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    Abstract
   Introduction
    Prostheses and I...
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   Postoperative Course
   Conclusion
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Table of Contents
REVIEW ARTICLE  
Year : 2012  |  Volume : 15  |  Issue : 1  |  Page : 54-63
Anesthetic management of transcatheter aortic valve implantation


Department of Cardiothoracic and Vascular Anaesthesia, Istituto Scientifico San Raffaele, Milan, India

Click here for correspondence address and email

Date of Submission15-Jul-2011
Date of Acceptance03-Dec-2011
Date of Web Publication5-Jan-2012
 

   Abstract 

Transcatheter aortic valve implantation (TAVI) is an emergent technique for high-risk patients with aortic stenosis. TAVI poses significant challenges about its management because of the procedure itself and the population who undergo the implantation. Two devices are currently available and marketed in Europe and several other technologies are being developed. The retrograde transfemoral approach is the most popular procedure; nevertheless, it may not be feasible in patients with significant aortic or ileo-femoral arterial disease. Alternatives include a transaxillary approach, transapical approach, open surgical access to the retroperitoneal iliac artery and the ascending aorta. A complementary approach using both devices and alternative routes tailored to the anatomy and the comorbidities of the single patient is a main component for the successful implementation of a TAVI program. Anesthetic strategies vary in different centers. Local anesthesia or general anesthesia are both valid alternatives and can be applied according to the patient's characteristics and procedural instances. General anesthesia offers many advantages, mainly regarding the possibility of an early diagnosis and treatment of possible complications through the use of transesophageal echocardiography. However, after the initial experiences, many groups began to employ, routinely, sedation plus local anesthesia for TAVI, and their procedural and periprocedural success demonstrates that it is feasible. TAVI is burdened with potential important complications: vascular injuries, arrhythmias, renal impairment, neurological complications, cardiac tamponade, prosthesis malpositioning and embolization and left main coronary artery occlusion. The aim of this work is to review the anesthetic management of TAVI based on the available literature.

Keywords: Anesthesia, aortic stenosis, transcatheter aortic valve implantation

How to cite this article:
Franco A, Gerli C, Ruggeri L, Monaco F. Anesthetic management of transcatheter aortic valve implantation. Ann Card Anaesth 2012;15:54-63

How to cite this URL:
Franco A, Gerli C, Ruggeri L, Monaco F. Anesthetic management of transcatheter aortic valve implantation. Ann Card Anaesth [serial online] 2012 [cited 2018 Dec 11];15:54-63. Available from: http://www.annals.in/text.asp?2012/15/1/54/91484



   Introduction Top


Aortic valve stenosis is the most common debilitating valvular heart lesion in adults. [1] Surgical aortic valve replacement is the treatment of choice for the vast majority of patients, but up to 30-40% of the patients are considered as having too high a risk for surgery and, hence, remain unreferred and untreated. [2] The size of this cohort is expected to increase in the next several years, reflecting the aging population and the improving therapeutic options in patients with multiple comorbidities and advanced medical conditions. Prognosis with medical management is poor, and effects of percutaneous balloon aortic valvuloplasty are modest and short lived. [3],[4],[5] Transcatheter aortic valve implantation (TAVI), a minimally invasive transcatheter technique, has been recently developed. The rationale is that of minimizing the overall surgical trauma by avoiding sternotomy, aortotomy, use of cardiopulmonary bypass (CPB) and by implanting the prosthesis on the beating heart, thereby avoiding cardiac arrest in order to improve postoperative patient outcome. [6] TAVI has become a rapidly evolving technique with a potential to create a paradigm shift similar to the introduction of percutaneous transluminal coronary angioplasty in the early 1980s. Nevertheless, according to the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) position statement, TAVI should be restricted only to high-risk patients or those with contraindications for surgery, and specific perioperative management issues should be considered for the safe implementation into routine clinical practice. [7]

We reviewed all available literature published in Pubmed till March 2011 that addressed the anesthetic management of TAVI.


