Minimalist TAVR

[OB1🤙]

Things are reaching their logical conclusion. The following pertains only to "straightforward" transfemoral cases. No hostile root, no marginal access vessels, etc. It DOES pertain to sick hearts- low EF, bad PA pressures, etc.

Pt to cath lab. NO arterial line placed by us. Have 2 good PIVs. Start propofol gtt via PIV. NO central line placed by us (for Sapien valves).

Cardiologist uses contralateral arterial access for transducing arterial pressure for case. Uses 9 Fr cordis for transvenous pacer, and gives me a sterile large-bore tubing for central venous access hooked up to this cordis.

Case proceeds as MAC. I prefer a deep MAC, others prefer light. Can't have them squirming/coughing/obstructing though. TTE prn. The Sapien 3 has less paravalvular leak so with aortography + prn TTE you can usually tell if you're good.

At end of case, assuming all has been routine, everything comes out. Only the PIVs remain, and they go to the regular PACU and then to tele. Out of bed ambulating same day.

Many then go home the next day, others POD#2.

Routine surgical AVR will soon be going the way of the dodo bird.

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[lakersbaby]

pretty pimp HB. are you doing the TTE periodically or does the cardiologist? If you are can you bill for TTE intraop?

 

[OB1🤙]

We have a dedicated echo cardiologist for the TTE, which is fine by me.

 

[drmwvr]

Why do you bother with the second iv?

 

[urge]

Things are reaching their logical conclusion. The following pertains only to "straightforward" transfemoral cases. No hostile root, no marginal access vessels, etc. It DOES pertain to sick hearts- low EF, bad PA pressures, etc.

Pt to cath lab. NO arterial line placed by us. Have 2 good PIVs. Start propofol gtt via PIV. NO central line placed by us (for Sapien valves).

Cardiologist uses contralateral arterial access for transducing arterial pressure for case. Uses 9 Fr cordis for transvenous pacer, and gives me a sterile large-bore tubing for central venous access hooked up to this cordis.

Case proceeds as MAC. I prefer a deep MAC, others prefer light. Can't have them squirming/coughing/obstructing though. TTE prn. The Sapien 3 has less paravalvular leak so with aortography + prn TTE you can usually tell if you're good.

At end of case, assuming all has been routine, everything comes out. Only the PIVs remain, and they go to the regular PACU and then to tele. Out of bed ambulating same day.

Many then go home the next day, others POD#2.

Routine surgical AVR will soon be going the way of the dodo bird.

Sounds like a CA1 case.

 

[narcusprince]

Sounds like a CA1 case.

Or a solo trained lesser equivalent......

 

[Direct Laryngoscopy]

Or a solo trained lesser equivalent......

Until the hits the fan. And if you do enough of these, it will one day. Presently these are the sickest patients with pipes for vessels, which can sometimes result in vascular disasters or calcium going down a coronary and all the badness that ensues or a good ole arrhythmia when ballooning. But I must say, it's a nice case when it goes uneventfully.

 

[sevoflurane]

Here is my most recent one:

-Patient insisted on a TAVR- R/B thoroughly explained.
97 y/o femoral TAVR. AVA .4cm^2 EF 10%. Severe MR.
A-line, GA, CVL, TEE by us as we always confirm CT annulus size via 3D TEE.
No balloon valvuloplasty. Pace at 180bpm , deploy a 23 mm Sapien 3 ---> perfect landing no PV leaks but wouldn't recover after we drove down the CO to nothing.
Epi, Epi, Epi. Compressions. Epi, Epi.
Perfusing rhythm. To CTICU. Doing well.

Def. not a carpel tunnel case.
Selection bias is a big factor on how easy these will be.
Most are easy cheese. Some that are not. One thing is for sure. We are def. going to see more and more of these 95+ y/o's with multiple comorbid factors.

