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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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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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- 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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- 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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- 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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- 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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