Rigshospitalet Hjertecentret TAVI and use of Local Anesthesia

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1 TAVI and use of Local Anesthesia Barbara Wulff, RN Cath.lab / TAVI Program Coordinator Rigshospitalet Copenhagen University Hospital 1

2 How many of you do TAVI under Local Anesthesia?? 2

3 Why did it take so long before we had the first patient in local anesthsia? The main problem were how to coordinate the patient-care during the procedure 3

4 Seminars in Cardiothorac and Vascular Anesthesia Sep 24. The Anesthetic Management of Transcatheter Aortic Valve Implantation. Guarracino Fabio, et al. 4

5 Heart May;100(9): doi: /heartjnl Epub 2014 Jan 23. Transcutaneous aortic valve replacement with the Edwards SAPIEN XT and Metronic CoreValve prosthesis under fluroscopic guidance and local anaesthesia Greif M, Lange P, Näbauer M, Schwarz F, 5

6 hjertecentret Journal of Thoracic Disease, dis 2015 : 7(9): Sedation or general aneasthesia for transcatheter aortic valve implantation TAVI N. Patrick Mayr, Jonathan Michel, Sabine Bleiziffer, 6

7 Circ Cardiovasc Interv Aug; Clinical outcomes and safety of transfemoral aortic valve implantation under general versus local anesthesia Subanalysis of the French Aortic National CoreValve and Edwards 2 registry. Oguri, Atsusi MD,; Yamamoto Masanori,MD ;, Eltchaninoff,Helene,MD, et al FRANCE 2 Registry Investigators 7

8 Benefits of Local Anestesia/Conscious Sedation What does it mean for the patient? The patient is hemodynamic stabil Recognize stroke Faster procedure Shorter time at ICU, but more of a challenge. Earlier mobilized Earlier discharged Martin Greif et al. 8

9 Cons of Local Anesthesia/Conscious Sedation What does it mean for the patient? Is it painfull for the patient? Do the patients have more hematomas? Is it difficult to observe PVL and AR during the procedure?, Atsushi Oguri et al 9

10 Questions regarding Local Anesthesia Is it more flexible whith less multidisiplinary teams involved? Do we need less staff? Nurses, eccocardiograf, - anestesia Is it lower cost? Greif M, Lange P, Näbauer M 10

11 Dato : Patientlabel : Vægt kg : Set af TVT spl : Musik : Ankomst/ monitorering Lokalbedøvelse i lyske Sheathanlæggelse 6F Anlæggelse af Prostar/Proglide Anlæggelse af stor sheath Pace ved prædillitation Klap indførelse kl NRS smerter NRS angst Fentanyl µg Medazolam mg Ugunstige episoder Ugunstige episoder, som kræver særlig opmærksomhed A : Udsving i systolisk BT>50mmHg B : Udsving i diastolisk BT>50mmHg C : Vasovagalt anfald D : Ilttilskud for at opretholde SAT > 90% E : Vedvarende brystsmerter F : Besvimelse eller nærbesvimelse G : Kvalme/opkast Pace ved klapsættelse Lukning med Prostar/Proglide Stent i lyske Angioseal Kompremering i lyske Overflyttelse fra leje til seng Afgang 11

12 Ankomst/ monetorering Lokalbedøvels e i lyske Sheathanlægge lse 6F hø+ve Anlæggelse af Prostar/Proglid e Anlæggelse af stor sheath Pace ved prædillitation k l NRS Pain NRS Anxiety Fentanyl µg Medazolam mg 1,1,1,1,1,2,2,2,2,2,2,2,2,3,3,5,5,6,9, 1,1,2,2,3,3,4,4,5,5,5,5,5,6, 7,10,10. 1,1,1,1,2,2,2,3,3,4,5,5, ,1,2,2,2,2,2,2,2,2,3,3,5,5,5,8,9, 1,1,1,2,2,3,3,3,5, , , 2,4,4,5,8,8,8, 1,5,5, ,25 2,2,3,3,3,3,4,4,5,5,6,6,7,7,7,8,8,8,9,10 5,8, ,3,3,7,8, 1,4,5,5, 25 Klap indførelse 1,1,2,2,3,8,8,10, 2,5,8,10, ,25 0,25-0,25-0,25-0,25-0,25 Pace ved klapsættelse Lukning med Prostar/Proglid e Stent i lyske 2,2,3,8, 2,5,8, 25 0,25 2,2,2,3,4,4,8,8,9, 2,3,3,8,9, ,25 Angioseal 2,3,3,3,4,4,5, 1,2, Kompremering i lyske Overflyttelse fra leje til seng Afgang 2,3,3,3,5,

13 Patient selection Percutaneous Transfemoral procedure Patient has to be abel to maintain immobility through the procedure The patient have to understand Danish or English 13

14 PVK CVK Pacemaker TOE Intubation ECG Non invasiv BP invasive arteriel pressure Pulse oximetry 18F sheath 6F sheath 7F venesheath CAD 14

15 Kardiologisk Laboratorium 15

16 Kardiologisk Laboratorium 16

17 hjertecentret The Future 17

18 hjertecentret 18