Version May 2024
INTRODUCTION — Transcatheter approaches for the treatment of aortic, mitral, pulmonic, and tricuspid valve disease are less invasive than open surgical treatment options, often avoid the need for an open incision, and generally obviate the need for cardiopulmonary bypass (CPB). Aortic stenosis (AS) and mitral regurgitation (MR) are the most common cardiac valvular lesions requiring intervention in the United States and other developed countries.
This topic will discuss anesthetic management of patients undergoing the following percutaneous cardiac valve interventions. Indications, technical approaches, and complications for specific percutaneous valve procedures are discussed in separate topics:
●Aortic valve interventions
•Transcatheter aortic valve implantation (TAVI; also termed transcatheter aortic valve implantation [TAVI]) (see 'Transcatheter aortic valve implantation' below and "Transcatheter aortic valve implantation: Periprocedural and postprocedural management" and "Transcatheter aortic valve implantation: Complications")
-For native AS (and native aortic regurgitation [AR]) (see "Choice of intervention for severe calcific aortic stenosis" and "Natural history and management of chronic aortic regurgitation in adults", section on 'Investigational transcatheter alternative')
-Valve-in-valve for bioprosthetic aortic valve dysfunction (see "Bioprosthetic valve thrombosis, thromboembolism, and obstruction: Management", section on 'Aortic valve-in-valve procedure' and "Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation", section on 'Aortic valve-in-valve procedure')
•Percutaneous balloon aortic valvotomy (see 'Percutaneous balloon aortic valvotomy' below and "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults")
●Mitral valve interventions
•Transcatheter edge-to-edge mitral repair (TEER) for MR (see "Transcatheter edge-to-edge mitral repair")
•Percutaneous mitral balloon valvotomy for mitral stenosis (see "Percutaneous mitral balloon commissurotomy in adults")
•Valve-in-valve implantation for bioprosthetic mitral valve dysfunction (see "Bioprosthetic valve thrombosis, thromboembolism, and obstruction: Management", section on 'Mitral valve-in-valve procedure' and "Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation", section on 'Mitral valve-in-valve procedure')
●Pulmonic valve interventions
•Percutaneous pulmonic valve implantation (PPVI) (see "Transcatheter pulmonary valve implantation")
•Percutaneous pulmonic balloon valvotomy (see "Pulmonic valve stenosis in adults: Management", section on 'Balloon valvotomy')
●Tricuspid valve intervention
•Transcatheter tricuspid valve repair or replacement (see 'Transcatheter tricuspid valve repair' below and "Management and prognosis of tricuspid regurgitation", section on 'Transcatheter tricuspid valve repair')
•Percutaneous tricuspid balloon valvotomy (see 'Percutaneous tricuspid balloon valvotomy' below and "Tricuspid stenosis", section on 'For balloon valvotomy')
The term "minimally invasive" valve surgery refers to a set of open cardiac surgical techniques that employ direct thoracoscopic or robotic approaches developed specifically for use of a smaller incision than the traditional median sternotomy approach to perform cardiac surgical interventions. Anesthetic and surgical management for minimally invasive surgical aortic and mitral valve procedures are addressed in separate topics:
●(See "Anesthesia for cardiac valve surgery", section on 'Minimally invasive mitral valve repair'.)
ANESTHETIC MANAGEMENT: GENERAL CONSIDERATIONS — General considerations for anesthetic planning and management of percutaneous valve interventions include the team, the procedure location, selection of anesthetic technique and agents, and timing and location of extubation and recovery.
Team and location — These procedures require a multidisciplinary team, which typically includes an interventional cardiologist, cardiac surgeon, imaging specialist/radiologist, and cardiac anesthesiologist. While cardiopulmonary bypass (CPB) is not generally required for percutaneous valve procedures, a perfusionist should be available to provide back-up for CPB if needed.
Whether a procedure is performed in a hybrid operating room or in the cardiac catheterization laboratory is dependent on a number of factors including whether the patient is a sternotomy candidate, the anticipated risk of surgical conversion, the availability of a hybrid setting, and institutional practice. According to the expert consensus statement for transcatheter aortic valve implantation (TAVI) procedures, a hybrid setting is preferred but is not mandatory if other standards are met [1]. These requirements include specifications regarding room size; heating, ventilation, and air conditioning systems; lighting; power; ability to provide volatile anesthetics; and ability to operate various mechanical circulatory support devices (eg, CPB, extracorporeal membrane oxygenation, intra-aortic balloon pump).
Monitoring and team communication — Whether the patient is receiving moderate sedation or general anesthesia, standard American Society of Anesthesiologists (ASA) monitors should be employed. These include monitoring the electrocardiogram, noninvasive blood pressure, oxygenation via pulse oximeter, temperature, and exhaled carbon dioxide monitoring (capnography). Capnography facilitates early detection of apnea and/or airway obstruction and predicts the development of hypoxemia during moderate sedation, and may reduce patient injury related to respiratory depression. If an intra-arterial catheter is placed by the interventionalist for the procedure, it is used for continuous monitoring of arterial blood pressure. Each of these monitors is described in detail in a separate topic. (See "Basic patient monitoring during anesthesia".)
In all cases, frequent communication among team members is required to inform selection and dosing of vasoactive agents, determine whether ongoing interventional procedures are successful, and to rapidly recognize and treat new complications.
Imaging (eg, fluoroscopy and echocardiography) during valve procedures is discussed in the sections below.
Selection of anesthesia technique — The selected anesthetic technique for percutaneous cardiac valve interventions may be general anesthesia (loss of consciousness without arousability (table 1)) with endotracheal intubation, monitored anesthesia care (MAC) with moderate or deep sedation (depressed consciousness with a preserved response to verbal stimulus), or nurse-administered sedation supervised by the interventionalist unless and until emergency anesthetic care becomes necessary [2]. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
Considerations in selecting the anesthetic technique include the specific valve procedure involved (as described in the sections below), operator and institutional experience and preferences, patient-specific factors (eg, orthopnea, obstructive sleep apnea, obesity, difficult airway, severe pulmonary disease, right heart dysfunction, inability to cooperate, anxiety, high baseline requirement for pain medications), and whether transesophageal echocardiography (TEE) use is planned (which typically requires general anesthesia and endotracheal intubation).
