Evaluate the patient as you would any high-risk candidate for cardiac surgery Consider the anesthetic implications

s present in most TAVR patients

Multiple co-morbid conditions Advanced age Frailty

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 Routine
ECG Pulse oximetry Capnography Invasive and noninvasive blood pressure Large-bore peripheral and central venous access TEE Foley catheter

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 Important Considerations
Pulmonary artery catheter
Frequent MR/MS, pulmonary hypertension, RV failure, low cardiac output Systolic and/or diastolic dysfunction

EEG monitor
Frequent difficult anesthetic depth titration

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 General anesthesia preferred by most anesthesiologists

No adequate published data providing superiority of any particular anesthetic technique Advantages to general anesthesia
Maintains patient immobility to permit stable valve positioning and deployment Maximizes patient comfort during TEE and direct repair of the vascular access site, if necessary Facilitates patient management should complications that require CPB and/or sternotomy occur

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 Short-acting agents used most frequently

Facilitates fast-tracking

Supine position
Pressure-points padded

Radiolucent external defibrillator pads Warming devices

Blankets, forced-air heating Fluids

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 Assess adequacy of cardiovascular function

Maintain euvolemia
Improve cardiac output May require > 1 liter IV fluid Guidance Adequate LV filling on TEE Consider trends of CVP and PCWP Consider urine output > 1 cc/kg/hr Beware of over-hydration Systolic and diastolic dysfunction

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 If cardiac index remains low despite volume

Consider inotropic support Dobutamine especially if HR is low Milrinone

If cardiac index remains low despite inotropic support

Consider mechanical support IABP Cardiopulmonary bypass

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 Heparin dose
Maintain ACT > 250 seconds
1 - 1.5 mg/kg unfractionated heparin

Emergent CPB
Bolus additional heparin to maintain ACT > 400 seconds

Systemic blood pressure maintained at a level to ensure coronary and cerebral perfusion
Vasopressors
Phenylephrine, norepinephrine, vasopressin, ephedrine

Vasodilators
Nitroglycerin, short-acting calcium channel blocker

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 Rapid ventricular burst pacing

Induces an instantaneous, reversible fall in cardiac output
Reduces ejection of balloon and valve from aortic annulus during inflation

Pacemaker settings
Ventricular rate Start rapid pacing at 180 bpm Rate should be adjusted (typical pacing rates range between 160 and 220 bpm) and the pacing sequence should be repeated until sustained 1:1 capture, SBP of 50 mmHg or below is achieved, and pulse pressure < 10 mmHg 20 MA Asynchronous Atrial off

Pacemaker operator should only act on the direction of the primary implanting physician
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 Backup pacemaker available

Primary pacemaker fails Treat bradycardia Faster solution than trying to reset primary pacemaker Backup pacemaker settings Ventricular rate 80 bpm MA > threshold Synchronous Atrial off

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 Assess cardiovascular stability prior to rapid burst pacing

Rule-out a serious or prolonged cause of ventricular dysfunction
Ensure balloon-manipulation hypotension is transient Consider removing balloon and further optimization

Consider a bolus dose of phenylephrine or norepinephrine to achieve faster recovery of blood pressure and coronary perfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing

Allow sufficient hemodynamic recovery before initiating another episode of rapid pacing

Minimize the number and duration of rapid burst pacing episodes

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 Refractory hemodynamic instability after BAV

Echocardiographic findings key Acute aortic insufficiency
May not be tolerated, particularly in patients without preexisting aortic insufficiency Treat with immediate valve deployment

Stunned myocardium after pacing-induced subendocardial ischemia

Optimize coronary perfusion

Aortic rupture/dissection
Emergent CPB

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 Rapid ventricular burst pacing

Pacemaker settings same as BAV

Consider a bolus dose of phenylephrine or norepinephrine to achieve faster recovery of blood pressure and coronary perfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing

Hold ventilation during valve deployment

Decreases ventricular ejection Decreases motion artifact

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 Successful valve deployment typically results in a rapid return or increase in cardiac output and blood pressure
Sustained significant hypertension
Nitroglycerin, short-acting calcium channel blocker

Refractory hemodynamic instability

Echocardiographic findings key Aortic insufficiency
Severe paravalvular leak Balloon dilatation of valve Severe transvalvular leak Valve-in-a-valve*
* No testing has been performed to determine the long-term durability in this configuration
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 Myocardial ischemia
Stunned myocardium after pacing-induced subendocardial ischemia Optimize coronary perfusion Coronary artery obstruction PCI, IABP, CPB, mechanical ventricular assistance

Acute aortic or ventricular rupture/dissection

CPB

AV block
Pacemaker

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 Refractory hemodynamic instability

Vascular-access bleeding
Fluid replacement Balloon occlusion of vascular injury site and repair of artery

Reverse anticoagulation
Protamine
Administer when no more interventions are anticipated Dosage strategies Heparin-level based Fixed ratio from heparin dose

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 Extubate when meets standard criteria

Immediate extubation in the OR is appropriate for most
Minimum patient core temperature > 36 C Patient awake and able to follow simple commands Patient able to protect airway and has a normal respiratory pattern and rate, with oxygen saturation > 90% Full reversal of neuromuscular blockade if utilized

Patient is not bleeding significantly Patient is hemodynamically stable

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 Pain management
Typically minimal postoperative pain unless extensive vascular access issues Medications
Consider dexmedetomidine Analgesia and sedation without delirium Narcotics Judicious doses Delirium frequent in elderly population Non-narcotic analgesics

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1.
2.

Fassl J, Augoustides JGT: Transcatheter Aortic Valve Implantation - Part 2: Anesthesia Management. J Cardiothorac Vasc Anesth 24:691699, 2010
Guinot P, Depoix J, Etchegoyen L, et al: Anesthesia and Perioperative Management of Patients Undergoing Transcatheter Aortic Valve Implantation: Analysis of 90 Consecutive Patients With Focus on Perioperative Complications. J Cardiothorac Vasc Anesth 24:752-761, 2010 Ree RM, Bowering JB, Schwarz SK: Case series: Anesthesia for retrograde percutaneous aortic valve replacement Experience with the first 40 patients. Can J Anaesth 55:761-768, 2008 Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encountered and proposed solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009 Fassl J, Kodavatiganti R, Ingerski MS: Anesthesia management for retrograde aortic valve replacement. Can J Anaesth 56:336, 2009 Fassl J, Seeberger M, Augoustides JGT: Transcatheter Aortic Valve Implantation: Is General Anesthesia Superior to Conscious Sedation? J Cardiothorac Vasc Anesth 25:576-577, 2011 Covello D, Maj G, Landoni G, et al: Anesthetic Management of Percutaneous Aortic Valve Implantation: Focus on Challenges Encountered and Proposed Solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009 Bergmann L, Kottenberg E, Heine T, et al: [Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and hemodynamic observations]. Herz 34:381-387, 2009 Frederic T. Billings IV, Susheel K. et al: Transcatheter Aortic Valve Implantation: Anesthetic Considerations. Anesth Analg 108:1453-1462, 2009 Cheung A: Transcatheter aortic valve replacement. Anesthesiol Clin 26:465-479, 2008 Klein AA: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 103:792-799, 2009 Heinze H: Percutaneous aortic valve replacement: Overview and suggestions for anesthestic management. J Clin Anesth 22:373-8, 2010

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

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For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards Lifesciences, Edwards and the stylized E logo are trademarks of Edwards Lifesciences Corporation. respective owners. 2011 Edwards Lifesciences Corporation. All rights reserved. All other trademarks are the property of their

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