- Email: [email protected]
Anesthetic Management for a Patient With Transcatheter Mitral Valve Implantation
Anesthetic Management for a Patient With Transcatheter Mitral Valve Implantation Kazim Karaaslan, MD,* Ufuk Topuz, MD,* Mehmet Akif Vatankulu MD,† and Erdogan Ozturk MD*
M
ITRAL VALVE REDO OPERATIONS due to failing bioprostheses are known to be associated with high rates of morbidity and mortality. Transcatheter mitral valve implantation (TMVI) procedures in high-risk patients with severe mitral regurgitation have become a promising treatment option. We report a new transcatheter technique as an alternative to redo operations in patients with degenerative mitral valve bioprosthesis. There are a limited number of studies on the use of this technique. The main objective of the administration of anesthesia for TMVI application is to maintain hemodynamic stability. In this report, the authors present the anesthesia management of TMVI for a 79-year-old female patient with severe mitral valve regurgitation resulting from a degenerative mitral bioprosthetic valve. Although a standard method of anesthesia in this high-risk group of patients has not yet been established, the authors prefer general anesthesia because it provides airway safety in cases of pulmonary edema and facilitates the implementation of transesophageal echocardiography (TEE).
CASE REPORT A 79-year-old female patient was admitted to the authors’ hospital, complaining of dyspnea that had lasted for a month and increased over the last 5 days. The patient had an attack of acute rheumatic fever when she was 9 years of age. Mitral bioprosthetic valve replacement was performed in 2001 due to mitral stenosis, and 7 years later, aortic bioprosthetic valve replacement surgery was performed due to severe aortic stenosis, moderate aortic valve insufficiency, and pulmonary hypertension. In the preoperative imaging by transthoracic echocardiography, a maximum of 27 mmHg and mean of 14 mmHg gradients were observed on the mitral bioprosthetic valve. The patient underwent TEE evaluation, which confirmed the findings of the transthoracic echocardiography and added more information about the mitral bioprosthetic valve. The TEE results showed that one of the valve leaflets was deformed and entered into the left atrium. There was also severe mitral regurgitation (Fig 1). On the aortic bioprosthetic valve, a maximum of 25 mmHg and a mean of 15 mmHg gradients were observed. There were mild aortic regurgitation, moderate tricuspid regurgitation, and pulmonary hypertension (systolic pulmonary artery pressure: 80 mmHg), and her ejection fraction was 38%. The result of coronary angiography was normal. Furthermore, the older mitral bioprosthetic valve annulus was evaluated to determine the size of a new valve. After performing a three-dimensional (3D) TEE, a 26-mm valve was selected for implantation. Monitoring consisted of 5-channel electrocardiography, pulse oximetry, and noninvasive arterial pressure; 2 external defibrillator pads were attached to the patient’s chest. The first values observed on the catheterization table were blood pressure, 128/45 mmHg; heart rate, 104 beats/min (normal sinus rhythm); and SpO2, 95%. Oxygen was administered at 3 L/min via a face mask; 2 mg of midazolam and 50 mg of fentanyl were administered to the patient, and then arterial cannulation was performed in the right radial artery. For the induction of general anesthesia, etomidate (0.2 mg/kg), vecuronium bromide (0.1 mg/kg), and lidocaine (1 mg/kg) were used. Then, orotracheal intubation was performed. A 7F central venous catheter was inserted through the right internal jugular vein. Anesthesia was maintained with a mixture of isoflurane (1% minimum alveolar concentration) and 50%