 

[GA8314]

Here is my most recent one:

-Patient insisted on a TAVR- R/B thoroughly explained.
97 y/o femoral TAVR. AVA .4cm^2 EF 10%. Severe MR.
A-line, GA, CVL, TEE by us as we always confirm CT annulus size via 3D TEE.
No balloon valvuloplasty. Pace at 180bpm , deploy a 23 mm Sapien 3 ---> perfect landing no PV leaks but wouldn't recover after we drove down the CO to nothing.
Epi, Epi, Epi. Compressions. Epi, Epi.
Perfusing rhythm. To CTICU. Doing well.

Def. not a carpel tunnel case.
Selection bias is a big factor on how easy these will be.
Most are easy cheese. Some that are not. One thing is for sure. We are def. going to see more and more of these 95+ y/o's with multiple comorbid factors.

Not to play god, but wtf are we doing these on 90+ yo pts for?? The societal costs are astronomical.

 

[urge]

Here is my most recent one:

-Patient insisted on a TAVR- R/B thoroughly explained.
97 y/o femoral TAVR. AVA .4cm^2 EF 10%. Severe MR.
A-line, GA, CVL, TEE by us as we always confirm CT annulus size via 3D TEE.
No balloon valvuloplasty. Pace at 180bpm , deploy a 23 mm Sapien 3 ---> perfect landing no PV leaks but wouldn't recover after we drove down the CO to nothing.
Epi, Epi, Epi. Compressions. Epi, Epi.
Perfusing rhythm. To CTICU. Doing well.

Def. not a carpel tunnel case.
Selection bias is a big factor on how easy these will be.
Most are easy cheese. Some that are not. One thing is for sure. We are def. going to see more and more of these 95+ y/o's with multiple comorbid factors.

What happens when the ct measurement and the echo measurement don't agree?

 

[drmwvr]

What happens when the ct measurement and the echo measurement don't agree?

Why we don't measure the annulus in the OR. The cardiologist ignores it anyway.

 

[sevoflurane]

Not to play god, but wtf are we doing these on 90+ yo pts for?? The societal costs are astronomical.

Not my fight.
However, I see more and more of this everyday.
Our Edwards reps have been doing 100 year olds for a while now.
Don't worry... It's only going to get better.

http://www.cornellcardiology.com/ne...mally-invasive-procedure-tavr-narrowed-aortic

 

[sevoflurane]

What happens when the ct measurement and the echo measurement don't agree?

We make a decision based on the quality of both studies.
We have gone up or down on valve size based on our intra-operative measurements.

 

[PainDrain]

Here is my most recent one:

-Patient insisted on a TAVR- R/B thoroughly explained.
97 y/o femoral TAVR. AVA .4cm^2 EF 10%. Severe MR.
A-line, GA, CVL, TEE by us as we always confirm CT annulus size via 3D TEE.
No balloon valvuloplasty. Pace at 180bpm , deploy a 23 mm Sapien 3 ---> perfect landing no PV leaks but wouldn't recover after we drove down the CO to nothing.
Epi, Epi, Epi. Compressions. Epi, Epi.
Perfusing rhythm. To CTICU. Doing well.

Def. not a carpel tunnel case.
Selection bias is a big factor on how easy these will be.
Most are easy cheese. Some that are not. One thing is for sure. We are def. going to see more and more of these 95+ y/o's with multiple comorbid factors.

So my 93 yo grandfather started getting winded about two years ago. He was always complaining of being tired but he figured it was due to recent passing of his wife and some mild depression. I urged him to get checked out. Well, he was dx with critical AS. Otherwise, prior to this diagnosis, he had no medical problems, none. I kept urging him to get a TAVR and he went for a Cath. Results showed normal EF with LVH and diastolic dysfunction. Valve was tricuspid, calcified, area 0.4ish. He had 75% circumflex lesion, 50% right and 50% left main dz. They refused to do it and my question is why? He wasnt in failure then ( is now) and I couldn't understand the cards guys reasoning. This guy was playing golf walking 9 holes five days a week until 88, slowed down to 3 days a week until stopping at 90.

