Risk and Timing of Noncardiac Surgery After Transcatheter Aortic Valve Implantation

High-Degree Heart Block During Noncardiac Surgery Soon After Transcatheter Aortic Valve Replacement: A Case Report

Patients undergoing transcatheter aortic valve replacement (TAVR) as a bridge to noncardiac surgery have improved outcomes. Older clinical trials concluded no increased risk of performing noncardiac surgery within 30 days of the TAVR procedure. Emerging evidence suggests patients with preexisting conduction abnormalities may require additional intervention to proceed safely with noncardiac surgery. More data are needed to clarify this clinical situation, especially for the anesthesiologist whose job is to mitigate risk for these patients. We present a patient who received a TAVR and suffered associated complications during subsequent surgery. We further discuss preventative measures and perioperative considerations for this patient population.

Defining high bleeding risk in patients undergoing transcatheter aortic valve implantation: a VARC-HBR consensus document

The identification and management of patients at high bleeding risk (HBR) undergoing transcatheter aortic valve implantation (TAVI) are of major importance, but the lack of standardised definitions is challenging for trial design, data interpretation, and clinical decision-making. The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) is a collaboration among leading research organisations, regulatory authorities, and physician-scientists from Europe, the USA, and Asia, with a major focus on TAVI-related bleeding. VARC-HBR is an initiative of the CERC (Cardiovascular European Research Center), aiming to develop a consensus definition of TAVI patients at HBR, based on a systematic review of the available evidence, to provide consistency for future clinical trials, clinical decision-making, and regulatory review. This document represents the first pragmatic approach to a consistent definition of HBR evaluating the safety and effectiveness of procedures, devices and drug regimens for patients undergoing TAVI..

Impact of stroke history on procedural cerebrovascular insult probability and long-term outcome after TAVI

BACKGROUND

In TAVI procedural stroke is one of the most feared complications and for this reason also extensively studied. But there is a lack of data concerning the impact of previous stroke on procedural stroke and on long-term survival. The aim of this registry-based cohort study is to evaluate the prevalence of previous stroke in TAVI patients and its impact on procedural stroke risk as well as long-term outcome.

METHODS

We included all patients treated with TAVI between January 2007 and December 2020 and investigated concerning previous stroke in their medical history. Among 958 patients, 55 patients had previous stroke and were included in the present analysis.

RESULTS

The salient finding of the present study is that previous stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI. This is also observed after adjusting for confounders like EuroSCORE II (European system for cardiac operative risk evaluation) and AF (atrial fibrillation) as one of the main underlying diseases for cerebrovascular insult (CVI). However, previous stroke is not associated with higher rates of procedural CVI.

CONCLUSION

A history of stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI without higher rates of procedural stroke.

Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery

Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.

Management of concurrent aortic stenosis and pheochromocytoma

A man in his mid 60s with known aortic stenosis developed progressive symptoms. Echocardiography confirmed severe calcific aortic stenosis. Further evaluation revealed an elevated white blood cell count leading to a diagnosis of chronic lymphocytic leukaemia. CT of the abdomen revealed a left adrenal mass, confirmed by MRI. 24-hour urine catecholamines were elevated, confirming the diagnosis of a pheochromocytoma.

This case was complicated by the concurrent aortic stenosis and pheochromocytoma, requiring considerable multidisciplinary teamwork to develop a safe management strategy. A decision to perform a transcatheter aortic valve replacement (TAVR) with alpha and beta blockade with monitored anaesthesia care followed by laparoscopic adrenalectomy and postoperative haemodynamic control was made. A successful TAVR procedure was performed, complicated only by postoperative transient atrial tachycardia followed 6 weeks later by a laparoscopic robotic-assisted left adrenalectomy. The patient recovered fully and was discharged 2 days later.