The sixth stage of cloud rounds: Transapical approach and transcatheter aortic valve replacement in elderly patients with heart failure [with the Chinese expert consensus on clinical pathway management for anesthesia in TAVR surgery (2018)]

Thank you to Professor Wang Tianlong of Xuanwu Hospital.
Thank you to the China Gerontology Group for building such a good learning platform.
In order for everyone to better understand the study and analysis of cases, Ling Jun has organized the study notes.
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cn/#/meeting_notice_detail?meeting_id=48075 📒Provide Chen Lingjun 🎬Typesetting Dingdang Wanzi Ma Focus on clinical problems 250 million elderly people in 2020 (over 60 years old is defined as the elderly) More than 2025 300 million will enter the ranks of the elderly.
From 2025 to 2030, there will be more than 100 million elderly people over 80 years old.
Therefore, anesthesia management of elderly patients is a big challenge.
Transapical Transcatheter Aortic Valve Replacement (TAVR) in Patients with
Failure
Chief Complaint: He was admitted to the hospital due to "edema of both lower extremities for 2+ years, shortness of breath for 3+ months, and aggravation for 20 days"
.

Preoperative medical medication: digoxin 0.
125mg qd, trimetazidine hydrochloride 20mg qd, betaloc 23.
75mg qd, furosemide 20mg qd, spironolactone 20mg qd
.

Past history: 2+ years of gout, mainly involving both knees
.

Physical examination: heart rate 100bpm, blood pressure 105/59mmHg, respiration 24bpm
.

Physical examination: clear consciousness, dark complexion, no cyanosis of lips, neat breathing rhythm, autonomous posture, auscultation of aortic valve area systolic murmur, no edema in both lower extremities
.

Auxiliary examination: cTnl 2.
07ng/l, cTnT 21.
1ng/L, natriuretic peptide 9447ng/L
.

Chest CT: bilateral little-to-moderate pleural effusion, emphysema, bullae in both lungs, and scattered inflammation in both lungs
.

ECG: sinus rhythm, atrial premature, left ventricular high voltage
.

Echocardiography: left ventricular hypertrophy, bi-atrial enlargement, aortic valve annulus diameter of about 24 mm, valve thickening and calcification, diastolic valve leaflet opening was significantly impaired, systolic insufficiency, forward blood flow was significantly accelerated, average transvalvular valve The pressure difference was 72 mmHg, with moderate aortic and mitral regurgitation, and left ventricular ejection fraction was 48%
.

Coronary CTA: mild stenosis
.

Admission diagnosis: heart valve disease, aortic stenosis (severe), regurgitation (mild-moderate), mitral regurgitation (mild-moderate), cardiac function class IV, COPD, pleural effusion, peripheral atherosclerosis , CAD
.

Intended operation: Transcatheter aortic valve implantation (TAVR) under general anesthesia with SPRING Question 1: What are the indications and contraindications of TAVR surgery? What are the key steps of this type of surgery and the links that require the good cooperation of the anesthesiologist? (For Cardiac Surgeons) For high-risk elderly patients
.

(ACC/AHA) guidelines propose that patients with severe calcified aortic stenosis and symptomatic calcified severe aortic stenosis with contraindications to surgery or high-risk surgery and with a life expectancy of more than 1 year are class I indications for TAVR, while patients in the intermediate-risk group of surgery are upgraded to class IIa.
Indication
.

Relative contraindications include: (1) left ventricular thrombus; (2) left ventricular outflow tract obstruction; (3) myocardial infarction within 30 days; (4) left ventricular ejection fraction <20%; (5) severe right ventricular dysfunction (6) The anatomical shape of the aortic root is not suitable for TAVR treatment; (7) There are other serious complications, and the life expectancy is less than 1 year even if the valve stenosis is corrected
.

Different from conventional thoracotomy, most patients have poor cardiac function, severe valve stenosis, and large transvalvular pressure difference.
Although the incision is small and the trauma is small, the hemodynamic fluctuations are large
.

Good preoperative assessment and early prediction
.

Intraoperative blood pressure management: blood pressure drops during rapid pacing; blood pressure drops after balloon dilation, and dilation is pre-treated to avoid blood pressure drops
.

Question 2: What are the common complications of TAVR surgery and the unexpected situations that may occur during the operation? What emergency and effective treatments are needed for the assistance of an anesthesiologist? (For Cardiac Surgeons) Complications: Common complications of TAVR surgery include severe bleeding, vascular injury, hemopericardium/tamponade, valvular misplacement, coronary artery occlusion, heart block, paravalvular leak, and stroke and postoperative myocardial infarction
.

Bleeding throughout the operation
.

Reason: A catheter with a diameter of approximately 9 mm is placed in the heart, the left ventricle is a high pressure chamber, and the apical purse is prone to bleeding
.