O2/air. During the procedure, invasive arterial pressure, central venous pressure, urinary output, bladder temperature, and serial arterial blood gas analysis were observed. Heparin (100 U/kg) was given to achieve an activated coagulation time of 4250 seconds. Temporary cardiac pacing was placed in the right ventricle by the left femoral vein. A guidewire, which was inserted through the right femoral vein, was placed in the left ventricle by passing the interatrial septum from the apical area of the right atrium with the help of the TEE and fluoroscopy. Balloon valvuloplasty was performed successfully under rapid ventricular pacing (RVP) of 200 beats/min. The duration of the low cardiac output during RVP was less than 10 seconds. Blood pressure and cardiac rhythm were restored after RVP. Systolic blood pressure was 110 to 140 mmHg, and diastolic blood pressure was 40 to 60 mmHg before and after RVP. The interatrial septum was perforated and dilatated at the place that corresponds to the closed foramen ovale area with 14- to 18-French size catheters. While the perforation and dilatation procedures of the interatrial septum were being performed, hypotension, increased airway pressure, and desaturation suddenly occurred. As detected via the TEE, there was no problem with cardiac contractility, and tamponade did not develop. The presence of pulmonary congestion was compatible with acute pulmonary edema. Epinephrine was given (0.5 mg intravenously) and ventilation was provided with 100% O2, while an infusion of dopamine (10 mg/kg/min) was started. Minute ventilation was increased with augmented respiratory rate, and positive end-expiratory pressure of 7 cmH2O. Hypoxemia and hypercapnia were observed in the arterial blood gases. Then, 40 mg of Furosemide was administered intravenously and the process was continued. With the guidance of real-time 3D TEE, an EdwardsSapien transcatheter bioprosthetic valve was placed successfully into the mitral annulus (Fig 2). After the implantation, there was no mitral regurgitation (Fig 3). Following the procedure, the mildly hypothermic and low-dose inotrope-supported patient was transferred intubated to the intensive care unit to provide extubation under more suitable conditions. The hemodynamic findings showed improvement in the patient, and the inotropic support was gradually stopped in the intensive care unit. Four hours after the procedure, the patient was extubated. Twenty-four hours after the procedure, the patient was transferred to the service.
DISCUSSION
The main objective of administering anesthesia for TMVI is to maintain hemodynamic stability. To maintain adequate cardiac output and to avoid an increased regurgitant volume in patients with severe mitral regurgitation, several precautions
From the Departments of *Anesthesiology and Reanimation, and yCardiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey. Address reprint requests to Kazim Karaaslan, MD, Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Vatan cad, 34093 Fatih, Istanbul, Turkey. E-mail: [email protected] & 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2012.12.011 Key words: anesthesia management, transcatheter mitral valve implantation, transesophageal echocardiography
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 1 (February), 2014: pp 115–117
115
116
Fig 1. Transesophageal echocardiography showed deformation of the mitral bioprosthetic valve and severe mitral regurgitation. (Color version of figure is available online.)
should be taken. Specifically, fluids should be titrated carefully, hypoxemia and hypercapnia (which can cause pulmonary hypertension) should be avoided, the ventricular response to atrial fibrillation should be controlled, an excessive heart rate should be treated, and the left ventricular afterload should be decreased. A standard method of anesthesia in this high-risk group of patients was not established. General anesthesia has several benefits, such as ensuring that the airway is safe and that inhalation agents have a protective effect in ischemic procedures with myocardial preconditioning. Another benefit of general anesthesia is to facilitate procedures like TEE. Regional anesthesia techniques in transcatheter aortic valve implantation (TAVI) procedures are preferred by some clinicians owing to their advantages of early recovery and less impairment of hemodynamic and cognitive functions.1-3 Although intercostal nerve, thoracic epidural, and paravertebral blocks have a high likelihood of success when used in TAVI procedures, the need for the use of antiplatelet agents in these cases limits the selection of these methods.4 In patients with pulmonary dysfunction, awake TAVI under thoracic epidural may be an alternative option.5 Recently, sedation with local anesthesia
KARAASLAN ET AL
Fig 3. Transesophageal echocardiography showed no residual mitral regurgitation after the implantation. (Color version of figure is available online.)
