Anesthesia for TAVR
These cases and patient population present unique challenges during your cardiac rotation. They combine high acuity cardiac illness with anesthesia for octogenarian and nonagenarian patients. Several concurrent moderate to severe comorbidities need to be taken into account, usually including extreme frailty, and these patients are often not candidates for traditional surgical AV replacement (SAVR).
The procedure is straightforward but has the potential to become extremely complex including emergent institution of CPB and sternotomy. A dedicated team performs the procedure: an interventional cardiologist, a cardiac surgeon, a perfusionist and cardiac anesthesia. A primed CPB pump will in the cath lab on standby (brought in once patient stretcher is removed).
Note: Most TAVRs at Stanford are performed under GETA, but patients receiving specific valves (eg, Medtronic Corevalve) are candidates for MAC. Always discuss the plan with your attending.
Preparation
- Machine check, suction, backup airway equipment check (this is an out-of-OR location and things are sometimes not in their usual place – make sure you know where the LMAs and Ambubag are)
- Drugs to draw up
- Heparin: 10,000 unit syringe + 20,000 units immediately accessible
- Fentanyl 100-250mcg (remembers this is usually a minimally invasive procedure)
- Rocuronium
- Propofol (or other induction agent of choice if previously discussed with attending)
- “Uppers”: phenylephrine, vasopressin, epinephrine
- “Downers”: nitroglycerin +/- nicardipine or nitroprusside
- Infusions: norepinephrine, epinephrine, nitroglycerin or others based on ventricular function and attending preference
- Drugs to have available (not drawn up): albumin, protamine, CaCl2, NaHCO3, KCl
- Lines: start with peripheral IV & pre-induction arterial line
- Post-induction volume line/s: IJ line (by us) or groin (by cardiology), or additional large bore PIV/s
- Some patients (Medtronic Corevalve and Boston Scientific Lotus Valve recipients) require transvenous pacing wire placed via 5 or 6Fr right IJ introducer. Ask cath lab nurses for equipment, confirm with fluoroscopy and TEE, secure it well, stays in place for 2-3 days) Transvenous pacing via IJ is usually not needed for Edwards Sapien valves
- Trial participants may require 9Fr introducer with PA catheter for cardiac output recordings. Check with attending or cardiologist if this is necessary. Also consider PA catheter if patient has severe ventricular dysfunction (systolic or diastolic), pulmonary hypertension or other significant valve disease
- Blood: consider having cooler in the room
Pre-valve deployment
- Antibiotics (usually cefazolin and vancomycin); baseline ABG (send to lab) and ACT (give to perfusionist)
- TEE exam & measure cardiac output (if PA catheter in place)
- Ensure blood is in the room (≥2u PRBCs), lines are connected appropriately (x3 = CVP, infusions, volume)
- Heparin dose with goal ACT >250
- Volume: minimal crystalloid (usually <500mL), consider albumin as volume expander
Valve Deployment
- A technique called “rapid ventricular pacing” (RVP) with pacing of the RV at 160-180bpm stops ventricular ejection. Watch the invasive pressure tracings. Your attending or fellow will guide you to any action. Used for balloon expandable valves (not for primary deployment of self-expanding valves)
- RVP may be used multiple times if initial valvuloplasty is desired, for valve deployment, and for any additional expansion of deployed valve if paravalvular leak is present
- Consider pre-RVP bolus of vasoactive substance: discuss with attending
- Hemodynamics (usually) recover quickly after cessation of RVP
- Notable exceptions to ‘usually recover’ scenario: 1. De novo severe AR after balloon valvuloplasty; 2. Severe MR or LVOT obstruction due to transvalvular sheath or undeployed valve (treatment for 1 & 2 is to deploy new valve asap); 3. Heart block/severe bradycardia post valve deployment (use RV pacing wire to pace at 70-90bpm); 4. Bad ventricular function
Post Valve Deployment
- Hemodynamic control to maintain MAP usually 70-80mmHg (transaortic may be 60-70mmHg)
- Repeat ABGs as needed (usually q1h), repeat ACT after reversal of heparin with protamine
- Comprehensive TEE exam to assess for paravalvular leaks, ventricular function, other issues
- May consider extubation after sheaths are out, no vascular access issues and otherwise uncomplicated