[Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and hemodynamic observations]. / Anästhesie bei transfemoraler und transapikaler Aortenklappenimplantation: Periinterventionelles Vorgehen und hämodynamische Beobachtungen.

Percutaneous transfemoral and transapical aortic valve implantations are novel procedures that often confront the anesthesiologist with bigger challenges than surgical aortic valve replacements using cardiopulmonary bypass. Due to old age and the presence of severe comorbidities including pulmonary vascular hypertension, most patients have a very high risk. Individual comorbidities and their severity are as important for the choice of the anesthetic technique as pharmacological cardiovascular therapy and communication during the respective phases of the intervention. Since severe hemodynamic alterations (cardiogenic shock, coronary ischemia, arrhythmias) and potential interventional complications (bleeding, ventricular and vascular injury) may occur, the authors routinely perform an extended cardiovascular monitoring. General endotracheal anesthesia may be advantageous even for transfemoral valve implantation and was not associated with a worse outcome. Following valve implantation a substantial increase in cardiac index, but also of all filling pressures was measured. Anesthesia coverage time for the first 100 cases averaged 263 min (+/- 96) for transfemoral and 297 (+/- 78) for transapical valve implantation, which appears greater than for conventional aortic valve replacement surgery, but it decreased significantly for transfemoral valve implantation over the course of interventions. Accordingly, the anesthesiologist, besides providing anesthesia and managing the airway, assumes responsibility for invasive cardiopulmonary monitoring, cardiovascular pharmacotherapy tailored to intervention phases, and "troubleshooting" in the event of complications for these still developing interventions.

[Experience and learning curve with transapical aortic valve implantation]. / Erfahrungen und Lernkurve mit der transapikalen Aortenklappenimplantation.

BACKGROUND AND PURPOSE: Transapical transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients with degenerative aortic valve stenosis. The aim of this study was to assess a potential learning curve with the former technique based on the own experience with this novel procedure. PATIENTS AND METHODS: 40 consecutive high-risk patients (82 +/- 5 years, logistic EuroSCORE 42% +/- 16%) with symptomatic aortic valve stenosis underwent transapical aortic valve implantation (balloon expandable Sapien bioprosthesis, Edwards Lifesciences, Irvine, CA, USA) in the hybrid operating room between October 2007 and May 2009 at the West German Heart Center Essen. To assess a potential learning curve, patients were allocated and compared according to the implantation date (initial n = 20: 10/2007 to 10/2008; second n = 20: 11/2008 to 05/2009). RESULTS: All but one transapical aortic valve implantations were successful (procedural success rate 97.5%) and no prosthesis migration/embolization or coronary artery obstruction was observed. Comparing the groups, procedural time, fluoroscopy time, and contrast media volume decreased significantly (139 +/- 30 min vs. 112 +/- 41 min; 6.8 +/- 1.9 min vs. 5.5 +/- 1.5 min; 226 +/- 75 ml vs. 169 +/- 23 ml; p

Vascular access site complications after percutaneous transfemoral aortic valve implantation.

BACKGROUND AND PURPOSE: Transcatheter aortic valve implantation (TAVI) is a rapidly emerging treatment option for patients with aortic valve stenosis and high surgical risk. Different access routes have been proposed for TAVI including transapical, transsubclavian and transfemoral, with percutaneous transfemoral being the preferred because least invasive and nonsurgical. However, vascular access site complications due to the large-bore delivery catheters remain an important clinical issue, particularly with respect to the elderly patient collective typically considered for TAVI. In the study, the authors analyzed their 4-year TAVI experience with respect to vascular complications and their management in patients undergoing completely percutaneous transfemoral TAVI procedures. PATIENTS AND METHODS: Since 2006, TAVI was performed in 101 consecutive patients at the West German Heart Center Essen. 33 patients underwent transapical TAVI, eight patients transfemoral TAVI with surgical access or closure, and 60 patients percutaneous transfemoral TAVI using two commercially available prosthetic valve devices. RESULTS: Completely percutaneous TAVI was technically successful in all but one patient with malpositioning in the aortic arch during valve retrieval. There was no intraprocedural death and 30-day mortality was 12% (7/60). Vascular access site complications occurred in 19 patients (32%), necessitating surgical repair in six of them (10%). Complications included retroperitoneal hematoma (n = 2), iliac or femoral artery dissection (n = 10), (pseudo)aneurysm formation (n = 3), and closure device-induced vessel stenosis/ occlusion (n = 6). Of these, 13 cases could be managed either conservatively (n = 5) or by contralateral endovascular treatment (n = 8). CONCLUSION: Completely percutaneous TAVI has a high acute success rate with low intraprocedural and 30-day mortality. The patient collective appears to be prone to vascular complications which remain an important limitation of this novel technique. Although conservative or endovascular management is possible in the majority of cases, further technological developments are obliged to reduce the vascular complication rate.