Cardiothoracic Procedures

What does the term "Minimally Invasive" usually refer to? What are the Three examples of this? Is this approach commonly used?

-"Minimally invasive" usually refers to one of the following: 1. Thoracotomy approach 2. Davinci Robotic approach 3. Endovascular approach (the only "true" minimally invasive approach in my opinion) -The minimally invasive approaches are less common but gaining popularity

What are the Two names for an Endovascular Aortic Valve Replacement?

-This is referred to as either: TAVI 1. (Transcatheter Aortic Valve Implantation) or TAVR 2. (Transcatheter Aortic Valve Replacement)

What does the term "Invasive" usually refer to? What is it best and worst for?

1. "Invasive" usually refers to an open sternotomy technique This provides the best exposure, but perhaps the most possible complications

What are the Three surgical approaches in Cardiac Surgery?

1. "Open" heart surgery -This refers to any time the chest is opened (sternotomy or thoracotomy) 2. Davinci robotic cardiac surgery -This is more of a "laparoscopic" (thoracoscopic) technique rather than an open technique, because the incisions are smaller and CO2 insufflation pressure is utilized 3. Endovascular cardiac surgery -Possible with valve repair and some types of aortic repair

How is a MICS CABG performed (what technique)? What restrictions does the surgeon have with this approach?

1. A "MICS CABG" is performed with a small thoracotomy incision 2. Because exposure is limited, this is typically reserved for 1 or 2 vessel disease, since exposure is limited to the anterior vessels

What Two ways do we try to ensure Renal Protection during an Endovascular TAVR?

1. Adequate perioperative volume loading 2. Administration of N-acetylcysteine prior to surgery

Why do we plan for the Placement of Transvenous Pacing leads?

1. Can establish rapid ventricular pacing during valve deployment 2. Can pace the heart in case of heart block following the procedure

If you get an Aortic Valve repaired, what medication will you be on for the rest of your life?

1. Coumadin (warfarin)

What are the Two possible catheter/stent pathways for an endovascular aortic valve replacement?

1. Femoral artery -> aortic valve (most common) 2. Axillary artery -> aortic valve

Explain how Endovascular TAVR can result in cardiac conduction abnormalities? What % incidence of patients dose this occur with? Because of this, what will many patients require after undergoing this procedure?

1. Final prosthesis position can cause mechanical impingement of the conduction system, which can lead to a high incidence of left bundle branch block (LBBB) 2. The incidence of complete heart block ranges from 19-22% in patients with pre-existing right bundle branch block (RBBB) 3. Many patients may require permanent pacemaker implantation after TAVR

For Hybrid coronary revascularization for multi-vessel coronary artery disease, what procedure would we use to repair the anterior vessels? What procedure would we use for the "more difficult to expose" coronary arteries?

1. For multi-vessel coronary artery disease, the MICS procedure can be used for the anterior vessels 2. The other "more difficult to expose" coronary arteries are stented during the same operation

Hybrid Cardiac Operating Rooms are used for what Two kinds of Procedures? What Two kinds of medical personnel are needed for these two procedures?

1. Hybrid coronary revascularization 2. Transcatheter aortic valve replacement (TAVR)/transcatheter aortic valve implantation (TAVI) -Need a cardiac surgeon for the anterior vessels and an interventional Cardiologist for the posterior more difficult vessels

Is a MICS CABG performed on or off pump? What bypass approach (what vessels) are an option here?

1. Most commonly performed Off pump 2. CPB can be done via the femoral vessels

What are the Four Surgical options for CABG? Which is the least invasive approach and why?

1. On pump with an arrested heart 2. On pump with a beating heart 3. Off pump 4. Sternotomy vs. thoracotomy vs. Davinci -Davinci perhaps provides the least invasive approach (smallest incisions) for CABG

What are the Five techniques (Surgical Options) for Valve Repair/Replacement?

1. On pump with an arrested heart 2. On pump with a beating heart Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time 3. Sternotomy vs. thoracotomy vs. Davinci 4. What about replacing a valve with an open, off pump technique? This isn't possible with a traditional open technique, but is possible with the "transapical" open approach (mitral & aortic) (see slides 29-30) 5. Endovascular valve repair/replacement

What are the Ten Anesthetic Management considerations for Endovascular TAVRs?

1. Renal protection (because of the contrast dye used) 2. Stroke prevention 3. Lower dose of heparin 4. Placement of transvenous pacing leads 5. Attaching of external defibrillator pads 6. Utilization of TEE 7. Amicar administration is unnecessary (from what I could read) 8. Preparation to "keep the heart still" during valve deployment 9. Hemodynamic goals typical for patients with aortic stenosis 10. Continuous postoperative electrocardiogram monitoring for at least 48 hrs

When would the surgeon want to use an endovascular approach to repair a valve? Explain the factors that contribute to this reason?

1. Replacing the valve through an endovascular technique provides an option for patients who may not qualify for open heart surgery 2. Up to 30-40% of the patients with aortic stenosis are considered as having too high a risk for surgery 3. As for now, "...according to the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) position statement, TAVI should be restricted only to high-risk patients or those with contraindications for surgery"

How do we try to prevent Strokes with Endovascular TAVR patients?