   Prostheses and Implantation Techniques Top


Two devices are currently available and marketed in Europe: the balloon-expandable Edwards SAPIEN valve, based on Cribier's design (Edwards SAPIEN, Edwards Lifesciences, Irvine, CA, USA) [Figure 1] and the self-expanding CoreValve ReValving System (CoreValve ReValving Technology Medtronic Inc., Minneapolis, MN, USA) [Figure 2]. Several other technologies are being developed and have entered or are expected to enter an active phase of clinical testing in the near future. Implantation of both the Edwards SAPIEN and the CoreValve is usually performed with the transfemoral approach, which requires a transfemoral artery access, negotiation of femoral, iliac and aortic vasculature, retrograde crossing of the aortic valve and retrograde valve deployment within the native aortic valve. Deployment may be performed by a balloon inflation under rapid ventricular pacing (RVP) (Edwards SAPIEN) [Figure 3] or slowly retracting the outer sheath without RVP (CoreValve) [Figure 4].
Figure 1: Edwards SAPIEN TX. Edwards SAPIEN, Edwards Lifesciences, Irvine, CA, USA

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Figure 2: CoreValve Prosthesis. CoreValve ReValving Technology Medtronic Inc., Minneapolis, MN, USA

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Figure 3: Novaflex Edwards delivery system. Edwards SAPIEN, Edwards Lifesciences, Irvine, CA, USA

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Figure 4: CoreValve ReValving Technology Medtronic Inc., Minneapolis, MN, USA

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Despite progressive miniaturization of the sheaths of both devices, the transfemoral approach may not be feasible in patients with significant aortic or ileo-femoral arterial disease. The transaxillary approach (Tax-TAVI) is feasible with the CoreValve, and is usually performed via surgical isolation and direct puncture of the left axillary artery. [8,9] The presence of a patent left internal mammary artery (LIMA) graft is a relative contraindication to the use of this approach because of the risk of occlusion or dissection. In the TA-TAVI, access to the left ventricular cavity is typically obtained through a small anterolateral thoracotomy. [10],[11] The risk of lung injury, pneumothorax or pleural bleeding associated with the TA seems low. Chest wall discomfort and potential for respiratory compromise and prolonged ventilation are a major concern, especially in patients with severe respiratory dysfunction. Postprocedural low-grade bleeding might result in cardiac tamponade and may require further repair, whereas management of large tears might require institution of CBP. The theoretical lower risk of stroke (less manipulation in the aortic arch in comparison with the transfemoral approach) has not been a universal finding. A complementary approach using both CE-approved devices and alternative routes tailored to the anatomy and the comorbidities of the single patient is a main component for the successful implementation of a TAVI program. [12],[13] Alternatives to transfemoral access include open surgical access to the retroperitoneal iliac artery and the ascending aorta. [14] The continued efforts to downsize devices will further enhance suitability for TAVI while reducing the risk of periprocedural complications [Table 1].
Table 1: Procedural approaches, anaesthetic techniques and possible complications of transcatheter aortic valve implantation

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   Preoperative Evaluation Top


Risk assessment is important as the current indication is restricted to high surgical risk or nonoperable patients. Appropriate patient selection and screening is crucial for success and for avoiding complications. The best characterization of individual risk should be a combination of objective quantitative predictive models (Europen System for Cardiac Operative Risk Evaluation [EuroSCORE] and the Society of Thoracic Surgeon [STS]) and subjective assessment by experienced surgeons, cardiologists and anesthesiologists. [15],[16] Patients are excluded if a reasonable quality or duration of life (>1 year) is considered unlikely because of comorbidities. Besides comorbidities, older age "per se0" raises several anesthetic concerns related to the major frailty. Patient's preference for a percutaneous approach cannot be considered an indication for TAVI when the surgery is an option.

Although specific guidelines about antiplatelet therapy are not still available for TAVI, the common practice is to administer a loading dose of asprin ranging from 300 mg to 325 mg and clopidrogel 300 mg before the procedure. In the postoperative period, the dual antiplatelet therapy is continued at a daily dose of 75-100 mg of aspirin and clopidrogel 75 mg for 6 months consecutively. However, several instituitions differ from this policy.

To minimize the risk for renal impairment, a correct preprocedural hydration and N-acetylcysteine can be administered the day before the TAVI.

The antihypertension drugs, including angiotensin-converting enzyme inhibitors, should be administrated until the day of the procedure. On the contrary, the antiarrythmic drugs should be discontinued.

Careful evaluation of the iliofemoral vessels by angiography and high-quality computed tomography (CT) is indispensable as vascular injury is the most common cause of morbidity and mortality in these procedures. [17] The relation among the annulus, plaque in the left coronary leaflet and the distance to the left coronary ostium is crucial.


