Trans-aortic TAVR

[sevoflurane]

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What is your room set up like? Where are you and/or the echocardiographer positioned in the room?
What is your access?
As a cardiac anesthesiologist are you doing both echo AND patient care or do you have a second cardiac anesthesiologist or a cardiologist doing the echo sperately?

 

[Gimlet]

We have a cardiologist in the room to do the TEE for all TAVRs. I am happy to give that job away so I can focus on hemodynamics. Echo machine is off to the left of the head of the bed. Anesthesia machine is pulled way back and to the left of its usual position (extension on the circuit) so the surgeon can stand off to the right of the head of bed with enough room to manipulate the device. It leaves me about a 2 square foot spot right at the HOB to hang out. Access is usually one good large bore IV, a RIJ MAC introducer, PA catheter, and brachial A-line. We are going to start foregoing the PA catheter in most patients and place a dedicated pacing line via the introducer rather than running one up from the groin.

 

[mostwanted]

We have a cardiologist in the room to do the TEE for all TAVRs. I am happy to give that job away so I can focus on hemodynamics. Echo machine is off to the left of the head of the bed. Anesthesia machine is pulled way back and to the left of its usual position (extension on the circuit) so the surgeon can stand off to the right of the head of bed with enough room to manipulate the device. It leaves me about a 2 square foot spot right at the HOB to hang out. Access is usually one good large bore IV, a RIJ MAC introducer, PA catheter, and brachial A-line. We are going to start foregoing the PA catheter in most patients and place a dedicated pacing line via the introducer rather than running one up from the groin.

Why a brachial?

 

[OB1🤙]

Haven't done one of these since the third generation valves came out, hope to keep it that way.

Yeah, machine is behind me and to the left to give surgeons room. Echo in its usual position to the left (I.e. to the left of the anesthesia machine. Cardiologist does the echo.

My access is a radial Aline and a MAC in the IJ. I don't swan TAVRs.

 

[OB1🤙]

Why a brachial?

Probably trained at CCF. That's their thing.

 

[Gimlet]

Probably trained at CCF. That's their thing.

Nope. Our cardiac surgeon likes brachials for all his open valves (not from CCF either), so I think we just kind of carried it over for TAVRs. Some of my partners have started doing radials for them....I will probably head that way too. We just sent one of our guys to an Edwards-sponsored conference about moving to doing almost all transfemorals under MAC , so we are moving toward doing things in a more goal-directed toward early discharge manner.

 

[sevoflurane]

Haven't done one of these since the third generation valves came out, hope to keep it that way.

Yeah, machine is behind me and to the left to give surgeons room. Echo in its usual position to the left (I.e. to the left of the anesthesia machine. Cardiologist does the echo.

My access is a radial Aline and a MAC in the IJ. I don't swan TAVRs.

HB. What do you guys do with torturous iliacs or severe PVD where you can't place the magna french introducer through which the device is deployed? Are you guys doing trans-apical approach for candidates don't meet criteria for trans-femoral approach? Trans-apical is not my favorite approach as with the trans-aortic you can go onto bypass rather quickly as the aorta is staring right back at you. You also avoid the thoracotomy, ventriculotomy and positioning issues associated with the trans-apical approach.

I think the guidelines are going to loosen up and a lot of AVRs are going to be done via TAVRs. I am yet to do a trans-apical approach, so I carry zero experience with that procedure.

 

[sevoflurane]

Why not bring in a cardiac anesthesiologist and bill for the TEE and have an extra set of hands if things don't go well. (also bill for a second anesthesiologist)?
At my shop, we are staffing 2 cardiac anesthesiologists. One for the case and one for the echo as well as backup if we need to emergently go onto bypass. In that case you bill for 2 anesthesiologists.

Space and ability to access the airway is always an issue with the trans-aortic approach. Rather annoyed at the lack of space for those cases. I haven't used a circuit extender, but that may give us some more room. The arm of the fluoro machine is big and def. in the way. Probably need to buy one of those TEE arms.

 

[sevoflurane]

This is an extremely crowded OR indeed.

We are doing double sticks. For now we are doing introducer + triple lumen. Introducer comes out post-op if everything goes smooth. No swan with an echo in place.
Radial a-line. I have no problems with brachials. I place them in patients who are on medium-high dose pressors as they tend not to dampen as easily. These patients aren't the elective TAVR patients- they get radials.

Looking for a workaround the space issues. I don't think there is one. Notice that the anesthesiologist is somewhere behind person number 2- not even in the picture.

Have all your drips ready to go before they drape. This is key for the trans-aortic.

