Mod3: TRANSCATHETER VALVE REPLACEMENT

Question 1

_{TRANSCATHETER VALVE REPLACEMENT}

Minimally invasive valvular replacement therapy accomplished without the use of CPB

Answer 1

TRANSCATHETER VALVE REPLACEMENT

Question 2

TRANSCATHETER VALVE REPLACEMENTS

Where are they performed? by whom? using which type of anesthesia?

Answer 2

Usually performed in Cath Lab

By an Interventional Cardiologist

Under GA or moderate sedation

Question 3

_{TRANSCATHETER VALVE REPLACEMENT}

T/F: Currently, therapy for Transcatheter Aortic Valve Replacement (TAVR) is considered routine therapy and has been highly successful

Answer 3

True

Transcatheter valve replacement (TAVR) = preferred treatment for patients with severe aortic stenosis

Question 4

_{TRANSCATHETER VALVE REPLACEMENT}

T/F: Transcatheter Mitral valve replacement and Tricuspid valve replacement still in early developmental stages

Answer 4

True

Question 5

_{TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)}

There are three types of approaches for a TAVR:

Answer 5

Transvenous approach

Transarterial approach

Transapical approach

Question 6

_{TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)}

TAVR approach where the guidewire inserted through femoral vein sheath into right atrium; and the the valve is advanced across septum into the left atrium

Answer 6

Transvenous TAVR

A second device is inserted into the femoral artery and it smears the gidewire

The puncture site is dilated and the diseased valve is valvuloplastied

The prostetic valve is loaded unto the guidewire, compressed and deployed across the septum during rapid ventricular pacing

Question 7

_{TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)}

TAVR approach where the guidewire is inserted through femoral artery into the aortic position where valve is deployed?

Answer 7

Transarterial TAVR

Has replaced the transvenous approach

The guidewire is inserted through femoral artery into the aortic and across the aortic valve

The diseased valve is valvuloplastied

The prostetic valve is deployed and positioned during rapid ventricular pacing

Question 8

_{TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)}

TAVR approach where LV apex is exposed by a cardiothoracic surgeon through an anterolateral intercostal incision

Answer 8

Transapical TAVR

LV apex is exposed by a cardiothoracic surgeon through an anterolateral intercostal incision

A guide wire is inserted into the aortic valve and the compressed valve is deployed into position

Question 9

_{TAVR PATIENT SELECTION}

Potential TAVR recipients must satisfy three criteria:

Answer 9

They must have Severe symptomatic aortic stenosis

They must be either High-risk for surgical candidate or deemed inoperable

They must also not have any contraindications to TAVR placement

Question 10

_{TAVR PATIENT SELECTION}

Current “gold standard” for assessing the severity of aortic stenosis is:

Answer 10

TEE

Question 11

_{TAVR PATIENT SELECTION}

What’s the current definition for Aortic stenosis?

Answer 11

AVA equal to or less than 1 cm² or

A mean aortic valve gradient of equal to or > 40 mmHg

Question 12

_{TAVR PATIENT SELECTION}

TAVR placement is indicated in certain patients who are either high risk for traditional aortic valve replacement or have been deemed inoperable. What are the two surgical risk quantifiers currently used

Answer 12

The EuroScore and the STS Predicted risk of mortality

Question 13

_{TAVR PATIENT SELECTION}

Surgical risk quantified using the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of which value indicates high surgical risk?

Answer 13

<15%

Question 14

_{TAVR PATIENT SELECTION}

Surgical risk quantified using the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) of which value indicates high surgical risk?

Answer 14

<10%

Question 15

_{TAVR PATIENT SELECTION}

While the EuroScore and the STS have been usefull for predicting mortality risk, they do share some important limitations, including:

Answer 15

They do not take intoconsideration a pt’s hx of chronic lung disease, hx of liver cirrhosis, previous cardiac surgery, etc.

Question 16

_{TAVR PATIENT SELECTION}

TAVRs are typically done on older adults that are how old?

Answer 16

over 70 years of age

Question 17

_{TAVR PATIENT SELECTION}

Why should Futility and Frailty be assessed?