Preoperative counseling for patients undergoing moderate sedation rather than general anesthesia should include explanations regarding use of local anesthesia, possible awareness during the procedure, expectations for a sensation of rapid ventricular pacing, and the possible need for conversion to general anesthesia [3,4]. Also, the interventionalist should be aware that some patient movement may occur, and that intraprocedural imaging will generally be limited to fluoroscopy and transthoracic echocardiography (TTE).
With either moderate sedation or general anesthesia, short-acting anesthetic agents are preferred. Local anesthetic is often injected at incision sites to lessen the anesthetic requirement. Normothermia should be maintained throughout the procedure to maintain patient comfort and ensure rapid awakening and recovery.
Moderate sedation — Sedative and analgesic agents and doses for percutaneous valve procedures performed with MAC and moderate (or deep) sedation are similar to those selected for other types of procedures performed with MAC and moderate (or deep) sedation and local anesthetic infiltration.
Anesthetic agents and doses are tailored to the individual patient. For MAC and moderate (or deep) sedation, agents initially administered by this author typically include a low dose remifentanil infusion or a low dose dexmedetomidine infusion. If needed, small dose(s) of intravenous (IV) midazolam are added. If an additional anesthetic agent is required to achieve the desired depth of sedation, propofol may be administered in small boluses or as an infusion added to the initial drug combination. One retrospective study compared the use of propofol versus remifentanil infusions to achieve sedation during TAVI procedures, noting that both agents were safe and effective, with similar rates of conversion to general anesthesia [5]. However, remifentanil was associated with lower oxygen saturation nadir values, while propofol infusion was associated with a higher rate of vasopressor use. (See "Monitored anesthesia care in adults", section on 'Drugs used for sedation and analgesia for monitored anesthesia care'.)
If nurse-administered sedation is supervised by the interventionalist, midazolam plus fentanyl is typically used to provide light to moderate sedation.
Use of adjuncts to maintain a patent airway such as an oral airway or a nasal trumpet is limited. An oral airway may not be well tolerated if the sedation level is light. A nasal trumpet could cause significant nasal bleeding due to anticoagulation with heparin during the procedure.
Conversion to general anesthesia — Some patients receiving moderate sedation are unable to cooperate during the procedure because of increasing anxiety, delirium, discomfort, shortness of breath, or development of hemodynamic instability. In such cases, conversion to general anesthesia is usually necessary [6-8]. For this reason, back-up from the anesthesiology team is ideal for all percutaneous cardiac valve interventions to provide support if necessary. Considerations in such cases may include:
●Airway management – Access to the patient's head may be difficult due to the position of radiography and other equipment. A laryngeal mask airway (LMA) may be inserted in an emergency, but placement of an endotracheal tube (ETT) is generally preferable since repositioning of the fluoroscopy equipment and/or performance of cardiopulmonary resuscitation (CPR) may dislodge an LMA.
●Hemodynamic support – Hemodynamic support with infusion of a vasoconstrictor (eg, phenylephrine or vasopressin) or inotropic agent (eg, epinephrine or norepinephrine) may be necessary in some unstable patients (table 2). Central vascular access is preferred for administration of vasoactive infusions, but initiation of vasoactive infusions should not be delayed for placement of a central venous catheter (CVC). In this setting, emergent management of hemodynamic instability may be accomplished by infusing vasoactive agents through the side-arm of the femoral sheath previously inserted by the interventional cardiologist.
General anesthesia — Short-acting IV anesthetic agents such as propofol, fentanyl or remifentanil, midazolam, ketamine, and/or a volatile inhalation anesthetic, as well as a short-acting neuromuscular blocking agent (NMBA) are preferred to facilitate rapid awakening and recovery after general anesthesia [9]. Our induction sequence typically includes low doses of propofol and fentanyl administered with an NMBA. Maintenance is typically accomplished with sevoflurane and, if needed, additional doses of an NMBA.
Postoperative extubation and recovery — Tracheal extubation after general anesthesia occurs in the procedure room after ensuring hemostasis (including neutralization of heparin given during the procedure), or, in some cases, shortly after the procedure. Notably, many patients undergoing percutaneous cardiac interventions must lie supine for four to six hours in the immediate postoperative period to reduce risk for groin hematoma or other vascular complications. This may impact comfort or respiratory mechanics in a critically ill patient. These factors are considered in decisions to perform extubation in the procedural room or a few hours later. Patients can often be transferred to a high-dependency setting rather than to an intensive care unit depending on type of procedure performed, anesthetic technique employed, preexisting patient factors, and potential for complications. In hospitals without stepdown or intermediate care units, a post-anesthesia care unit is often used for this purpose.
AORTIC VALVE INTERVENTIONS — For patients with severe calcific native aortic stenosis (AS), selection of surgical aortic valve replacement (SAVR), transcatheter aortic valve implantation (TAVI) (figure 1), or palliative medical therapy is based on estimated surgical risk and other factors. Indications for percutaneous balloon aortic valvotomy as a temporizing measure are very limited.
Transcatheter aortic valve implantation
General considerations — With expanding indications for TAVI, the number of TAVI procedures performed in the United States has increased, while the number of SAVR procedures has decreased [10,11]. Choice of intervention (TAVI or SAVR) for severe AS is discussed separately. (See "Choice of intervention for severe calcific aortic stenosis".)
