proceedings

in Intensive Care
Cardiovascular Anesthesia

original article

28
Percutaneous aortic valve implantation:
the anesthesiologist perspective
R.D. Covello1, G. Landoni1, I. Michev3, E. Bignami1, L. Ruggeri1,
F. Maisano2, M. Montorfano3, O. Alfieri2, A. Colombo3, A. Zangrillo1
1
Department of Anesthesia, Intensive Care; 2Cardiac Surgery; 3Laboratory of Interventional Cardiology, Università Vita-Salute
San Raffaele, Milano, Italia e Istituto Scientifico San Raffaele, Milano, Italy

ABSTRACT
Percutaneous aortic valve implantation is an emergent technique alternative to surgical aortic valve replace-
ment in high risk patients with aortic stenosis. Percutaneous aortic valve implantation techniques are under-
going rapid development and currently represent a dynamic field of research. Perioperative optimal strategies
keep on evolving too. At a review of the literature, only three previous papers on Pubmed focused specifically
on anesthesiological challenges of percutaneous aortic valve implantation. In one of them our first 6 months
experience was reported. In this new paper we describe the anesthesiological management of percutaneous
aortic valve implantation at our Centre, reporting the results of our implantation program from November 2007
to February 2009.

Keywords: percutaneous aortic valve implantation, aortic stenosis, general anesthesia, local anesthesia.

INTRODUCTION aortic valve replacement is the treatment

of choice for a vast majority of patients (2).
Rapid progress in interventional cardiol- However, in a subset of patients, mainly el-
ogy has recently seen the rate of percuta- derly patients with declining overall health
neous coronary intervention overtake that status or severe comorbidities, aortic valve
of coronary artery bypass surgery. Now at- replacement is considered either too high
tention is directed towards the treatment risk or contraindicated (3).
of valvular heart diseases, with exciting The size of this cohort is expected to in-
developments in balloon and stent tech- crease in the next several years, reflecting
nology having the potential to transform the aging population and the improving
the management of many common heart therapeutic options in patients with mul-
conditions, such as aortic stenosis (1). tiple and advanced medical conditions.
Aortic stenosis is the most common form Moreover, prognosis with medical man-
of valvular heart disease in adults, affect- agement is poor (2), and effects of percuta-
ing thousands of patients every year and neous balloon aortic valvuloplasty (BAV)
causing significant morbidity and mortal- are modest and short-lived (4, 5). Given
ity in case of advanced disease. Surgical the limited therapeutic options in these
patients, there has been interest in the
Corresponding author: development of transcatheter aortic valve
Landoni Giovanni, MD
Department of Cardiothoracic Anesthesia and Intensive Care implantation (TAVI) techniques. The ra-
Istituto Scientifico San Raffaele, Milano, Italia
Via Olgettina, 60 - 20132 Milano, Italy
tionale is that of minimizing the overall
E-mail: [email protected] surgical trauma by avoiding sternotomy,
 Percutaneous aortic valve implantation: the anesthesiologist perspective

