Original article
Anesthetic Management of Transcatheter Aortic Valve Implantation With Transaxillary Approach

https://doi.org/10.1053/j.jvca.2010.08.015Get rights and content

Objective

To describe the anesthetic management of transcatheter aortic valve implantation (TAVI) with the transaxillary approach.

Design

An observational cohort study.

Setting

Two university hospitals.

Participants

Twenty-two patients with severe aortic stenosis (± regurgitation) at high risk for surgical valve replacement, with contraindications for transfemoral TAVI (81 ± 4.9 years; logistic EuroSCORE, 27% ± 16.9%).

Intervention

General anesthesia or local anesthesia plus sedation followed by postoperative care.

Measurements and Main Results

Local anesthesia plus sedation and general anesthesia were used in 14 and 8 patients, respectively. Two patients undergoing local anesthesia were monitored with transesophageal echocardiography and supported with noninvasive mask ventilation during the procedure. Main complications included hemodynamic instability requiring inotropes (2 patients), severe postimplant aortic regurgitation requiring immediate second valve-in-valve implantation (1 patient), valve embolization requiring open-valve surgery (1 patient), subclavian artery dissection compromising the flow to a mammary artery graft (1 patient), ascending aortic dissection (1 patient), stroke (2 patients), and atrioventricular block requiring pacemaker implantation (3 patients). Four patients experienced an increased (baseline value × 1.5) postoperative serum creatinine. Five patients required red blood cell tranfusions (2 units). Intensive care unit stay and hospital stay were 6 (4-23) hours and 8 (8-9) days, respectively. All patients were alive 30 days after the procedure. The 6-month mortality was 9%.

Conclusions

Transaxillary TAVI is feasible in high-risk patients with aortic stenosis and peripheral vasculopathy. Nevertheless, severe procedural complications are possible, and anesthesiologists should be prepared to assist in the management of these conditions.

Section snippets

Methods

After ethical committee approval and patients' written consent, the authors prospectively collected data of patients with severe symptomatic AS undergoing transaxillary TAVI from March 2009 to October 2009 in 2 teaching hospitals. Most of the patients had severe symptomatic AS. In selected cases, TAVI was proposed for the treatment of pure or predominant aortic regurgitation and dysfunctional aortic bioprosthesis.

Patients were evaluated by a team of cardiologists, cardiac surgeons, and

Results

Between March 2009 and October 2009, 108 patients underwent TAVI at the authors' institution. In 22 patients (20.3%), the procedure was performed via the transaxillary approach. All patients presented high risk for surgery and nonpermissive iliac-femoral arteries, which contraindicated the transfemoral approach. Preoperative characteristics are reported in Table 1. Twenty patients suffered from severe AS, 1 patient presented a dysfunctional aortic bioprosthesis, and another one had severe

Discussion

TAVI currently is emerging as an alternative therapy for patients with severe aortic stenosis at high risk for conventional surgery.5 The transfemoral retrograde approach is feasible in the majority of patients, with high success rates.5, 6, 7 Alternatively, a transaxillary approach can be used in patients with small or diseased iliofemoral arterial systems. The aim of this study was to describe, from the point of view of anesthesia and intensive care specialists, the perioperative management

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