Anesthetic management for a patient with aortic stenosis who underwent transcatheter aortic valve implantation after introduction of percutaneous cardiopulmonary support
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KeywordsTranscatheter aortic valve implantation Low output syndrome Percutaneous cardiopulmonary support
Balloon aortic valvuloplasty
Intensive care unit
Low output syndrome
Percutaneous cardiopulmonary support
Transcatheter aortic valve implantation
To the Editor
The patient was a 74-year-old male with a height of 155 cm and a body weight of 41 kg. At the age of 63, he underwent off-pump coronary artery bypass grafting due to a previous myocardial infarction. The patient had been hospitalized several times due to heart failure secondary to aortic stenosis (AS) since approximately 71 years of age. On transthoracic echocardiography, the patient’s left ventricle showed diffuse hypokinesis and an ejection fraction of 27%. The aortic valve was highly calcified and showed mobility restrictions together with the tricuspid valve; moderate to severe AS was also present.
On transthoracic echocardiography, the patient’s left ventricular function did not change compared with the preoperative condition, but the mobility of the implanted artificial valve was good.
Since TAVI became covered by health insurance, it has gained wide clinical use in our country. It is anticipated that TAVI will become more popular in the future .
However, patients scheduled for TAVI are in critical condition. PCPS is effective in the treatment of circulatory failure secondary to valvular heart disease or heart failure . In this case, it is important to determine whether the patient can withstand the reduction in blood pressure accompanying general anesthesia introduction and valve expansion due to low left ventricular function. Regarding the low left ventricular function, the patient’s intraoperative vital signs were stabilized by circulatory assistance by PCPS. During anesthesia, we tried to maintain a sufficient preload to preserve the PCPS flow. To maintain the patient’s blood pressure, we used a high dose of inotropic agents. There have been reports using supplementary circulation such as PCPS at the time of a sudden change in preventive or intraoperative disorder [3, 4, 5, 6], but we could not identify any report describing the introduction of PCPS after a sudden change in the condition of a patient with AS and the urgent implementation of TAVI. We believe that the emergent TAVI following PCPS is rare and that most Japanese anesthesiologists are not familiar with this type of perioperative management. In Japan, TAVI is difficult to perform at the emergent setting, as the decision for the indication and preparation of several devices cannot be made in a short time. In this case, this patient was scheduled for TAVI; therefore, it was fortunate that the device was ready.
PCPS is useful for the circulatory management of LOS, making it possible to treat the original disease after saving the patient’s life.
This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
TK drafted and revised the manuscript. SO organized the patients’ the data and images. KSS supervised the activity. All authors read and approved the final manuscript.
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