aortotomy, use of cardiopulmonary bypass fication coupled with multiple small vol- 29
(CPB), and by implanting the prosthesis ume aortograms. One patient converted
on the beating heart, thereby avoiding car- from sedation to general anesthesia. One
diac arrest. patient in the general anesthesia group
died from respiratory complications. They
concluded that TAVI can, in the majority
LITERATURE REVIEW of cases, be performed under remifentanil-
based sedation resulting in a shorter im-
To the best of our knowledge, only three plant procedure time, reduced stay in high
groups focused on the anesthesiological dependency areas, and shorter time to hos-
management of TAVI so far. pital discharge
Ree et al. (6) described both the evolution We recently published our initial six
and the main associated complications months experience in anesthesiological
in the anesthetic management of the ini- management for TAVI (8). In our expe-
tial 40 patients undergoing percutaneous rience updated to February 2009, 50 pa-
retrograde aortic valve replacement at St. tients (79+7.3 years, logistic EuroSCORE
Paul’s Hospital (Vancouver, Canada). The 25.4+15) underwent TAVI using a bal-
first four patients received monitored an- loon expandable (34 patients) or a self-
esthesia care, while the subsequent 36 un- expandable (16 patients) prosthesis.
derwent general anesthesia. Valve deployment was visualized by high-
There were no anesthesia-related adverse resolution fluoroscopy and contrast an-
events. The prosthetic valve was placed giography. Nineteen patients received
successfully in 33/40 patients (83%). Me- general anesthesia, and 31 received local
dian anesthetic time was 3.5 hours (range, anesthesia plus sedation.
1.25-7.25 hours). Two patients had to be converted from
Thirty-two/40 patients required vasopres- local anesthesia to general anesthesia (1
sor support. The most common, serious refractory ventricular fibrillation and one
procedural complications were myocardial pt was resteless). Procedural complica-
ischemia and arrhythmia following rapid tions included prosthesis embolization
ventricular pacing, hemorrhage from vas- (1 patient), ascending aorta dissection (1
cular injury secondary to the placement patient), arrhythmias following rapid ven-
and removal of the large-bore sheath in tricular pacing (5 patients) and vascular
the ilio-femoral artery, aortic rupture, and access site complications (8 patients). One
prosthetic valve maldeployment; 30-day valve-in-valve implantation because of se-
mortality was 13% (n=5/40). vere aortic regurgitation after the first pro-
Behan M et al. (7) described the experi- cedure was performed.
ence of the Sussex Cardiac Centre (Brigh- Five patients in the general anesthesia
ton and Sussex University Hospital, Brigh- group were extubated in the theatre and
ton, UK) performing TAVI procedures in mechanical ventilation time in intensive
12 patients Three of them underwent care unit (ICU) was 12 hours. Mean ICU
the procedure under general anesthesia stay in the general anesthesia group was
and nine under remifentanil-based seda- 34+3 hours vs 15+3 hours in the local
tion. There were no differences between anesthesia group (p=.009). Postopera-
the groups in terms of comorbidities and tive complications included acute renal
clinical characteristics. The procedure was failure (7 patients), III° atrio-ventricular
visualized using fluoroscopic aortic calci- block (12 patients), sepsis (9 patients) and
 R.D. Covello, et al.

30 stroke (1 patient). All 50 patients were delivering system is removed and vascular
alive 30 days after the procedure. At the 6 access sites are closed either surgically or
moths follow-up 4 out of 30 patients died percutaneously. Iliac and femoral angiog-
for non-cardiac reasons. raphy is advocated to ensure the integrity
of vessel repair and the absence of vascular
complications such as perforation, dissec-
PROCEDURES tion and occlusion. Surgical repair of these
complications may be required; endovas-
Two technologies, the balloon-expandable cular stenting can be beneficial in selected
Edwards/Sapien Bioprosthesis (Edwards cases.
Life-sciences Inc., Orange, CA), and the
self-expandable CoreValve ReValving Sys-
tem (CRS TM, CoreValve Inc., CA, USA) PATIENT SELECTION AND
have been used in the largest clinical series PREOPERATIVE EVALUATION
(9). These technologies present differenc-
es in design and implantation technique. A number of predictive risk models have
Several other technologies are being devel- been employed to ascribe an objective
oped and have entered or are expected to quantitative risk profile for the purpose of
enter an active phase of clinical testing in patients selection for TAVI. The two risk
the next future. models most commonly used are the Eu-
All current TAVI procedures start with ropen System for Cardiac Operative Risk
conventional BAV to provide an enlarged Evaluation (EuroSCORE) (13) and the
passageway for the subsequent insertion Society of Thoracic Surgeon (STS) data-
of the prosthesis. Although initial proce- base (14). Notably, these predictive tools
dures were performed using the so-called for operative risk assessment are impre-
“antegrade” approach (10), via transfem- cise, especially at high levels of risk, not
oral vein access, this procedure has been entirely consistent from model to model,
complication-prone and has been largely and generally omit important risk factors,
abandoned. Most commonly, the preferred such as severe thoracic aorta calcification,
“retrograde” approach requires transfemo- previous chest wall radiation or liver cir-
ral artery access (percutaneously, surgical- rhosis (15-17).
ly or hybrid) negotiation of femoral, iliac Most appropriately, the best characteriza-
and aortic vasculature, retrograde crossing tion of individual risk should be a combi-
of the native aortic valve and valve deploy- nation of objective quantitative predictive
ment in the subannular region (9, 10). A models and subjective assessment by expe-
vascular access via subclavian artery (11) rienced surgeons, cardiologists and anes-
and the hybrid “transapical” approach thesiologists.
(12), through the left ventricular apex, The therapeutic option of TAVI has to
provide an alternative route to retrograde be discussed extensively for the individ-
transfemoral access in patients with dis- ual patient and approved on the basis of
eased femoral, iliac and aortic anatomy. a consensus that conventional surgery is
The positioning of the prosthesis is mostly excessively high risk in terms of antici-
aided by high-resolution fluoroscopy, con- pated mortality and morbidity. The defi-
trast angiography and transesophageal nition of the “inoperable” patient remains
echocardiography. After the final assess- a pivotal consideration. Patients are ex-
ment of device position and function, the cluded if a reasonable quality or duration
 Percutaneous aortic valve implantation: the anesthesiologist perspective

