TRANSCATHETER AORTIC VALVE IMPLANTATION
GENERAL ANAESTHESIA FOR TAVI ?… IS IT PREFERRED OPTION
MOHAMMED SALLAM CONSULTANT CARDIAC ANAESTHESIOLOGIST NATIONAL GUARD HOSPITAL
Introduction
Debilitating valvular heart lesion in adults Replacement is the treatment of choice having high risk for surgery 40%-30%
Introduction
Introduction - 300,000 of A.S are diagnosed / year, 50% (150,000) die within one year 75% (225,000) die after 2 years & 99% die after 3 years University of Michigan (C.V.C)
Introduction S-AVR
TAVI
Introduction Prof. Alain Cribier First Clinical Experiences Implanted first percutaneous aortic valve on a patient on April 16, 2002
Introduction
Introduction 70,000
MORE THAN 50,000 PROCEDURES HAVE BEEN DONE WORLIDWIDE
Introduction
TAVI CASES IN KING ABDELAZIZ CARDIAC CENTER
16
7 4
DEATHS
3
2
Prediction: Repetition of an Old Story
PCI
CABG CABG
Now
PCI
s, 1990’s’1980
TAVI
?
?
S-AVR
s, 2012’s’2002
Future
S-AVR TAVI
’The ‘Team Approach CARDIOLOGISTS
CARDIAC SURGEONS
TAVI
ANAESTHESUIOLOGIST
)IMAGING SPECIALISTS (Echo, CT, MRI
TAVI procedure Edwards SAPIEN
Valvuloplasty
Core-Valve
TAVI procedure
TAVI procedure
.Preparation of delivery system
TAVI procedure
.Engagement of the valve into delivery system
Edwards SAPIEN
Core-Valve
Access
TAVI procedure
TF
TA
TF
TAx
TAVI procedure Balloon Aortic Valvuloplasty
Delivery system insertion
Valve deployment
TAVI procedure Balloon Aortic Valvuloplasty
BAV is performed under rapid right ventricular pacing (180 – 220 beats per minute)
Induce cardiac ischemia or arrhythmias
Kept to a minimum (<15 sec).
TAVI procedure Balloon Aortic Valvuloplasty
Complications associated with BAV : 1. Coronary ostial obstruction or embolization ECG and TEE 2. Aortic root rupture can be useful 3. Myocardial depression to rule out 4. Arrhythmias, conduction blocks several of 5. Severe aortic regurgitation these 6. Stroke complications.
TAVI procedure Balloon Aortic Valvuloplasty
Delivery system isertion
Valve deployment
TAVI procedure Complications associated with this stage: 1. Incorrect placement (too high or too low) 2. Device embolization distally into the aorta or proximally into the left ventricle 3. Central or paravalvular regurgitation 4. Coronary ostial obstruction 5. Arrhythmias 6. AV block 7. Impingement of the anterior mitral valve leaflet affecting its function
Valve deployment
TEE
TAVI procedure Predictors for PPM Medtronic CoreValve
TAVI procedure Delivery system withdrawal
Assessment of valve function
Access closure
TAVI procedure Valve Position Any Regurgitation Re-Evaluate LV Function Evaluate for Pericardial Effusion Coronary Flow
Assessment of valve function
TAVI procedure Delivery system withdrawal
Assessment of valve function
Access closure
TAVI procedure Stenting
Access closure
Anesthetic Management of TAVI
Anesthetic Management of TAVI High risk patients
Prior pericardiectomy Prior sternal infection with complex reconstruction
High risk and/or Contraindication For S-AVR Patent left internal mammary graft
Very High risk patients Careful assessment of the selected patients
Anesthetic Management of TAVI Careful assessment and optimization of the patient Proper preoperative examination Optimization of patientâ&#x20AC;&#x2122;s condition Challenge
TAVI procedure What may goes wrong How to manage side effects & complications Safe conduction of anesthesia
General
Local + sedation Rationale selection of anesthesia
Anesthetic Management of TAVI
Hypothermia
Anesthetic Management of TAVI
Anesthetic Management of TAVI Monitoring
Braithwaite et al. Current Opinion in Anaesthesiology 2010, 23:507â&#x20AC;&#x201C;512
Anesthetic Management of TAVI Some patients may require inotropic and/or vasopressor support before induction of anesthesia.
ď&#x192;&#x2DC; For this purpose we need to prepare infusions of: 1. 2. 3. 4.
Adrenaline. Phenylephrine. Nitroglycerine. Noradrenaline.
Anesthetic Management of TAVI Hemodynamic stability is the main objective during induction & maintenance . Hemodynamic goals: Intravenous fluid to provide adequate preload
to a hypertrophic left ventricle Tachycardia should be avoided Sinus rhythm should be maintained Systemic blood pressure must be maintained
Anesthetic Management of TAVI Common problems during TAVI are: 1. Blood loss 2. Hypothermia: During TAVI all patients are actively warmed with air blanket warming systems 3. Renal : Patients having preexisting renal insufficiency and/or diabetes mellitus are at risk of nephrotoxicity and acute renal failure due to the use of radiocontrast media 4. Arrhythmias: Sinus tachycardia, atrial arrhythmias, SVT & Ventricular arrhythmias are not uncommon & should be managed to maintain hemodynamic stability
Anesthetic Management of TAVI ď&#x192;&#x2DC;The choice of the anesthetic technique varies among centers and is probably not associated with a significant difference in outcome .
Periprocedural TEE Facilitaded management of complication
GENERAL
NO
Better control of respiratory function
Control of respiratory interference during valve positioning and deployment
-P - N atien - A eed t m - D nxie for i ovem ins isco ty d ntub ent pr erti mfo u to ation oc on rt R du ed , p du VP rin ur gp e ositi ring roc o n ca t ed or h ure lon eter gt im e
Long preparation and operative time
le
GENERAL
Lo ng ho Mo sp re it a req ls He u tay ir m mo an en dr dyn dc t ug t a os oI s , mi t C U int c in & ub st HD a ati b U on ilit y & ex due tub to ati GA on
si b Po s
No contenuous neurological monitoring
Local Anesthesia May Be Enough for TAVI By Crystal Phend, Senior Staff Writer, MedPage Today Published: May 09, 2012 University of California, San Francisco
May 2006 through January 2011. 151 patients Only local anesthesia and fluoroscopic guidance conventional cardiac catheterization lab Only 3.3% of patients had to be converted to general anesthesia, all related to complications with the valve procedure rather than with IV sedation or because of an uncooperative patient. Major aortic regurgitation
Vascular rupture
aortic annulus rupture with tamponade
Aortic dissection
Less time spent in the intensive care unit and in the hospital
Lower overall need for inotropes
Avoidance of complications of prolonged ventilation for the many high-risk patients with chronic pulmonary disease
Potential advantages of local & sedation
Ability to evaluate pain during dilator and sheath placement in the femoral artery, which should help in knowing when to stop to avoid vascular complication
Ability to monitor neurological status during the procedure, "considered important because of the high stroke rate"
Patient movements
No TEE guidance
Discomfort during catheter insertion, position or long time procedure
Potential disadvantages of local & sedation
Limited access to the airway because of the fluoroscopy equipments
Possible worsening of pulmonary hypertension
Depressed ventilation and hypercarpia because of sedation
?
Deep sedation
Guarracino et al, Echocardiogr. 2010; 11:554-6
Patients and circumstances !!!!
Expected complication Uncooperative Canâ&#x20AC;&#x2122;t lie down
Co-operative Mild to moderate respiratory disorder Skills of the cardiologist ( no TEE )
Mohammed Sallam NGHA RIYADH