Although approval in the United States is only for patients with AS, TAVI has also been used for selected patients with aortic regurgitation (AR) [12]. In Europe, a transcatheter heart valve has been approved for use in patients who have native AR with high to prohibitive surgical risk. (See "Natural history and management of chronic aortic regurgitation in adults".)
Transcatheter aortic valve-in-valve procedures are an alternative to redo sternotomy with redo SAVR for select patients with bioprosthetic valve dysfunction. These procedures are used for treatment of bioprosthetic stenosis or regurgitation or a combination of both. The decision to perform this procedure requires careful consideration of anatomic and patient-specific factors [13]. (See "Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation", section on 'Aortic valve-in-valve procedure'.)
The transfemoral arterial approach is used in nearly all (>95 percent) TAVI cases. For patients who are not candidates for the transfemoral approach due to unfavorable iliofemoral artery characteristics, the most common current alternatives are the subclavian/axillary approach, two transthoracic approaches (transaortic and transapical), transcaval, or a transcarotid approach. (See "Transcatheter aortic valve implantation: Periprocedural and postprocedural management", section on 'Access routes'.)
As center and operator experience has grown, there has been a move toward performing TAVI with a less invasive approach [9,14,15]. While practice varies considerably, this approach includes performing the procedure under moderate sedation with local anesthesia (typically with monitored anesthesia care [MAC]), without transesophageal echocardiography (TEE), and with selective use of temporary pacing. (See 'Anesthetic techniques and management' below and 'Imaging for TAVI procedures' below.)
Further discussions of technical aspects, preoperative and postoperative care, complications, and outcomes of the TAVI procedure are found in separate topics. (See "Transcatheter aortic valve implantation: Periprocedural and postprocedural management" and "Transcatheter aortic valve implantation: Complications".)
Imaging for TAVI procedures — Fluoroscopy and angiography are used during TAVI procedures. Intraprocedural angiography is commonly combined with pre-implant, three-dimensional angiographic or multidetector computed tomography reconstructions to identify the optimal deployment projection. Intraprocedural echocardiography (transthoracic echocardiography [TTE]) or transesophageal echocardiography (TEE) is also commonly used [16]. Significant inter-institutional heterogeneity exists regarding selection of imaging modalities for the critical phases of valve deployment and evaluation of its function immediately post-deployment. (See "Imaging for transcatheter aortic valve implantation".)
TEE is used to provide technical guidance during positioning and insertion of the aortic valve, and to detect and quantify paravalvular leaks after deployment of the valve [17,18]. Use of contrast media during fluoroscopy is typically avoided when TEE is used. TEE is also highly sensitive for detecting post-procedure paravalvular leaks, which are associated with risk for late mortality [19-21]. Although fluoroscopy can detect presence or absence of a leak, precise localization of the leak and quantification of its significance (ie, mild, moderate, severe) is not always possible. However, improvements in device technology have reduced the risk of significant paravalvular leaks [22]. Rapid detection of pericardial effusion is also possible with TEE (or TTE), but may be missed with fluoroscopy. (See "Imaging for transcatheter aortic valve implantation", section on 'Identifying complications'.)
Some institutions use only fluoroscopy for imaging during the procedure. An alternative is fluoroscopy use during the procedure with a limited transthoracic echocardiography examination (TTE) performed prior to and immediately after valve deployment to identify and evaluate the significance of any paravalvular leak and/or pericardial effusion.
Anesthetic techniques and management — Selection of general anesthesia or moderate sedation with general anesthesia back-up for TAVI is based on careful assessment of the benefits and risks associated with each technique in an individual patient, including consideration of center and operator practice, patient comorbidities, planned use of TEE, and the TAVI access route [4,6,9,17,23].
There has been a trend toward greater use of moderate sedation with MAC rather than general anesthesia in centers in the United States and particularly in Europe [24-26]. However, as a practical matter, general anesthesia is preferred when use of TEE is planned [7,27]. Moderate sedation with MAC, can be utilized for TAVI when TEE is indicated, but a deeper level of sedation is required, with may increase the risk of hemodynamic and/or airway compromise. Broad indications for intraprocedural use of TEE include [16]:
●Use of general anesthesia
●Poor acoustic TTE windows
●Uncertainty in valve sizing
●Concurrent procedures which require TEE
●Desire to limit the amount of contrast given
Although most studies comparing general anesthesia versus moderate sedation with MAC and local or regional anesthetic techniques have focused on the transfemoral approach, a few reports have described successful use of the latter technique at alternative vascular access sites including transcarotid, subclavian, transcaval, or transapical approaches for TAVI (see "Transcatheter aortic valve implantation: Periprocedural and postprocedural management", section on 'Procedural considerations'):
●A 2020 randomized trial in patients undergoing transfemoral TAVI compared outcomes in those who had local anesthesia together with moderate sedation with MAC versus general anesthesia with endotracheal intubation [28]. A composite endpoint (all-cause mortality, stroke, myocardial infarction, infection requiring antibiotic treatment, and acute kidney injury at 30 days) occurred with similar incidence in the moderate sedation (27.2 percent of 222 patients) and general anesthesia groups (26.4 percent of 225 patients; rate difference [RD] 0.8, 90% CI -6.2 to 7.8). Patients receiving moderate sedation had a lower need for inotropes or vasopressors (63 versus 97 percent; RD -34, 90% CI -41 to -28). However, 12 patients receiving moderate sedation required urgent conversion to general anesthesia, and one additional patient required elective conversion for pain prophylaxis [28].