of life (>1 year) are considered unlikely require to manage difficult airways and 31
despite valve replacement because of co- hemodynamically unstable patients. Ide-
morbidities. A comprehensive evaluation ally, all operations should be performed in
of patients’overall medical condition and a hybrid operation theatre, i.e. a standard
non-cardiac comorbidities is essential and operative room with an additional angiog-
follows the same algoritm as used in surgi- raphy system.
cal patients. Besides comorbidities, older Since the risk of hemodynamic instability
age arises special anesthesiological con- and the need of emergent CPB and open
cerns. Some patients may have unrealistic surgery decreases with increasing equipe’s
expectations regarding the risk and degree experience, given the proven feasibility of
of invasiveness of the procedure. performing the procedure under local an-
An honest and appropriate explanation of esthesia plus sedation, may be a tendency
the anesthetic management of the proce- to simplify the anesthesiological setup.
dure and the risks involved is an essential The perceived excess of prophylactic anes-
feature of the preoperative encounter. thetic preparations versus a more relaxed,
A thoughtful management planning re- confident and less complex approach has
quires that the specialist opinion of the to be interpreted in the light of possible se-
anesthesiologist, and not just that of car- vere periprocedural complications.
diologists and cardiac surgeons, should At our Institution, all patients are moni-
always be sought early. Moreover, it is im- tored with five-electrodes EKG, pulsoxym-
perative for the “valve team” to plan pre- etry, urinary catheter, bladder tempera-
operative strategies of treatment in case of ture, arterial and central venous lines.
procedural complications, determining the Two external adhesive pads are attached
potential for surgical bailout in advance of to the patient, for early management of ar-
the procedure. rhythmias.
Maintenance of normothermia is accom-
plished by an external convective warming
MONITORING AND system, an under body blanket and an in-
ANESTHESIOLOGICAL SETUP travenous fluid heater system. Pulmonary
artery catheterization is not routinely per-
The anesthesiologist has to take a partici- formed and reserved to specific situations,
pative role in developing monitoring and such as left ventricular dysfunction and/
standards of care in the cath lab for this or pulmonary hypertension.
kind of procedures. It is important to note A pulmonary artery catheter sheath may
that physical environment of the cath lab be placed at the time of initial central ve-
is mostly designed to accommodate the nous cannulation, allowing for further
needs of cardiologists, having an anesthe- monitoring and providing a ready access
siologist taking an active role in patient to transvenous pacing routes in case of
care was not a primary concern when de- atrioventricular block, besides an adjunc-
signing the cath lab (18). tive access for fluids.
Basic monitoring equipment and setup Periprocedural transesophageal echocar-
items that are considered standards in op- diography (TEE) during PAVI may provide
erative rooms, may therefore not be pres- useful informations (19, 20). It aides the
ent in the cath lab. The cath lab has to be advancement of guidewires and delivery
stocked with additional equipment and system and it allows to evaluate the effects
drugs that anesthesia providers typically of BAV (leaflet mobility, aortic regurgita-
 R.D. Covello, et al.