 

[sevoflurane]

So my 93 yo grandfather started getting winded about two years ago. He was always complaining of being tired but he figured it was due to recent passing of his wife and some mild depression. I urged him to get checked out. Well, he was dx with critical AS. Otherwise, prior to this diagnosis, he had no medical problems, none. I kept urging him to get a TAVR and he went for a Cath. Results showed normal EF with LVH and diastolic dysfunction. Valve was tricuspid, calcified, area 0.4ish. He had 75% circumflex lesion, 50% right and 50% left main dz. They refused to do it and my question is why? He wasn't in failure then ( is now) and I couldn't understand the cards guys reasoning. This guy was playing golf walking 9 holes five days a week until 88, slowed down to 3 days a week until stopping at 90.

Seems like he would have been (and still could be) a good candidate for a TAVR at the time of diagnosis- I don't know the specifics besides what you have presented.
These patients feel a lot better post TAVR from a decrease in cardiac work. Additionally, some with LVH demonstrate early regression of ventricular mass further enabling the heart to work less while meeting systemic needs at rest and during exercise.

 

[seinfeld]

Things are reaching their logical conclusion. The following pertains only to "straightforward" transfemoral cases. No hostile root, no marginal access vessels, etc. It DOES pertain to sick hearts- low EF, bad PA pressures, etc.

Pt to cath lab. NO arterial line placed by us. Have 2 good PIVs. Start propofol gtt via PIV. NO central line placed by us (for Sapien valves).

Cardiologist uses contralateral arterial access for transducing arterial pressure for case. Uses 9 Fr cordis for transvenous pacer, and gives me a sterile large-bore tubing for central venous access hooked up to this cordis.

Case proceeds as MAC. I prefer a deep MAC, others prefer light. Can't have them squirming/coughing/obstructing though. TTE prn. The Sapien 3 has less paravalvular leak so with aortography + prn TTE you can usually tell if you're good.

At end of case, assuming all has been routine, everything comes out. Only the PIVs remain, and they go to the regular PACU and then to tele. Out of bed ambulating same day.

Many then go home the next day, others POD#2.

Routine surgical AVR will soon be going the way of the dodo bird.

We are in the same boat. Even the TransAortic we are extubating in the room.

 

[ProRealDoc]

Until the

hits the fan. And if you do enough of these, it will one day. Presently these are the sickest patients with pipes for vessels, which can sometimes result in vascular disasters or calcium going down a coronary and all the badness that ensues or a good ole arrhythmia when ballooning. But I must say, it's a nice case when it goes uneventfully.

And it does. We've done about 30 TAVRs and lost one patient who went into ischemic v-post pacing and who required

Things are reaching their logical conclusion. The following pertains only to "straightforward" transfemoral cases. No hostile root, no marginal access vessels, etc. It DOES pertain to sick hearts- low EF, bad PA pressures, etc.

Pt to cath lab. NO arterial line placed by us. Have 2 good PIVs. Start propofol gtt via PIV. NO central line placed by us (for Sapien valves).

Cardiologist uses contralateral arterial access for transducing arterial pressure for case. Uses 9 Fr cordis for transvenous pacer, and gives me a sterile large-bore tubing for central venous access hooked up to this cordis.

Case proceeds as MAC. I prefer a deep MAC, others prefer light. Can't have them squirming/coughing/obstructing though. TTE prn. The Sapien 3 has less paravalvular leak so with aortography + prn TTE you can usually tell if you're good.

At end of case, assuming all has been routine, everything comes out. Only the PIVs remain, and they go to the regular PACU and then to tele. Out of bed ambulating same day.

Many then go home the next day, others POD#2.

Routine surgical AVR will soon be going the way of the dodo bird.

At our institution, we are still intubating and performing TEEs to verify annular dimensions and assess for PV leaks.

