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Ibrahim Sultan, MD, FACS, FACC
Center for Thoracic Aortic Disease and Center for Aortic Valve Disease
The management of aortic stenosis has evolved dramatically over the past several decades. After John Ross and Eugene Braunwald presented their seminal work in 1968, it became clear to cardiologists and surgeons that the natural history of symptomatic patients with aortic stenosis is predictable and poor without intervention.1 This led to a significant increase in the trend of surgical aortic valve replacement (SAVR), with advancement in surgical techniques and prostheses. This was accompanied with a substantial decrease in mortality and morbidity with SAVR prior to the introduction of transcatheter aortic valve replacement (TAVR) in the mainstream.2 The introduction of TAVR as a technique and its procedural success, as demonstrated in trials for patients who are extreme risk, high risk, and, to some extent, intermediate risk for surgery, has led to an exponential increase in its use. As techniques for TAVR have been refined over the past several years, the focus has shifted to patient selection, periprocedural management, and ways to minimize the complications that are associated with TAVR. Our team at UPMC has continued to be on the forefront of these issues to ensure the best care for our patients.
A 66-year-old woman with a history of severe symptomatic aortic stenosis and aortic regurgitation, chronic kidney disease, coronary artery disease (left main and ostial LAD), and chronic lung disease presented to UPMC Shadyside in heart failure with reduced ejection fraction. She had a history of Non-Hodgkin’s lymphoma and had undergone mantle radiation. She underwent a sternotomy in 2010 for constrictive pericarditis, at which point she was found to have a porcelain aorta. She was found to be at extreme risk for AVR CABG with a 17.3 percent STS predicted risk of mortality. After discussion in heart team and with the patient, she was offered TAVR with PCI. As is routine at UPMC for transfemoral TAVR, this procedure was performed under conscious sedation in the hybrid operating room. In light of her porcelain aorta and risk for stroke, a 6 French sheath was placed in the right radial artery to be utilized for a cerebral protection device. The right common femoral artery was utilized for valve delivery, and the left common femoral artery was utilized for diagnostic purposes. After systemic heparinization, a Sentinel® cerebral protection device (Clared Medical, Santa Rosa, CA) was inserted via the right radial sheath into the ascending aorta. The proximal filter was deployed in the innominate artery and the distal filter in the left carotid artery with success. A balloon expanding valve was successfully placed under rapid pacing. This was followed by coronary angiography to identify the left main and the ostial LAD lesions. PCI of the left main and the ostial LAD was performed with good result. She was transferred toa telemetry floor after recovering in the postanesthesia care unit (PACU) and was discharged two days after surgery.
The TAVR team at UPMC has continued to concentrate on multiple procedural facets to ensure a decrease in morbidity in the postoperative period. The use of conscious sedation has been found to be associated with a shorter length-of-stay and lower in-hospital mortality after TAVR.3 However, this was only utilized in 15 percent of patients across TAVR sites around the country. We had recognized the potential of this simple but effective technique for TAVR, and have used conscious sedation in over 90 percent of transfemoral TAVRs over the past three years. The ability of our anesthesia team to be able to do this without significant narcotics, along with ilioinguinal blocks performed in the operating room, has helped significantly with pain scores and time-to-recovery and ambulation in the PACU.4 This also has kept our conversion to general anesthesia rate well below the national average. Discharge the day after surgery has been the default plan for most outpatients undergoing TAVR as long as it is medically appropriate. The length-of-stay has decreased significantly over the past three years and continues to be consistently between one to two days of inpatient stay post-TAVR. Readmissions continue to be a cause of concern, and patients are closely monitored by our lead nurse practitioner (NP), Lisa Henry, along with her team to ensure appropriate screening and management at home to minimize visits to the emergency department.
The ability to perform most TAVRs under conscious sedation has allowed us to be vigilant about neurocerebral monitoring. Strokes continue to be a dreadful complication after TAVR that can lead to significant disability. Despite the stroke rate after TAVR being relatively low (3.3 percent in 2018), we continue to be aggressive about neurocerebral protection. The U.S. Food and Drug Administration (FDA) approval and availability of a cerebral protection device as described in our patient is used in select individuals who are considered to be at high risk for neurological events.
Finally, as Allegheny and surrounding counties are home to a significant number of patients over the age of 65 (15 to 19 percent), peripheral vascular disease is commonly seen, as is expected in elderly patients. Despite a low incidence of vascular complications from access-related techniques, we continue to offer patients alternative access TAVR, particularly with the use of the subclavian artery. We have had one of the largest experiences with subclavian access and have shown that postoperative morbidity and mortality are no different in patients undergoing subclavian TAVR versus transfemoral TAVR.5,6
The patient presented above would have had to undergo an ascending aortic replacement with circulatory arrest apart from an AVR CABG to achieve the same objective, which she may not have tolerated as well as her TAVR PCI because of her significant deconditioning and her multiple comorbidities. However, because of lack of durability and follow-up data (> 10 to 15 years) with transcatheter valves, patients should be adequately counseled by an experienced heart team prior to offering TAVR as a treatment modality.
1. Ross J Jr, Braunwald E. Aortic Stenosis. Circulation. 1968; 38(1)(suppl): 61-67.
2. Barreto-Filho JA, Wang Y, Dodson JA, et al. Trends in Aortic Valve Replacement for Elderly Patients in the United States, 1999-2011. JAMA. 2013; 310(19): 2078-2085.
3. Hyman MC, Vemulapalli S, Szeto WY. Conscious Sedation Versus General Anesthesia for Trans-- catheter Aortic Valve Replacement: Insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circulation. 2018; 136(22): 2132-2140.
4. Bianco V, Gleason TG, Kilic A, et al. Open Surgical Access for Transfemoral TAVR Should Not Be a Contraindication for Conscious Sedation. J Cardiothorac Vasc Anesth. 2018 May 26. pii: S1053-0770(18)30369-0.
5. Gleason TG, Schindler JT, Hagber RC, et al. Subclavian/Axillary Access for Self-Expanding Transcatheter Aortic Valve Replacement Renders Equivalent Outcomes as Transfemoral. Ann Thorac Surg. 2018; 105(2): 477-483.
6. Cardounel A, Gleason TG, Lee JS, et al. Surgical Cut Down for Vascular Access With Conscious Sedation for Transcatheter Aortic Valve Replacement: The Best of Both Worlds? Interact Cardiovasc Thorac Surg. 2018; 27(4): 494-497.