32 tion), the position of the prosthesis at de- adequate diastolic filling time, and sinus
ployment, and post-implant valve assess- rhythm should be maintained to preserve
ment (area and gradient, leaflet mobility, the contribution that atrial contraction
regurgitation grade and location). TEE is adds to ventricular filling.
of particular value when valve calcifica- The systemic blood pressure must be
tion are mild and fluoroscopic imaging dif- maintained at a level to ensure coronary
ficult. Moreover it provides informations perfusion.
about preload and ventricular function, This may be accomplished through the use
thoracic aorta anatomy and procedure- of vasopressor drugs, such as ethilephrine
related complications, such as pericardial or norepinephrine. Since a significant
effusion and iatrogenic mitral regurgita- proportion of the left ventricular afterload
tion, thus guiding a prompt management is produced by the stenostic aortic valve,
of these events. vasopressor agents may be used without
Drawbacks of periprocedural TEE may be concern of adversely affecting ventricular
the fact that it requires general anesthe- performance, even in patients with poor
sia, it is sometimes limited in its ability left ventricular function.
to clearly distinguish the prosthesis while Moreover, TAVI poses significant specific
crimped on the delivery system and it may periprocedural challenges. Performing a
interfere with fluoroscopic imaging, ne- BAV first allows easier passage of the pros-
cessitating probe withdrawal at the time thesis through the severely stenotic native
of implantation. aorti valve. Furthermore, the dilated aortic
At our Institution, all patients receive a valve permits cardiac ouput circumvent-
transthoracic or transesophageal (if gen- ing the delivery system and better hemo-
eral anesthesia is used) echocardiographic dynamics especially in patients with criti-
evaluation at the end of the procedure, cal aortic stenosis. During BAV and the
while periprocedural TEE evaluation is balloon-expandable prosthesis implanta-
usually performed in selected high risk tion, a transient partial cardiac standstill
cases (aortic disease, concomitant heart is induced to minimize cardiac motion and
valve problems) and when complications pulsatile transaortic flow, which would
are suspected. otherwise act to eject the inflated balloon,
Newer modalities including intra-cardiac resulting in balloon slippage and device
and three dimensional echocardiography, embolization and malpositioning. In ear-
and CT angiography may further assist lier cases, CPB has been used to unload the
these procedures. left ventricle and to support the circulation
during the deployment (21).
Pharmacologic agents such as adenosine
HEMODYNAMIC MANAGEMET and beta-blockers have also been employed;
however, with inconsistent result. At pres-
Hemodynamic stability is the main objec- ent rapid ventricular pacing (RVP) is the
tive of anesthesiological management dur- preferred method to achieve this purpose
ing TAVI. Goals of hemodynamic manage- (22), with suggested mechanism of action
ment are those typical of aortic stenosis. including induced atrio-ventricular asyn-
Intravenous fluid administration should chrony, left ventricular dyskinesis, com-
be carefully titrated to provide adequate promised ventricular filling and reduction
preload to a hypertrophied left ventricle. in stroke volume and cardiac output. RVP
Tachycardia should be avoided to allow is performed at 220 bpm, and in case of
 Percutaneous aortic valve implantation: the anesthesiologist perspective

