menachem m. weiner assistant professor of anesthesiology … · 2018. 11. 16. · anesthetic care...

Menachem M. Weiner Assistant Professor of Anesthesiology

Icahn School of Medicine at Mount Sinai

Anesthetic care and considerations

Intraoperative events

TEE

Perioperative complications

•Most common valvular disease

•Degenerative disease- Senile calcification

•Rheumatic disease

•Congenital (e.g. Bicuspid)

Severe Aortic Stenosis

• Angina

• CHF

• Syncope

Otto et al. Circulation. 1997;95:2262-70.

Parameter

Preload

Afterload

Contractilty

Heart rate Maintain

Sinus Rhythm

Table 10.

Summary of recommendations for AS: Choice of surgical or transcatheter intervention

Recommendations COR LOE

Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk I A

For patients in whom TAVR or high-risk surgical AVR is being considered, members of a Heart Valve Team should collaborate to provide optimal patient care I C

TAVR is recommended in patients who meet an indication for AVR for AS who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo I B

TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk IIa B

Percutaneous aortic balloon dilation may be considered as a bridge to surgical or transcatheter AVR in severely symptomatic patients with severe AS IIb C

TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS

III: No Benefit B

2014 AHA/ACC guideline for the management of patients with valvular heart disease : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Alfirevic A, Mehta AR, Svensson LG. Transcatheter aortic valve replacement. Anesthesiol Clin. 2013;31:355-81.

• Preparation

• Hemodynamics *monitoring/management

• GA or MAC

• TEE (TTE)

• Complications

Communication

Surgical team

CPB readiness

IABP

Ethical dilemma

Invasive arterial access

Central venous access

PAC

Vasopressors

Transvenous pacemaker

Anesthesia induction

Balloon valvuloplasty

Between valvuloplasty and deployment

Valve deployment

Complications of deployment

General anesthesia

? Extubation

MAC

Midazalam

Propofol

Dexmedetomidine

Fentanyl

Remifentanyl

Mount Sinai Cocktail

General anesthesia

Advantages TEE monitoring throughout procedure Secured airway at all times Ability to suspend mechanical ventilation Better pain control

Disadvantages Airway manipulation and potential damage Potential for prolonged intubation Hemodynamic instability throughout the procedure

MAC Advantages Avoidance of airway manipulation Quicker emergence and recovery, shorter hospital stay Neurologic monitoring

Disadvantages Inability to use TEE Procedural need for lying in one position for prolonged period of time Intolerance to decrease in CBF with RVP Unprotected airway (with increase chance for sudden instability) Inability to suspend ventilation Local anesthetic toxicity Escalation in sedation reaching general anesthesia levels

Confirm diagnosis and prosthesis size

Exclude unfavorable anatomy

Guide wires and valve into place

Examine for AI after BAV

Examine for procedural success

Transvalvular vs. Paravalvular AI

Diagnose complications

Aortic regurgitation

Vascular injury

Electrophysiological

Pericardial hemorrhage

Valve malpositioning

Stroke

Mitral valve disruption

Aortic dissection/ Annular Rupture

Death

• TAVR is now main stream

• Need to know anesthetic considerations • Avoid tachycardia and decreased CPP • Maintain systemic pressure during RVP • Limit cardiac ejection during BAV and valve implant • Extubate safely

• Advance planning

• Younger/lower risk patients