Transcatheter Aortic Valve Replacement

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Transcatheter Aortic Valve Replacement Andrej Alfirevic, MD, Anand R. Mehta, MD, Lars G. Svensson, MD Anesthesiology Clinics Volume 31, Issue 2, Pages 355-381 (June 2013) DOI: 10.1016/j.anclin.2012.12.004 Copyright © 2013 Terms and Conditions

Fig. 1 Six different approaches used for transcatheter aortic valve replacement (TAVR) with a stent-valve. (A) Retrograde transfemoral arterial approach from femoro-iliac vessels. (B) Antegrade left ventricular transapical approach via anterolateral mini-thoracotomy. (C) Antegrade transfemoral venous approach, used during initial experience. (D) Retrograde transaortic approach via mini–anterior thoracotomy. (E) Retrograde trans-subclavian artery approach via surgical cut-down. (F) Retrograde trans-axillary artery approach via percutaneous Seldinger method. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 2 Edwards SAPIEN aortic valve prosthesis. The prosthesis is crimped onto the expandable balloon and positioned via the retrograde arterial approach at the level of the aortic valve annulus. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 3 CoreValve aortic valve prosthesis. This valve is self-expandable, with 2 anchoring points at the annulus and the sinotubular junction. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 4 Catheterization laboratory modified for the purpose of performing the TAVR procedure. Note the location of the anesthesia equipment and its relationship with the patient’s table, floor-mounted biplane fluoroscopy machine, and positioning of the rest of the multidisciplinary team members. ARKS, Anesthesia Record-Keeping System; IV, intravenous. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 5 Hybrid operating room and location of the anesthesia equipment, and its relationship with the patient’s table and single-plane fluoroscopy machine coming in from the patient’s right-hand side. LIJ, left internal jugular; PAC, pulmonary artery catheter; TEE, transesophageal echocardiography. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 6 Mid-esophageal long-axis view depicting properly positioned balloon (arrow) during the act of valvuloplasty. Note the electrocardiogram tracing during the rapid ventricular pacing. LA, left atrium; LV, left ventricle; AV, aortic valve. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 7 Mid-esophageal long-axis view depicting properly positioned Edwards SAPIEN stent-valve before deployment. The stent-valve is positioned approximately 50/50 at the annulus. The measurement represents the length of the stent-valve (≈16 mm for the 26-mm size valve). Note the difficulty of 2-dimensional echocardiography in depicting accurate coaxial alignment between the axis of crimped stent-valve and left ventricular outflow tract axis/aortic valve axis. Also note the shadowing of the anterior aortic valve annulus by the deployment device and stent-valve, representing potential difficulty in positioning of the stent-valve perpendicular to the annulus. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 8 Two orthogonal mid-esophageal (LAX, long-axis; SAX, short-axis) views with color-flow Doppler depicting the paravalvular insufficiency after stent-valve deployment. Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions

Fig. 9 Mid-esophageal short-axis view of the aortic valve with a color-flow Doppler demonstrating area percentage measurements of the paravalvular insufficiency jets compared with the stent-valve circumferential area. Note the multiple paravalvular jets with crescent-shaped irregular origin. The calculated ratio of measures areas is greater than 20%, suggesting moderate paravalvular insufficiency. Treatment options will include reexpansion and/or deployment of the second stent-valve (valve-in-valve). (Modified from Bloomfield GS, Gillam LD, Hahn RT, et al. A practical guide to multimodality imaging of transcatheter aortic valve replacement. JACC Cardiovasc Imaging 2012;5:441–55, with permission.) Anesthesiology Clinics 2013 31, 355-381DOI: (10.1016/j.anclin.2012.12.004) Copyright © 2013 Terms and Conditions