the presence of exit block, the rate is low- during valve deployment, consideration 33
ered by 20 bpm sequentially until reliable should be given to complete valve deploy-
capture is achieved and a reduction in sys- ment before electrical cardioversion, thus
tolic arterial pressure to below 50 mmHg avoiding prosthesis malpositioning or em-
is observed. bolization when sinus rhythm is restored.
A coordinated approach has been devel- If the hemodynamic status fails to improve
oped wherein one operator observes the and the valve has not yet been deployed,
fluoroscopic image and maintain the ideal the deployment of the prosthesis is the
valve position, a second operator starts next step in management.
pacing, and a third confirms reliable pace- The main benefit of valve deployment is
maker capture and effective reduction in that it reduces left ventricular afterload,
arterial pressure before rapidly inflating ventricular wall tension and myocardial
and then deflating the balloon. oxygen demand, as well as it improves
Only when the balloon is fully deflated the cardiac output. In the patient with acute
pacing ends. While RVP is advantageous aortic insufficiency following BAV, valve
for valve positioning, the combination of deployment may be the definitive manage-
rapid heart rate, myocardial hypertrophy ment. If the patient remains unstable fol-
and low coronary perfusion pressure pro- lowing valve deployment, femoral-femoral
duces an ischemic deficit in the myocar- CPB can be rapidly instituted.
dium. In most cases this ischemic deficit is By intention CPB has been used in some
well tolerated, most likely because of the centres during the first TAVI procedures,
brief duration of the RVP (12 seconds on but it has been largely abandoned because
average). However, it is prudent to mini- the procedures appear to be well tolerated
mize the number and duration of rapid without extracorporeal support in most
pacing episodes during the procedure, and patients. Still, we suggest that an experi-
allow hemodynamic recovery before fur- enced cardiac surgeon and a perfusionist
ther pacing. should be present or on call, in case of rap-
A bolus dose of a vasopressor such as id cardiovascular deterioration requiring
etilephrine administered just prior or im- emergent CPB.
mediately after the rapid pacing episode In case of hypotension during TAVI, be-
will allow coronary perfusion pressure to sides ischemia ad aortic regurgitation, dif-
be regained sooner. If the blood pressure ferential diagnosis must include cardiac
does not recover promptly after an epi- tamponade, acute mitral regurgitation and
sode of RVP, myocardial ischemia must be major arterial bleeding/rupture.
suspected. The ischemic insult is usually Cardiac tamponade causing cardiovascu-
caused by pacing, but coronary artery em- lar collapse may result from perforation
bolism from disruption of the calcified na- of the right ventricle during pacing wire
tive aortic valve, or obstruction of one or placement, and aortic or left ventricular
both coronary ostia by the prosthetic valve perforation by guidewires or catheters. If
or the displaced native valve leaflets must tamponade occurs, it is easily detected by
be considered. an associated increase in central venous
Treatment of post-pacing myocardial isch- pressure, visualization of the pericardial
emia is based initially on the restoration fluid and right-sided collapse on TEE, and
of coronary perfusion pressure through abnormal movement of the heart on fluo-
the use of vasopressor agents. In case of roscopy.
ischemia-induced ventricular fibrillation The management may consist of percuta-
 R.D. Covello, et al.