   Anesthetic Management Top


The anesthesiologist has to take a participative role in developing monitoring and standards of care in the catheterisation laboratory. The catheterisation laboratory has to be stocked with additional equipment and drugs that the anesthesiologists typically require to manage difficult airways and hemodynamically unstable patients. Ideally, all procedures should be performed in a hybrid operation theater, i.e. a standard operative room with an additional angiography system. [18],[19]

Patients are commonly monitored with five-electrodes EKG, pulse oxymetry, urinary catheter, bladder temperature and arterial and central venous lines. [20] Two external adhesive defibrillator pads are attached. Pulmonary artery catheterization is reserved to specific situations, such as left ventricular dysfunction and/or pulmonary hypertension. A large bore (14 G) peripheral intravenous line is usually inserted at the very beginning. Minimally invasive monitoring devices may be ideal in this setting, but pitfalls of these kinds of monitoring must be kept in mind, particularly those due to typical aortic stenosis waveform contour. Patients suffering from chronic cerebral vasculopathy or those at risk for neurological events may benefit from noninvasive cerebral monitoring. Periprocedural transesophageal echocardiography (TEE) during TAVI may provide useful information beyond X-ray fluoroscopy about the results of balloon valvuloplasty and the position of the prosthetic valve [Figure 5] and [Figure 6]. Moreover, it may identify procedure-related complications. TEE is of particular value when valve calcification is mild and fluoroscopic imaging is difficult [Figure 7]. However, it is sometimes limited in its ability to clearly distinguish the prosthesis while mounted on the balloon catheter, may interfere with fluoroscopic imaging, necessitating probe withdrawal at the time of implantation, and may increase the operator's preferences for general anesthesia. Newer modalities, including intracardiac and three-dimensional echocardiography, and CT angiography may further assist these procedures. Guarracino et al. recently described three cases during which TEE was performed passing the probe through a hole in a NIV face mask on deep sedation [Figure 8]. [21]
Figure 5: Midesophageal aortic valve long-axis view of an implanted CoreValve Prosthesis

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Figure 6: Midesophageal aortic valve long-axis view of an implanted Edwards SAPIEN-XT prosthetic valve

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Figure 7: Midesophageal aortic valve long-axis view of a calcific aortic valve

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Figure 8: Interventional setting. The transesophageal echocardiography probe passing through a hole on the anterior part of the mask. Guarracino et al., Eur J Echocardiogr. 2010;11:554-6. For permissions: Dr Fabio Guarracino, Cardiothoracic Department University Hospital of Pisa, Italy

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Notably, TAVI procedures are accomplished with the aid of angiography as the primary imaging technique, and several contrast injections are often required. Recently, Bagur et al. demonstrated that TEE used as primary imaging is associated with the same clinical and hemodynamic results as angiography-guided procedures. [22] A recent experience during transapical valve implantation without angiography has been reported by Ferrari. [23]

Hemodynamic stability is the main objective of anesthetic management during TAVI. Goals of hemodynamic management are those typical of aortic stenosis. Preload augmentation by means of intravenous fluid administration is often necessary to maintain an adequate preload to a hypertrophied left ventricle. Low heart rates (50-70 beats/min) have to be preferred to rapid heart rates (greater than 90 beats/min) to allow adequate diastolic filling time, and sinus rhythm should be maintained. [24] Supraventricular arrhythmias and ventricular ectopy should be managed aggressively. Hypotension should be treated early with α -adrenergic agonists. Moreover, TAVI poses significant specific periprocedural challenges. During aortic valve ballooning and balloon prosthesis implantation, a transient partial cardiac standby is induced. At present, RVP is the preferred method to achieve this purpose. RVP permits temporary reversible cessation of cardiac output for optimal conduct of balloon valvuloplasty and aortic valve deployment. [25] This is essential during aortic valve deployment to prevent malposition and embolization of the prosthesis. A reduction of systolic arterial pressure to below 60 mmHg is considered adequate. RVP is a key feature of the procedure and needs full attention and communication by the anesthesiologist and the entire team. The patient's hemodynamic response to rapid ventricular pacing initiation and termination is important. If initial pacing wire testing or valvuloplasty creates severe or prolonged hypotension during and after rapid ventricular pacing, the patient may require a larger bolus of a vasopressor before the subsequent pacing period. In fact, the increase of the mean arterial pressure (MAP) before starting RVP seems to be logical to avoid significant hypotension. [26],[27]

