Development of our TAVI protocol for emergency initiation of cardiopulmonary bypass

Left ventricular ejection fraction is associated with intraoperative circulatory collapse during transcatheter aortic valve implantation

Background

Intraoperative hemodynamic collapse during transcatheter aortic valve implantation (TAVI) is a devastating complication that requires mechanical support. In this study, we sought to analyze our early experience in using cardiopulmonary bypass (CPB) support to circumvent circulatory compromise during TAVI.

Methods

Between January 2018 and December 2020, 102 consecutive patients (54 males; mean age, 71.2±8.9 years) received TAVI at Tianjin Chest Hospital, and an emergency CPB device was used in 6 of these patients (5.9%). The clinical data of the CPB and no-CPB groups were analyzed to identify the factors associated with intraoperative hemodynamic collapse requiring CPB.

Results

All 6 patients who needed emergency CPB support were successfully weaned from the device. This group had a higher Society of Thoracic Surgeons Score [4.09 (2.02, 6.85) vs. 7.47 (5.07, 23.46); P=0.030], more patients with a left ventricular ejection fraction (LVEF) ≤30% [4 (66.7%) vs. 2 (2.1%); P=0.000], a larger right ventricle anteroposterior diameter [20.50 (19.75, 21.25) vs.19.00 (17.00, 20.00); P=0.016], and a higher degree of aortic regurgitation [4.50 (2.75, 5.00) vs. 2.00 (1.00, 4.00); P=0.018] compared to the no-CPB group. The CPB group also had a higher in-hospital mortality rate than did the no-CPB group (16.7% vs. 4.7%; P=0.026). Multivariable analysis determined that the presence of lower pre-TAVI LVEF was associated with intraoperative hemodynamic collapse.

Conclusions

Our results indicate that LVEF is an independent risk factor for requiring emergency CPB during the TAVI procedure. The need for emergency CPB support was associated with higher in-hospital mortality.

Delayed right coronary ostial obstruction after J-valve deployment in transcatheter aortic valve implantation: A case report

BACKGROUND

Aortic stenosis is the most common valve disease in adults. Transcatheter aortic valve implantation (TAVI) is being increasingly applied for intermediate- to low-risk patients. Here, we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.

CASE SUMMARY

A 73-year-old woman with a EuroSCORE II of 1.21% underwent transapical TAVI because of severe aortic stenosis. The surgical procedure was uneventful. However, during routine monitoring after valve placement, the patient had a sudden onset of slow heart rate, the systolic blood pressure dropped sharply from 115 to 60 mmHg, and the central venous pressure abruptly increased from 10 to 33 cmH₂O. The patient had a poor response to vasoactive agents. Transesophageal echocardiography revealed poor myocardial contractility, and electrocardiography showed a significant depression of ST-segment. Another angiography was performed immediately, which suggested complete obstruction of the right coronary artery. An emergency protocol was initiated. Cardiopulmonary bypass was established immediately. An aortic biological valve replacement under cardiopulmonary bypass was performed.

CONCLUSION

Perioperative monitoring, early recognition, and diagnosis of obstruction of coronary arteries in TAVI are important. Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation. Emergency protocols should be established during TAVI.

The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events

This prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.

Clinical and economical impact of the presence of an extended heart team throughout the balloon-expandable transcatheter aortic valve implantation procedure

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a standard therapy for aortic valve stenosis in patients at intermediate-to-high surgical risk. Previously, TAVI at our site was performed by a minimalist heart team (MHT), comprised of two interventional cardiologists, echocardiography staff and two cardiac catheterization laboratory nurses. After revision of German Federal Joint Committee (G-BA) guidelines in September 2015, the presence of an extended heart team (EHT; including a full cardiac surgical team) became mandatory throughout the TAVI procedure. We aimed to evaluate the impact of the EHT on clinical and economical outcomes.

METHODS

Data was retrospectively extracted from the medical records of patients receiving an Edwards SAPIEN 3 valve at the University Hospital Tübingen, Germany, between 2014 and 2017 and matched with cost data from the national invoice system of hospitals (InEK). For comparison, patients were grouped according to whether they underwent TAVI with or without the EHT.

RESULTS

Overall, data for 341 patients (MHT 233; EHT 118) were analysed. Baseline characteristics were largely similar between groups (mean age 81.0 years; 54.5% female), though EHT patients had a lower mean logEuroSCORE (17.5% vs. 19.8%; p = 0.011) and more prior PCI/stenting (39.0% vs. 26.9%; p = 0.022). The rate of immediate procedural death (1.7%) was comparable between groups, as was mortality at 30 days (4.2%). Overall, 1.2% of patients required conversion to surgery. The cost of the index hospitalisation (minus the prosthesis) was higher in the EHT condition (difference + €1604), largely driven by expenditure on physicians (difference + €581; p < 0.001), medical technicians (difference + €372; p < 0.001) and medical supplies (difference +€244; p = 0.001).

CONCLUSION

At our site, the presence of an EHT throughout the TAVI procedure appears to substantially increase hospital expenditure without significantly improving patient outcomes. We suggest that TAVI by a minimalist HT with a surgical team on call in case of emergency may be sufficient.