Partner

Aortic stenosis is a condition that limits a patient's activities, causes symptoms like chest pain and syncope, and can even be the cause of death. However, patients with aortic stenosis often have many other comorbidities making open heart surgery and valve replacement highly risky. Some patients have pathology like porcelain aorta that make open valve replacement technically difficult or impossible. In these cases, a new approach called transcatheter aortic valve replacement has been developed. Placed in the femoral artery in the groin and advanced retrograde to the heart under fluoroscopy, these catheters balloon open the tight stenotic valve and replace it with a valve deployed under cardiologist guidance with a transesophageal echocardiogram. The studies involving these transcatheter approaches, called the Partner trials, demonstrated that this new approach may be superior than medical therapy in patients who are not surgical candidates. In the short term, it appears to be a reasonable alternative to open surgery. The complications include vascular damage and strokes, but this approach saves the patient a sternotomy, cardiopulmonary bypass, and the long involved surgery of the open approach.

I recently was able to provide anesthesia for a patient undergoing transcatheter aortic valve replacement. The set-up is quite involved because we prepare to open or crash onto bypass if necessary. We have a large surgical team; along with the surgeons and anesthesiologists, we have the perfusionist for bypass, cardiologists,  an operating room nursing team, a team from the cath lab, and representatives from the company that manufactures the valves. It's a good example of expecting the best but preparing for the worst. The surgery went smoothly; we were done in a third of the time of an open repair, and when I saw the patient that afternoon, he was extubated, shook my hand, and felt hungry. The technology we have to replace a heart valve through a small cut-down in the groin is amazing.

Image of heart valve shown under Fair Use, from heart.bmj.com.