Menachem M. Weiner Assistant Professor of Anesthesiology Icahn School of Medicine at Mount Sinai

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1 Menachem M. Weiner Assistant Professor of Anesthesiology Icahn School of Medicine at Mount Sinai

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3 Anesthetic care and considerations Intraoperative events TEE Perioperative complications

4 Most common valvular disease Degenerative disease- Senile calcification Rheumatic disease Congenital (e.g. Bicuspid)

5 Severe Aortic Stenosis

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7 Angina CHF Syncope Otto et al. Circulation. 1997;95:

8 Parameter Preload Afterload Contractilty Heart rate Maintain Sinus Rhythm

9 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 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 B

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

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15 Preparation Hemodynamics *monitoring/management GA or MAC TEE (TTE) Complications

16 Communication Surgical team CPB readiness IABP Ethical dilemma

17 Invasive arterial access Central venous access PAC Vasopressors Transvenous pacemaker

18 Anesthesia induction Balloon valvuloplasty Between valvuloplasty and deployment Valve deployment Complications of deployment

19 General anesthesia? Extubation MAC Midazalam Propofol Dexmedetomidine Fentanyl Remifentanyl Mount Sinai Cocktail

20 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

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23 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

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25 Aortic regurgitation Vascular injury Electrophysiological Pericardial hemorrhage Valve malpositioning Stroke Mitral valve disruption Aortic dissection/ Annular Rupture Death

26 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

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