for TAVI supported by noninvasive mechanical ventilation has been reported in high-risk patients with respiratory problems.6 In the present case, however, the authors preferred general anesthesia because it improved airway safety in case of pulmonary edema and facilitated the implementation of TEE. The TMVI procedure can be divided into the following major parts: vascular access, perforation and dilatation of the interatrial septum, testing of transvenous ventricular pacing, balloon mitral valvuloplasty, mitral valve positioning, and mitral valve deployment. In particular, during the atrial septum perforation, pericardial tamponade or acute pulmonary edema may occur. Before the procedure, the patient should be ventilated with 100% O2. Oxygenation and airway pressure should be watched closely, monitoring should be done with TEE, and inotropic support should be ready at all times. For the balloon valvuloplasty procedure, the hypotensive response during venous pacing, is reversed with short-term inotropic support. It is also important to avoid hypothermia during TMVI. Temperature monitoring is essential, and the use of external warming systems and intravenous fluid warmers is required. After the procedure, TEE imaging showed minimal leakage at the iatrogenic defect in the interatrial septum, which was made by perforation and dilatation. The remaining septal defect was assumed to close spontaneously within 6 months. The authors believe that invasive monitoring, securing the airway using general anesthesia, and TEE images during the procedure may increase the success with anesthesia management of TMVI patients. This is the first use of real-time 3D TEE guidance to ensure proper valve placement reported in the literature. REFERENCES
Fig 2. Real-time 3D TEE image while the bioprosthetic valve was placed successfully into the mitral annulus. (Color version of figure is available online.)
1. Tamburino C, Capodanno D, Ramondo A, et al: Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation 123:299-308, 2011 2. Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encountered and proposed solutions. J Cardiothorac Vasc Anesth 23: 280-285, 2009
ANESTHETIC MANAGEMENT FOR TRANSCATHETER MITRAL VALVE IMPLANTATION
3. Guarracino F, Covello RD, Landoni G, et al: Anesthetic management of transcatheter aortic valve implantation with transaxillary approach. J Cardiothorac Vasc Anesth 25:437-443, 2011 4. Chawla A, Wielogorski A: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 104:659-660, 2010
117
5. Mukherjee C, Walther T, Borger MA, et al: Awake transapical aortic valve implantation using thoracic epidural anesthesia. Ann Thorac Surg 88:992-994, 2009 6. Guarracino F, Cabrini L, Baldassarri R, et al: Noninvasive ventilation for awake percutaneous aortic valve implantation in high-risk respiratory patients: A case series. J Cardiothorac Vasc Anesth 25:1109-1112, 2011
M
ITRAL VALVE REDO OPERATIONS due to failing bioprostheses are known to be associated with high rates of morbidity and mortality. Transcatheter mitral valve implantation (TMVI) procedures in high-risk patients with severe mitral regurgitation have become a promising treatment option. We report a new transcatheter technique as an alternative to redo operations in patients with degenerative mitral valve bioprosthesis. There are a limited number of studies on the use of this technique. The main objective of the administration of anesthesia for TMVI application is to maintain hemodynamic stability. In this report, the authors present the anesthesia management of TMVI for a 79-year-old female patient with severe mitral valve regurgitation resulting from a degenerative mitral bioprosthetic valve. Although a standard method of anesthesia in this high-risk group of patients has not yet been established, the authors prefer general anesthesia because it provides airway safety in cases of pulmonary edema and facilitates the implementation of transesophageal echocardiography (TEE).
