Monday 3 June, 0945-1030H, Room Stolz
This Monday refresher course on what is a now a very common procedure — Trans-catheter Aortic Valve insertion (TAVI) — will be presented by Professor Benedikt Preckel, an anaesthesiologist based at Amsterdam University Centers, The Netherlands.
“For more than a decade now, patients with severe aortic valve stenosis (AoV) can be treated by trans-catheter valve implantations,” explains Prof Preckel. “Not only have the catheters and respective valves been constantly improved and optimised, we have also changed patient selection and peri-procedural management during these years.”
Within this update the pathophysiology of AoV stenosis will be briefly summarised. The indications for and different options of TAVI will be described. A significant change in patient selection is ongoing: while in the beginning, only patients unsuitable for conventional surgical AoV release were considered to be candidates for TAVI, nowadays also younger patients are offered this treatment option. And in fact, recent results from clinical registries show that long-term results of TAVI are not inferior to results obtained from open AoV replacement.
“Different aspects are relevant for anaesthesiologists involved in these procedures,” explains Prof Preckel. “First, because most patients undergoing TAVI procedures are still regarded as not suitable for open heart surgery, these patients suffer from numerous concomitant diseases and have high risks for periprocedural complications.”
He adds: “Second, due to improvement of the procedure itself, the age of the patients undergoing TAVI is constantly increasing, and facing patients at the age of 90 years or older is no longer rare. Third, during the years, anaesthesia management has changed: while in the beginning most patients received general anaesthesia even for transfemoral TAVI, nowadays there is plenty of data available showing that local anesthesia with/without light sedation is not inferior, possibly even superior to general anaesthesia. Arguments for general anaesthesia have, for a long time, been related to the use of transoesophageal echocardiography (TEE) during the TAVI procedure. However, with newer techniques available to our cardiologists (radiologic pre-treatment and preparing/calculating size of the valve, including angle of implantation), TEE is rarely needed for the TAVI procedure anymore.”
Prof Preckel stresses that the medical team has to keep in mind that treated patients still have a significant risk for complications: haemodynamic changes and complications resulting from rapid pacing and dilation of the mostly calcified AoV with the possibility of embolisations into the cerebral vessels, as well as procedural complications like bleeding on the insertion site, bleeding from perforation of the vascular system, but also valve displacement or valve dysfunction after placement of TAVI, or coronary artery obstruction caused by the newly placed AoV.
He concludes: “Current research is investigating immediate and late haemodynamic changes after TAVI. This might add valuable information for the value-based healthcare approach for our patients: they have to decide on a personal basis which procedure they (still) would prefer (in case there are options to choose), and we as physicians will most likely face new challenges like simultaneous interventional and surgical procedures. Could we have, in the future, a patient with hip fracture and a severe aortic stenosis first receive a transfemoral TAVI and subsequently undergo surgical treatment of hip fracture? And how must these patients then be treated with anti-coagulation therapies?”