Pre-op issues:



·      Aortic stenosis

·      Associated cardiac disease (e.g. failure)

·      Comorbidities


·      MDT

·      Nothing vs TAVI vs SAVR


·      Medication

·      Fluid


Intra-op issues:



Remote environment

·      Prepare for airway difficulty

·      Prepare for vascular injury

·      Prepare for arrest

Sedation vs GA

Sedation benefits:

·      Avoid haemodynamic insult of GA

·      Rapid V-pacing is well tolerated

·      Shorter procedure and hospital stay


GA benefits:

·      Can do TOE: detect paravalvular leak

·      Prepared for vascular disaster


Sedation pre-requisites:

·      Can lie flat

·      Can lie still

·      Can co-operative

·      Can keep airway patent (i.e. beware OSA + sedation)



Vascular disaster

·      Cardiac surgeon + perfusionist + gear on-site

·      Group and hold

·      Consent for blood transfusion

Valve deployment / balloon dilatation

·      Need rapid ventricular pacing + apnoea

·      Prepare: FiO2 100%, SBP 120mmHg


Aortic stenosis:

Death spiral


·      Full: euvolaemia for preload

·      Slow: normal HR for filling time, sinus rhythm for atrial kick

·      Tight: maintain SVR hence mAP hence coronary perfusion

Ischaemia risk

·      ↑Demand: hypertrophy + pressure work

·      ↓Supply: if hypotension (common in anaesthesia)

Low cardiac output

·      Dependent on SVR for mAP

Fixed cardiac output

·      Dependent on HR for CO

Diastolic dysfunction

·      Dependent on preload, but also risk of pulmonary congestion

·      Dependent on sinus rhythm

Pulmonary HTN

·      See other document

·      Maintain coronary perfusion

·      Minimise afterload i.e. PVR



·        Bleeding

·        Stroke

·        Paravalvular regurgitation

·        AV block

·        Arrhythmias

·        Annular rupture

·        Myocardial injury

·        Tamponade

·        Mitral valve damage

·        Hypotension

·        Dynamic LVOTO

·        Death


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