 

[sevoflurane]

We have a cardiologist in the room to do the TEE for all TAVRs. I am happy to give that job away so I can focus on hemodynamics. Echo machine is off to the left of the head of the bed. Anesthesia machine is pulled way back and to the left of its usual position (extension on the circuit) so the surgeon can stand off to the right of the head of bed with enough room to manipulate the device. It leaves me about a 2 square foot spot right at the HOB to hang out. Access is usually one good large bore IV, a RIJ MAC introducer, PA catheter, and brachial A-line. We are going to start foregoing the PA catheter in most patients and place a dedicated pacing line via the introducer rather than running one up from the groin.

Thanks Gimlet. Are you guys placing the pacing line or is cardiology.

 

[Gimlet]

Thanks Gimlet. Are you guys placing the pacing line or is cardiology.

We are placing the line, but at cardiology's request. Unfortunately, the pacing line they have for us is too thin to occlude the diaphragm on our 9 Fr introducers, so we have to place a smaller intro that isn't nearly as good for volume. I may double stick the IJ in patients on whom I can't get good peripheral access.

I work in a care team practice, but we single staff the TAVRs with a CRNA (the only type of case we do this on), so I don't think we could justify a second cardiac anesthesiologist in the room when the on-call cardiologist can run down from the echo lab to run the TEE.

 

[seinfeld]

Machine behind us. TEE to the left, we do the TEE. 2 large bore IVs and also we connect into the femoral venous cordis that the cardiologist places; radial aline. It is 1 hole in the aorta that can be seen by the cardiac surgeon i don't get too worried about bleeding. If they tear the ascending aorta in half only femoral cannulation and cross clamping the aorta gonna make difference.

Essentially for the case i am as close to the incision as the CT surgeon but not gowned and gloved.

Most often we have a CRNA with us but not all the time. IF we do have a CRNA then we cover a second room, like a long spine case.

 

[sevoflurane]

Essentially for the case i am as close to the incision as the CT surgeon but not gowned and gloved.

Not me. We still have a drape that separates the sterile vs non-sterile field. I am anywhere between 3-8 feet away from the field and the AW. It's not like looking over the drapes during a routine valve case. Sounds like your setup is a little different than ours.

It is 1 hole in the aorta that can be seen by the cardiac surgeon i don't get too worried about bleeding.

In my experience, these are very sick people. A lot of them have been on chronic steroids for severe COPD (not a candidate for trans-apicals), EF's in the 20%, dialysis dependent, severe PVD, + very old patients with critical AV areas. Tissue dynamics are usually at the very bottom of the barrel. Pacing them to 180 to bring their CO down to zero for balloon valvuloplasty has proven to be challenging to recover from at times.

You're right though Seinfield. These cases tend to go well. You do enough of them however, you will eventually find yourself crashing onto bypass in the hybrid due to poor patient protoplasm.

 

[sevoflurane]

Machine behind us. TEE to the left, we do the TEE.

👍

 

[itwasalladream]

We do a good PIV, quad lumen CVC, radial a-line. No introducer or PAC (where I trained at a big academic center we had also stopped placing them). Machine is pulled back a bit on the right, cardiologist doing TEE on the left. Pacing line from the groin, but we will place it occasionally in the neck especially if there is concern for needing it post-procedure. Our head of bed is very cramped but I'm basically right at the head.

Gimlet, I'm curious if there's a benefit to routinely placing the pacing line in the neck as opposed to the groin?

Also, not to hijack the thread but what kind of set ups are people using for TAVR under MAC? Are people still placing awake central lines, especially introducers? Sedation plans? What do you do if TTE isn't sufficient for post deployment evaluation? It seem like things are headed this way but I have no experience with it...

 

[bullard]

Preop nurses place 18g PIV, but I'll take whatever they give me because I'm placing 9 Fr MAC introducer without a Swan. A-line where I can get it (have placed a brachial or two for these). We've done mostly transfemoral, a couple of transapical, no transaortic (yet).

I was involved with room setup from the beginning so I have the anesthesia machine to the right of the patient, TEE to left, and so I'm close to airway. However, the C-arm makes doing TEE and case impossible. Cardiology does TEE and if they're unavailable, we cover with two anesthesiologists. No CRNAs (yet).

We finally had our first crash onto bypass. I didn't do the case, but if I had, I might have pushed hard to get bypass cannulas in prior to rapid pacing. Does anybody have criteria that their program uses to decide who (if anybody) to cannulate before trying to deploy rather than doing so emergently?