CASE REPORT A 79-year-old female patient was admitted to the authors’ hospital, complaining of dyspnea that had lasted for a month and increased over the last 5 days. The patient had an attack of acute rheumatic fever when she was 9 years of age. Mitral bioprosthetic valve replacement was performed in 2001 due to mitral stenosis, and 7 years later, aortic bioprosthetic valve replacement surgery was performed due to severe aortic stenosis, moderate aortic valve insufficiency, and pulmonary hypertension. In the preoperative imaging by transthoracic echocardiography, a maximum of 27 mmHg and mean of 14 mmHg gradients were observed on the mitral bioprosthetic valve. The patient underwent TEE evaluation, which confirmed the findings of the transthoracic echocardiography and added more information about the mitral bioprosthetic valve. The TEE results showed that one of the valve leaflets was deformed and entered into the left atrium. There was also severe mitral regurgitation (Fig 1). On the aortic bioprosthetic valve, a maximum of 25 mmHg and a mean of 15 mmHg gradients were observed. There were mild aortic regurgitation, moderate tricuspid regurgitation, and pulmonary hypertension (systolic pulmonary artery pressure: 80 mmHg), and her ejection fraction was 38%. The result of coronary angiography was normal. Furthermore, the older mitral bioprosthetic valve annulus was evaluated to determine the size of a new valve. After performing a three-dimensional (3D) TEE, a 26-mm valve was selected for implantation. Monitoring consisted of 5-channel electrocardiography, pulse oximetry, and noninvasive arterial pressure; 2 external defibrillator pads were attached to the patient’s chest. The first values observed on the catheterization table were blood pressure, 128/45 mmHg; heart rate, 104 beats/min (normal sinus rhythm); and SpO2, 95%. Oxygen was administered at 3 L/min via a face mask; 2 mg of midazolam and 50 mg of fentanyl were administered to the patient, and then arterial cannulation was performed in the right radial artery. For the induction of general anesthesia, etomidate (0.2 mg/kg), vecuronium bromide (0.1 mg/kg), and lidocaine (1 mg/kg) were used. Then, orotracheal intubation was performed. A 7F central venous catheter was inserted through the right internal jugular vein. Anesthesia was maintained with a mixture of isoflurane (1% minimum alveolar concentration) and 50%
O2/air. During the procedure, invasive arterial pressure, central venous pressure, urinary output, bladder temperature, and serial arterial blood gas analysis were observed. Heparin (100 U/kg) was given to achieve an activated coagulation time of 4250 seconds. Temporary cardiac pacing was placed in the right ventricle by the left femoral vein. A guidewire, which was inserted through the right femoral vein, was placed in the left ventricle by passing the interatrial septum from the apical area of the right atrium with the help of the TEE and fluoroscopy. Balloon valvuloplasty was performed successfully under rapid ventricular pacing (RVP) of 200 beats/min. The duration of the low cardiac output during RVP was less than 10 seconds. Blood pressure and cardiac rhythm were restored after RVP. Systolic blood pressure was 110 to 140 mmHg, and diastolic blood pressure was 40 to 60 mmHg before and after RVP. The interatrial septum was perforated and dilatated at the place that corresponds to the closed foramen ovale area with 14- to 18-French size catheters. While the perforation and dilatation procedures of the interatrial septum were being performed, hypotension, increased airway pressure, and desaturation suddenly occurred. As detected via the TEE, there was no problem with cardiac contractility, and tamponade did not develop. The presence of pulmonary congestion was compatible with acute pulmonary edema. Epinephrine was given (0.5 mg intravenously) and ventilation was provided with 100% O2, while an infusion of dopamine (10 mg/kg/min) was started. Minute ventilation was increased with augmented respiratory rate, and positive end-expiratory pressure of 7 cmH2O. Hypoxemia and hypercapnia were observed in the arterial blood gases. Then, 40 mg of Furosemide was administered intravenously and the process was continued. With the guidance of real-time 3D TEE, an EdwardsSapien transcatheter bioprosthetic valve was placed successfully into the mitral annulus (Fig 2). After the implantation, there was no mitral regurgitation (Fig 3). Following the procedure, the mildly hypothermic and low-dose inotrope-supported patient was transferred intubated to the intensive care unit to provide extubation under more suitable conditions. The hemodynamic findings showed improvement in the patient, and the inotropic support was gradually stopped in the intensive care unit. Four hours after the procedure, the patient was extubated. Twenty-four hours after the procedure, the patient was transferred to the service.