34 neous needle drainage of the pericardial ANESTHESIA TECHNIQUES

blood or surgical intervention.
Acute mitral regurgitation may result Anesthesia techniques for TAVI may vary
from mitral impingement by the delivery according to patient’s characteristics and
catheters and the valve prosthesis. It can coexisting diseases, and procedural in-
be readily diagnosed by continuous TEE stances. Advantages of general anesthesia
monitoring. are easily clear. First, general anesthesia
Major arterial bleeding/rupture may com- facilitates positioning of the valve prosthe-
plicate transfemoral artery procedures. A sis by maintaining patient immobility dur-
steady loss of blood through the valved ing fluoroscopy.
sheath may be appreciated when cath- Neuromuscolar paralysis allows the anes-
eters or wires in the vessels compromise thesiologist to control respiratory motion
the valve closure. A sudden unexplained during radiographic filming and program
decrease in blood pressure, particularly on short periods of apnoea, thus avoiding
decannulation, should alert to the possibil- breathing artifacts interfering with pros-
ity of a major vascular rupture which may thesis placement.
require prompt intervention, whether by Moreover, some patients undergoing TAVI
open or endovascular route. with local anesthesia may become restless
Blood loss may be not readily apparent, as lying completely still for an hour or more,
significant volumes may be lost retroperi- which is usually the time required for the
toneally, but it is easily detected by con- procedure.
trast aortography. Thus, general anesthesia may be more fa-
An occlusion balloon may be deployed vorable when the patient is unable to tol-
proximal to the perforation to attenuate erate the operation secondary to fatigue
the hemorrhage, and vigorous volume re- or having to maintain the same position
suscitation with fluid and blood products through the entire procedure. Second,
may be required in addition to the use of general anesthesia facilitates introducer
vasopressor agents to maintain coronary sheaths placement and removal and even-
perfusion. Usually an arterial guide wire tual surgical repair of arterial access sites,
is left in situ during the decannulation which can be potentially complicated and
process so that if a vascular damage oc- prolonged. Third, it allows the use of TEE
curs the defect may be immediately fixed as an adjunctive imaging modality. Final-
endoluminally without the need for open ly, it facilitates management of procedural
surgery. complications.
Mild-to-moderate aortic regurgitation, Induction of general anesthesia can be
mostly paravalvular, is observed in 50% done with a variety of agents. In patients
of cases (23). However, the availability of undergoing TAVI anesthetic requirements
larger prostheses and their careful match- are reduced because of advanced age and
ing with the size of the aortic annulus led decreased cardiac output due to the severe-
to the decrease in the incidence of severe ly stenotic aortic valve. The procedure it-
aortic regurgitation to 5%. self does not produce a significant amount
Further dilatation of the valve stent and of surgical stimulation.
valve-in-valve procedures have been sug- The choice of induction agents seems to
gested, but a severe periprosthetic aortic matter less than the manner in which they
regurgitation with cardiogenic shock may are administered, which should be slowly
require emergent surgery (24). and titrated to effect carefully. Mainte-
 Percutaneous aortic valve implantation: the anesthesiologist perspective

nance of anesthesia may be accomplished almost exclusive use of local anesthesia 35

with inhalational agents, intravenous plus sedation.
agents, or a combination of both. Inhala- At our Institution the anesthetic regimen
tional agents may have some advantage of- for local anesthesia technique consists of
fering some protection from the ischemic 1% lidocaine injected subcutaneously at
insult produced during the procedure by the arterial and venous access sites (maxi-
myocardial preconditioning. mum dose 4 mg/kg). In adjunct, sedation
Short acting agents that are rapidly cleared is accomplished with remifentanil infu-
are preferred to facilitate extubation at the sion adjusted according to response (target
end of the procedure. Airway management level: score 2-3 with modified Wilson se-
is usually performed by endotracheal intu- dation scale (27); starting dose 0.02 mcg/
bation. Because of the possible prolonged kg/min, maximum dose 0.2 mcg/kg/min).
procedure and the use of TEE, use of la- Combined use of remifentanil and propo-
ryngeal mask airway is not advised. fol (range dose 2-5 mg/kg/h) may be used
Yet general anesthesia is associated with according to patient’s and procedural re-
important potential complications, partic- quirements in order to reach the above
ularly respiratory, which high risk patients mentioned sedation level. Operator-deliv-
who are unfit for surgical aortic valve re- ered sedation is unlikely to be successful
placement may tolerate poorly (25). On for these patient whose hemodynamics
the basis of the EUROSTAR data, high- are brittle and tolerance of invasive proce-
risk patients in particular attain important dures may be limited.
advantages from minimally invasive anes- A potential advantage of local anesthesia
thetic techniques during endovascular aor- may be the fact that overstretching the ar-
tic aneurysm repair: mortality, morbidity, terial system by the delivery sheath induc-
hospital stay and intensive care unit (ICU) es discomfort which alerts the physician of
admission are significantly lower for re- the risk of vascular injury or rupture.
gional and local versus general anesthesia In our experience, the passage of rela-
in the EUROSTAR registry (26). tively large and stiff deployment catheters
Similar benefits could be expected in high- through the arteries is well tolerated with
risk patients undergoing TAVI with local local anesthesia, and concerns of patients
anesthesia. tolerance for vascular repair with local
A trend for shorter procedure time, time anesthesia are perhaps unfounded, since
to ambulation, high-dependency unit stay intravenous sedation is used to maximize
and overall hospital stay has been observed comfort rather than to provide analgesia.
in our experience (8). Each of these factors A preoperative ilioinguinal/iliohypogas-
is of significance both for patient morbid- tric block can be performed to reduce the
ity and satisfaction, and for hospital effi- total dose of infiltration local anesthetics
ciency and costs. in patients with reduced metabolic capac-
In our experience, general anesthesia has ity, at increased risk for neurologic and
been the preferred technique at the begin- cardiac toxicity.
ning of our implantation program, accom- If local anesthesia plus sedation is em-
panying operator’s learning curve. With ployed, the anesthesiologist must be ready
increasing equipe’s experience, since the to institute full general anesthesia at any
technique became straightforward and the moment. This concept of “standby” gen-
feasibility of local anesthesia plus sedation eral anesthesia appears to offer enhanced
became apparent, a shift was seen towards flexibility in scheduling patients for these
 R.D. Covello, et al.