Answer 17

They are possible contraindications to TAVR

Frailty is a distinct clinical syndrome that significantly increase the risk of adverse event

Futility implies that despite successfull procedure, the risk of mortality or mobidity at one year is > 50%

Question 18

_{TAVR PATIENT SELECTION}

The distinct clinical syndrome, characterized by decreased muscle mass, increased energy expenditure, and malnutrition, all of which significantly increase the risk of adverse event is known as:

Answer 18

Frailty

Question 19

_{TAVR PATIENT SELECTION}

Situation that implies that a patient’s condition is so advanced that meaningful improvement will not be achieved despite technically successful intervention is also known as:

Answer 19

Futility

In other words, despite successfull procedure, their risk of mortality or mobidity at one year is > 50%

Question 20

_{TAVR PATIENT SELECTION}

T/F: >50% compromise of >3 major organs is contraindication for TAVR

Answer 20

True

Question 21

_{TAVR PATIENT SELECTION}

T/F: Mortality and Morbidity at 1 year >50% as determined by STS PROM is contraindication for TAVR

Answer 21

True

Question 22

_{TAVR SURGICAL CONSIDERATIONS}

Pre procedural planning includes

Answer 22

Selecting the bioprostehtic valve and size

Question 23

_{TAVR SURGICAL CONSIDERATIONS}

There are currently two systems used for implantation

Answer 23

The Sapien valve

Medtronic Core valve

Question 24

_{TAVR SURGICAL CONSIDERATIONS}

What’s the major difference between the Sapien valve and the Medtronic CoreValve?

Answer 24

There is a higher rate of permanent pacemaker requirements post procedure with the Medtronic CoreValve

15-47% Medtronic CoreValve, compared to

4-21% with Sapien valve

Question 25

_{TAVR SURGICAL CONSIDERATIONS} Why do most facilities stick to one type of valve?

Answer 25

***Operator experience*** is also an important factor when selecting between the two valves so most facilities stick to one type of valve .

Question 26

_{TAVR SURGICAL CONSIDERATIONS} Valve size depends on:

Answer 26

Pts' **aortic annulus** This should be measure prior to the procedure with at TEE

Question 27

_{TAVR SURGICAL CONSIDERATIONS} Selecting the vascular site should be patient specific. why?

Answer 27

Pts should undergo vascular screening to evaluate the peripheral vasculature for size, how tortuous it is and calcification of ilio-femoral vessels Peripheral vasculature screening for luminal diameter, tortuosity, and calcification of iliofemoral arteries.

Question 28

_{TAVR SURGICAL CONSIDERATIONS} All patients assessed for feasibility of femoral approach

Answer 28

True

Question 29

_{TAVR SURGICAL CONSIDERATIONS} If the peripheral vasculature is unfavorable, what do you do?

Answer 29

an alternative site should be chosen. may consider ***transapical TAVR***

Question 30

_{TAVR SURGICAL CONSIDERATIONS​} In the event of emergency, what should be discussed with the surgical team?

Answer 30

A “Bail-out” plan

Question 31

_{TAVR SURGICAL CONSIDERATIONS} What must the "Bail out" plan include?

Answer 31

​Cardiothoracic surgeon and CPB on standby

Question 32

_{TAVR SURGICAL CONSIDERATIONS} What is the typical Bail out until a sternotomy can be made?

Answer 32

ECMO However, depending on what the adverse event is, TAVR are typically catastrophic

Question 33

_{TAVR ANESTHETIC CONSIDERATIONS} Which should be on stanby during TAVR

Answer 33

Cardiothoracic surgeon Cardiopulmonary bypass machine Perfusionist

Question 34

_{TAVR ANESTHETIC CONSIDERATIONS} T/F: External defibrillator pads should be placed on the pt and the pacemaker should be readily available

Answer 34

True

Question 35

_{TAVR ANESTHETIC CONSIDERATIONS} What should be available for pts with AICD implanted?

Answer 35

Magnet

Question 36

_{TAVR ANESTHETIC CONSIDERATIONS} Monitors for TAVR procedures include:

Answer 36

5-lead EKG Pulse oximetry Temperature monitoring Radial arterial line ? Central venous catheter/Introducer with pacing Swan-Ganz Catheter

Question 37

_{TAVR ANESTHETIC CONSIDERATIONS} Why are Foley Catheters not typically inserted?

Answer 37

Procedures last 2 hours or less

Question 38

_{TAVR ANESTHETIC CONSIDERATIONS} TTE versus TEE: what determines which is used?

Answer 38

Moderate sedation vs. General anesthesia

Question 39

_{TAVR ANESTHETIC CONSIDERATIONS} The primary goal for anesthesia during TAVR procedures includes

Answer 39

Hemodynamic stability Avoiding on-table patient moving Achieving early extubation if general anesthesia is used

Question 40

_{TAVR ANESTHETIC CONSIDERATIONS} TAVR is Multidisciplinary approach that requires

Answer 40

OPEN COMMUNICATION

Question 41

_{TAVR ANESTHETIC CONSIDERATIONS} It’s important to assess the patient’s ability to both lay flat and still for the procedure; why?

Answer 41

Because coughing and movement can lead to catastrophic events especially if they occur while the valve is being deployed Movement during valve deployment can lead to poor valve seating, paravalvular leak, or aortic dissection

Question 42

_{TAVR ANESTHETIC CONSIDERATIONS} So why not intubate all pts to prevent on-table movement?

