R02 y2010n04a0287

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R02 y2010n04a0287

  1. 1. MINERVA MEDICA COPYRIGHT® POINT OF VIEW Transcatheter implantation of an aortic valve: anesthesiological management S. CATTANEO, M. LAGROTTA Department of Anesthesia and Intensive Care, Ospedali Riuniti di Bergamo, Bergamo, Italy ABSTRACT Aortic stenosis (AS) is the most common form of valvular disease in adults. This condition also causes significant mor- bidity and mortality, especially among the elderly. Recent progress in balloon and stent technologies has offered the potential to transform the management of aortic stenosis. Transcatheter aortic valve implantation (TAVI) represents a new technique for the treatment of AS. Two devices are currently available for TAVI, which are the Edwards-Sapien valve and the CoreValve Revalving System. The goals of hemodynamic management during this procedure are the same as those performed during surgical aortic valve replacement. Namely, hemodynamic stability is the main goal of anesthesiological management during TAVI. The reduced invasivity of the TAVI approach demands careful monitor- ing of cardiovascular function because of the increased comorbidity associated with these patients. Furthermore, because of their carotid, aortic, valvular, coronary and peripheral vascular diseases, patients undergoing TAVI are at risk for hemodynamic instability. Moreover, two risk models are commonly used for patient selection for TAVI: the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Society of Thoracic Surgeon database. However, these two risk models are not entirely appropriate for the current assessments because they omit important risk factors. This bias is probably due to recent advances in intraoperative mortality and improved postoperative care. Notably, TAVI probably requires a “failing health patient” score. In our opinion, the evaluation of procedural risk should include the specific scoring of newer parameters that are not currently in use. TAVI offers a number of advan- tages to patients and medical teams, but there are still accompanying anesthesiological risks, and the hemodynamic peripro- cedural setting is an important issue for this type of procedure. (Minerva Anestesiol 2010;76:287-9) Key words: Aortic valve stenosis - Aortic valve - Anesthesiology.V alve disease is an important public health problem, and its prevalence is strongly linkedto the phenomenon of an aging population. even in elderly patients, when properly selected. However, the risk of surgery may be higher in eld- erly patients with significant comorbidities. InCurrently, the most frequently observed valve dis- addition, some centers have shown that physiciansease among Europeans is aortic stenosis (AS), denied at least one third of patients for surgerywhich is most often seen in elderly patients with because of high comorbidities. Therefore, despitevarying comorbidities.1, 2 Valve replacement is the the good results of valve surgery, a less invasivedefinitive therapy for patients with severe AS who approach has emerged as a viable alternative tohave symptoms or pathological consequences such open-chest surgery.as left ventricular (LV) dysfunction. The opera- Transcatheter aortic valve implantation (TAVI)tive mortality of valve replacement is quite low, currently represents a new technique for theVol. 76 - No. 4 MINERVA ANESTESIOLOGICA 287
  2. 2. MINERVA MEDICA COPYRIGHT®CATTANEO TRANSCATHETER IMPLANTATION OF AN AORTIC VALVE: ANESTHESIOLOGICAL MANAGEMENTtreatment of AS.1 Two different approaches are a patient with significant tortuosity, a physicianavailable for aortic valve insertion, including would prefer to use the smaller-profile CoreValve.transfemoral and transapical routes. Moreover, Nevertheless, most centers currently use only onetwo devices are currently available for TAVI: the type of device, which is either the CoreValve orEdwards-Sapien valve (balloon expandable) and the Sapien.the CoreValve Revalving System (self expand- Most patients undergoing TAVI with generalable). Currently, only the Edwards Sapien valve anesthesia can be extubated in the surgical theatreis suitable for the transapical approach; howev- at the end of procedure, whereas patients whoer, both devices can be used for the transfemoral require mechanical ventilation postoperatively canroute. usually be extubated within 4-6 hours. In addi- Patient care in the perioperative period can be tion, pain control must address the differentialchallenging when using this technique. Notably, pharmacokinetics of the elderly. Because of thepoor ventricular function associated with AS leads high degree of comorbidity, these patients areto marked hemodynamic instability during and prone to several complications at any time duringafter the procedure. their hospital stay, and these complications most The reduced invasivity of the TAVI approach often include renal insufficiency. Therefore, alldemands careful monitoring of cardiovascular patients should stay in the intensive care unit (ICU)function because of the high degree of comorbid- for at least 24 hours. In contrast, if a rapid dis-ity associated with these patients. Hemodynamic charge from the ICU is feasible, an early transferstability is the main goal of anesthesiological man- to the recovery ward with bedside telemetry is aagement during TAVI.3 A pulmonary artery suitable long-term strategy.catheter should be considered as the gold standard The evaluation