TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)

 

Transcatheter Aortic Valve Replacement (TAVR), also known as Transcatheter Aortic Valve Implantation (TAVI), is a minimally invasive surgical procedure that replaces a diseased aortic valve in the heart. This procedure is typically used for patients who are at intermediate or high risk for traditional open-heart surgery. Here's an overview of TAVR:

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1. Procedure: TAVR involves inserting a catheter (a thin, flexible tube) into the patient's blood vessel, usually through a small incision in the leg. The catheter is then guided to the heart, and a replacement valve is positioned inside the diseased aortic valve. Once in place, the new valve is expanded, pushing the old valve leaflets out of the way and taking over the regulation of blood flow.

2. Valve Types: The replacement valves used in TAVR are typically made from biological materials, such as cow or pig heart tissue, and are mounted on a collapsible metal frame.

3. Candidates: TAVR is often recommended for patients who have severe aortic stenosis (a narrowing of the aortic valve opening) and are considered at increased risk for traditional surgery due to factors like age, other medical conditions, or previous heart surgeries.

4. Advantages: The main advantage of TAVR is its minimally invasive nature, which generally results in shorter hospital stays, faster recovery times, and lower risks of complications compared to open-heart surgery.

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TAVR represents a significant advancement in the treatment of heart valve diseases, especially for those patients for whom traditional surgery is not a viable option. 

                                                                                                 

Minimally invasive transcatheter aortic valve replacement (TAVR) may involve either a percutaneous (transfemoral or transaxillary/subclavian) approach or an open (transapical or transaortic) approach.

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                                 Anesthetic Implications for Transcatheter Aortic Valve Replacement (TAVR)

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Anesthesia type: General, Monitored Anesthesia Care (MAC)

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Airway: ETT, natural airway

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Preoperative:

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• Assess for acute decompensated heart failure, pulmonary hypertension, CAD, OSA, pulmonary edema

• Assess ECG and Echocardiography

• Low left ventricular EF is a risk factor for persistent hypotension after rapid pacing

• TAVR is guided by angiography and fluoroscopy

• Left arterial line placement preferred

• Have heparin and protamine available

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Intraoperative:

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• The aortic valve is retrogradely accessed via one of the femoral arteries

• Position: Supine, arms tucked

• Duration: 1-3 hours

• Venous access is obtained for transvenous pacing

• Rapid pacing will be induced during TAVR deployment

• Rapid ventricular pacing minimizes heart movement during implantation of device

• Watch for hypotension during induced fibrillation

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Postoperative:

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• Assess for vascular complications associated with femoral access including hematoma, retroperitoneal bleeding, and arterial occlusion

• Clinical findings of retroperitoneal bleeding include back, flank, or abdominal pain; hypotension, decreased H/H, and tachycardia. 

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Complications:

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• Bleeding

• Hypotension 

• Arrhythmia 

• Vascular injury

• Stroke

• Emboli

• Pericardial effusion/tamponade

• Complete heart block

• MI

• Aortic dissection

• Contrast-induced nephropathy

• Perivalvular leaks

• Pneumothorax

• Acute coronary obstruction

• Retroperitoneal hematoma

• Femoral artery dissection

• Femoral seroma

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Sources:

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Elisha, S. (2010). Case Studies in Nurse Anesthesia.

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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