organs is contraindication for TAVR

A

True

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21
Q

TAVR PATIENT SELECTION

T/F: Mortality and Morbidity at 1 year >50% as determined by STS PROM is contraindication for TAVR

A

True

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22
Q

TAVR SURGICAL CONSIDERATIONS

Pre procedural planning includes

A

Selecting the bioprostehtic valve and size

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23
Q

TAVR SURGICAL CONSIDERATIONS

There are currently two systems used for implantation

A

The Sapien valve

Medtronic Core valve

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24
Q

TAVR SURGICAL CONSIDERATIONS

What’s the major difference between the Sapien valve and the Medtronic CoreValve?

A

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

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25
Q

TAVR SURGICAL CONSIDERATIONS

Why do most facilities stick to one type of valve?

A

Operator experience is also an important factor when selecting between the two valves

so most facilities stick to one type of valve

.

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26
Q

TAVR SURGICAL CONSIDERATIONS

Valve size depends on:

A

Pts’ aortic annulus

This should be measure prior to the procedure with at TEE

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27
Q

TAVR SURGICAL CONSIDERATIONS

Selecting the vascular site should be patient specific. why?

A

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.

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28
Q

TAVR SURGICAL CONSIDERATIONS

All patients assessed for feasibility of femoral approach

A

True

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29
Q

TAVR SURGICAL CONSIDERATIONS

If the peripheral vasculature is unfavorable, what do you do?

A

an alternative site should be chosen.

may consider transapical TAVR

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30
Q

TAVR SURGICAL CONSIDERATIONS​

In the event of emergency, what should be discussed with the surgical team?

A

A “Bail-out” plan

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31
Q

TAVR SURGICAL CONSIDERATIONS

What must the “Bail out” plan include?

A

​Cardiothoracic surgeon and CPB on standby

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32
Q

TAVR SURGICAL CONSIDERATIONS

What is the typical Bail out until a sternotomy can be made?

A

ECMO

However, depending on what the adverse event is, TAVR are typically catastrophic

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33
Q

TAVR ANESTHETIC CONSIDERATIONS

Which should be on stanby during TAVR

A

Cardiothoracic surgeon

Cardiopulmonary bypass machine

Perfusionist

34
Q

TAVR ANESTHETIC CONSIDERATIONS

T/F: External defibrillator pads should be placed on the pt and the pacemaker should be readily available

A

True

35
Q

TAVR ANESTHETIC CONSIDERATIONS

What should be available for pts with AICD implanted?

A

Magnet

36
Q

TAVR ANESTHETIC CONSIDERATIONS

Monitors for TAVR procedures include:

A

5-lead EKG

Pulse oximetry

Temperature monitoring

Radial arterial line ?

Central venous catheter/Introducer with pacing Swan-Ganz Catheter

37
Q

TAVR ANESTHETIC CONSIDERATIONS

Why are Foley Catheters not typically inserted?

A

Procedures last 2 hours or less

38
Q

TAVR ANESTHETIC CONSIDERATIONS

TTE versus TEE: what determines which is used?

A

Moderate sedation vs. General anesthesia

39
Q

TAVR ANESTHETIC CONSIDERATIONS

The primary goal for anesthesia during TAVR procedures includes

A

Hemodynamic stability

Avoiding on-table patient moving

Achieving early extubation if general anesthesia is used

40
Q

TAVR ANESTHETIC CONSIDERATIONS

TAVR is Multidisciplinary approach that requires

A

OPEN COMMUNICATION

41
Q

TAVR ANESTHETIC CONSIDERATIONS

It’s important to assess the patient’s ability to both lay flat and still for the procedure; why?

A

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

42
Q

TAVR ANESTHETIC CONSIDERATIONS

So why not intubate all pts to prevent on-table movement?

A

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

43
Q

TAVR ANESTHETIC CONSIDERATIONS

General anesthesia with a regular endotracheal tube is typically done for which TAVR approach?

A

The trans-apical approach

44
Q

TAVR ANESTHETIC CONSIDERATIONS

Which anesthesia technique is widely accepted for trans-femoral cases?

A

Moderate sedation with incision site localization

45
Q

TAVR ANESTHETIC CONSIDERATIONS

When General Anesthesia is chosen, which drugs are used? What’s the ultimate goal?

A

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

46
Q

TAVR ANESTHETIC CONSIDERATIONS

What’s the goal of Moderate Sedation?

A

Keep patient comfortable

Limit movement

Keep pt arousable, so they can alert providers of any chest discomfort

47
Q

TAVR ANESTHETIC CONSIDERATIONS

Chest discomfort during TAVR procedure could be indicative of:

A

Acute ischemic episode

Aortic dissection,

Rupture aortic annulus

48
Q

TAVR ANESTHETIC CONSIDERATIONS

Benefits of keeping patients comfortable, but arousable include:

A

Monitor neurologic status, procedural complications

They can alert providers of acute chest discomfort

Better hemodynamic control

Reduced length of stay

49
Q

TAVR ANESTHETIC CONSIDERATIONS

Which drug are used for Moderate Sedation?

A

Propofol** infusion versus Precedex infusion

Minimal opioid administration

50
Q

TAVR ANESTHETIC CONSIDERATIONS

How is BP maintained during TAVR?

