TAVR (Transcatheter Aortic Valve Replacement)
Patient phenotype
Severe AS with high surgical risk (STS score > 8% historically; expanding to intermediate + low risk). Typically 75-95, multi-comorbid, often deemed too sick for SAVR. Outpatient or 1-night admission becoming common.
Procedure
Hybrid OR or cath lab. Transfemoral (most common) or transapical / subclavian / axillary access. Catheter-mounted bioprosthetic valve deployed across native AS. Rapid pacing (180-200 bpm) for valve deployment to immobilize heart. ~60-90 min.
Anesthetic plan
Modern trend: MAC + femoral nerve block + light sedation for transfemoral; GA reserved for transapical, complications, or patient unable to tolerate MAC. TEE for pre/post valve assessment.
Setup
- ·Standard ASA + 5-lead ECG
- ·Two large PIVs (one for blood, one for fluids)
- ·A-line — radial preferred, contralateral to femoral access
- ·Defibrillator pads (always — risk of VF on rapid pacing)
- ·Cardioversion paddles ready
- ·TEE if GA; TTE if MAC
- ·Cardiac surgery on standby (back-up SAVR if catastrophic)
- ·ECMO standby for high-risk cases
Biggest concerns by phase
Severe AS physiology — same as SAVR but you can't put them on bypass quickly
Maintain SR, normal HR, MAP > 70, normovolemia. Avoid rapid induction agents. Pre-position vasopressor. Patient must lie flat 60-90 min — verify they can tolerate.
MAC vs. GA tradeoff
MAC: faster recovery, less hemodynamic perturbation, allows neuro exam during procedure (stroke is 2-5% complication). Light midaz + minimal opioid + dex for sedation. GA: better TEE, immobile patient, pre-empt complications. Choose per institutional protocol + patient factors.
Rapid ventricular pacing for valve deployment
Cardiologist paces ventricle at 180-200 bpm to immobilize heart for 5-10 sec while valve deploys. Transient catastrophic hypotension. Pre-position phenylephrine bolus + vasopressin if needed. Monitor for sustained VF/VT post-pacing.
Stroke — neuro monitoring during MAC
Embolic stroke 2-5% incidence. Catheter manipulation in aortic arch dislodges atheroma. Cerebral oximetry helpful. Awake patient under MAC: ask them to talk + move during catheter manipulation. Sudden change → call cards + neuro.
Complications: paravalvular leak, AV block, vascular injury
Paravalvular leak (TEE-detected — surgeon may post-dilate). Heart block (AV node injury — temporary pacing wire often left in place 24-48h, sometimes permanent pacemaker). Vascular injury at femoral access (hematoma, perforation — vascular surgery).
Quick recovery if MAC, watch for delayed complications
MAC patients: out of cath lab in 30-60 min, walking same day. Watch for: vascular access bleeding, conduction abnormalities, delayed stroke. Most discharged POD 1-2.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
TAVR patient under MAC, transfemoral access. The cardiologist is about to do rapid ventricular pacing for valve deployment. You're aware BP at baseline is 130/70 on a phenylephrine 0.3 mcg/kg/min infusion. What do you anticipate and what do you do?
What an examiner probes for
- ▹Anticipates transient catastrophic hypotension during 5-10 sec of pacing
- ▹Pre-position: phenylephrine bolus 200 mcg drawn + given before pacing
- ▹Monitor for sustained arrhythmia post-pacing
- ▹Have epi + atropine + defibrillator ready
- ▹Communicate with cards — confirm pacing duration + valve deployment go-ahead
Sources
- ACC/AHA TAVR Guidelines
- Kaplan Cardiac Anesthesia 8e
- STS TVT Registry
Anatomy reference
Sourced reference images. 4 matches for "heart aorta valve catheter".
Browse the full image library →