Prior observational studies in patients undergoing transfemoral TAVI procedures identified better outcomes with moderate sedation (eg, lower 30 day mortality, reduced length of hospitalization) compared with general anesthesia [3,4,15,27,29-31]. For example, in the National Cardiovascular Data Registry, which included nearly 11,000 patients, moderate sedation was employed in 16 percent, while general anesthesia was employed in 84 percent [15]. Moderate sedation was associated with lower mortality (both in-hospital [1.5 versus 2.4 percent] and at 30 days [2.3 versus 4.0 percent), less intraprocedural inotrope use (29 versus 44 percent), and shorter hospital stay (6.0 versus 6.5 days) compared with general anesthesia. However, these observational studies have been limited by selection bias and lack of explicit definition of the type of anesthesia and role of the anesthesia care team [15,27]. Classification in the general anesthesia group was typically based on whether the patient had an endotracheal tube, while the term "conscious sedation" usually referred to varying levels of anesthetic depth provided by an anesthesia care team (ie, MAC), although some studies included nurse-administered sedation supervised by the interventionalist.
The need for transfemoral surgical cutdown for TAVI is an indication for general anesthesia at some institutions. However, in one retrospective study of 282 TAVI patients, transfemoral surgical cutdown was performed using a regional anesthetic technique (ilioinguinal block) together with moderate sedation with MAC [32]. In this study, the conversion rate to general anesthesia was only 3.9 percent, with a high procedural success rate of 99.3 percent.
●Subclavian/axillary TAVI is usually performed with general anesthesia. However, regional anesthesia (eg, pectoralis plus interscalene blocks [33] or superficial cervical plus interscalene blocks [34]) together with moderate sedation with MAC has been described.
●Transaortic or transapical TAVI is usually performed with general anesthesia. However, regional anesthesia (serratus anterior plane block) together with moderate sedation with MAC has been described for the transapical approach [35].
●Transcaval TAVI may be performed with either general anesthesia or with local anesthesia together with moderate sedation with MAC.
●Transcarotid TAVI is typically performed with general anesthesia, although use of moderate sedation with MAC has been described. These procedures are performed in hybrid rooms with a multidisciplinary team that include anesthesiologists, interventional cardiologists, and cardiac surgeons. Prior to the procedure, some centers assess risk of cerebral hypoperfusion by cerebral magnetic resonance angiography screening and transcranial Doppler imaging [36]. Cerebral perfusion can be continuously monitored during the procedure using cerebral oximetry with near infrared spectrometry [36,37].
In a series of 174 patients undergoing a transcarotid approach, 30 day mortality, one year mortality, one month clinical efficacy, and early safety outcomes were similar in 122 patients receiving general anesthesia compared with 52 patients receiving moderate sedation [37]. Periprocedural cerebrovascular events (ie, stroke or transient ischemic attack) were observed in 5.6 percent of those receiving general anesthesia, but in none of the smaller group receiving moderate sedation with MAC.
Anesthetic management involves:
●Hemodynamic management – Key points for management of patients with AS undergoing an interventional procedure are summarized in the table (table 3).
●Monitoring – Appropriate monitoring during a TAVI procedure is based in part on the selected anesthetic technique. Although invasive monitoring may be similar to that used for conventional SAVR procedures (eg, intra-arterial catheter and central venous catheter or pulmonary artery catheter) (see "Anesthesia for cardiac valve surgery", section on 'Surgery for aortic stenosis'), use of a full complement of these invasive cardiovascular monitors is decreasing [9,24,38,39]. In fact, for TAVI procedures performed via a transfemoral approach (or for some alternative access routes) in low-risk patients, an intra-arterial catheter is not always necessary, especially if MAC is selected. Monitoring blood pressure via the intra-aortic sheath placed by the proceduralist (to be used for TAVI deployment) may suffice.
In patients undergoing general anesthesia, TEE is often employed to provide technical guidance, detect and quantify paravalvular leaks after valve deployment, and avoid use of contrast media during fluoroscopy [17,18]. (See 'Imaging for TAVI procedures' above.)
●Considerations for general anesthesia – Short-acting anesthetic agents selected for general anesthesia are described above. (See 'General anesthesia' above.)
●Considerations for moderate sedation with MAC – Short-acting anesthetic agents selected for moderate sedation with MAC are carefully titrated to minimize the need for vasopressor and/or inotropic support and avoid postoperative respiratory depression as described above [3,31,40-43]. (See 'Moderate sedation' above.)
Usually, moderate sedation with MAC is administered by an anesthesia provider for a TAVI procedure [9], although some centers use nurse-administered sedation, typically with back-up from the anesthesia care team [2]. We favor the presence of an anesthesiologist during TAVI given the likelihood of development of hemodynamic instability in patients with advanced age, frailty, or significant comorbidities, as well as the possible need for conversion to general anesthesia [6-8,15]. The American Association for Thoracic Surgery (AATS)/American College of Cardiology (ACC)/Society for Cardiovascular Angiography (SCA)/Society of Thoracic Surgeons (STS) expert consensus statement recommends that TAVI programs have a comprehensive multidisciplinary team that includes an anesthesiologist [1]. Although an anesthesiologist may not be constantly present for every individual procedure, immediate availability is necessary to provide support when urgently needed. (See 'Moderate sedation' above.)
Need for conversion from sedation to general anesthesia was 5.9 percent in a large observational study of nearly 11,000 TAVI patients in the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry [15]. Reasons for conversion in this and other studies have included vascular complications, hemodynamic compromise, and respiratory failure (particularly in patients with preexisting lung disease) [15,44-46]. (See 'Selection of anesthesia technique' above.)
Most low-risk patients without complications can be transferred to a high-dependency setting after moderate sedation with MAC, rather than to an intensive care unit after TAVI performed without general anesthesia.
Percutaneous balloon aortic valvotomy
General considerations — The use of percutaneous balloon aortic valvotomy plays an important role in the treatment of children, adolescents, and young adults with AS, although its use in older adults with severe symptomatic AS is very limited and is not considered to be definitive treatment. For selected older adults with severe symptomatic AS this technique is a potential option to serve as a bridge to SAVR or TAVI [47]. (See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults", section on 'Use'.)
