engleski

Anesthesia management for the transcatheter aortic valve implementation (TAVI)

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) is the procedure of choice for treatment severe aortic stenosis in nonsurgical or high-risk patients to undergo open surgical aortic valve replacement. In this study, we present our results in anesthetic management for TAVI procedure. METHODS: Procedures were performed in Department of Cardiovascular Anesthesiology and Intensive Care Medicine, in hybrid operating room (HOR) between March 2011 and November 2013. In this period, we performed 37 procedures in patients with severe symptomatic aortic stenosis. The average age was 79.27 years, and all patients had contraindications for classic surgical valve replacement. Of all 36 patients, in 23 patients, self-expanding valve was implanted and in remaining 14 patients, baloon-expanding valve was implanted. In 36 patients, TAVI was performed with transfemoral approach and in one patient valve implanted by transaortic way through J-sternotomy. In one patient, due to failing previously implanted aortic valve bioprosthesis, we performed valve-in-valve implantation. Two hours before procedure, all patients received 5 mg of midazolam and clopidogrel in doses between 75 and 150 mg orally depending to the previous coagulation state and the type of valve. Induction in general anesthesia achieved with sevoflurane, 0.25 mg of fentanyl and 8.0 mg of vecuronium at the beginning of the procedure. Anesthesia maintenance was performed only with sevoflurane up to the end of procedure. Temporary pacemaker for rapid ventricular pacing (RVP) and central venous catheter were placed in all patients across jugular vein and left for the next two days. During procedure, in all patients transesophageal echocardiography (TEE) was used for evaluation of aortic valve, aortic root, left ventricular outflow tract, measurement of heart chambers and their function, and for estimation of mitral valve function. Finally, with TEE also evaluated post- procedure position of implanted valve and its function, the valve shape and existence of possible paravalvular leakage. For monitoring of cerebral perfusion, cerebral tissue oximetry by near-infrared spectroscopy (NIRS) was applied in all patients. RESULTS: Procedures were successfully in 36 patients ; one valve displaced and not positioned adequately. In nine patients TEE showed perivalvular regurgitation and need for valve re-expanding. Four patients needed short- term of norepinephrine usage due to hemodynamic instability. All patients extubated in HOR and transferred to ICU for the further 24 hours. In all patients, NIRS showed short-term decrease of cerebral oxygenation (mean fall 24%) during RVP, with quick recover. Early postoperative complications included new left bundle branch block in 1 patient, total AV block in 2 patients, heart failure in 1 patient and stroke in 1 patient. In those two patients with total AV block, permanent pacemaker was implanted few days later. All patients were discharged from hospital within 7 days after the procedure in good conditions. CONCLUSION: TAVI procedure has successful outcome and decreases risks of serious complications of classic aortic valve surgery in high-risk patients. NIRS is high-quality monitor for cerebral perfusion, but cannot predict possibility of stroke, especially if stroke is consequence of calcium dispersion from the biologic valve. We preferred general anesthesia in our patients because it is easier to control hemodynamic stability, makes easier for patients to tolerate the TEE probe during procedure and it is more comfortable for the patient if the procedure has prolonged. Furthermore, general anesthesia is recommended in case of serious complications and possible conversion of procedure on cardiopulmonary bypass and sternotomy.

TAVI; anesthesiology management; aortic valve; aortic stenosis

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