Catheter-based Cardiac Surgery 125

Figure 1. Paraprosthetic and central (wire-related) aortic regurgitation after implantation of an Edwards SAPIEN valve (TEE, midesophageal aortic valve, long-
axis view). Ao ¼ aorta; LA ¼ left atrium; LVOT ¼ left ventricular outflow tract; TEE ¼ transesophageal echocardiography. From Klein AA, Skubas NJ, Ender J:
Controversies and complications in the perioperative management of transcatheter aortic valve replacement. Anesth Analg 2014; 119:784–98. Copyright r
2014, International Anesthesia Research Society.

allows delivery via either a 16 or 19 Fr sheath. TA approaches anesthetic evaluation should also focus on degree of lung
utilize a 26 Fr delivery sheath. The CoreValve system is dif- disease to predict extubation after the procedure, airway
ferent altogether, and utilizes a self-expandable system that anatomy, overall cardiac functional status, neurological
deforms when cold and regains its shape when warmed in the status, and any history of previous anesthetic difficulties.
patient. Sizes available include 22 and 26 mm devices that are TEE is routinely used, so any esophageal pathology that
delivered via 18 or 19 Fr sheaths.34 There is more published might preclude use of TEE should be noted.
experience in the United States with the SAPIEN compared The procedural specifics for the SAPIEN valve typically
with the CoreValve, thus much of this discussion will reflect include placement of standard monitors, adequate intra-
that experience. venous (IV) access, and arterial line, followed by induction
Patient selection and preoperative evaluation for TAVR of general anesthesia and intubation with a single-lumen
varies from the typical patient for whom a multi- endotracheal tube. Frequently, this is followed by central
disciplinary team discussion and selection process is typi- access including placement of a pulmonary artery catheter
cally employed (largely on the basis of a process developed and the TEE probe. The surgical team, consisting of a
in the PARTNER trial).30,31,35 In addition to the usual cardiothoracic surgeon and an interventional cardiologist,
preoperative evaluation for AVR (i.e., symptomatic AV then obtains appropriate femoral access. A temporary
stenosis), TAVR patient selection includes the following pacing wire is placed in the RV, followed by heparinization
criteria for most centers: adequately sized aortic annulus; to an activated clotting time goal of 250 to 300 seconds.
elevated Society of Thoracic Surgeons risk score (typically Repeat imaging by TEE is routinely done to verify size
more than 9 to 10%), denial of surgery by two surgeons, or estimates of the AV annulus. A trial of rapid ventricular
both; advanced lung disease; functional coronary vessels/ pacing (RVP) is undertaken to verify adequate capture, but
grafts; degree of frailty; functional status; and the usual this also gives the anesthesiologist a sense of how the pa-
comorbidities of diabetes, renal disease, and coronary ar- tient will respond once RVP is terminated. Often, there is a
tery disease. Exclusion criteria may include advanced liver 1- or 2-minute period of hypotension after RVP, which
disease, advanced dementia, severe mitral valve disease, may require vasopressors such as phenylephrine or epi-
severe LV failure, nonrevascularized severe coronary ar- nephrine. Often it is helpful to elevate the systolic blood
tery disease, pulmonary hypertension, severe arrhythmias pressure slightly above baseline (to 130 to 140 mmHg)
(atrial fibrillation), and severe chronic obstructive pulmo- before RVP. Once the delivery sheaths are placed, AV bal-
nary disease.34,35 The next phase of diagnostics includes loon valvuloplasty is performed. Next, the device is in-
evaluation of the aortic annulus, typically via transthoracic serted retrograde through the aorta and positioned across
echocardiography or TEE, in addition to computerized the AV annulus with confirmation by TEE and fluoros-
tomography and angiography. Additional critical details copy. RVP from 160 to 200 bpm is then initiated to reduce
are evaluation of the femoral and iliac vessels to determine LV ejection, typically reducing the systolic blood pressure
degree of tortuosity, caliber, and atherosclerotic burden to to 60 to 80 mmHg and pulse pressures to 20 to 30 mmHg.
determine the feasibility of the TF approach.34,35 Pre- During this time, respirations are usually held as well to