36 procedures. Patients with anticipated dif- modinamics, vascular access, rhythm dis-
ficult airway are obviously unsuitable for turbances and renal function.
this technique, because the risk of delay in In this regard, main concerns may be arised
airway access during emergent situations by atrioventricular block (4-8%), neces-
may be worse than the potential benefits sitating pacemaker implantation in up to
of a less invasive anesthetic technique. 24% with self-expandable devices (23).
Notably, fluoroscopy equipment regularly The transvenous pacing lead is routinely
limits access to patient’s head which may left in situ after the procedure if self-ex-
be difficult once the procedure has start- pandable device is implanted. Moreover,
ed. acute renal injury remains a frequent
We are planning a large randomized trial cause of morbidity in patients undergoing
of general versus local anesthesia to evalu- TAVI. General risk factors include diabetes
ate whether the choice of anesthetic tech- mellitus, pre-operative renal insufficiency,
nique affects the outcome of patients un- age, volume depletion-hypotension-low
dergoing TAVI. cardiac output, nephrotoxic drugs and
high volume of contrast media.
Among others, specific risk factors com-
POST-PROCEDURAL COURSE prise transapical access, number of blood
transfusions, post-interventional throm-
Most patients undergoing TAVI with gen- bocytopaenia and severe inflammatory
eral anesthesia are able to be extubated in response syndrome (SIRS). Preventive
the theatre at the end of the procedure, measures pre-procedure, as well as care-
unless they are hemodynamically compro- ful post-procedure management, should be
mised or difficult airways. It is imperative routine in all patients.
to continuously evaluate the patient for
the appropriateness of fast tracking as the
operation progresses. CONCLUSIONS
Patients who require mechanical ventila-
tion postoperatively are usually able to be Six years after the first-in-man, TAVI tech-
extubated within a few hours. Pain man- nique is undergoing rapid development
agement is accomplished in most patients and dissemination.
by nonsteroidal agents/paracetamol and As this new procedures is on its way to-
opioids low rescue doses. It is important wards clinical practice, perioperative opti-
to note that these high risk patients are mal strategies keep on evolving.
prone to complications at any time during Anesthesiologists must be aware of cur-
hospital stay, with a pattern of complica- rent technologies, playing a participative
tions substantially different from standard role in developing standards of care for
cardiac surgery. these high risk patients and supporting the
According to single Institution organiza- continuous refinement toward a more and
tion, an early transfer to an intermediate more minimally invasive approach.
care unit provided with bedside telemetry, Acknowledgments
could be a suitable strategy in selected pa- We’re indebted to Fichera M, RN and Virzo I, RN, and
tients with uneventful operative course. Zuppelli P, RA, for the careful revision of the manu-
script and the support in data entry.
Ideally, all patients should stay in ICU for
at least 24 hours and be closely monitored Conflict of interest statement: Maisano, Alfieri and
for several days especially as regards he- Colombo acknowledge teaching fee from Edwards.
 Percutaneous aortic valve implantation: the anesthesiologist perspective

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