[Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and...

Percutaneous transfemoral and transapical aortic valve implantations are novel procedures that often confront the anesthesiologist with bigger challenges than surgical aortic valve replacements using cardiopulmonary bypass. Due to old age and the presence of severe comorbidities including pulmonary vascular hypertension, most patients have a very high risk. Individual comorbidities and their severity are as important for the choice of the anesthetic technique as pharmacological cardiovascular therapy and communication during the respective phases of the intervention. Since severe hemodynamic alterations (cardiogenic shock, coronary ischemia, arrhythmias) and potential interventional complications (bleeding, ventricular and vascular injury) may occur, the authors routinely perform an extended cardiovascular monitoring. General endotracheal anesthesia may be advantageous even for transfemoral valve implantation and was not associated with a worse outcome. Following valve implantation a substantial increase in cardiac index, but also of all filling pressures was measured. Anesthesia coverage time for the first 100 cases averaged 263 min (+/- 96) for transfemoral and 297 (+/- 78) for transapical valve implantation, which appears greater than for conventional aortic valve replacement surgery, but it decreased significantly for transfemoral valve implantation over the course of interventions. Accordingly, the anesthesiologist, besides providing anesthesia and managing the airway, assumes responsibility for invasive cardiopulmonary monitoring, cardiovascular pharmacotherapy tailored to intervention phases, and "troubleshooting" in the event of complications for these still developing interventions.