Anesthetic techniques and management — Most centers undertake this procedure in adult patients using local anesthesia and light-to-moderate sedation, commonly administered by a nurse under the supervision of the interventional cardiologist. If a potentially life-threatening complication occurs, immediate availability of the anesthesia care team is critical to provide urgent endotracheal intubation and hemodynamic support [48]. (See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults".)
MITRAL VALVE INTERVENTIONS
Transcatheter edge-to-edge mitral repair
General considerations — For treatment of mitral regurgitation (MR), a potential advantage of transcatheter edge-to-edge mitral repair (TEER) "beating heart" approach rather than open cardiac surgical repair is the ability to use real-time transesophageal echocardiography (TEE) to assess adequacy of correction of MR so that immediate intra-procedural adjustments may be made if necessary.
The MitraClip procedure and the PASCAL procedure are FDA-approved devices to create an edge-to-edge repair (figure 2) (see "Transcatheter edge-to-edge mitral repair", section on 'Available technology'), resulting in double orifice mitral valve similar to that achieved after an Alfieri stitch performed during an open cardiac surgical procedure (figure 3) [49-54] (see "Anesthesia for cardiac valve surgery", section on 'Surgical mitral valve repair or replacement'). Other investigational devices for TEER are described separately. (See "Transcatheter edge-to-edge mitral repair", section on 'Investigational technologies'.)
Vascular access is obtained via transfemoral venous cannulation and a transseptal approach to the left atrium. Positioning of the transseptal puncture is critical to ensure that the mitral valve device can be maneuvered into the appropriate location. When the device is optimally positioned in the left ventricle, the mitral leaflets are grasped and the clip is released. Leaflet capture, residual MR, and degree of mitral stenosis are assessed post-procedure using TEE (see 'Imaging for TEER' below). If necessary, the device can be removed or repositioned, or more than one device can be deployed [55].
Further discussion of technical aspects, preoperative and postoperative care, complications, and outcomes of the MitraClip TEER procedure is found in a separate topic. (See "Transcatheter edge-to-edge mitral repair".)
Imaging for TEER — The procedure is performed using both fluoroscopy and TEE guidance. TEE is employed for preprocedural evaluation of the mitral valve to demonstrate the location of leaflet pathology, to delineate size and extent of any flail segment, and to confirm adequate leaflet length to facilitate clip placement for device implantation. Use of three-dimensional TEE enhances visualization of the mitral valve, thereby improving localization of leaflet pathology and demonstration of anatomic suitability for treatment with the device (eg, absence of cleft leaflet, vegetations, or perforations). During the procedure, TEE guidance is critical to ensure appropriate device placement, adequate reduction in MR, and maintenance of acceptable mitral inflow (ie, absence of a significant degree of mitral stenosis) which is impacted by placement of the device [21,53,54]. While transthoracic echocardiography (TTE) guidance for a MitraClip procedure has been reported [56], TEE is the standard imaging modality for TEER. (See "Pulmonic valve stenosis in adults: Management", section on 'Acute outcomes' and "Pulmonic valve stenosis in adults: Management", section on 'Balloon valvotomy'.)
Anesthetic techniques and management — Selection of anesthetic technique for TEER varies depending on institutional preferences, patient-specific factors, and planned use of TEE. General anesthesia with endotracheal intubation is generally selected since TEE is extensively employed (see 'Imaging for TEER' above); however, moderate or deep sedation with monitored anesthesia care (MAC) has also been described [53,57,58].
A 2020 meta-analysis with five randomized and non-randomized studies compared 430 patients receiving moderate sedation (with MAC or under supervision of an interventional cardiologist) versus 217 patients receiving general anesthesia during TEER [57]. Differences between techniques were not significant for hospital mortality, incidence of multiple clip implantation, procedure length, fluoroscopy time, eventual procedural success rate, or complications. Patients receiving sedation had a shorter intensive care unit length of stay (1.3 versus 3.8 days; standardized mean difference [SMD] = -0.97, 95% CI -1.75 to -0.20), but the difference in hospital stay was not significant (8.3 versus 10.3 days; SMD = 0.36, 95% CI -0.77 to 0.04).
●Hemodynamic management – Key points for hemodynamic management of patients with MR undergoing an interventional procedure are summarized in the table (table 4).
●Monitoring – An intra-arterial catheter is inserted and is helpful for early detection of pericardial effusion/tamponade, a recognized complication of this procedure. Placement of more invasive cardiovascular monitors (eg, central venous catheter) is not routine but may be used if peripheral access is inadequate or if vasopressor or inotropic infusions are likely. If necessary, the venous sheath placed by the procedural team for device deployment may be accessed during the procedure by the anesthesiologist [59].
Percutaneous mitral balloon valvotomy
General considerations — Selected symptomatic patients with severe rheumatic mitral stenosis who have an anatomically favorable native valve and subvalvular features are candidates for a percutaneous mitral balloon valvotomy (PMBV) procedure. Echocardiographic criteria for candidates for PMBV are discussed separately. (See "Percutaneous mitral balloon commissurotomy in adults", section on 'Use'.)
Anesthetic techniques and management
●Hemodynamic management – Key points for hemodynamic management of patients with mitral stenosis (MS) undergoing an interventional procedure are summarized in the table (table 5).
●Anesthetic considerations and echocardiography monitoring – The PMBV procedure is usually performed with light to moderate sedation, typically administered by a nurse under the supervision of the interventional cardiologist using transthoracic and/or intracardiac echocardiography, making this procedure particularly suitable for MS patients with high surgical risk [60].
However, general anesthesia with endotracheal intubation may be selected for some patients to enable performance of TEE before and during the procedure, to manage potential patient discomfort, and to avoid the risks of excessive sedation in an unintubated patient including hypoxemia, hypercarbia, and exacerbation of pulmonary hypertension [61,62]. In such cases, TEE is used immediately before PMBV to document that no more than moderate MR is present, and that there is no left atrial thrombus. Subsequently, during the procedure, TEE may be used to guide technical aspects of the PMBV procedure (eg, transseptal puncture, balloon placement) in some patients, and to monitor for complications. (See "Transesophageal echocardiography in the evaluation of mitral valve disease", section on 'Use for percutaneous balloon valvotomy'.)
