July Journal Club

[katevaughn]

This month's journal club is presented by Wai-Ling Lo. Fantastic reference for us to have for the future. Enjoy!

TAVR has proven to be an effective alternative therapy to surgery for patients of advanced age with severe aortic stenosis, frail, and multiple comorbidities. Dr. Brady gave a talk about the anesthesia management for TAVR in grand rounds a couple of months ago. It will be beneficial to our practice if we familiarize ourselves with the procedure. You never know when you will be pulled to cover for a TAVR case on the 5th floor.

Here is a link to the article. 

Questions to be encompassed within your response:

1. What are the potential complications for TAVR especially during rapid ventricular pacing?



2. What will be your anesthetic plan for a TAVR?

[mscotth2--can't remember sign]

Thanks for the article.

Potential complications for TAVR during rapid ventricular pacing include hemodynamic changes such as hypotension or dysrhythmias.

My anesthetic plan would be for GA It says a lot that the procedure is becoming increasingly safe and common that providers chose MAC. Procedural advancements are amazing!

Are any CRNAs covering these cases at JHH? I have read in various blogs that they are at other institutions.

Happy 4th of July everyone!

Mary

[LMEGINNIS]

My anesthetic plan for TAVR would also be GA. As Mary mentioned potential complications during rapid ventricular pacing include hopentension/dysrhythmias. Any sudden changes in the hemodynamic status of the patient during TAVR could indicate vascular injury.

[kels]

GA would be my anesthetic plan and I agree with looking out for hypotension/dysrhythmias during rapid ventricular pacing.

[faresha]

Potential complications are hemodynamic instability which includes hypotension and dysrhythmias. My anesthetic plan would be GA since I haven't done this type of case and even an experience provider may have more challenges with a MAC case.

[Kristen Horsman]

Potential complications are hypotension, sustained vtach or vfib upon cessation of RVP, vascular injury, coronary artery occlusion, and cardiac tamponade. I would elect to use GA to minimize patient movement, attenuate the stress response, and allow for a quicker conversion to an open procedure, if needed.

[LarSharVeA Bennett]

Hemodynamic decompensation is a risk with rapid ventricular pacing (RVP). The article recommends maintaining the mean arterial pressure above 75 mHg before initiation of RVP. The depth of anesthesia is also increased during RVP to minimize patient discomfort. With this is mind, in concordance with all you, general anesthesia would be the safest and most comfortable option. The candidates for TAVR are elderly with multiple comorbidities potentially limiting the amount of anesthesia that can be given to achieve acceptable levels of comfort without the threat of hypoventilation, hypercarbia induced pulmonary artery constrictions, hypoxemia, etc. Also, in the event of an emergency such as cardiac tamponade, vascular injury, or myocardial wall perforation, the airway would be well maintained and resuscitation efforts would ensue more rapidly.

[Carla Perez]

1. What are the potential complications for TAVR especially during rapid ventricular pacing?

Potential complications include but are not limited to intraarterial/venous decompansation with inadequate organ perfusion leading to potential AKI, brain deficit, cardiovascular collapse, vascular injury or hidden bleeds with surgical approach, etc.

2. What will be your anesthetic plan for a TAVR?

Well we do plenty of patients under MAC in EP who experience RVP, we just have to insure that there is an adequate depth of anesthesia on board to maintain pt comfort but also ensure maximum safety. Quick conversion to GA for any complications must always be available!

[belinda]

Timely article Lisa!

We are doing more of these types of cases up in cardiac however the cardiac anesthesia residents do most of them. The CRNA's in CVIL are starting to do some other valves (ie Melody Valves) and I believe we are coming up with a best practices for these cases. The Melody Valve I did was under GA and it is my understanding that we do these cases under GA here for all of the aforementioned reason: comfort in pacing, hemodynamic management, open conversions, etc. as well as TEE even though these valves are placed under fluoroscopy so TEE would be to assess the heart during the case and requires deep sedation. Also, arms are positioned over the head and secured in some instances which would we hard for some to tolerate under sedation. We do sedation frequently for V-Tach/SVT ablations which is tricky and requires increasing sedation for RVT and oftentimes defibrillation. I can see this becoming a sedation case as outcomes continue to improve and we become more comfortable with the procedure keeping in mind the potential need to convert to GA at any moment.

Potential complications: RVP- hypotension, VT/VF requiring defibrillation, as well as vascular/cardiac damage and tamponade. A-line and adequate vascular access is a must.

 

[kty67]

1. most of the complications during RVP are noted in the article: mainly hemodynamic instability, inadequate organ perfusion, renal injury, brain injury, vascular injury, bleeding.
2. I would go with GA. In one of the study they had 17 % of conversion to GA during. The conversion to GA most commonly occurs due to vascular complications. To me it is high enough rate to go with GA.

[Ben Waldbaum]

1. What are the potential complications for TAVR especially during rapid ventricular pacing?
Regardless of it being GA or MAC, rapid ventricular pacing will require hemodynamic support. If done under MAC, active communication between the procedurialist and anesthesia provider must be robust to ensure deepening of the sedation prior to the rapid ventricular pacing.


2. What will be your anesthetic plan for a TAVR?
As for my personal plan, it would depend on a number of factors such as the experience level of the procedurialist, anticipated length of the procedure, necessity of TEE over TTE, patient preference, ability of patient to remain still, patient comorbidities, risks of GA vs MAC. In other words, I could see doing it either way depending on the above.

[sfos]

Considering the potential complications of TAVR during rapid ventricular pacing being hemodynamic instability requiring end organ support, my anesthetic plan for TAVR would take into concern a few factors.
The type of valve that is being placed: Not sure the type that is usually used at Hopkins, however it is noted that the SAPIEN valve is the one needing RVP. In addition they require complete immobility and possible brief apnea for deployment since they basically have one shot of getting it right. Therefore, coupled with other factors including the hemodynamic instability and the necessity of TEE for placement verification, my choice would be GA. For other valves, I would explore the possibility of both GA vs MAC in accordance with Ben's response.

How frequently do we do these procedures here? Are CRNA's involved, and what valves are they using?

[Moishe Mayer]

Hi,

1: I would be concerned with profound hypotension during rapid ventricular pacing. I would pretreat rapid pacing with a Neosynephrine or Levophed bolus. Of course, this can lead to further dysrhythmias.

2: I would consider doing this case under MAC anesthesia. Propofol gtt, Remifentanil gtt, and availability of all cardiac drugs. Two peripheral IVs may suffice (16g), but a cordis may be considered. A Belmont infuser should be nearby incase of perforation.

Thanks!

[AugustineEmmanuel]

Potenial complications include and are not limited to dysthymia, hypotension and tamponade. In terms of an anesthetic preference its hard to make a choice since there's a lot of pertinent patient information lacking. I would proceed with either GA or MAC depending on patients comorbidities, patient cooperation, my comfort level and any additional interventions required in the procedure.

[dahlia rouchon]

1. Complications to TAVR may include vascular injury with severe precipitous hemorrhage, poor anticoagulation if clotting times not maintained/not run, and for RVP prolonged hypotension, VTACH, SVT with necessary defibrillation.
2. My anesthetic plan would be dependent on multiple factors some to include: how fast is the proceduralist (quick?-yes) patient rapport (great?-yes), pre-existing normotension to mildly hypertensive (yes?-yes) compared to any elevated RVSP (?- large gradient yes), any OSA/severe increased BMI? (no) then if the former applies, I would do MAC.
2b. If all the above were the opposite, I would do GETA with vasopressors ready.
3. I would use a cerebral oximeter. I would deepen anesthetic when indicated and try to maintain mod. sedation with BP support.