 

[itwasalladream]

Do you really gain all that much doing these MAC, and without your own dedicated art and central line? It sounds sexy and slick to do these MAC, but I don't really see the major benefit. Sure you maybe save a tiny bit of time going GA, and maybe a bit more time if you're not placing a central line, but these are small amounts of time. We're extubating nearly everyone in the OR anyway, tube is out as the drapes come down. I think TEE is better than TTE and aortography for post deployment eval (not just leaks but pericardial effusion, damage to mitral subvalvular apparatus, LV function, etc). Most of my patients want to be completely out, especially for central line placement. And when things go south, airway and good access (i.e. no one removing your distant, shared access with cardiology in order to cannulate for bypass, etc) are two less things you have to worry about. I don't know, it just doesn't seem all that beneficial. Very cool to hear about all the different ways people are doing things, though.

 

[OB1🤙]

So I was just as skeptical of this approach at first. I had the same argument- I can extubate them on the table anyway, so what's the difference? Why not control the airway if the isht hits the fan?

I've come around to this approach though. With the 3rd generation equipment, this procedure is a glorified balloon valvuloplasty- a procedure that has been done without us or our support for decades. What is the difference? After the balloon goes up, there's a brand new valve in there and the AS is fixed. Sheath sizes are essentially the same.

Keep in mind- we do a preprocedure TEE, so we already know annular dimensions, coronary heights, ectopic calcification, etc. I would argue the MAC for the preop TEE is potentially a more difficult anesthetic than the MAC for the TAVR.

Now that we're not shredding the iliofemoral system, and the incidence of paravalvular leak is so much lower with the new valves, it makes sense to reevaluate our traditional approaches. This is no longer surgery. This is a cath. We frame our approach according to what we see in the OR, and what our experience was with the first generation systems. But times have changed, and the technology has vastly improved.

Yes, bad things can and will happen on rare occasions. They can happen during all kinds of other MAC procedures we do as well. If you have to emergently intubate- just do it. Takes a few seconds. Fear of not having a controlled airway is blown out of proportion, IMO, but I understand it. Like I say, I used to have it myself. But I think this minimalist approach is safe. Are you going to do this on someone with a horrendous airway? Of course not.

So what are we gaining? Time, for one. If you can do 4 cases in a day instead of 3, the system is happy with you. Also, the length of stays are shorter. They're up and out of bed quicker, participating in rehab quicker, and going home quicker. Even if you extubate them in the room after GA, they're up and moving around sooner after MAC.

Finally, you're deranging the patient's physiology less with MAC. If you intubate and institute PPV on some of these folks, you're sometimes going to have to be on pressors, etc. With the MAC approach the hemodynamics are closer to the homeostasis the patient walked into the hospital with. I think this exposure to low BP and pressors will be proven to be clinically significant. Can't prove it yet of course.

Once you start doing it this way, you'll probably eventually convinced it's better. I was skeptical, now I'm a convert.

 

[chocomorsel]

Not to play god, but wtf are we doing these on 90+ yo pts for?? The societal costs are astronomical.

I am with you on this one. But I am a bit of a socialist though.

 

[drmwvr]

Not to play god, but wtf are we doing these on 90+ yo pts for?? The societal costs are astronomical.

Careful... if the premise is to avoid perceived 'astronomical' societal liability of one sort or another in what we do to\for patients, TAVR's in 90 year olds might begin to look like a bargain if you really start to look.

 

[seinfeld]

I didn't buy in right away with MAC for TAVR but what I really found was that the post op cognitive dysfunction was much less, respiratory issues declined. and the floor nurses starting being able to tell which got GA and which got MAC (GAWA). Interestingly i started even doing my ETT cases with the same doses of Propofol infusions and narcotic, with sux as my intubating relaxant with the same results as the MAC. I think there is something to be said for the idea of the Triple Score, we don't use the BIS, the residual gas and the residual NMB in the elderly.

TAVR is headed the road of the EVAR. soon intermediate risk will have the option.