Surgical Aortic Valve Replacement (SAVR)
Patient phenotype
Severe aortic stenosis (AVA < 1.0 cm², peak gradient > 40 mmHg) or aortic regurgitation. Typically 70-85, often with CAD, HTN, AF. May have syncope, angina, or CHF as presenting symptom.
Procedure
Median sternotomy + cardiopulmonary bypass + aortic cross-clamp + cardioplegia. Native valve excised, mechanical or bioprosthetic valve sewn in place. ~3-4 hours.
Anesthetic plan
GETA. TEE essential — pre-bypass valve assessment, post-bypass valve function + LV. Smooth induction critical (AS is preload + afterload + rate sensitive). Inotropic support often needed coming off bypass.
Setup
- ·5-lead ECG with ST analysis
- ·Pre-induction radial A-line + femoral A-line (backup)
- ·Multi-lumen central line (RIJ Cordis or MAC)
- ·PA cath OR TEE (most centers use TEE)
- ·Two large-bore PIVs
- ·Cell saver
- ·Pacing wire setup (often need temp pacing post-bypass)
- ·Inotrope infusions: epi + milrinone + NE drawn ready
Biggest concerns by phase
Severe AS physiology — the dangerous quartet
Hypotension is catastrophic in severe AS — fixed cardiac output cannot increase to compensate. Avoid: tachycardia (↓ diastolic filling time), bradycardia (↓ CO), hypotension (↓ coronary perfusion), volume loss (preload-dependent). Goal: maintain SR, normal HR (60-80), MAP > 70, normovolemia.
Slow, careful induction — MAC alone, no propofol bolus
Induction is the highest-risk moment. Pre-place A-line awake. Etomidate 0.1-0.2 mg/kg + fentanyl 5-10 mcg/kg + lidocaine 1 mg/kg + rocuronium 1 mg/kg. NO propofol bolus (sudden vasodilation = death in severe AS). Have phenylephrine drawn for any drop.
Cardioplegia + aortic cross-clamp time
Surgeon clamps aorta, infuses cold cardioplegic solution to arrest heart. Cross-clamp time matters — longer = more myocardial stunning post-bypass. Maintain cardioplegia delivery + temperature, monitor K (cardioplegia is high-K, may need correction).
Coming off bypass — TEE-guided valve function check
TEE assesses: valve seating (no paravalvular leak), valve gradients (acceptable for prosthetic type), LV function (often stunned, may need inotrope), residual air (left atrial appendage de-airing), wall motion (RWMA = ischemia).
Post-bypass conduction issues + pacing
AVR commonly causes: AV node injury (close proximity to non-coronary cusp) → heart block, requires pacing wires. Persistent AF possible. Have temporary pacer set up. Inotrope choice: epi + milrinone for combined inotropy + lusitropy.
ICU intubated — anticoag for mechanical valve, watch for bleeding
Mechanical valve = lifelong anticoagulation (warfarin INR 2.5-3.5 typically). Bioprosthetic = ASA only. Direct to ICU intubated overnight, awakening + extubation per ICU protocol. Watch chest tube output > 200 mL/hr (return to OR), hemodynamic stability, arrhythmias.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your AVR patient has severe AS, AVA 0.7 cm², EF 55%, on no inotropes pre-bypass. After cross-clamp release, you wean to 0.5 L/min on bypass. Patient cannot maintain CI > 1.8 even on epi 0.1 mcg/kg/min + milrinone 0.5 mcg/kg/min. TEE shows septal hypokinesis. What's your differential and plan?
What an examiner probes for
- ▹Differentiate: stunned LV (recovery after rewarming + inotrope time), incomplete revascularization, valve issue (paravalvular leak), tamponade, pneumothorax
- ▹Increase inotropy: titrate epi up, consider levosimendan if available
- ▹Volume status check via TEE
- ▹Decision: continue weaning vs. go back on for repair if structural issue
- ▹Consider IABP if persistent
Sources
- Kaplan Cardiac Anesthesia 8e
- STS AVR Guidelines
- ACC/AHA Valve Guidelines
Anatomy reference
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