Transcatheter aortic valve replacement - Revision history

JessicaWasMD at 19:20, 11 August 2022

2022-08-11T19:20:09Z

← Older revision		Revision as of 12:20, 11 August 2022
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	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->Usually cardiology floor with telemetry ~~===~~		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->===
			<blockquote>Usually cardiology floor with telemetry</blockquote>

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->Pain control is not usually difficult. Most patients have difficulty with back pain/aches due to laying flat for several hours after groin access. ~~===~~		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
			Pain control is not usually difficult. Most patients have difficulty with back pain/aches due to laying flat for several hours after groin access.

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

JessicaWasMD at 19:18, 11 August 2022

2022-08-11T19:18:41Z

← Older revision		Revision as of 12:18, 11 August 2022
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	== Postoperative management ==		== Postoperative management ==

	=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===		=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->Usually cardiology floor with telemetry ===

	=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===		=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->Pain control is not usually difficult. Most patients have difficulty with back pain/aches due to laying flat for several hours after groin access. ===

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

JessicaWasMD: Added pertinent complications, adjusted preop management

2022-08-11T19:16:44Z

Added pertinent complications, adjusted preop management

← Older revision		Revision as of 12:16, 11 August 2022
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	\| anesthesia_type = MAC vs. GA		\| anesthesia_type = MAC vs. GA
	\| airway = Natural airway vs. ETT		\| airway = Natural airway vs. ETT
	\| lines_access = 2 large bore PIV + art line (left preferred)		\| lines_access = 2 large bore PIV + art line (left preferred - clarify with proceduralist since sometime arterial line placed by them)
	\| monitors = Standard, ABP		\| monitors = Standard, ABP
	\| considerations_preoperative =		\| considerations_preoperative =
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	\|-		\|-
	\|Neurologic		\|Neurologic
	\|		\|Preoperative neurological deficits/previous CVA with residual deficit
	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|Symptoms of AS and functional status, LV EF
	\|-		\|-
	\|Pulmonary		\|Pulmonary
	\|		\|Coexisting pulmonary disease
	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
	Type and cross ~2 units for ~~risk of major bleeding~~		Type and Screen usually sufficient or type and cross ~2 units - check with local site for usual practice

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

	* Often done in remote anesthesia setting, so have emergency drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.		* Often done in remote anesthesia setting, so have emergency cardiac drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.
	* Heparin/protamine prepared		* Heparin/protamine prepared
	* Infusion and bolus pressors ready for BP swings with ~~induced fibrillation~~.		* Infusion and bolus pressors ready for BP swings with rapid pacing.

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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	* For MAC cases, can consider starting with remifentanil 0.02 mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.		* For MAC cases, can consider starting with remifentanil 0.02 mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.
	* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).		* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).
	* Venous access is obtained for transvenous pacing. ~~Fibrilliation~~ will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if ~~prolonged~~.		* Venous access is obtained for transvenous pacing. Rapid pacing will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if persistent following completion of rapid pacing.
	**Pacing may also be performed through native pacemaker if already present in patient.		**Pacing may also be performed through native pacemaker if already present in patient.
			*For MAC cases, assess neurological status following deployment of valve.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

	* Complete heart block~~, stroke~~, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks		* Complete heart block, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks
			*Stroke - risk can be minimized with use of sentinel device
	* Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma		* Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma
	* Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture		* Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture
			*Pericardial effusion/tamponade
			*Obstruction of coronary arteries: dependent on coronary heights (<12 mm for both right and left coronaries have been established as a risk factor), but more likely to happen for valve-in-valve procedures

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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	\|-		\|-
	\|Unique considerations		\|Unique considerations
	\|		\|Valve-in-Valve TAVR
	\|		\|
	\|-		\|-
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	\|-		\|-
	\|Potential complications		\|Potential complications
	\|		\|Same as above but slightly higher risk of coronary artery obstruction
	\|		\|
	\|}		\|}

Tony.Wang: pacemaker

2022-08-08T15:31:39Z

pacemaker

← Older revision		Revision as of 08:31, 8 August 2022
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	* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).		* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).
	* Venous access is obtained for transvenous pacing. Fibrilliation will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if prolonged.		* Venous access is obtained for transvenous pacing. Fibrilliation will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if prolonged.
			**Pacing may also be performed through native pacemaker if already present in patient.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Tony.Wang at 15:27, 8 August 2022

2022-08-08T15:27:40Z

← Older revision		Revision as of 08:27, 8 August 2022
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	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
	Often done in remote anesthesia setting, so have emergency drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.
			* Often done in remote anesthesia setting, so have emergency drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.
			* Heparin/protamine prepared
			* Infusion and bolus pressors ready for BP swings with induced fibrillation.