Anesthesia techniques for TAVI may vary according to patient's characteristics, coexisting diseases and procedural instances. The aim of the anesthesiologist should be to provide less-invasive anesthesia/analgesia without compromising the safety or comfort of the patient. Local anesthesia plus sedation is a reliable alternative to general anesthesia. General anesthesia is associated with good hemodynamic stability, cardioprotective properties, adequate attenuation of stress response and early awakening. Airway management is usually performed by endotracheal intubation. General anesthesia facilitates positioning of the valve prosthesis by maintaining patient immobility and neuromuscular paralysis allows the anesthesiologist to control respiratory motion. General anesthesia may be more favorable when the patient is unable to tolerate the operation secondary to fatigue or having to maintain the same position through the entire procedure. Second, general anesthesia facilitates introducer sheath placement and removal and eventual surgical repair of arterial access sites, which can be potentially complicated and prolonged. Third, it allows the use of TEE and facilitates management of procedural complications. On the other hand, general anesthesia is associated with potential respiratory complications. [28] However, the use of general anesthesia is closely related to the operator's learning curve. A possible protocol for the local anesthesia plus sedation consists of lidocaine injected subcutaneously at the arterial and venous access sites (maximum dose 4 mg/kg), with sedation accomplished with remifentanil infusion adjusted according to the patient's response (target level: score 2-3 with modified Wilson sedation scale; starting dose 0.025 μg/kg/min, maximum dose 0.2 μg/kg/min). [29] Combined use of remifentanil and propofol (dose 2-5 mg/kg/h) may be used. However, the invasiveness of the procedure and the difficult to achieve a stable hemodynamic are the major limitations to the widespread use of sedation. [30] The passage of relatively large and stiff deployment catheters through the arteries is well tolerated with local anesthesia. A preoperative ilioinguinal/iliohypogastric block can be performed to reduce the total dose of infiltration local anesthetics in patients with reduced metabolic capacity, at increased risk for neurologic and cardiac toxicity. If local anesthesia plus sedation is employed, the anesthesiologist must be ready to institute full general anesthesia at any moment. Patients with anticipated difficult airway are obviously unsuitable for this technique. With TA-TAVI, the general anesthesia is mandatory. However, Mukherjee et al. have recently suggested the use of thoracic epidural anesthesia. [31] Epidural anesthesia presents three major advantages: (1) the avoidance of intubation, (2) a good postoperative analgesia and (3) the chance to perform a fast-track. On the other hand, epidural anesthesia carries its own set of problems. In fact, hypotension may lead to myocardial ischemia. A second concern is the intraoperative use of heparin and the postoperative use of dual antiplatelet drugs.

In case of Tax-TAVI, general anesthesia or local anesthesia plus sedation can be performed. Superficial cervical plexus block with ropivacaine 0.75% (maximum dose 4 mg/kg) in addition to local infiltration has also been reported. [31],[32]


   Complications Top


Rapid ventricular pacing

While RVP is advantageous for valve positioning, the combination of rapid heart rate, myocardial hypertrophy and low coronary perfusion pressure produces an ischemic deficit in the myocardium. In most cases, this ischemic deficit is well tolerated, most likely because of the brief duration of the RVP (12 s on average). However, it is prudent to minimize the number and duration of rapid pacing episodes during the procedure, and allow hemodynamic recovery before further pacing. A bolus dose of a vasopressor, such as etilephrine administered just prior or immediately after the rapid pacing episode, will allow coronary perfusion pressure to be regained sooner. [26],[27],[32] If the blood pressure does not recover promptly after an episode of RVP, myocardial ischemia must be suspected. The ischemic insult is usually caused by pacing, but coronary artery embolism from disruption of the calcified native aortic valve or obstruction of one or both coronary ostia by the prosthetic valve or the displaced native valve leaflets must be considered. Treatment of postpacing myocardial ischemia is initially based on the restoration of coronary perfusion pressure through the use of vasopressor agents. In case of ischemia-induced ventricular fibrillation during valve deployment, consideration should be given to complete valve deployment before electrical cardioversion thus avoiding prosthesis malpositioning or embolization when sinus rhythm is restored. If the hemodynamic status fails to improve and the valve has not yet been deployed, the deployment of the prosthesis is the next step in management. [27] The main benefit of valve deployment is that it reduces left ventricular afterload, ventricular wall tension and myocardial oxygen demand as well as improving cardiac output.

