TAVI

Pre-op issues:

Assessment	· Aortic stenosis · Associated cardiac disease (e.g. failure) · Comorbidities
Planning	· MDT · Nothing vs TAVI vs SAVR
Optimisation	· Medication · Fluid

Intra-op issues:

General:

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)

TAVI:

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
Goals	· 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

Complications:

· Bleeding

· Stroke

· Paravalvular regurgitation

· AV block

· Arrhythmias

· Annular rupture

· Myocardial injury

· Tamponade

· Mitral valve damage

· Hypotension

· Dynamic LVOTO

· Death

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