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Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients

Présentation de cas : L’anesthésie pour un remplacement valvulaire aortique percutané rétrograde : notre expérience avec les 40 premiers patients

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Abstract

Purpose: To describe both the evolution and the main associated complications in the anesthetic management of the initial 40 patients at our centre who underwent percutaneous retrograde aortic valve replacement, a novel technique utilizing a catheterguided femoral artery approach.

Clinical features: With institutional Research Ethics Board approval, we retrospectively reviewed the medical records of the first 40 patients who underwent percutaneous retrograde aortic valve replacement between January 2005 and March 2006. Information obtained included patient characteristics, anesthetic management, details of the procedure, and complications. All procedures were scheduled to be performed in the cardiac catheterization laboratory. The first four patients received monitored anesthesia care, and the subsequent 36 underwent general anesthesia. There were no anesthesia-related adverse events. The prosthetic valve was placed successfully in 33/40 patients (83%). Median anesthetic time was 3.5 hr (range, 1.25–7.25 hr). Thirty-two/40 patients required vasopressor support. The most common, serious procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing, hemorrhage from vascular injury secondary to the placement and removal of the large-bore sheath in the ilio-femoral artery, aortic rupture, and prosthetic valve maldeployment; 30-day mortality was 13% (n=5/40).

Conclusions: Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges. Careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome. Serious complications, including major hemorrhage from vascular injury as well as arrhythmia and myocardial ischemia following rapid ventricular pacing, must be anticipated and managed in an expeditious fashion.

Résumé

Objectif: Décrire l’évolution et les principales complications associées à la prise en charge anesthésique des premiers 40 patients de notre centre à subir un remplacement valvulaire aortique percutané rétrograde, une technique innovante utilisant une approche échoguidée par l’artère fémorale.

Éléments cliniques: Une fois le consentement du Comité d’éthique de la recherche obtenu, nous avons révisé de façon rétrospective les dossiers médicaux des 40 premiers patients à avoir subi un remplacement valvulaire aortique percutané rétrograde entre janvier 2005 et mars 2006. Les caractéristiques des patients, la prise en charge anesthésique, les détails de l’intervention et les complications faisaient partie des renseignements obtenus. Toutes les interventions étaient prévues dans le laboratoire de cathétérisation cardiaque. Les quatre premiers patients ont reçu une sédation sous surveillance, et les 36 suivants une anesthésie générale. Il n’y a pas eu d’événements indésirables provoqués par l’anesthésie. La prothèse valvulaire a été positionnée avec succès chez 33/40 patients (83 %). Le temps d’anesthésie médian était de 3,5 h (extrêmes, 1,25 – 7, 25 h). Un vasopresseur a été nécessaire chez 32/40 patients. Suite à l’intervention, les complications graves les plus fréquentes étaient l’ischémie myocardique et l’arythmie à la suite d’un entraînement ventriculaire rapide, l’hémorragie provoquée par une lésion vasculaire due au positionnement et au retrait de la gaine à grand diamètre dans l’artère ilio-fémorale, la rupture aortique et le mauvais déploiement de la prothèse valvulaire. La mortalité à 30 jours était de 13 % (5/40).

Conclusion: Le remplacement valvulaire aortique percutané rétrograde est une intervention nouvelle qui présente à l’anesthésiologiste des défis spéciaux. Une évaluation préopératoire attentive, un monitorage peropératoire adapté à une intervention vasculaire majeure et une prise en charge méticuleuse de l’hémodynamie sont absolument nécessaires à un devenir réussi. Des complications graves, notamment une hémorragie majeure causée par une lésion vasculaire ainsi que de l’arythmie et une ischémie myocardique suite à un entraînement ventriculaire rapide doivent être anticipés et pris en charge rapidement.

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Author information

Correspondence to Stephan K. W. Schwarz md phd frcpc.

Additional information

Financial support: Supported by departmental/institutional funds. Dr. Schwarz is recipient of the 2006 Canadian Anesthesiologists’ Society (CAS) Research Award and the 2006-2008 CAS/Abbott Laboratories Ltd Career Scientist Award in Anesthesia.

Conflicts of interest: none.

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Ree, R.M., Bowering, J.B. & Schwarz, S.K.W. Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients. Can J Anesth 55, 761 (2008). https://doi.org/10.1007/BF03016349

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Keywords

  • Aortic Stenosis
  • Aortic Valve Replacement
  • Prosthetic Valve
  • Aortic Valve Area
  • Balloon Aortic Valvuloplasty