 

[seinfeld]

You do enough of them however, you will eventually find yourself crashing onto bypass in the hybrid due to poor patient protoplasm.

More frequent then i would like but still hard to predict which ones.

Regarding IJ pacer, we only place them for the Medtronic Valve as its self expanding nature could mean loss of conduction in 48 hours as pressure is put on the conduction system as the valve expands. Easier for a patient to get out of bed with IJ pacer than a femoral placed one.

I have started correlating the loss of rhythm after BAV or valve deployment with aortic rupture. The last 2 cases where we ended up having an aorta-RA and aorta LA fistulas had immediate loss of rhythm after deployment. Anyone else seeing this correlation?

 

[urge]

Preop nurses place 18g PIV, but I'll take whatever they give me because I'm placing 9 Fr MAC introducer without a Swan. A-line where I can get it (have placed a brachial or two for these). We've done mostly transfemoral, a couple of transapical, no transaortic (yet).

I was involved with room setup from the beginning so I have the anesthesia machine to the right of the patient, TEE to left, and so I'm close to airway. However, the C-arm makes doing TEE and case impossible. Cardiology does TEE and if they're unavailable, we cover with two anesthesiologists. No CRNAs (yet).

We finally had our first crash onto bypass. I didn't do the case, but if I had, I might have pushed hard to get bypass cannulas in prior to rapid pacing. Does anybody have criteria that their program uses to decide who (if anybody) to cannulate before trying to deploy rather than doing so emergently?

Correct me if I'm wrong, but my understanding is that tavr is currently indicated for extremely high risk patients not deemed candidates for bypass/open avr. I cannot imagine how they suddenly become candidates when SHTF during the procedure. I don't think bypass would be ethical.

 

[seinfeld]

very gray area and as always there is creep in the system, also its more about risk stratification as some may merely high risk but not have an absolute contraindication to bypass. Some patients who are on the edge "choose" (whether push from Cardiac surgeons watching their numbers or an aggressive cardiologist) TAVR or SAVR . We have had some we don't do heroic CPB after complications. I think in the next year they will get approval for intermediate risk patients.

 

[SouthSideSteve]

Correct me if I'm wrong, but my understanding is that tavr is currently indicated for extremely high risk patients not deemed candidates for bypass/open avr. I cannot imagine how they suddenly become candidates when SHTF during the procedure. I don't think bypass would be ethical.

Just because a TAVR is their best option doesn't mean it's their only option.

 

[OB1🤙]

what kind of set ups are people using for TAVR under MAC? Are people still placing awake central lines, especially introducers? Sedation plans? What do you do if TTE isn't sufficient for post deployment evaluation? It seem like things are headed this way but I have no experience with it...

We've gone to MAC as default for awhile now. With modern equipment, this procedure is a glorified balloon valvuloplasty, which has been done for decades with the same size arterial sheaths without anesthesiologists present.

Sedated central line (not introducer). I run low dose propofol. Tell them beforehand what to expect. Between TTE and aortography you can usually get a sense of the AR, which is less with the Sapien 3 valve anyway.

Put it this way- the procedure can be done reasonably with straight local. With proper experience (I.e. not a cardiologist doing this for the first time) and modern, small sheaths, MAC for these cases is really no big deal.

 

[seinfeld]

Did 2 cases today under sedation, my part ( aline, IJ pacer took 20-30 min) , procedure lasted 20-30 min, in other words longer for the scrub techs to setup for the case then to do the actual placement of the valve.

 

[sevoflurane]

We've gone to MAC as default for awhile now. With modern equipment, this procedure is a glorified balloon valvuloplasty, which has been done for decades with the same size arterial sheaths without anesthesiologists present.

Sedated central line (not introducer). I run low dose propofol. Tell them beforehand what to expect. Between TTE and aortography you can usually get a sense of the AR, which is less with the Sapien 3 valve anyway.

Put it this way- the procedure can be done reasonably with straight local. With proper experience (I.e. not a cardiologist doing this for the first time) and modern, small sheaths, MAC for these cases is really no big deal.

This thread is about trans-aortic TAVRs not transfemoral. The transfemoral approach is the clear winner when you can do them that way.

Trans-aortic and Trans-apical add a whole other aspect to the game. Zero chance of doing either of those two under sedation.

 

[sevoflurane]

Anyone deal with an annular rupture, major vascular tears or valve embolization?
These complications, when they happen, tend to turn a relatively straight forward procedure to a case with a vastly different level of complexity.

 

[sevoflurane]

 

[urge]

2 valves for the price of 1? Sounds like a deal!