Anesthesia and perioperative management of patients undergoing transcatheter aortic valve implantation: analysis of 90 consecutive patients with focus on perioperative complications.

OBJECTIVE: To describe, from the point of view of anesthesia and intensive care specialists, the perioperative management of high-risk patients with aortic stenosis who underwent transcatheter (transfemoral and transapical) aortic valve implantation (TAVI). The authors specifically focused on immediate postoperative complications. DESIGN: Retrospective review of collected data. SETTING: Academic hospital. PARTICIPANTS: Ninety consecutive patients with severe aortic stenosis who underwent TAVI. INTERVENTIONS: General anesthesia followed by postoperative care. Complications were defined by pre-established criteria. MEASUREMENTS AND MAIN RESULTS: Of 184 patients referred between October 2006 and February 2009, 90 were consecutively treated with TAVI because of a high surgical risk or contraindications to surgery. The transfemoral approach was used as the first option (n = 62), and the transapical approach when contraindications to the former were present (n = 28). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. Patients were 81 ± 8 years old, in New York Heart Association classes II (9%), III (54 %), or IV (37%); left ventricular ejection fraction was below 0.5 in 38% of patients. The predicted surgical mortality was 24% (16-32) and 15% (11-23) with the logistic EuroSCORE and STS-Predicted Risk of Mortality, respectively. The valve was implanted in 92% of the cases. The duration of anesthesia and (intra- and postoperative) mechanical ventilation was 190 (160-230) minutes and 245 (180-420) minutes, respectively. Hospital mortality was 11%. The most frequent cardiac complications were heart failure (20%) and atrioventricular block (16%), with 6% requiring a pacemaker. Vascular complications (major and minor) occurred in 29% of the patients. CONCLUSIONS: Despite their severe comorbidities, the mortality of the patients in this cohort was below that predicted by cardiac surgery risk scores. Monitoring, hemodynamic instability, and the frequency of complications require management and follow-up of these patients in similar ways as for open cardiac surgery. The frequency of complications in this cohort was comparable to that published by other groups.

Comparison of minithoracotomy and conventional sternotomy approaches for valve surgery.

OBJECTIVE: To compare patients undergoing valve surgery through a minithoracotomy approach with a matched group undergoing conventional valve surgery. DESIGN: Control study. SETTING: University hospital, single center. PARTICIPANTS: Forty-one consecutive patients scheduled for valve surgery by minithoracotomy approach were matched with a similar group of patients operated on by the sternotomy approach. INTERVENTIONS: Criteria for matching included type of valve procedure (aortic valve replacement or mitral valve repair), age, surgeons, and left ventricular function. Two surgeons performed the surgical procedures. Perioperative care was standardized for all patients. Operative and postoperative data were recorded. MEASUREMENTS AND MAIN RESULTS: The 41 pairs of patients were correctly matched, except for left ventricular function (n = 1). Twenty patients underwent mitral valve repair and 62 aortic valve replacement. Preoperative demographic data and clinical characteristics were similar in both groups. Cardiopulmonary bypass, aortic clamping, and surgery times were longer in the minithoracotomy group (p < 0.05). In 3 patients, the minithoracotomy approach had to be converted into a sternotomy during the surgical procedure for better visualization. Minithoracotomy patients had significantly increased postoperative total blood loss (p < 0.05). No difference was found between the groups for extubation time and intensive care or in-hospital lengths of stay. CONCLUSION: These results suggest that valve surgery is feasible in many cases through minithoracotomy. Nevertheless, this approach increases surgical complexity and in this comparative study no significant benefit was shown.