CONSIDERATIONS:

1. Low EF patients. Check

2. Anes providers will practice variety of approaches for MAC anesthesia. Consult attending for preferences and if no guidance default to this protocol.

3. Make sure you have your lead available

PRE-OP:

1. Two large bore IV's, A-line, Precedex drip 0.7mcg/kg/hr

2. Check for allergy to contract dye

3. Conduct Neuro assessment for post operative comparison

SETUP:

1. 20ml heparin syringe, Ephedrine, NEO, EPI 4mcg/ml, EPI 16mcg/ml, CaCl2

2. Versed optional (Caution - look for post op neuro impact)

3. Fentanyl optional (Field uses local for sheath insertion)

4. Propofol optional

5. Ketamine optional

6. Backup - Intubation setup, LMA Setup

7. NTG drip

8. Epi drip on pump, ready but not hooked up

9. Plan to use one IV for all drips and 2nd IV to push drugs

IN OR

1. Transfer pt to table

2. Anes attaches

   1. PulseOx

   2. Blood pressure

   3. O2 per canula or mask

   4. ETCO2  monitor

   5. Zero A-line, draw baseline labs plus ACT

   6. Attach all planned drips to IV lines before TAVR team tucks arms

3. TAVR Team attaches monitors

   • (Anes good practice is to mildly sedate pt while TAVR team attaches its equipment)

4. Surgical Pause (led by Circulator RN)

   1. Antibiotics, pt weight, baseline ACT, blood available, confirm pt is operable

   2. TAVR Checklist (led by TAVR Team) SPEAK UP! MAKE SURE YOU CAN BE HEARD!

      1. Each Surgical Team functional member is polled for GO/NOGO and critical information.

      2. Anes will report any additional critical information and confirm readiness to proceed.

SURGICAL PROCEDURE

1. Cardiologist establishes sheath access via femoral artery (Can be painful)

2. Listen for direction to give Heparin

3. Draw ACT should be +/- 300 - Verbally report result

4. BAV (Balloon Aortic Valvuloplasty) - Balloon is inflated to crush calcified AV

5. New valve is crimped on catheter and delivered to AV area.

6. Heart is rapid paced - balloon inflated with fluid - expanding new valve in place - continuous monitoring via x-ray to ensure minimal movement in the field - calcified leaflets will secure the new valve in place. (NOTE: self expanding valves may not need this.)

7. NOTE: Anes has a critical role in monitoring during this sequence of activities. IT IS ESSENTIAL TO BE READY. Expect numbers to behave as follows

   1. Systolic BP should be around 100 before rapid pace

   2. During rapid pace, BP will drop severely for 15-30 seconds (THIS IS NORMAL)

   3. Pulse pressure <10mm Hg before balloon expansion

8. Pt BP should return within 30-60 seconds after rapid pace cycle is complete - Do not give BP affecting meds during this phase as it will disrupt the normal process for this stage of the procedure.

9. Expect to see multiple attempts to achieve optimal valve position. you can therefore expect multiple cycles of rapid pace and BP swings.

10. IF BP does not return as expected at the end of a rapid pace cycle (6 seconds of zero change in BP):

    1. Ask surgeon to pause

    2. Request TAVR Team to pace the heart to restore cardiac output

    3. Treat BP and inform Surgical Team - NOTE: treating BP with Ephedrine or NEO at this point might cause the BP too be high for surgical team to position the valve

11. After deployment, several contrasts will be taken to verify the proper position (note: this can require over 200cc of contrast dye)

12. TTE is performed at this time to confirm proper position and no leak

13. TAVR Team will hold groin pressure per their protocol

14. Give Protamine - surgeon will specify dose and Circulator RN will provide

15. Measure ACT after 5-7 minutes circulation time

16. Pay attention to EBL - if high verify H&H concurrent with ACT

17. Continue to monitor VSS and initiate Nitro drip as needed

18. Ensure MAP 70 - 75mm Hg

TRANSPORT

1. To ICU on O2

2. Precedex can be reduced to .2mcg/kg/hr (or disconnected) so pt is awake enough for good neuro assessment

3. Conduct Neuro Assessment in conjunction with ICU Nurse. Compare with baseline results

COMPLICATIONS

1. Death

2. Stroke

3. Bleeding

4. Vascular complications