Prakash A. Patel

Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR)

The care pathway for patients undergoing transcatheter aortic valve replacement (TAVR), particularly in the US, was initially based on open surgical techniques and often includes general anesthesia, transesophageal echocardiographic monitoring, and cardiothoracic intensive care unit (ICU) stays. Whether a subgroup of patients could benefit from early extubation, fewer days in the ICU, and early ambulation in terms of both cost and effectiveness is unknown.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2009

The hybrid operating room is the venue for transcatheter therapy with the convergence of 3 specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Because pharmacologic conditioning and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia, and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass graft (CABG) surgery. Although off-pump CABG surgery is equivalent to on-pump CABG surgery, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel recently was approved for platelet blockade in PCI, it may be superseded by ticagrelor. Although PCI and CABG surgery appear equivalent for multivessel coronary disease, CABG surgery lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Because eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide, and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements.

Challenges After the First Decade of Transcatheter Aortic Valve Replacement: Focus on Vascular Complications, Stroke, and Paravalvular Leak

Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.

Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

Background: Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods: The National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to characterize the anesthesia choice and clinical outcomes of all US patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014, and June 30, 2015. Raw and inverse probability of treatment-weighted analyses were performed to compare patients undergoing TAVR with general anesthesia with patients undergoing TAVR with conscious sedation on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, intensive care unit and hospital length-of-stay, and rates of discharge to home. Post hoc falsification end point analyses were performed to evaluate for residual confounding. Results: Conscious sedation was used in 1737/10 997 (15.8%) cases with a significant trend of increasing usage over the time period studied (P for trend<0.001). In raw analyses, intraprocedural success with conscious sedation and general anesthesia was similar (98.2% versus 98.5%, P=0.31). The conscious sedation group was less likely to experience in-hospital (1.6% versus 2.5%, P=0.03) and 30-day death (2.9% versus 4.1%, P=0.03). Conversion from conscious sedation to general anesthesia was noted in 102 of 1737 (5.9%) of conscious sedation cases. After inverse probability of treatment-weighted adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% versus 98.6%, P<0.001) and a reduced rate of mortality at the in-hospital (1.5% versus 2.4%, P<0.001) and 30-day (2.3% versus 4.0%, P<0.001) time points. Conscious sedation was associated with reductions in procedural inotrope requirement, intensive care unit and hospital length of stay (6.0 versus 6.5 days, P<0.001), and combined 30-day death/stroke rates (4.8% versus 6.4%, P<0.001). Falsification end point analyses of vascular complications, bleeding, and new pacemaker/defibrillator implantation demonstrated no significant differences between groups after adjustment. Conclusions: In US practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality in comparison with TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, although comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.Background —Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods —The NCDR STS/ACC TVT Registry was used to characterize the anesthesia choice and clinical outcomes of all U.S. patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014 and June 30, 2015. Raw and inverse probability of treatment weighted (IPTW) analyses were performed to compare general anesthesia patients with conscious sedation patients on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, ICU and hospital length-of-stay, and rates of discharge to home. Post-hoc falsification endpoint analyses were performed to evaluate for residual confounding. Results —Conscious sedation was used in 1,737/10,997 (15.8%) cases with a significant trend of increasing usage over the time period studied (p for trend Conclusions —In U.S. practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality compared to TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, though comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.

Atrial Fibrillation After Cardiac Surgery: Clinical Update on Mechanisms and Prophylactic Strategies

ATRIAL FIBRILLATION (AF) is a common complication after cardiac surgery and is associated with increased cost, morbidity, and mortality. Minimally invasive surgical techniques such as transcatheter aortic valve replacement (TAVR) have not substantially reduced the risk of developing AF. The development of AF after cardiac surgery remains common and significantly increases mortality, morbidity, and total hospital costs, including readmission. In an effort to reduce these adverse consequences of this complication, considerable research recently has focused on identifying prophylactic strategies for AF after cardiac surgery. A thorough understanding of the mechanisms underlying the genesis of AF in this setting may aid in designing preventative paradigms and standardizing treatment. The purpose of this expert review is to highlight the incidence, pathogenesis, and preventative strategies for AF after cardiac surgery.

New frontiers in aortic therapy: focus on current trials and devices in transcatheter aortic valve replacement.

The first decade of clinical experience with transcatheter aortic valve replacement since 2002 saw the development of 2 main valve systems, namely the Edwards Sapien balloon-expandable valve series and the Medtronic self-expanding CoreValve. These 2 valve platforms now have achieved commercial approval and application worldwide in patients with severe aortic stenosis whose perioperative risk for surgical intervention is high or extreme. In the second decade of transcatheter aortic valve replacement, clinical experience and refinements in valve design have resulted in clinical drift towards lower patient risk cohorts. There are currently 2 major trials, PARTNER II and SURTAVI, that are both evaluating the role of transcatheter aortic valve replacement in intermediate-risk patient cohorts. The results from these landmark trials may usher in a new clinical paradigm for transcatheter aortic valve replacement in its second decade.

The Functional Aortic Annulus in the 3D Era: Focus on Transcatheter Aortic Valve Replacement for the Perioperative Echocardiographer

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

Anesthetic Evolution in Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers in Europe and the United States

Cite this article as: Prakash A. Patel, Abraham M. Ackermann, John G.T. Augoustides, Joerg Ender, Jacob T. Gutsche, Jay Giri, Prashanth Vallabhajosyula, Nimesh D. Desai, Megan Kostibas, Mary Beth Brady, Eun J. Eoh, Jeffrey G. Gaca, Annemarie Thompson and Michael G. Fitzsimons, Anesthetic Evolution In Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers In Europe And The United S t a t e s , Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2017.02.051

Progress in Platelet Blockers: The Target is the P2Y12 Receptor

The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.

Recent Advances in Perioperative Medicine: Highlights From the Literature for the Cardiothoracic and Vascular Anesthesiologist

There have been major advances in perioperative cardiothoracic and vascular medicine. Because of promising data, steroids, statins, and endothelin antagonists are being clinically tested in randomized trials with adult cardiac surgical patients. In vascular surgical patients, recent meta-analysis has revealed that interventions such as beta-blockade or endovascular stenting for peripheral vascular lesions may not improve outcome overall. Furthermore, a landmark trial has shown that anesthetic technique does not affect outcome after carotid endarterectomy. The surgical Apgar score may become part of routine clinical care of the vascular surgical patient because it predicts outcome and can be calculated at the bedside. Recent studies confirm that the serious perioperative risks of hyperglycemia also apply to nondiabetic and pediatric cardiac surgical patients. This has been highlighted in the new guidelines from the Society of Thoracic Surgeons. Perioperative myocardial protection is possible with ischemic preconditioning and omega-3 fatty acids. Pneumonia after lung resection may be reduced significantly by broadening antibiotic prophylaxis. Transfusion-related acute lung injury has immediate and delayed presentations that highlight the dangers of blood transfusion. Perioperative renal dysfunction after adult cardiac surgery is significantly reduced by the infusion of sodium bicarbonate. Although promising, further trials are required. Taken together, these recent advances will have significant influence on the future practice of cardiovascular and thoracic anesthesia as the ongoing search for perioperative outcome improvement achieves results.