1. Since the risk of stroke is so high, dual antiplatelet therapy (aspirin and clopidogrel) is started before the procedure and continued for 6 months 2. "Although specific guidelines about antiplatelet therapy are not still available for TAVI, the common practice is to administer a loading dose of aspirin ranging from 300 mg to 325 mg and clopidogrel 300 mg before the procedure"

What are the Six general Risks associated with Endovascular TAVR?

1. Stroke & TIA 2. Perivavlular leak 3. Vascular complications with the arteries used for vascular access 4. Acute kidney injury 5. Cardiac conduction abnormalities (i.e., left bundle branch block) 6. Postoperative bleeding and atrial fibrillation

Patients who need a CABG procedure have what disease? With Premedication for these CABG patients, what are our Two goals, and why? How does this effect our level/amount of premedication compared to Valve Replacement patients?

1. These patients have Coronary Artery Disease 2. The Two goals are to avoid Anxiety & Tachycardia, because patients with CAD need longer for diastolic coronary artery perfusion 3. For this reason, patients scheduled to undergo CABG typically will require heavier medication than patients scheduled to undergo valve replacement

What is the most common complication associated with endovascular TAVR? How can this risk be minimized?

1. Vascular complications with the arteries used for vascular access 2. This is the most frequent adverse outcome associated with TAVR, and can lead to life threatening hemorrhage -Due to vascular perforation, dissection, & rupture 3. This can be limited by using the transapical thoracotomy approach to TAVR

If you have to deflate a lung for a thoracotomy or Davinci approach, what airway device will you need? Can you perform this procedure on or off bypass? Explain which you would use and what approach you use for putting patient on bypass?

1. You will need to use a double lumen tube (possibly) 2. Since one of the lungs may need to be deflated, a double lumen tube might be requested 3. The procedure can be performed "off pump," although bypass can still be instituted with cannulation through the femoral vessels

What is the most dangerous complication associated with TAVR versus surgical replacement, and what percentage of patients experience this?

1.Higher risk of stroke with TAVR vs. surgical replacement 2. "Stroke remains the most feared and devastating complication associated with TAVR. At present, the 30-day frequency of clinically significant strokes after TAVR varies from 2% to 6% in different studies."

The large contrast load used in placing the valve with fluoroscopy with an endovascular TAVR can cause what kind of injury to the patient?

Acute Kidney Injury

What percentage of Perivalvular leak can occur with an Endovascular TAVR procedure?

Aortic regurge can be as high as 85% immediately post valve insertion and up to 75% at one year, with 1/3 having more than mild MR

When planning out premedication for patients presenting for valve repair, how should we adjust our approach, and why?

Because patients presenting for valve repair generally need to maintain preload and afterload, premedication should be used judiciously, if at all

What are the Two possible catheter/stent pathways for an endovascular Tricuspid and Pulmonic valve replacement?

Catheter/stent pathways Tricuspid Femoral veintricuspid valve Pulmonic valve Femoral veinright atriumright ventriclepulmonic valve

What is the catheter/stent pathway for an endovascular Mitral valve replacement?

Femoral Vein -> Intra-atrial septum -> Mitral valve

What is the goal of Heparin ACT levels for Endovascular TAVR?

Goal ACT of >250

What type of Cardiac procedure would we do for Multi-vessel coronary artery disease?

Hybrid Coronary Revascularization

What is the major benefit to Hybrid coronary vascularization procedures? Explain?

Hybrid coronary revascularization allows multi-vessel CAD to be performed without sternotomy, while still allowing a LIMA to LAD graft (which has been shown to be superior to intravascular stent placement)

What is the name often used to refer to a Thoracotomy or Davinci approach?

It is often referred to as a MICS (minimally invasive cardiac surgery) procedure

Why do we attach external defibrillator pads for Endovascular TAVRs?

Life threatening arrhythmias, including Vfib, can occur in up to 4% of TAVR patients

With patients who have Aortic stenosis, do we want their afterload high or low? Explain why?

Patients with aortic stenosis must have high afterload = keep high BP because otherwise they won't be able to push any blood through their coronary arteries and will have MI

What risk is actually lower with the TAVR approach when compared to the open surgical approach?

Postoperative bleeding and atrial fibrillation

What Valvular condition can be either repaired or replaced, but is more often repaired than replaced?

Regurgitant valves are more likely to be repaired than a stenotic valve

What Valvular condition has better outcomes with valve replacement, but can also be repaired by removing calcifications?

Stenotic Valves

What does the surgeon do to the heart in order to properly deploy the replacement valve in the correct placement in the heart during an Endovascular Valve repair?

Surgeon puts heart into vfib so that it will stay still during valve deployment because the positioning of the valve must be perfect, and you can do this with a dose of adenosine or you can do rapid ventricular pacing (greater than 200 bpm) which is not really beating and we do this in every TAVR

Which approach is more common: Open Aortic repair with cross clamps (invasive) or Endovascular Repair (minimally invasive)?

The Endovascular Repair (minimally invasive) approach is more commonly used

Are MICS Valve Repair/Replacement more commonly performed on or off pump? What site of bypass cannulation is possible with this?

These procedures are still most commonly performed on pump, with bypass cannulation possible via the femoral vessels

What is a rare example of a valve repair being performed "off pump" with an "open" approach?

a Transapical Open Valve Repair (TAVR) -Minimally invasive open valve repair that does not require a pump = TAVR

Hybrid coronary revascularization requires a cardiac room with what extra feature?

built in Fluoroscopy