Atrioventricular block

Percutaneous aortic valve implantation with the CoreValve prosthesis results in a high incidence of total atrioventricular (AV) block requiring permanent pacemaker implantation and new-onset left bundle branch block. Preexisting disturbance of cardiac conduction and a narrow left ventricular outflow tract predict the need for permanent pacing, while the only factor shown to be predictive for new-onset left bundle branch block is the depth of prosthesis implantation. No significant recovery of an intra- or periprocedural AV block is reported. Therefore, pacemaker (PM) implantation immediately after occurrence within the first 24-48 h is frequently employed. The conduction tissue impairment is provoked by mechanical compression with large prostheses in smaller annuli or in the larger area of the CoreValve covering the outflow tract. The AVA trioventricular block can appear suddenly during the implantation procedure or later during the postoperative period. In fact, a continuous postoperative electrocardiogram monitoring should be performed for at least 3 days in all patients after TAVI procedures and until discharge in patients with increased risk for this complication. The need of PM is four-times higher in the CoreValve implantation compared with the Edward Sapient implantation. To prevent periprocedural AV block during TF-AVI or Tax-TAVI, the transvenous pacemaker should be placed in the jugular or femoral vein, while during TA-TAVI, direct epicardial electrodes are placed. Because arrhythmias, especially AV block, may occur after the procedure, several centers maintain transvenous pacing in the intensive care unit.

Vascular complications

Vascular complications are a major threat during or immediately following the course of TAVI. A steady loss of blood through the valved sheath may be appreciated when catheters or wires in the vessels compromise the valve closure. [33],[34] A sudden unexplained decrease in blood pressure, particularly on decannulation, should alert to the possibility of a major vascular rupture. Rapid therapeutic management with adequate equipment preparation and peripheral skills is mandatory. Blood loss may not be readily apparent, as significant volumes may be lost retroperitoneally, but it is easily detected by contrast aortography. An occlusion balloon may be deployed proximal to the perforation to attenuate the hemorrhage, and vigorous volume resuscitation with fluid and blood products may be required in addition to the use of vasopressor agents to maintain coronary perfusion. Usually, an arterial guide wire is left in situ during the decannulation process so that if a vascular damage occurs, the defect may be immediately fixed endoluminally without the need for open surgery. Some tips in order to reduce arterial injuries are: (1) reject patients with poor access, (2) reject patients with poor angiograms, (3) advance sheath to aorta, (4) suture sheath in place, (5) watch out for sheath tip injury to aorta, (6) watch out for catheter trauma, (7) consider angio at time of sheath removal and (8) pull sheath out as soon as possible. The TA-TAVI carries its own set of complications related to thin and friable cardiac muscle. Hemostatic control of the apex is a critical step during TA-TAVI and may lead to severe bleeding complications requiring cardiopulmonary support, sternotomy or re-exploration. Another less-frequent complication after TA-TAVI is the development of an apical pseudoaneurysm. [35],[36]

Aortic regurgitation, malpositioning and embolization

Mild-to-moderate aortic regurgitation, mostly paravalvular, is observed in 50% of the cases. However, the availability of larger prostheses and their careful matching with the size of the aortic annulus have led to a decrease in the incidence of severe aortic regurgitation to 5%. [33] Trivial paraprosthetic regurgitations are generally associated with a favourable outcome. However, more severe paraprosthetic regurgitations might cause hemodynamic deterioration, left ventricular remodeling or hemolytic anemia, or require reintervention. Further dilatation of the valve stent and valve-in-valve procedures have been suggested, but a severe periprosthetic aortic regurgitation with cardiogenic shock may require emergent surgery. Significant paravalvular aortic regurgitation might be related to undersized prosthesis, malpositioning of the device, the presence of heavily calcified aortic cusps of the native valve or a bicuspid valve. [37],[38],[39],[40]

Except for premature stopping of rapid pacing during valve deployment, valve embolization has mostly surgical reasons, such as not completely inflating the balloon, too aggressive predilation and possible undersizing of bioprosthesis (annulus too large) or an excessive force applied too close to the balloon during deployment. If bioprosthesis embolizes and there is inability to reposition it in the correct location, additional expansion of the balloon, enough to grab and reposition in stable location, preferably the descending aorta, is requested. In the event of ventricular embolization and inability to correct valve position, conversion to open heart surgery is the only chance.