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

126 We i t z e l

Table 5. Summary of Key Anesthesia Management Factors key to success for anesthesia
Points for TAVR34
management include identifying specific risk
Intervention/
Procedure Anesthetic Management Points* areas for each patient and planning how best
TAVR General anesthesia—but possible with local to counteract them with the knowledge of the
anesthesia and sedation
Arterial line þ TEE monitoring planned procedure.
Adequate IV access required; central access and
possible PAC
Type and cross-match with products immediately
Anesthetic planning for any procedure must take into
available
account a working knowledge of known or possible com-
Cardiothoracic surgeon participation/availability
plications. The list of complications for TAVR includes
Perfusion standby peripheral vascular injury, paravalvular leak, rupture of
Cardiac anesthesiologist† the annulus, heart block, coronary artery occlusion or
*All cases should have standard ASA monitoring in place. Specific anesthesia compromise leading to ischemia, stroke, bleeding, device
planning should be based on individual medical conditions and may be altered
from these recommendations. malposition, and low-output cardiac syndrome after
†There is current debate surrounding whether cardiothoracic anesthesiolo- RVP.32–35 Factors key to success for anesthesia manage-
gists should staff these cases, and the decision may depend on whether
cardiology versus anesthesiology is performing TEE. ment include identifying specific risk areas for each patient
ASA ¼ American Society of Anesthesiologists; IV ¼ intravenous; PAC ¼ pulmo- and planning how best to counteract them with the
nary artery catheter; TAVR ¼ transcatheter aortic valve replacement; TEE ¼
transesophageal echocardiography. knowledge of the planned procedure (Table 5). Also crit-
ical is TEE imaging of the device and device placement,
which may be done by the anesthesia team or a cardiology
team, depending on the scenario. Discussion is encouraged
regarding management with general anesthesia versus IV
reduce patient motion and to allow for the most ideal de- sedation for TAVR, especially since a number of studies
ployment conditions. Immediately after deployment, at- using IV sedation have been published. A recent meta-
tention is focused on resolution of hemodynamics as well analysis that spans seven nonrandomized studies, includ-
as evaluation by TEE and fluoroscopy for proper seating of ing more than 1,500 patients, indicates that the 30-day
the prosthetic valve, degree of paravalvular leak (if any), mortality did not differ between the general anesthesia
pericardial effusion, and any evidence of compromise of versus IV sedation groups.36 One obvious challenge to IV
coronary flow. Occasionally, repeat balloon stenting of the sedation includes lack of TEE capability, as these are
valve is employed to treat paravalvular leak, which re- lengthy procedures and the patient will not tolerate the
quires additional RVP. TEE probe for that duration. Reported advantages of IV
The overall procedure is very similar for the TA sedation include reduced hospital stay, reduced ventilator-
approach, with the obvious exception of the need for associated pneumonia, and shorter overall procedure
minithoracotomy and direct cannulation of the LV apex. times. Given the lack of randomized trials, the authors
TAVR management by the TA approach follows the same were hesitant to make sweeping conclusions, but suggest
induction and monitoring plans as for TF and, like TF, uses that either approach may be appropriate on the basis of
a single-lumen endotracheal tube and two-lung ven- patient, provider, and system preferences. Finally, dis-
tilation. The LV apex is exposed surgically and punctured cussion with the patient and the care team should include
with a needle, a finder wire is then placed into the LV (with the backup plan should there be a severe complication.
visual confirmation by TEE), and the valvuloplasty sheath Often, sternotomy, cardiopulmonary bypass, and SAVR
is introduced, all followed by the deployment sheath. RVP comprise the backup plan, but some patients and surgeons
is utilized as in the TF procedure, and the same consid- may refuse this option.
erations apply. Advantages include no risk of iliac or aortic
intervention, which can be critical in patients with severe
atherosclerosis, as well as an ideal placement angle for the
device.34 Disadvantages include pain associated with the
need for a thoracotomy, risk of myocardial damage, and
CONCLUSIONS
risk of severe bleeding from the LV apex. Initial results Catheter-based cardiac surgery represents an ever-growing
seemed to demonstrate some differences in outcomes be- frontier for anesthesiologists. As techniques improve, pa-
tween TA and TF; however, recent larger-scale and longer- tient volumes will likely follow, and a working knowledge
term studies appear to indicate that procedural success, of these complex procedures is required for appropriate
short-term and long-term mortality, and stroke outcomes anesthetic planning (Supplemental Digital Content 5,
are similar between these two groups.34 http://links.lww.com/ASA/A566).

Copyright r 2015 American Society of Anesthesiologists. All rights reserved.

Catheter-based Cardiac Surgery 127

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Copyright r 2015 American Society of Anesthesiologists. All rights reserved.