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

Tony.Wang: various additions

2022-08-08T15:25:42Z

various additions

← Older revision		Revision as of 08:25, 8 August 2022
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	\| monitors = Standard, ABP		\| monitors = Standard, ABP
	\| considerations_preoperative =		\| considerations_preoperative =
	\| considerations_intraoperative =		\| considerations_intraoperative = Hypotension during induced fibrillation
	\| considerations_postoperative =		\| considerations_postoperative =
	}}		}}

	<ref>{{Cite journal\|last=Clegg\|first=Stacey D.\|last2=Krantz\|first2=Mori J.\|date=2012-07\|title=Transcatheter Aortic Valve Replacement: What's in a Name?\|url=http://dx.doi.org/10.1016/j.jacc.2012.03.049\|journal=Journal of the American College of Cardiology\|volume=60\|issue=3\|pages=239\|doi=10.1016/j.jacc.2012.03.049\|issn=0735-1097}}</ref>TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.		<ref>{{Cite journal\|last=Clegg\|first=Stacey D.\|last2=Krantz\|first2=Mori J.\|date=2012-07\|title=Transcatheter Aortic Valve Replacement: What's in a Name?\|url=http://dx.doi.org/10.1016/j.jacc.2012.03.049\|journal=Journal of the American College of Cardiology\|volume=60\|issue=3\|pages=239\|doi=10.1016/j.jacc.2012.03.049\|issn=0735-1097}}</ref>TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.

			There are many techniques

	== Preoperative management ==		== Preoperative management ==
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
	Type and ~~Cross~~ 2 units of ~~pRBCs~~		Type and cross ~2 units for risk of major bleeding

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
	Often done in a remote anesthesia setting.		Often done in remote anesthesia setting, so have emergency drugs available in case of severe hemorrhage, as TAVR deployment can disrupt cardiac structure/function.

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
			Typically on antiplatelet medications, which should be taken the morning of surgery as well.

	=== Regional and neuraxial techniques ===		=== Regional and neuraxial techniques ===
			N/A

	== Intraoperative management ==		== Intraoperative management ==
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	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
			For MAC, a very small bolus of propofol is adequate prior to starting maintenance infusions.

	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
	~~For MAC cases, can consider starting with remifentanil 0.02mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.~~

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		* For MAC cases, can consider starting with remifentanil 0.02 mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.
			* Arterial access is obtained and LVOT and LV pressures are transduced (to measure transaortic pressure gradient).
			* Venous access is obtained for transvenous pacing. Fibrilliation will be induced during TAVR deployment, resulting in significant hypotension that may warrant treatment if prolonged.

			=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

	== Postoperative management ==		== Postoperative management ==
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	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
	~~Complete heart block, stroke, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks~~

	~~Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma~~

	Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture		* Complete heart block, stroke, MI, aortic dissection, contrast induced nephropathy, perivalvular leaks
			* Valvular access site issues: Groin seromas, femoral artery dissection, thrombosis with lower extremity ischemia, retroperitoneal hematoma
			* Transapical approach: new onset MR, pericardial effusion, pneumothorax, late apical rupture

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

David.Leon at 17:49, 27 June 2022

2022-06-27T17:49:21Z

← Older revision		Revision as of 10:49, 27 June 2022
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	}}		}}

	TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.		<ref>{{Cite journal\|last=Clegg\|first=Stacey D.\|last2=Krantz\|first2=Mori J.\|date=2012-07\|title=Transcatheter Aortic Valve Replacement: What's in a Name?\|url=http://dx.doi.org/10.1016/j.jacc.2012.03.049\|journal=Journal of the American College of Cardiology\|volume=60\|issue=3\|pages=239\|doi=10.1016/j.jacc.2012.03.049\|issn=0735-1097}}</ref>TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.

	== Preoperative management ==		== Preoperative management ==
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	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

	=== Regional and neuraxial techniques~~<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->~~ ===		=== Regional and neuraxial techniques ===

	== Intraoperative management ==		== Intraoperative management ==

David.Leon: TAVR

2022-06-27T17:38:27Z

TAVR

← Older revision		Revision as of 10:38, 27 June 2022
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	}}		}}

	~~Provide a brief summary~~ of ~~this surgical procedure~~ and ~~its indications here~~.		TAVR, also sometimes referred to as TAVI [Transcatheter Aortic Valve Implantation], is an alternative to surgical repair/replacement of heavily diseased/calcified aortic valves contributing to significant aortic stenosis. It involves placing an artificial valve over the existing diseased aortic valve, guided by angiography and fluoroscopy.

	== Preoperative management ==		== Preoperative management ==

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:46:15Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:46, 21 February 2022
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	\|		\|
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|		\|
	\|-		\|-

William.Hsu: Monitoring

2022-01-20T23:09:59Z

Monitoring

← Older revision		Revision as of 16:09, 20 January 2022
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	=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===		=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
			Type and Cross 2 units of pRBCs

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
			Often done in a remote anesthesia setting.

	=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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	=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===		=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
	~~Arterial~~ line prior to induction		2 PIVs: one for infusion. one for push line.

			If doing MAC: do not need to place an invasive A-line. Cardiologists will place a femoral and radial A-line that will monitor aortic and LV pressures; these can be used intra-op by the anesthesia team to monitor BP. Can use a non-invasive a-line such as a clear-sight if available.

			If doing GA, place arterial line prior to induction.

	=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===		=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
	For MAC cases, can consider ~~either~~ remifentanil 0.~~25mcg~~/kg/min titrated to effect or propofol ~~25mcg~~/kg/min titrated to effect		For MAC cases, can consider starting with remifentanil 0.02mcg/kg/min titrated to effect +/- propofol 20mcg/kg/min titrated to effect.

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===


	== Postoperative management ==		== Postoperative management ==