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  • Large range of surgical approaches, including:
    • Mini sternotomy, minimally invasive/thoracotomy, percutaneous valves (transfemoral/transapical aortic valve insertion)
  • Anesthetic management:
    • Need to accommodate surgical requirements
    • Be prepared to convert to open procedure

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Pros and Cons of Minimally Invasive Technique
Potential advantagesPotential problems
  • Less trauma, smaller incisions
  • Reduced postoperative pain (except thoracotomy)
  • Faster extubation, shorter ICU/hospital stay
  • Faster return to normal activities
  • Cost savings
  • Expanded patient inclusion
  • Technically more difficult
  • If arterial or venous injury, need for expeditious full exposure
  • One-lung ventilation for some procedures and associated complications
  • Pain management issues if thoracotomy
  • Percutaneous valves: vascular injury, arrhythmias, device malfunction, device malpositioning, coronary occlusion, stroke
  • Valvuloplasty: vascular injury, creation of regurgitant lesions, embolic events, short duration of symptom relief
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Mini sternotomy: Open heart procedure with smaller incision

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No significant difference from standard sternotomy procedure

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Thoracotomy approach mainly for aortic and mitral valve surgery

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  • Physiologic consideration—similar to mini sternotomy with some additional concerns
    • Neuro: potential cerebral blood flow changes with one-lung ventilation
    • Cardiovascular
      • Dysrhythmias
        • Hypercapnia may cause decrease in myocardial contractility and lower arrhythmia threshold
      • Right ventricular failure with one-lung ventilation and increased pulmonary vascular pressures
    • Pulmonary
      • One-lung ventilation
      • Splinting and hypoventilation if thoracotomy pain not well controlled

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Preoperative

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  • Double lumen ETT may improve surgical exposure
  • Be prepared for standard sternotomy and need for cardiopulmonary bypass
  • Arterial line and central venous access as with normal cardiac surgery

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Induction

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  • Specific goals for blood pressure and heart rate will depend on specific patient and pathology
  • Additional airway equipment available such as tube exchanger and fiberoptic scope

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Maintenance

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  • Thorough transesophageal echo (TEE) evaluation pre-, intra-, and postoperatively
  • Careful management of one-lung ventilation
  • Vasoactive agents readily available
  • Be prepared to convert to cardiopulmonary bypass (CPB) at any time

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Postoperative

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  • TEE evaluation for adequacy of surgical repair
  • Recovery in ICU
  • More pain from thoracotomy
    • Multimodal analgesic regimen
    • Opioids, nonsteroidal anti-inflammatory drugs
    • Consider epidural and local anesthetics

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Transapical or transfemoral aortic valve

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  • Physiologic considerations
    • Neuro
      • Concern for embolic events during valve manipulation and deployment
      • Potential for one-lung ventilation and changes in cerebral blood flow with changes in PaCO2
    • Cardiovascular
      • Dysrhythmias
        • Mechanical stimulation with guide wire during percutaneous procedures
        • Ventricular fibrillation initiated prior to valve deployment will cause changes in blood pressure which need to be anticipated
        • Hypercapnia may cause decrease in myocardial contractility and lower arrhythmia threshold.
      • Left ventricular failure with acute aortic insufficiency with valvuloplasty
      • Coronary ischemia if percutaneous valve deployment occludes coronary ostia
      • Right ventricular failure with one-lung ventilation and increased pulmonary vascular pressures
    • Pulmonary
      • One-lung ventilation and thoracotomy pain for transapical
    • Renal/Fluids/Electrolytes
      • Renal injury if dye used during percutaneous procedures

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Preoperative

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  • Thorough history and physical...

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