Left main coronary artery occlusion

During TAVI, the reasons for the impaired coronary flow or the complete occlusion of the coronary orifice with consecutive fatal myocardial infarction are: (1) obstruction by the native valve leaflets folded upwards and compressed against the coronary orifice and (2) direct occlusion by parts of the valved stent. Appropriate interventional cardiology skills and set-up are critical to gain a favorable outcome in these cases. In this setting, it is crucial to consider the use of mechanical-assist devices (intra-aortic balloon pump, extra-corporeal membrane oxygenation) that must be available and ready to be placed in function during these procedures. To lower the left main coronary artery occlusion risk, careful attention must be paid to aortogram, TEE and coronary angiogram prior to valve implantation. When the transaxillary approach is chosen as the unique feasible route of implantation, the presence of a patent left mammary graft represents an additive challenge, and particular attention must be given to the risk of subclavian dissection. [11],[21]

Cardiac tamponade

Cardiac tamponade causing cardiovascular collapse may result from perforation of the right ventricle during the pacing wire placement and aortic or left ventricular perforation by guidewires or catheters. Wrong aortic annulus sizing may lead to annular rupture during valve deployment with catastrophic consequences. If tamponade occurs, it is easily detected by an associated increase in central venous pressure, visualization of the pericardial fluid and right-sided collapse on TEE and abnormal movement of the heart on fluoroscopy. The management may consist of percutaneous needle drainage of the pericardial blood or surgical intervention.

Acute renal failure

The etiology of renal failure after TAVI recognizes a combination of multiple factors either patient-related (arteriopathy, hypertension, physiological age-related decline in nephron mass, presence of preexisting renal dysfunction and diabetes) or procedure-related (contrast media injection, debris embolization and several hypotension phases). When TAVI is not one of the mechanisms involved in the genesis of acute kidney injury (AKI, it is frequently associated with an improvement of renal function. [41],[22] Hypertension, chronic obstructive pulmonary disease history and, finally, the number of blood transfusions were identified by Bagur et al. as strong independent predictors of postoperative AKI (defined according to RIFLE criteria) in patients undergoing TAVI. [42],[43]

The prophylactic strategies of the renal function preservation during TAVI are: (1) avoidance of nephrotoxic insult reducing the amount of contrast media, (2) prevention or reversibility of the renal hypoperfusion supporting the renal perfusion pressure and (3) the avoidance of unnecessary blood transfusions. [44]

Neurological complications

Almost 4.5% of the patients undergoing TAVI suffer a major neurological event such as stroke. [45] Notably, the occurrence of intraprocedure major stroke is generally fatal and strictly associated with an increased mortality. Ghanem et al. observed in patients undergoing transfemoral aortic valve implantation that permanent neurological events are relatively rare (3.6%) compared with the rate of clinically silent embolism (73%) assessed by cerebral diffusion-weighted magnetic resonance imaging (DW-MRI). [46] These data are confirmed by Arnold et al. in a cohort of 25 patients scheduled for transapical aortic valve implantation. [47] The cerebral hypoperfusion and the cerebral embolization look to be involved in the postoperative neurological dysfunction.

In conclusion, the only approaches able to significantly reduce the embolic risk include preprocedural screening for friable aortic atheroma, more attention to a gentle passage of catheters through the aortic arch, the use of embolic protection devices and, finally, the use of a lower profile with less-traumatic transarterial catheters.


   Postoperative Course Top


At the moment, an attempt to deliver anesthesia that is compatible with enhanced recovery is made in most patients. The poor left ventricle function is not an absolute contraindication to fast track if the hemodynamic stability is maintained during the procedure. Postoperative pain has been easily managed with nonsteroidal agents/paracetamol and low dose of opioids. According to each center organization, after a brief time in the recovery room, an early transfer to an intermediate care unit provided with bedside telemetry could be a suitable alternative strategy in selected patients with an uneventful operative course. After valve implantation, an immediate improvement of systolic and diastolic function is frequently observed due to afterload lowering, allowing reduction and discontinuation of inotropic drugs given during the procedure. Continuous postoperative electrocardiogram monitoring should be performed for at least 48 h in all patients after TAVI procedures because of the potential for new onset of rhythm disturbances. Temporary pacemaker is usually left to prevent cardiac arrest in all patients with AV block. Pressure control must be frequent and precise.


   Conclusion Top


In conclusion, TAVI is a novel technique developed to deal with an increasing risk profile of patients with aortic stenosis. The technique has been proven to be feasible in selected high-risk patients, representing a unique challenge for the anestesiologist involved in the care of these patients. Anesthesiologists must be aware of current technology, playing a participative role in developing standards of care for these high-risk patients and supporting the continuous refinement toward a more minimally invasive approach.

 
   References Top

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DOI: 10.4103/0971-9784.91484

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