Further discussion of technical aspects, complications, and outcomes of the PMBV procedure is found elsewhere. (See "Percutaneous mitral balloon commissurotomy in adults".)
Valve-in-valve implantation — Transcatheter valve-in-ring implantation is an option for treatment of bioprosthetic mitral valve dysfunction (stenosis or regurgitation), particularly when severe mitral valve dysfunction and/or severe annular calcification of the native valve is present [54]. In such cases, devices used for transcatheter aortic valve implantation (TAVI) have been used in the mitral position [63,64]. However, since the anatomy of the mitral valve differs from that of the aortic valve, placing a TAVI device in the mitral position is not ideal. Development of percutaneous mitral valve replacement devices is underway. (See "Bioprosthetic valve thrombosis, thromboembolism, and obstruction: Management", section on 'Mitral valve-in-valve procedure' and "Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation", section on 'Mitral valve-in-valve procedure'.)
General anesthesia with endotracheal intubation is generally selected for transcatheter mitral valve-in-valve or valve-in-ring replacement in order to facilitate use of TEE, although moderate sedation with MAC is feasible for selected cases [59,65].
PULMONIC VALVE INTERVENTIONS
Percutaneous pulmonic valve implantation
General considerations — Percutaneous pulmonic valve implantation (PPVI) is indicated for selected patients with right ventricular outflow tract (RVOT) conduit (or native) severe stenosis or regurgitation. (See "Transcatheter pulmonary valve implantation", section on 'Clinical setting'.)
Notably, patients are positioned supine with arms above the head to allow appropriate fluoroscopy and the PPVI procedure may be long. Furthermore, the procedure consists of several phases including valve deployment, RVOT balloon dilation (which typically causes a precipitous drop in cardiac output), and stenting of the landing zone. If a large paravalvular leak develops after valve deployment (rare), the newly implanted pulmonic valve can be balloon dilated or, rarely, a second valve-in-valve can be deployed.
Imaging for PPVI procedures — Typically fluoroscopy and, if needed, intracardiac echocardiography provide adequate imaging for PPVI procedures, so transesophageal echocardiography (TEE) is not usually required for a PPVI procedure.
Anesthetic techniques and management — General anesthesia with endotracheal intubation is typically used for PPVI procedures, although moderate sedation with monitored anesthesia care (MAC) is used for selected patients in some centers [66-68].
In one case series that included 79 adults undergoing elective PPVI, all were performed with general anesthesia and endotracheal intubation, with successful extubation at the conclusion of the case in 85 percent [69]. Three patients required mechanical ventilation for >24 hours and three required reintubation. Other complications of PPVI include stent fracture, which generally has no significant hemodynamic effect but may lead to embolization of stent parts, restenosis, or conduit rupture (contained or non-contained). (See "Transcatheter pulmonary valve implantation", section on 'Complications by valve type'.)
●Hemodynamic management – Key points for hemodynamic management of patients with pulmonic regurgitation (PR) undergoing an interventional procedure are summarized in the table (table 6).
In particular, a normal to fast heart rate (HR) is maintained, since a faster HR minimizes regurgitant volume through the insufficient valve. In addition, normal to low pulmonary vascular resistance (PVR) is maintained to facilitate forward flow in the pulmonary arterial circulation. Increasing the fraction of inspired oxygen (FiO2) and mild hyperventilation to maintain a PaCO2 30 to 35 mmHg will lower PVR. Hypoxia, hypercarbia, and acidosis are avoided to prevent increases in PVR that may exacerbate right ventricular dysfunction.
●General anesthesia – A radial intra-arterial line is commonly placed. Only rarely is a separate central venous catheter inserted since the side port of the femoral or jugular venous delivery sheath can provide central venous access to the anesthesia team if necessary [69].
Because coronary compression is a potential complication of PPVI, a balloon test to exclude potential coronary artery compression should be performed prior to valve deployment, as described separately. (See "Transcatheter pulmonary valve implantation", section on 'Balloon test'.)
At the end of a PPVI procedure, tracheal extubation is usually possible in the procedure room or shortly thereafter. Patients are observed in the intensive care unit for at least 12 to 24 hours to detect development of complications such as pulmonary edema, hemoptysis, or bradycardia.
Further discussion of technical aspects, complications, and outcomes of the PPVI procedure is found elsewhere. (See "Transcatheter pulmonary valve implantation".)
Percutaneous pulmonic balloon valvotomy
General considerations — Severe pulmonic valve stenosis (PS) with a domed valve is usually treated percutaneously with pulmonic balloon valvotomy, while open cardiac surgery is reserved for patients with associated hypoplastic pulmonary annulus, dysplastic pulmonic valve, subvalvular PS, supravalvular PS, severe PR, or severe tricuspid regurgitation (TR). (See "Pulmonic valve stenosis in adults: Management".)
Anesthetic techniques and management — Data regarding the choice of anesthetic technique for adults undergoing elective pulmonic balloon valvotomy are sparse [70,71]. Many institutions use moderate sedation administered by catheterization laboratory nursing staff under the supervision of the interventionalist for this procedure. When general anesthesia with endotracheal intubation is used, extubation is usually possible at the end of the procedure.
●Hemodynamic management – Key points for hemodynamic management of patients with PS are summarized in the table (table 6).
●Monitoring for complications – Use of TEE or intracardiac echocardiography may be useful to diagnose RVOT obstruction, PR, TR, pulmonary artery rupture, pulmonary edema, cardiac perforation, or tamponade in a patient who develops hemodynamic instability during or shortly after pulmonic balloon valvotomy.