Answer 42

Many facilities have adopted Fast-track protocols for these pts And because the TAVR pt population tends to be high risk population with multiple commorbidities, standardizing general anesthesia would lead to longer length of stay and more complications

Question 43

TAVR ANESTHETIC CONSIDERATIONS General anesthesia with a regular endotracheal tube is typically done for which TAVR approach?

Answer 43

The trans-apical approach

Question 44

_{TAVR ANESTHETIC CONSIDERATIONS} Which anesthesia technique is widely accepted for trans-femoral cases?

Answer 44

Moderate sedation with incision site localization

Question 45

_{TAVR ANESTHETIC CONSIDERATIONS} When General Anesthesia is chosen, which drugs are used? What's the ultimate goal?

Answer 45

Volatile anesthetics with vasopressors for BP control Watch opioid administration *^{(There is not a lot of post op pain a/w the procedure)}* Goal is early extubation

Question 46

_{TAVR ANESTHETIC CONSIDERATIONS} What's the goal of Moderate Sedation?

Answer 46

Keep patient comfortable Limit movement Keep pt arousable, so they can alert providers of any chest discomfort

Question 47

_{TAVR ANESTHETIC CONSIDERATIONS} Chest discomfort during TAVR procedure could be indicative of:

Answer 47

Acute ischemic episode Aortic dissection, Rupture aortic annulus

Question 48

_{TAVR ANESTHETIC CONSIDERATIONS} Benefits of keeping patients comfortable, but arousable include:

Answer 48

Monitor neurologic status, procedural complications ^{They can alert providers of acute chest discomfort} Better hemodynamic control Reduced length of stay

Question 49

_{TAVR ANESTHETIC CONSIDERATIONS} Which drug are used for Moderate Sedation?

Answer 49

Propofol\*\* infusion versus Precedex infusion Minimal opioid administration

Question 50

_{TAVR ANESTHETIC CONSIDERATIONS} How is BP maintained during TAVR?

Answer 50

Vasopressors IVP or infusions as necessary

Question 51

_{TAVR ANESTHETIC CONSIDERATIONS} Why should IVP drugs that are short acting be used for Blood pressure management?

Answer 51

Because Blood pressure management should be ***precise control***

Question 52

_{TAVR ANESTHETIC CONSIDERATIONS} The use of which drugs is acceptable for the management of hypertension during TAVR?

Answer 52

Nicardipine NTG (small doses)

Question 53

_{TAVR ANESTHETIC CONSIDERATIONS} The use of which drugs is acceptable for the management of hypotension during TAVR?

Answer 53

Phenylepherine Norepinepherine Epinepherine

Question 54

_{TAVR ANESTHETIC CONSIDERATIONS} There are times where rapid ventricular pacing (160-200 bmp) will be required. Why is this done?

Answer 54

To produce a ***functional asystole*** that will momentarily minimize LV outflow This will *facilitate balloon valvuloplasty* and *proper valve positioning* Done to reduce left ventricular stroke volume and the risk of device migration during deployment

Question 55

_{TAVR ANESTHETIC CONSIDERATIONS} What are the possible negative effects of the reduced left ventricular stroke caused by Rapid ventricular pacing (160-200 bmp)?

Answer 55

Significant hypotension can occur since SV and thus CO reduced Can induce ventricular arrhythmias. Treat with Lidocaine or cardioversion if necessary Ventricular pacing can lead to ventricular dyssynchrony

Question 56

_{TAVR ANESTHETIC CONSIDERATIONS} After the valve is placed, what could cause myocardial stunning? How is it treated?

Answer 56

Improved blood flow through valve Consider treating Myocardial stunning with low-dose inotropic agents

Question 57

_{TAVR ANESTHETIC CONSIDERATIONS} How is Anticoagulation achieved for the procedure?

Answer 57

Heparin 100 units/kg for ACT of 300 s for procedure.

Question 58

_{TAVR ANESTHETIC CONSIDERATIONS} Why should the surgical team be consulted prior to heparin reversal with Protamine?

Answer 58

May only want partial reversal of Heparin with Protamine Consult with surgical team

Question 59

_{TAVR COMPLICATIONS} Complications of TAVR include:

Answer 59

Paravalvular leaking *Need for post-procedure pacing versus permanent pacemaker placement* Ruptured aortic annulus Acute ischemia Aortic dissection Stroke Respiratory insufficiency Bleeding Perforation of femoral artery

Question 60

_{TAVR COMPLICATIONS} What can increase the risk for complication a/w TAVR?

Answer 60

Pts commordidities This is why proper pt selection an screening is important A full pt's picture should be used to guide decision during TAVR therapy

Question 61

_{TAVR COMPLICATIONS} Paravalvular leaking - incidence?

