1. Minimalist Approach to T-AVR
Pichard,
L. Satler, R Waksman, I Ben-Dor, G Maluenda, P. Corso, S Boyce, K Kent,
W Suddath, N Bernardo, S Goldstein, Z Wang, G Weissman,
G Weigold, J Lindsay, J Panza

2. Gus Pichard, MD Edwards Lifesciences. Proctor
St Jude Medical. Speaker Bureau

3. Percutaneous Aortic Valve without Intubation

4. Mitral Valvuloplasty with TEE

5. TEE without Intubation in the Cath Lab. Abstract Presented Sept 2000.
700 procedures
Average duration of TEE 60 minutes
Procedure well-tolerated
No complications related to TEE 5

6. At the Washington Hospital Center Cath Labs we use TEE for:
All mitral valvuloplasties (>1000 patients).
All alcohol septal ablations (± 25/year).
All ASD/PFO closures until 2008, when TEE was replaced with ICE.
Other structural HD (LAA closure, LV parachute, MV clip, VSD closure, etc).
Percutaneous aortic valves.

7. Protocol for TEE in Cath Lab.
Standard conscious sedation is initiated (Fentonyl and Versed) by the cath lab nurse.
Have never used anesthesiology.
TEE probe is introduced as the femoral sheaths are placed.
Intervention proceeds under continuous TEE guidance.
Patient is awake at end of procedure and is informed about the results of the procedure in the company of his/her family.

8. Is TEE needed for T-AVR? We always use it (protocol reasons).
Probably not needed for valve deployment.
Important for analysis of AR post implant.
Essential for analysis of complications:
- marked hypotension
- valve malfunction or malposition.

9. Conscious Sedation Protocol for TF T-AVR
Anesthesiologist assesses patient the day before.
Anesthesiologist in the Lab
Anesthesia equipment in the Lab
Anesthesiologist has the usual set up for cardiac anesthesia: Swan through IJV, radial artery pressure, etc.
Anesthesia monitors BP, PAP, 02 and C02, CO.
Generous Lidocaine at the access site in the groin.

12. Drugs used for Conscious Sedation
A. Start with VERY light sedation: 1mg versed , 50 mcg Fentonyl while placing A-line, and right IJ Swan.
B. Maitenance drugs. 2 protocol options:
1. "Ketaphol" 10mg Ketamine with 200mg (20cc) Propofol. Dose: Propofol 10mcg/kg/min and up to 75 mcg/kg/min.
Ketamine adds some analgesia with less respiratory depression than Propofol alone.
2. Dexmetetomidine (Precedex) (sedative used in the ICU with little hemodynamic consequence and minimal respiratory depression).
Can be started without any other drugs.
Dose: mcg/kg/hr with or without a bolus.

13. Variable
Conscious sedation N=70
General anesthesia N=22
P value
Age (years)
84.1±5.1
83.7 ± 7.9
0.8
Female
41(58.5%)
14 (63.6 %)
0.3
Society of Thoracic Surgeons score (%)
11.3±3.4
10.9±3.7
0.6
Logistic EuroSCORE
40.1±19.4
28.1±16.1
0.01
High risk surgical
42(60%)
11(50%)
0.7
Non-surgical candidate
28(40%)
NYHA class IV
34(48.6%)
12(54.5%)
Diabetes
21(30.0%)
7(31.8%)
Hypertension
63(90.0%)
21(95.5%)
0.4
Coronary artery disease
39(55.7%)
10(45.5%)
Prior myocardial infarction
13(18.6%)
2(9.1%)
Prior CABG
23(32.8%)
6(27.2%)
COPD
10(14.3%)
Renal failure (CrCl <60 ml/min)
26(37.1%)
11(50.0%)
Prior CVA/TIA
0.04
Atrial fibrillation
30(42.8%)

14. Conscious Sedation vs. General Anesthesia
Procedure Duration
(minutes)
ICU Stay
(hours)
Hospital Stay
(days)

15. Conversion to Intubation
8(11.4%) converted to general anesthesia.
3(4.2%) due to respiratory failure.
2(2.8%) due to hemodynamic compromise.
3(4.2%) retroperitoneal approach was required.

16. Minimalist Approach: Alain Cribier
A. Cribier
WHC
Intubation No
TEE
Yes
Swan Ganz
Radial artery pressure
Gradients pre-post
Heart-Lung Equipm. in room
Vascular Instruments Table
Percutaneous Access

18. Conclusions
PHV with TEE guidance is perfectly feasible without intubation.
All the side effects of general anesthetics are avoided.
No safety concerns.
No increased discomfort to the patient.
We highly recommend it!

19. The end

22. PHV with Concious Sedation and NO intubation
74 year old male
PMH:
Severe COPD
FEV , 30% predicted
PCO mmHg, pO2 50.
On Home Oxygen
Recurrent GI bleed of unknown origin
Diabetic.
262 pounds.
Seen by 3 pulmonary specialists and by Cardiac Surgery
Not operative candidate
Cohort B

23. PHV on 2/21/08 Surgical access: very deep to reach, took >25 min
Tunneled the sheath
Dilators went up easy. Same with large sheath.
TEE: annulus mm
26 mm valve delivered without problems. Excellent position. 1+ AR
No intubation, tolerated case very very well. Was talking at the end of the case.
Duration: 8 am to 10 am.