Fast-track anesthesia in lateral mini-thoracotomy for transapical transcatheter valve implantation

Ali Haddad; Cynthia Szalai; Lena van Brakel; Yacine Elhmidi; Sven Arends; Marco Rabis; Anca Pop; Arjang Ruhparwar; Thorsten Brenner; Sharaf-Eldin Shehada

doi:10.21037/jtd-21-751

Fast-track anesthesia in lateral mini-thoracotomy for transapical transcatheter valve implantation

J Thorac Dis. 2021 Aug;13(8):4853-4863. doi: 10.21037/jtd-21-751.

Authors

Affiliations

¹ Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany.
² Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany.
³ Department of Cardiac Surgery, Ludwigshafen Heart Centre, Ludwigshafen, Germany.

Abstract

Background: Patients who undergo transapical transcatheter aortic/mitral valve implantation are at higher risk of morbidity and mortality than those undergoing transvascular procedures. In addition, these patients have prolonged intensive care and hospital courses. Fast-track anesthesia could reduce perioperative complications and admission stays in such patients.

Methods: This retrospective single-center study, evaluates six high-risk patients undergoing transapical valve implantation between 01/2020 till 01/2021. All patients received a paravertebral block (PVB) as part of a fast-track approach. The airway was secured with a Gastro-double-lumen laryngeal mask which includes one orifice was for ventilation and one for the transesophageal echocardiography probe. Anesthesia was maintained with a volatile anesthetic (Sevoflurane MAC 1%). Immediately post procedure, all patients were awakened and admitted to the intermediate/intensive-care unit.

Results: Three patients were females, mean age =71±6 years, patients' risk profiles were high (mean Log. EuroSCORE-I 22% & STS-PROM 10%). No incidents of re-intubation, atelectasis/pneumonia, low output syndrome, stroke, dialysis, pacemaker implantation or operative mortality were reported. One patient (16.7%) underwent re-exploration for bleeding and developed a wound infection. Postoperative pain scores showed that no patient required additional analgesics after the initial eight hours post procedure. Mean postoperative intermediate/intensive-care stay was 13.8±3.2 hours and patients were mobilized early and discharged to the normal ward.

Conclusions: Fast-track anesthesia using paravertebral-blockade for transcatheter transapical valve replacement in high-risk patients is a possible anesthetic approach. An effective PVB, in addition to a double-lumen laryngeal mask, provide an alternative strategy to conventional general anesthesia. These promising results could encourage further consideration of this approach in similar cardiac surgery patients.

Keywords: Paravertebral-block; fast-track cardiac surgery; high-risk cardiac patients; transapical valve implantation.