of procedural risk is currentlyfor CO monitoring, but its invasiveness limits its of critical concern, especially for the anesthesiol-use in some patients. However, a less invasive mon- ogist. The two most used risk models are likelyitoring system, such as the PRAM (pressure record- the European System of Cardiac Operative Risking analytic method), has been demonstrated to be Evaluation (EuroSCORE) and the Society ofa useful alternative, as reported by Romagnoli.3-5 Thoracic Surgeon (STS) database,4 which are asso-In addition, other less invasive monitoring sys- ciated with a high degree of comorbidity amongtems such as LIDCO, may have a place during or elderly patients. This bias probably comes fromafter the TAVI procedure. Nevertheless, this tech- recent advances in intraoperative mortality andnique remains challenging for the anesthesiolo- higher postoperative care. However, TAVI proba-gist, particularly in regard to the absence of aid bly requires a “failing health patient” score. In ourfrom a cardiopulmonary bypass, the necessity of opinion, the evaluation of procedural risk shouldthe TEE probe withdrawal at the time of implan- include the specific scoring of newer parameterstation, and the necessity of a rapid recovery from that are not currently being used.anesthesia. Furthermore, the choice of perform- Surgical AVR has an average operative mortal-ing the procedure under general anesthesia dur- ity of 3% to 8%, with a large variability due toing the beginning of the surgeon’s learning curve comorbidities. Even in octogenarians, mortalityis more suitable for most circumstances. ranges from 5% to 10%.6 The transfemoral Regarding the choice of device, this decision is approach has a procedural success rate thatoften guided by anatomical considerations. approaches 90% in experienced centers. However,Specifically, at the American Heart Association vascular complications (with an incidence of 26%)2009 scientific sessions, Dr. Maurice Buchbinder remain a significant cause of mortality and mor-(Foundation for Cardiovascular Medicine, La Jolla, bidity, whereas the survival rate at one year is 78%CA, USA) argued that presenting data for these (The Partner EU Trial- Euro PCR 2009 Barcelona,two devices side by side is not possible outside of May 2009). In addition, data from the TCTa direct, randomized comparison, particularly (2009) reported a percent mortality at 30 daysbecause the choice of device can be biased by the ranging from 6.3% (SOURCE Registry) to 10.3%patient’s baseline characteristics. For example, for (CoreValve Registry).288 MINERVA ANESTESIOLOGICA April 2010
  3. 3. MINERVA MEDICA COPYRIGHT®TRANSCATHETER IMPLANTATION OF AN AORTIC VALVE: ANESTHESIOLOGICAL MANAGEMENT CATTANEO Conclusions TAVI possesses a steep learning curve due to the tremendous skill required to implant it; hence, TAVI offers a number of advantages to patients the widespread implementation of this techniqueand medical teams. These include a fast discharge will be a long and slow process.from the hospital and rapid return to functionalstatus, the avoidance of a cardiopulmonary bypass Referencesand sternotomy, as well as a decreased incidence of 1. Billings FT, Kodali SK, Shanewise JS. Transcatheter aorticwound infection and blood transfusion. In con- valve implantation: anaesthetic considerations. Anesth Analgtrast, this procedure demands advanced planning 2009;108:1453-62. 2. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP,and the skills of a multidisciplinary team. The Freed MD et al. ACC/AHA 2006 guidelines for the manage-implantation procedure itself has become very safe ment of patients with valvular heart disease. Circulation 2006;114:e84-e231.and predictable thanks to careful orchestration 3. Berry C, Oukerraj L, Asgar A, Lamarche Y, Marcheix B,and synchronization among individual partici- Denault AY et al. Role of echocardiography in percutaneous aortic valve replacement with the CoreValve revalving sys-pants. For example, each step is preassigned, and tem. Echocardiography 2008; 25:840-8.the precise timing of events during balloon angio- 4. Brown ML, Schaff HV, Sarano ME, et al. Is the European System for Cardiac Operative Risk Evaluation model validplasty and device deployment is essential, where- for estimating the operative risk of patients considered forby corrective maneuvers are defined beforehand percutaneous aortic valve replacement? J Thorac Surg 2008;136:566-71.for immediate execution. Moreover, the manage- 5. Romagnoli S, Romano SM, Bevilacqua S, Lazzeri C, Santoroment during the procedure is complex and places G, Ciappi F et al. Pulse Contour Cardiac Output Monitoring during a complicated percutaneous aortic valve replacement.the anesthesiologist at the forefront of the multi- J Cardiothorac Vasc Anesth 2009 [Epub ahead of print].disciplinary team. Nevertheless, risk evaluation is 6. Klein AA, Webb ST, Tsui S, Sudarshan C, Shapiro L, Denseman open problem, and the creation of a newer, ad C. Transcatheter aortic valve insertion: anaesthetic implications of emerging new technology. British J Anaesth 2009;103:hoc scoring system is highly desirable. Accordingly, 792-9.Received on February 2, 2010 - Accepted for publication on March 5, 2010.Corresponding author: S. Cattaneo, Department of Anesthesia and Intensive Care, Ospedali Riuniti di Bergamo, Largo Barozzi 1, 24128Bergamo, Italy.Vol. 76 - No. 4 MINERVA ANESTESIOLOGICA 289

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