The suturing requires the cooperation of the anesthesiologist: to ensure a slower heart rate, to avoid high blood pressure and low blood pressure, and to avoid arrhythmia
.

Avoiding epinephrine until the apical purse-string suture is complete can increase myocardial irritability
.

Question 3: Intraoperative management goals for patients undergoing TAVR surgery
.

① Management of limited diastolic function: adequate volume; use of vasoconstrictor drugs to reduce aortic valve transvalvular pressure gradient; ② perfusion of hypertrophic myocardium: maintain slower heart rate, reduce oxygen consumption; maintain higher mean artery ③Reduce myocardial irritability and reduce oxygen consumption: use epinephrine with caution to strengthen the heart to reduce cardiac irritability; stabilize electrolyte and internal environment; combine with other drugs: lidocaine, remifentanil,
etc.

④ After balloon dilation, stenosis becomes reflux: use of temporary pacemaker; use of vasoactive drugs
.

Question 4: The choice of transfemoral and transapical TAVR anesthesia
.

Cardiology teams often consider deep sedation and analgesia + local anesthesia, and it is difficult for the catheterization lab to meet the requirements of general anesthesia
.

Surgeons advocate general anesthesia
.

Be vigilant that patients with respiratory and cardiac insufficiency are prone to CO2 accumulation under deep sedation
.

There is no difference in prognosis between the two methods of anesthesia, but general anesthesia is more comfortable and safer, the patient has no movement, the Tee is clearer, and the ultrasound doctor receives fewer rays, which can better cope with unforeseen situations during surgery
.

Question 5: The patient has difficulty breathing after extubation.
What are the reasons for consideration? How to correctly assess the indications for extubation in such patients? Extubation is performed in a strict weaning sequence, and patients tolerate noninvasive positive pressure ventilation no better than invasive ones
.

1.
Preoperative cardiac function of the patient 2.
Surgical success 3.
Volume analgesia and deep muscle relaxation reversal during anesthesia management 4.
Arrhythmia and unstable circulation in the offline experiment before extubation.
Develop standard extubation specifications
.

Question 6: If the patient suffers from severe cardiac insufficiency after aortic valve implantation and requires cardiac compression, can cardiac compression be performed, and will it affect the newly implanted aortic valve? If not is there a better way? There are two types of TAVR valves: balloon-expandable and self-expandable
.

For patients with balloon-expandable valves, resuscitation compression is not affected; for patients with self-expandable valves, if they are patients with valvular stenosis before surgery, cardiac compression can be performed at a deep valve implantation position; for patients with valvular insufficiency, due to the valve Placed in a high position, cardiac compressions will be affected
.

But regardless of whether the valve is displaced, press aggressively first
.

It is recommended that the support wire and catheter be retained until the circulation is stabilized
.

Attachment: Contingency plan for unexpected events
.

①The chief surgeon initiates the emergency plan, emergency transfer to thoracotomy or establishes vascular access through the femur; ②The anesthesia team stabilizes the circulation and directs the rescue; ③The circuit nurse calls for cardiopulmonary bypass (the perfusionist must be in the operating room); ④The radiology team removes the C-arm , imaging equipment, other instruments on the operating table, etc.
; ⑤ The surgeon on the right side of the patient immediately started CPR; ⑥ The surgeon moved to the right side of the patient for emergency thoracotomy; ⑦ The perfusionist moved to the operating table immediately after the cardiopulmonary bypass machine was ready; ⑧ The hand-washing nurse prepares the arteriovenous intubation; ⑨ the chief surgeon is responsible for exposing the heart and giving heparin instructions, and the assistant assists in completing the intubation and connecting the pipeline; ⑩ starts the cardiopulmonary bypass
.

Appendix: Chinese Experts' Consensus on Clinical Pathway Management of TAVR Surgical Anesthesia (2018) Wonderful Recommendation Phase 1 [Monday] Perioperative management of multi-level vertebral fusion in elderly patients after cloud rounds and mitral valve replacement Phase 2 [Monday] 】Geriatric anesthesia cloud rounds · Anesthesia management for elderly patients with giant anterior mediastinal tumor resection Phase III [Monday] Elderly anesthesia cloud rounds · Anesthesia management for patients with acute intussusception and acute coronary syndrome The fourth phase [Monday] Cloud The fourth phase of ward rounds, the fifth phase of anesthesia management of pituitary tumor resection in elderly patients with coronary heart disease and arrhythmia The fourth day of mid-spring spring is in the middle of the green field, the moon is sunny, the cloud is intermittent, the selected article, the latest guide, the consensus, the dispute, the case note, the classic book, the note, the online class, the super strong note, the excellent courseware, the case discussion, the spark, the polyneural block, the learning, the literature reading, the high school, the anesthesia The news has long known that it is recommended to watch and enjoy the live wallpaper, and the summary is posted here! ! Anesthesia knowledge, we are intimately prepared in the public account of anesthesia Q & A.
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