Answer 61

15-20%

Question 62

_{TAVR COMPLICATIONS} Paravalvular leaking - Causes?

Answer 62

Valve malpositioning Under expansion of the annulus Heavy annular calcification

Question 63

_{TAVR COMPLICATIONS} Need for post-procedure pacing versus permanent pacemaker placement - Cause?

Answer 63

AV block

Question 64

_{TAVR COMPLICATIONS} Need for post-procedure pacing versus permanent pacemaker placement - Research notes higher incidence with which type of valve?

Answer 64

***CoreValve*** versus Sapien Valve

Question 65

_{TAVR COMPLICATIONS} Ruptured aortic annulus - risk factor?

Answer 65

Highly calcified aortic annulus

Question 66

_{TAVR COMPLICATIONS} Acute ischemia - Mechanisms?

Answer 66

Pre-existing CAD + Rapid ventricular pacing =\> decrease in myocardial O2 supply also Poorly positioned prosthetic valve

Question 67

_{TAVR COMPLICATIONS} Aortic dissection

Answer 67

!!!

Question 68

_{TAVR COMPLICATIONS} Stroke - causes?

Answer 68

Embolic lesions Calcification from aortic valve and aortic arch

Question 69

_{TAVR COMPLICATIONS} Respiratory insufficiency - Factors?

Answer 69

Prolonged mechanical intubation Reintubation Existing pulmonary comorbidities directly associated with pulmonary complications

Question 70

_{TAVR COMPLICATIONS} Bleeding at the site d/t?

Answer 70

Use of sheaths in groins

Question 71

_{TAVR COMPLICATIONS} Bleeding - Other cause?

Answer 71

Full reversal of heparin not always done

Question 72

_{TAVR COMPLICATIONS} How could bleeding be reduced at suture sites?

Answer 72

Adequate blood pressure control

Question 73

_{TAVR COMPLICATIONS} How is perforation of femoral artery treated

Answer 73

Requires ***stenting*** of femoral vessels

Question 74

_{TAVR POSTPROCEDURE CONSIDERATIONS} T/F: If General anesthesia was used, pts are typically stable enough for intra-op extubation

Answer 74

True

Question 75

_{TAVR POSTPROCEDURE CONSIDERATIONS} If transported to the ICU, early extubation is a/w?

Answer 75

Lower in-hospital mortality

Question 76

_{TAVR POSTPROCEDURE CONSIDERATIONS} Why should pain control be optimize?

Answer 76

Pain requirements not high for procedure Patients must lay flat for ~4 hours post procedure While there isn't a lot of pain a/w TAVR, these pt are typically older and have other issues like osteoporosis

Question 77

_{TAVR POSTPROCEDURE CONSIDERATIONS} It's important to understand that TAVR pts must be heparinized during the procedure. What's a post consideration for heparin?

Answer 77

Full reversal of the heparin w/ Protamine may not have been done

Question 78

_{TAVR POSTPROCEDURE CONSIDERATIONS} Why must the pt lay flat for 4 hours after the procedure?

Answer 78

Because large sheaths were inserted into the pt's groin; so the risk of bleeding is higher Patients must lay flat for ~4 hours post procedure so that uninterrupted clots can form at the insertion site This may be difficult for pts w/ osteoporosis or back pain The pain should be controlled

Question 79

_{TAVR POSTPROCEDURE CONSIDERATIONS} Why should patients have continuous cardiac monitoring for a few days post procedure?

Answer 79

Because the majority of AV blocks will occur within 3-7 days following implantation This is especially important in patients more susceptible to AV conduction issues

Question 80

_{TAVR POSTPROCEDURE CONSIDERATIONS} What's the incidence of permanent pacemaker following TAVR?

Answer 80

10-50%.

Question 81

_{TAVR POSTPROCEDURE CONSIDERATIONS} Which pts are more susceptible to AV conduction issues and therefore require continuous cardiac monitoring for a few days post procedure?

Answer 81

\> 75 years of age Oversizing of implanted valve Small annulus Pre-existing bradycardia (\<55 bpm)

Question 82

AMERICAN HEART ASSOCIATION Scientific Statement on Minimally Invasive Procedures

Answer 82

* The American Heart Association has been carefully monitoring minimally invasive procedures and their outcomes * While all the surgeries appear promising, the conclusion of the AHA is that they need much more study before they are recommended over conventional methods * If these surgeries can be refined to the point where they are no more invasive than angioplasty, they will end up having a distinct advantage over angioplasty * Based on the preceding, at this point in time, ***minimally invasive surgeries*** are considered ***experimental*** and are ***NOT recommended over more conventional, time tested techniques*** * This may change as more data is collected, but at this time no recommendation can be made for or against them