VOLUME 30, ISSUE 1

The widespread adoption of percutaneous coronary intervention in the 1980’s was the beginning of a revolution in the care of patients with coronary artery disease. Over the following 30 years we’ve witnessed the growing acceptance and utilization of advanced percutaneous options for treatment of diseases of the heart. In 2002, the first percutaneous aortic valve replacement was performed in France, and though it’s taken over a decade to gain widespread acceptance in the United States, that bold idea is now in the midst of revolutionizing the care of patients with valvular disease of the heart.

Transcatheter Aortic Valve Replacement (TAVR), which is the displacement and replacement of the aortic valve via a percutaneously inserted catheter, is revolutionizing the care of patients with severe aortic stenosis. At its outset, TAVR was originally considered an experimental, last ditch effort to help patients who were considered “too sick” or “too high risk” for surgery that were suffering from severe aortic stenosis.

At my home institution, Scott & White Medical Center – Temple, we began performing TAVR procedures in May 2012 and to date have performed over 400 of these procedures.

Other hospitals around the state have adopted TAVR programs as well. The Heart Hospital Baylor Plano has performed over 1000 of these procedures. Numerous other hospitals in Texas boast similar numbers, and for many hospitals, 2017 will mark the first year that the number of TAVRs performed will surpass the number of surgical aortic valve replacements. This is a trend that is expected to continue as time goes on, mirroring what is already happening across Europe.

We have witnessed the remarkable and rapid evolution of technology used to implant these percutaneous valves and, in response, our change in patient management during the perioperative period. Technological advancements such as smaller sheath sizes, new skirts incorporated into the valve to reduce regurgitation, self-expanding valves and even recapturable valves have increased the safety of these procedures at a rapid rate. This increase in safety has led to an ever expanding inclusion criteria of patients eligible to receive a TAVR instead of a traditional surgical aortic valve replacement and significant change in the type of anesthetic most commonly performed. In the US, the most common anesthetic approach when first starting a TAVR program was a general anesthetic with a “Full Cardiac Setup”. When we first began performing these procedures in 2012 at Scott & White, we would almost always utilize a general anesthetic, arterial line, central line and transesophageal echocardiography. Post-operatively, the patient remained intubated and was transferred to the ICU. However, given the rapid progression of technology and expanded indications to include patients with fewer and fewer comorbidities, we performed our first TAVR under moderate sedation in April 2015. At our hospital, the majority of these procedures are now being performed under moderate sedation with local anesthesia, while some are even being performed with “minimal access” – standard ASA monitors and two large bore IVs with no dedicated arterial line or central line (femoral arterial and venous sheaths placed by the cardiologists are used for vascular access and monitoring). Now, instead of sending all patients to the ICU after their procedure, many are now going to the PACU prior to transfer to the floor. There have even been cases of patients being discharged on the very same day after having their aortic valve replaced.

What was once a procedure reserved only as a last resort for patients considered too high risk to undergo SAVR, TAVR has now had its indications expanded to include high surgical risk and even intermediate surgical risk patients^1,2. Trials are currently ongoing that compare its safety in low surgical risk patients in need of aortic valve replacement due to aortic stenosis. Should TAVR prove equivalent or better than traditional open surgical valve replacement, we could see the near disappearance of one of the most common cardiac surgical procedures in the United States.

Currently, there are 27 hospitals throughout the state registered in the Transcatheter Valve Therapy Registry, which was created by a collaboration between the Society for Thoracic Surgeons and the American College of Cardiology. That number is expected to grow as the TAVR procedure spreads to more and more hospitals throughout the state. Structural heart programs will continue to evolve and we will see an increase in the number and types of percutaneous procedures being performed in both the operating room and in off-site anesthetizing locations, such as the cardiac catheterization lab and electrophysiology suite. Procedures ranging from percutaneous mitral regurgitation repair with Mitraclips, percutaneous occlusion of left atrial appendages with the Watchman device, ligation of the left atrial appendage with the Lariat device, and the replacement of valves in other locations such as the mitral, tricuspid, and pulmonic positions will continue to increase.

It is incumbent upon us as physician anesthesiologists to lead the way in providing safe perioperative care and helping to guide our patients through this latest revolution in the care of cardiac surgical patients. As more hospitals begin to adopt this revolutionary procedure, we must be engaged members of the heart team, involved in the decision making ranging from determination of the most appropriate location to perform these procedures, whether that be in an operating room, a hybrid suite or in the cardiac catheterization lab, patient pre-operative optimization, and determining post-operative disposition. As we move forward during this rapidly evolving time, the only thing that remains certain is change.

References:

1. FDA statement regarding expanded indications for TAVR with Sapien XT and Sapien 3 valves: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm517281.htm
2. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet 2016;387:2218-25.