Notably, transient severe RVOT obstruction may occur shortly after relief of pulmonic valvular obstruction with balloon valvotomy [72,73]. Such RVOT obstruction is treated with volume expansion and beta blocker therapy, and tends to lessen with time.
Other acute complications of pulmonic balloon valvotomy are generally self-limited and minor. These include catheter-induced ventricular ectopy, right bundle branch block, vagal response, or transient high grade atrioventricular [AV] nodal block, which on occasion may become permanent. (See "Pulmonic valve stenosis in adults: Management", section on 'Acute outcomes' and "Pulmonic valve stenosis in adults: Management", section on 'Balloon valvotomy'.)
Further discussion of percutaneous pulmonic balloon valvotomy for treatment of severe PS is found separately. (See "Pulmonic valve stenosis in adults: Management", section on 'Balloon valvotomy'.)
TRICUSPID VALVE INTERVENTIONS
Transcatheter tricuspid valve repair
General considerations — Tricuspid regurgitation (TR) is usually secondary to other pathology such as left-sided heart failure, left-sided valvular disease, and pulmonary hypertension, but correction of the primary underlying condition may not reverse secondary TR. TR as a result of a primary condition affecting the tricuspid valve apparatus is less common than secondary or functional TR. Causes of primary TR include iatrogenic injury of the valve, infective endocarditis, rheumatic heart disease, carcinoid syndrome, and Ebstein anomaly. (See "Etiology, clinical features, and evaluation of tricuspid regurgitation", section on 'Etiology'.)
When left-sided valve surgery is performed, concomitant surgical repair of the tricuspid valve is indicated for severe TR and may be helpful for selected patients with less than severe TR [47]. In selected patients, isolated surgical repair for severe TR may be indicated. Management details are discussed in separate topics. (See "Management and prognosis of tricuspid regurgitation", section on 'Tricuspid valve surgery' and "Management and prognosis of tricuspid regurgitation", section on 'Transcatheter tricuspid valve repair'.)
Selected patients who are not undergoing open left-sided cardiac valve surgery may be candidates for transcatheter tricuspid valve repair, typically those with moderate to severe central secondary TR without severely impaired RV function [74,75] (see "Management and prognosis of tricuspid regurgitation", section on 'Timing and risk stratification'). Devices that are approved for this purpose in Europe (ie, Triclip and PASCAL devices) are investigational in the United States, and other devices are undergoing feasibility testing. (See "Management and prognosis of tricuspid regurgitation", section on 'Transcatheter tricuspid valve repair'.)
Imaging for transcatheter tricuspid valve repair procedures — Typically, combinations of fluoroscopy and echocardiography (transesophageal echocardiography [TEE] and/or intracardiac echocardiography [ICE]) are used for procedural guidance. ICE may be used in conjunction with TEE as TV leaflets may not be clearly defined using TEE alone. When extensive use of TEE is planned, general anesthesia with endotracheal intubation is usually selected.
Anesthetic techniques and management — The procedural steps for transcatheter tricuspid valve repair vary depending on the device to be implanted, which may impact anesthetic management. Initial reports from the multicenter International TriValve Registry with data on 106 high-risk patients treated with transcatheter tricuspid valve devices have noted that all but one of the procedures had been performed using general anesthesia with endotracheal intubation [74,75].
●Hemodynamic management – Hemodynamic goals for patients with TR undergoing an interventional procedure include maintenance of a normal to fast heart rate (HR) at 80 to 100 beats per minute (bpm) because a faster HR minimizes regurgitant volume. Maintenance of a normal to low pulmonary vascular resistance (PVR) facilitates forward flow in the pulmonary arterial circulation. Avoidance of hypoxia, hypercarbia, and acidosis is particularly important to prevent increases in PVR which may exacerbate RV dysfunction. Systemic vascular resistance (SVR) is maintained in the normal range. (See "Anesthesia for cardiac valve surgery", section on 'Surgery for tricuspid valve disease'.)
●Anesthetic techniques – Initial reports from the multicenter International TriValve Registry note that an intra-arterial catheter is usually inserted [74,75]. Placement of more invasive cardiovascular monitors (eg, central venous catheter) is not routine. Patients are recovered in a high-dependency setting or an intensive care unit [76]. (See "Management and prognosis of tricuspid regurgitation", section on 'Transcatheter tricuspid valve repair'.)
Percutaneous tricuspid balloon valvotomy
General considerations — The most common cause of tricuspid stenosis (TS) in adults is rheumatic heart disease. These patients may also have coexisting TR and/or other cardiac valve lesions, but severe, symptomatic TS without TR or other cardiac valve disease is rare [77,78]. The choice between tricuspid valve surgery (repair or replacement) or percutaneous balloon valvotomy of the tricuspid valve is discussed separately. (See "Tricuspid stenosis", section on 'Treatment'.)
Anesthetic techniques and management
●Hemodynamic management – Hemodynamic goals for patients with TS undergoing an interventional procedure include maintenance of a normal to slow HR at 60 to 80 bpm, a normal to low PVR, and a normal SVR. (See "Anesthesia for cardiac valve surgery", section on 'Surgery for tricuspid valve disease'.)
●Anesthetic techniques – Percutaneous tricuspid balloon valvotomy is usually performed with moderate sedation using transthoracic and/or intracardiac echocardiography. However, in some patients, TEE may be desired to guide technical aspects of the procedure. or to monitor for complications. In these cases, general anesthesia with endotracheal intubation is preferred.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cardiac valve disease" and "Society guideline links: Transcatheter aortic valve implantation".)
SUMMARY AND RECOMMENDATIONS
●Location for procedures – Percutaneous valve interventions require a multidisciplinary team (ie, interventional cardiologist, cardiac surgeon, imaging specialist/radiologist, cardiac anesthesiologist, and perfusionist to provide back-up cardiopulmonary bypass [CPB] if needed). (See 'Team and location' above.)
