SHA24/072003

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