A

Vasopressors IVP or infusions as necessary

51
Q

TAVR ANESTHETIC CONSIDERATIONS

Why should IVP drugs that are short acting be used for Blood pressure management?

A

Because Blood pressure management should be precise control

52
Q

TAVR ANESTHETIC CONSIDERATIONS

The use of which drugs is acceptable for the management of hypertension during TAVR?

A

Nicardipine

NTG (small doses)

53
Q

TAVR ANESTHETIC CONSIDERATIONS

The use of which drugs is acceptable for the management of hypotension during TAVR?

A

Phenylepherine

Norepinepherine

Epinepherine

54
Q

TAVR ANESTHETIC CONSIDERATIONS

There are times where rapid ventricular pacing (160-200 bmp) will be required. Why is this done?

A

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

55
Q

TAVR ANESTHETIC CONSIDERATIONS

What are the possible negative effects of the reduced left ventricular stroke caused by Rapid ventricular pacing (160-200 bmp)?

A

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

56
Q

TAVR ANESTHETIC CONSIDERATIONS

After the valve is placed, what could cause myocardial stunning? How is it treated?

A

Improved blood flow through valve

Consider treating Myocardial stunning with low-dose inotropic agents

57
Q

TAVR ANESTHETIC CONSIDERATIONS

How is Anticoagulation achieved for the procedure?

A

Heparin 100 units/kg for ACT of 300 s for procedure.

58
Q

TAVR ANESTHETIC CONSIDERATIONS

Why should the surgical team be consulted prior to heparin reversal with Protamine?

A

May only want partial reversal of Heparin with Protamine

Consult with surgical team

59
Q

TAVR COMPLICATIONS

Complications of TAVR include:

A

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

60
Q

TAVR COMPLICATIONS

What can increase the risk for complication a/w TAVR?

A

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

61
Q

TAVR COMPLICATIONS

Paravalvular leaking - incidence?

A

15-20%

62
Q

TAVR COMPLICATIONS

Paravalvular leaking - Causes?

A

Valve malpositioning

Under expansion of the annulus

Heavy annular calcification

63
Q

TAVR COMPLICATIONS

Need for post-procedure pacing versus permanent pacemaker placement - Cause?

A

AV block

64
Q

TAVR COMPLICATIONS

Need for post-procedure pacing versus permanent pacemaker placement - Research notes higher incidence with which type of valve?

A

CoreValve versus Sapien Valve

65
Q

TAVR COMPLICATIONS

Ruptured aortic annulus - risk factor?

A

Highly calcified aortic annulus

66
Q

TAVR COMPLICATIONS

Acute ischemia - Mechanisms?

A

Pre-existing CAD + Rapid ventricular pacing

=> decrease in myocardial O2 supply

also

Poorly positioned prosthetic valve

67
Q

TAVR COMPLICATIONS

Aortic dissection

A

!!!

68
Q

TAVR COMPLICATIONS

Stroke - causes?

A

Embolic lesions

Calcification from aortic valve and aortic arch

69
Q

TAVR COMPLICATIONS

Respiratory insufficiency - Factors?

A

Prolonged mechanical intubation

Reintubation

Existing pulmonary comorbidities directly associated with pulmonary complications

70
Q

TAVR COMPLICATIONS

Bleeding at the site d/t?

A

Use of sheaths in groins

71
Q

TAVR COMPLICATIONS

Bleeding - Other cause?

A

Full reversal of heparin not always done

72
Q

TAVR COMPLICATIONS

How could bleeding be reduced at suture sites?

A

Adequate blood pressure control

73
Q

TAVR COMPLICATIONS

How is perforation of femoral artery treated

A

Requires stenting of femoral vessels

74
Q

TAVR POSTPROCEDURE CONSIDERATIONS

T/F: If General anesthesia was used, pts are typically stable enough for intra-op extubation

A

True

75
Q

TAVR POSTPROCEDURE CONSIDERATIONS

If transported to the ICU, early extubation is a/w?

A

Lower in-hospital mortality

76
Q

TAVR POSTPROCEDURE CONSIDERATIONS

Why should pain control be optimize?

A

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

77
Q

TAVR POSTPROCEDURE CONSIDERATIONS

It’s important to understand that TAVR pts must be heparinized during the procedure. What’s a post consideration for heparin?

A

Full reversal of the heparin w/ Protamine may not have been done

78
Q

TAVR POSTPROCEDURE CONSIDERATIONS

Why must the pt lay flat for 4 hours after the procedure?

A

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

79
Q

TAVR POSTPROCEDURE CONSIDERATIONS

Why should patients have continuous cardiac monitoring for a few days post procedure?

A

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

80
Q

TAVR POSTPROCEDURE CONSIDERATIONS

What’s the incidence of permanent pacemaker following TAVR?

A

10-50%.

81
Q

TAVR POSTPROCEDURE CONSIDERATIONS

Which pts are more susceptible to AV conduction issues and therefore require continuous cardiac monitoring for a few days post procedure?

A

> 75 years of age

Oversizing of implanted valve

Small annulus

Pre-existing bradycardia (<55 bpm)

82
Q

AMERICAN HEART ASSOCIATION

Scientific Statement on Minimally Invasive Procedures

A
  • 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

8361 Exam I (18 decks)

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