●Anesthetic technique – Percutaneous valve interventions are performed with either general anesthesia with endotracheal intubation or sedation (generally moderate; with or without monitored anesthesia care [MAC]) with general anesthesia back-up. The anesthesia technique is selected depending on the specific procedure, institutional preferences, and patient-specific factors. General anesthesia is generally required if transesophageal echocardiography (TEE) is planned. With either technique, short-acting anesthetic agents are preferred and normothermia is maintained to ensure rapid awakening and recovery. (See 'Selection of anesthesia technique' above.)
•General anesthesia – Short-acting intravenous (IV) anesthetic agents such as propofol, fentanyl or remifentanil, midazolam, ketamine, and/or a volatile inhalation anesthetic, as well as a short-acting neuromuscular blocking agent (NMBA) are preferred to facilitate rapid awakening and recovery. (See 'General anesthesia' above.)
•Sedation with monitored anesthesia care (MAC) – Anesthetic agents typically include a low dose remifentanil infusion or a low dose dexmedetomidine infusion. If needed small dose(s) of intravenous (IV) midazolam are added. If an additional anesthetic agent is required to achieve the desired depth of sedation, propofol may be administered. (See 'Moderate sedation' above.)
●Aortic valve procedures
•Transcatheter aortic valve implantation (TAVI) – TAVI is used predominantly to treat severe aortic stenosis (AS) but is also used for selected patients with aortic regurgitation (AR; investigational in the US) (figure 1). For TAVI, selection of anesthetic technique for an individual patient includes consideration of center and operator practice, patient comorbidities, planned use of TEE, and the TAVI access route. Although an intra-arterial catheter and TEE are usually inserted for patients undergoing general anesthesia, use of a full complement of invasive cardiovascular monitors (eg, central venous catheter) is decreasing. Key points for hemodynamic management of patients with AS and for patients with AR are summarized in tables (table 3 and table 4). (See 'Transcatheter aortic valve implantation' above and 'Anesthetic techniques and management' above.)
-Transfemoral TAVI is most common, and may be performed with either moderate sedation with MAC and local or regional anesthetic techniques or with general anesthesia.
-Procedures via other access routes (eg, subclavian/axillary, transaortic or transapical, transcaval, transcarotid) are usually performed with general anesthesia, although some centers use moderate sedation with MAC in selected patients.
•Percutaneous balloon aortic valvotomy – Balloon valvotomy for severe AS is generally performed using local anesthesia and light-to-moderate sedation. (See 'Percutaneous balloon aortic valvotomy' above.)
●Mitral valve procedures
•Transcatheter edge-to-edge mitral repair (TEER) – The TEER "beating heart" approach to treat MR has the advantage of use of real-time TEE to assess adequacy of correction so that immediate intra-procedural adjustments may be made if necessary (figure 2). Key points for hemodynamic management of patients with MR are summarized in the table (table 4). General anesthesia is usually selected for TEER procedures since TEE is extensively employed, although use of moderate sedation or MAC has also been described. (See 'Transcatheter edge-to-edge mitral repair' above.)
•Percutaneous mitral balloon valvotomy (PMBV) – Balloon valvotomy is an option for selected patients with MS. PMBV is usually performed with minimal sedation using transthoracic echocardiography (TTE). However, if TEE is planned to guide the procedure during transseptal puncture and balloon placement as well as monitoring for complications, then general anesthesia with endotracheal intubation is typically necessary. Key points for hemodynamic management of patients with MS are summarized in the table (table 5). (See 'Percutaneous mitral balloon valvotomy' above and "Percutaneous mitral balloon commissurotomy in adults".)
●Pulmonic valve procedures
•Percutaneous pulmonic valve implantation (PPVI) – PPVI is indicated for selected patients with right ventricular outflow tract (RVOT) conduit (or native) severe stenosis or regurgitation. General anesthesia with endotracheal intubation is usually employed. Key points for hemodynamic management of patients with pulmonic regurgitation (PR) are summarized in the table (table 6). (See 'Percutaneous pulmonic valve implantation' above and "Transcatheter pulmonary valve implantation".)
•Percutaneous pulmonic balloon valvotomy – Balloon valvotomy may be used for selected patients with severe pulmonic stenosis (PS) and a domed valve. Sedation is employed more commonly than general anesthesia. Key points for hemodynamic management of patients with PS are summarized in the table (table 6). (See 'Percutaneous pulmonic balloon valvotomy' above and "Pulmonic valve stenosis in adults: Management", section on 'Indications for intervention'.)
●Tricuspid valve procedures
•Tricuspid regurgitation (TR) procedures – Transcatheter tricuspid valve repair of TR is usually performed with general anesthesia. TEE is utilized. Intracardiac echocardiography (ICE) can be used as an adjunct to help define TV leaflets. Hemodynamic goals for patients with TR include maintenance of a normal to fast heart rate (HR) at 80 to 100 beats per minute (bpm), normal to low pulmonary vascular resistance (PVR), avoidance of hypoxia, hypercarbia, and acidosis to prevent increases in PVR which may exacerbate RV dysfunction, and normal systemic vascular resistance (SVR). (See 'Transcatheter tricuspid valve repair' above and "Management and prognosis of tricuspid regurgitation", section on 'Transcatheter tricuspid valve repair'.)
•Percutaneous tricuspid balloon valvotomy – Balloon valvotomy for patients with tricuspid stenosis (TS) is usually performed with moderate sedation using TTE and/or intracardiac echocardiography, but general anesthesia may be employed if TEE use is planned. Hemodynamic goals for patients with TS include maintenance of a normal to slow HR at 60 to 80 bpm, normal to low PVR, and normal SVR. (See 'Percutaneous tricuspid balloon valvotomy' above and "Tricuspid stenosis", section on 'Intervention'.)
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