Transcatheter Aortic Valve Replacement (TAVR)

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Overview

  • TAVR is a minimally invasive procedure to replace the aortic valve in patients with symptomatic aortic stenosis who are at high risk for open-heart surgery.
  • Guidelines:
    • Class 1 (A) Recommendation: For inoperable and high-risk patients.
    • Class IIa (B) Recommendation: For intermediate-risk patients.
  • Access Sites: The heart is accessed via the femoral, subclavian, or direct aortic arteries.

Procedure

  • Valve Deployment: The bioprosthetic valve is threaded through a catheter and positioned within the diseased native valve using imaging guidance. Rapid pacing via a transvenous pacer may be used to stabilize the heart during deployment.
  • Completion: The valve is fully expanded, replacing the function of the native valve.

Indications for TAVR

  • Preoperative Assessment: Patients are evaluated by a multidisciplinary team using a combination of medical history, physical examination, and imaging studies (TTE, TEE, cardiac catheterization, and cardiac CT).
  • Patient Selection:
    • TAVR is indicated for patients considered “too high risk to operate” by two independent cardiac surgeons.
    • High-risk patients typically have:
      • STS Risk Score >10%.
      • EuroSCORE II >20%.
    • Ongoing Trials: Indications may expand to include low-risk patients.

Complications and Management

Complication Management
Coronary Artery Occlusion Maintain MAP >70 mm Hg; IABP placement; coronary stenting may be necessary.
Post-Procedural Aortic Stenosis Deployment of additional valve using “valve-in-valve” technique.
Paravalvular Leak Balloon aortic valvuloplasty; valve-in-valve technique.
Post-Procedural AV Block Continue transvenous pacing postoperatively; permanent pacemaker placement may be required.

Anaesthetic Considerations

  • Anaesthesia Types:
    • General Anaesthesia: Preferred for non-femoral access and when TEE is anticipated for valve evaluation.
    • MAC Anesthesia: Increasingly used for femoral access TAVR; TTE is used intraoperatively for valve assessment.
  • Monitoring:
    • Standard ASA monitors, large-bore peripheral access, arterial line, and central access (often placed by the cardiologist).
    • Transcutaneous pacing pads due to the risk of arrhythmias during device deployment.
  • Anticoagulation:
    • Heparin is administered before valve deployment, with ACT monitoring to ensure adequate anticoagulation.

MitraClip™ Procedure

Overview

  • MitraClip™ is a percutaneous procedure used to treat mitral regurgitation (MR) in patients who are not candidates for surgery or who have symptomatic heart failure despite medical therapy.
  • Procedure:
    • A clip is used to secure the mitral leaflets, introduced via the right femoral vein with transseptal puncture to access the left atrium.
    • The resulting iatrogenic atrial septal defect (iASD) is usually left open, though its long-term consequences are not fully understood.

Anaesthetic Considerations

  • General Anesthesia: Necessary for TEE guidance during septal puncture and accurate clip placement.
  • Monitoring: Invasive blood pressure monitoring and central venous access are required.

Complications

  • iASD:
    • Often not clinically significant and may even relieve left atrial pressure.
    • However, significant bidirectional shunting may worsen clinical outcomes, making percutaneous closure of iASD desirable in select cases.
  • Post-Procedural Mitral Stenosis:
    • Accurate patient selection and valve imaging (3D TEE) are critical to avoid iatrogenic mitral stenosis.
    • Treatment: Surgery is required if severe mitral stenosis occurs due to the MitraClip™ device.

Links

References:

  1. Afshar AH, Pourafkari L, Nader ND. Periprocedural considerations of transcatheter aortic valve implantation for anesthesiologists. J Cardiovasc Thorac Res. 2016;8(2):49–55.
  2. Al-Azizi K, Szerlip M. Mitral stenosis after MitraClip: how to avoid and how to treat. Curr Cardiol Rep. 2020;22(7):50.
  3. Hart EA, Zwart K, Teske AJ, et al. Haemodynamic and functional consequences of the iatrogenic atrial septal defect following Mitraclip therapy. Neth Heart J. 2017;25(2):137–142.

Summaries:

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