ABSTRACT
OBJECTIVE: To report the authors' initial experience of transcarotid transcatheter aortic valve replacement (TAVR) managed with ultrasound-guided intermediate cervical plexus block. DESIGN: A single-center prospective study. SETTING: A teaching hospital in Paris, France. PARTICIPANTS: All consecutive patients undergoing a transcarotid TAVR were included. INTERVENTIONS: The ultrasound-guided intermediate cervical plexus block was performed in 28 of 31 patients. In 3 patients, the procedure was scheduled under general anesthesia: 2 because of failure of previous transfemoral procedures under local anesthesia, and 1 for an emergency procedure in a pulmonary edema context. MEASUREMENTS AND MAIN RESULTS: Anesthesia and all perioperative parameters were recorded, as well as any complications after the procedure. Twenty-eight patients were managed with intermediate cervical plexus block and light sedation without any anesthesia-related complication. No conversion to general anesthesia was required. The use of vasopressor was only required in 11% of the patients. In 2 patients, a loss of consciousness after the common carotid artery cross-clamping test occurred, leading to the use of a temporary femoral-carotid shunt; no other change in consciousness was recorded during the procedure. CONCLUSIONS: Ultrasound-guided intermediate cervical plexus block appeared to be an alternative anesthetic technique for carotid TAVR, providing adequate surgical conditions, continuous neurologic monitoring, and arterial pressure stability.
Subject(s)
Aortic Valve Stenosis , Cervical Plexus Block , Transcatheter Aortic Valve Replacement , Aortic Valve/surgery , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/surgery , Cervical Plexus Block/adverse effects , France , Humans , Prospective Studies , Transcatheter Aortic Valve Replacement/adverse effects , Treatment Outcome , Ultrasonography, InterventionalABSTRACT
INTRODUCTION: Quantitative neuromuscular monitoring is now widely recommended during anesthesia using neuromuscular blocking agents to prevent postoperative residual paralysis and its related complications. We compared the TOF-Watch SX™ accelerometer requiring initial calibration to the TOF-Scan™, a new accelerometer with a preset stimulation intensity of 50mA not necessitating calibration. STUDY DESIGN: This pilot, prospective, observational study included adults undergoing general anesthesia with endotracheal intubation and muscle relaxation, having both arms free during surgery. Accelerometers were set up randomly on each arm. Anesthesia was started with remifentanil and propofol before an intubation dose of atracurium or rocuronium. Train of four stimulation was performed every 15s. Differences between measures were tested using Student's t-test and agreement assessed by Bland and Altman analysis. RESULTS: Thirty-two patients were included. During onset, a mean bias of -26seconds with a limit of agreement from -172 to +119seconds was observed between TOF-Watch SX™ and TOF-Scan™ to obtain 0 response to TOF. During recovery, TOF-Scan™ showed a significantly later recovery from 1 response to T4/T1>10%, but a bias of 0minute and limits of agreement from -4 to +4minutes for T4/T1>90% (NS). CONCLUSION: These results suggest a poor agreement between the calibrated TOF-Watch SX™ and the fix intensity TOF-Scan™ for onset and early recovery of relaxation (i.e. deep neuromuscular blockade) but a good agreement for recovery to TOF 90%. Data are not interchangeable between the devices, but both can be useful to detect residual paralysis.