DISCUSSION
The main objective of administering anesthesia for TMVI is to maintain hemodynamic stability. To maintain adequate cardiac output and to avoid an increased regurgitant volume in patients with severe mitral regurgitation, several precautions
From the Departments of *Anesthesiology and Reanimation, and yCardiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey. Address reprint requests to Kazim Karaaslan, MD, Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Vatan cad, 34093 Fatih, Istanbul, Turkey. E-mail: [email protected] & 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2012.12.011 Key words: anesthesia management, transcatheter mitral valve implantation, transesophageal echocardiography
Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 1 (February), 2014: pp 115–117
115
116
Fig 1. Transesophageal echocardiography showed deformation of the mitral bioprosthetic valve and severe mitral regurgitation. (Color version of figure is available online.)
should be taken. Specifically, fluids should be titrated carefully, hypoxemia and hypercapnia (which can cause pulmonary hypertension) should be avoided, the ventricular response to atrial fibrillation should be controlled, an excessive heart rate should be treated, and the left ventricular afterload should be decreased. A standard method of anesthesia in this high-risk group of patients was not established. General anesthesia has several benefits, such as ensuring that the airway is safe and that inhalation agents have a protective effect in ischemic procedures with myocardial preconditioning. Another benefit of general anesthesia is to facilitate procedures like TEE. Regional anesthesia techniques in transcatheter aortic valve implantation (TAVI) procedures are preferred by some clinicians owing to their advantages of early recovery and less impairment of hemodynamic and cognitive functions.1-3 Although intercostal nerve, thoracic epidural, and paravertebral blocks have a high likelihood of success when used in TAVI procedures, the need for the use of antiplatelet agents in these cases limits the selection of these methods.4 In patients with pulmonary dysfunction, awake TAVI under thoracic epidural may be an alternative option.5 Recently, sedation with local anesthesia
KARAASLAN ET AL
Fig 3. Transesophageal echocardiography showed no residual mitral regurgitation after the implantation. (Color version of figure is available online.)
for TAVI supported by noninvasive mechanical ventilation has been reported in high-risk patients with respiratory problems.6 In the present case, however, the authors preferred general anesthesia because it improved airway safety in case of pulmonary edema and facilitated the implementation of TEE. The TMVI procedure can be divided into the following major parts: vascular access, perforation and dilatation of the interatrial septum, testing of transvenous ventricular pacing, balloon mitral valvuloplasty, mitral valve positioning, and mitral valve deployment. In particular, during the atrial septum perforation, pericardial tamponade or acute pulmonary edema may occur. Before the procedure, the patient should be ventilated with 100% O2. Oxygenation and airway pressure should be watched closely, monitoring should be done with TEE, and inotropic support should be ready at all times. For the balloon valvuloplasty procedure, the hypotensive response during venous pacing, is reversed with short-term inotropic support. It is also important to avoid hypothermia during TMVI. Temperature monitoring is essential, and the use of external warming systems and intravenous fluid warmers is required. After the procedure, TEE imaging showed minimal leakage at the iatrogenic defect in the interatrial septum, which was made by perforation and dilatation. The remaining septal defect was assumed to close spontaneously within 6 months. The authors believe that invasive monitoring, securing the airway using general anesthesia, and TEE images during the procedure may increase the success with anesthesia management of TMVI patients. This is the first use of real-time 3D TEE guidance to ensure proper valve placement reported in the literature. REFERENCES
Fig 2. Real-time 3D TEE image while the bioprosthetic valve was placed successfully into the mitral annulus. (Color version of figure is available online.)
1. Tamburino C, Capodanno D, Ramondo A, et al: Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation 123:299-308, 2011 2. Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encountered and proposed solutions. J Cardiothorac Vasc Anesth 23: 280-285, 2009
ANESTHETIC MANAGEMENT FOR TRANSCATHETER MITRAL VALVE IMPLANTATION
3. Guarracino F, Covello RD, Landoni G, et al: Anesthetic management of transcatheter aortic valve implantation with transaxillary approach. J Cardiothorac Vasc Anesth 25:437-443, 2011 4. Chawla A, Wielogorski A: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 104:659-660, 2010
117
5. Mukherjee C, Walther T, Borger MA, et al: Awake transapical aortic valve implantation using thoracic epidural anesthesia. Ann Thorac Surg 88:992-994, 2009 6. Guarracino F, Cabrini L, Baldassarri R, et al: Noninvasive ventilation for awake percutaneous aortic valve implantation in high-risk respiratory patients: A case series. J Cardiothorac Vasc Anesth 25:1109-1112, 2011