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• W3135972890 abstract "Learning objectivesBy reading this article, you should be able to:•Explain how technological advances and increased experience with transcatheter aortic valve implantation (TAVI) have reduced the requirement for general anaesthesia, transoesophageal echocardiography and pulmonary artery catheter insertion.•Detail the basic steps involved, including vascular access, valve deployment, haemostasis of primary interventional access and the implications of each step for the anaesthetist.•Describe the minimalist approach to TAVI, the possible complications and their management.Key points•The anaesthetist has several important roles in TAVI, including perioperative preparation, leadership, risk mitigation and management of complications.•The most common approach is transfemoral TAVI, with vascular access of the femoral artery using 14–20 Fr gauge systems.•Some steps require rapid ventricular pacing at 180–220 beats min−1 to reduce the systolic blood pressure to <50 mmHg for 5–10 s.•Injury to the femoral artery is common and open surgical repair under general anaesthesia may be needed.•Other important complications include conduction abnormalities, such as heart block requiring a permanent pacing system, coronary artery occlusion and stroke. By reading this article, you should be able to:•Explain how technological advances and increased experience with transcatheter aortic valve implantation (TAVI) have reduced the requirement for general anaesthesia, transoesophageal echocardiography and pulmonary artery catheter insertion.•Detail the basic steps involved, including vascular access, valve deployment, haemostasis of primary interventional access and the implications of each step for the anaesthetist.•Describe the minimalist approach to TAVI, the possible complications and their management. •The anaesthetist has several important roles in TAVI, including perioperative preparation, leadership, risk mitigation and management of complications.•The most common approach is transfemoral TAVI, with vascular access of the femoral artery using 14–20 Fr gauge systems.•Some steps require rapid ventricular pacing at 180–220 beats min−1 to reduce the systolic blood pressure to <50 mmHg for 5–10 s.•Injury to the femoral artery is common and open surgical repair under general anaesthesia may be needed.•Other important complications include conduction abnormalities, such as heart block requiring a permanent pacing system, coronary artery occlusion and stroke. The main advantages of transcatheter aortic valve implantation (TAVI) compared with surgery are the avoidance of sternotomy and cardiopulmonary bypass, and expedited recovery from the procedure.1Kennon S. Lim Z. Transcatheter aortic valve implantation without general anaesthetic.Interv Cardiol Rev. 2014; 9: 130-132Crossref Google Scholar Dramatic improvements in assessment, refinement of the indications and technology have led to simplification of the TAVI procedure. The reliance on, and role of, the anaesthetist has therefore also changed rapidly. In part 1 of this article we discussed the selection and preparation of patients for TAVI.2Charlesworth M. Williams B.G. Buch M.H. Advances in transcatheter aortic valve implantation: Part 1. Patient selection and preparation.BJA Educ. 2021; 6 ([xxxx])Google Scholar In part 2 we detail the perioperative care including preprocedural assessment, procedural steps, complications and specific implications for the anaesthetist. This article focuses on the transfemoral approach (Fig. 1), which is by far the most common type of TAVI undertaken at our institution and in the UK. Meticulous assessment and planning before the procedure is essential to achieve effective outcomes from TAVI. High-quality decision-making needs careful integration of the clinical and anatomical factors involved. We previously described the importance of selecting appropriate patients and decision-making by the multidisciplinary team to ensure the best outcomes.2Charlesworth M. Williams B.G. Buch M.H. Advances in transcatheter aortic valve implantation: Part 1. Patient selection and preparation.BJA Educ. 2021; 6 ([xxxx])Google Scholar Large randomised clinical trials within the past few years have demonstrated equivalence and net superiority of TAVI over surgical aortic valve replacement (SAVR) in high- and intermediate-risk patients.3Leon M.B. Smith C.R. Mack M. et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5194) Google Scholar, 4Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4549) Google Scholar, 5Leon M.B. Smith C.R. Mack M.J. et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (2916) Google Scholar, 6Reardon M.J. Van Mieghem N.M. Popma J.J. et al.Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2017; 376: 1321-1331Crossref PubMed Scopus (1582) Google Scholar Assessment for SAVR or TAVI based on age and surgical risk scores (EuroSCORE or Society of Thoracic Surgeons score) have inherent limitations because the datasets were based largely on coronary procedures and the patients' characteristics were different. The 2017 ESC/EACTS (European Society of Cardiology/European Association of Cardiothoracic Surgery) guidelines on valvular heart disease recommend integration of multiple variables by the ‘heart team’ including clinical profile, coexisting diseases, frailty, functional status, anatomical and technical factors and complexity.7Baumgartner H. Falk V. Bax J.J. et al.2017 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar Advances in preprocedural imaging have contributed significantly to decision making and improved TAVI outcomes. Gated cardiac CT has become a standard of care for patients undergoing TAVI for aortic valve, aortic root and vascular access assessment. CT enables important anatomical and technical factors to be considered, which may favour SAVR or TAVI with respect to outcome and risk of complications. It also allows for tailoring of transcatheter heart valves to the patient's anatomy, which may result in better outcomes; provides more detailed evaluation of iliofemoral anatomy and suitability for the access route for TAVI with a preference for the transfemoral approach; and allow for assessment of anatomical and technical aspects of alternative access routes (subclavian, axillary, transcarotid, direct aortic, transcaval, transapical) if the transfemoral approach is not possible.8Jones B.M. Krishnaswamy A. Tuzcu E.M. et al.Matching patients with the ever-expanding range of TAVI devices.Nat Rev Cardiol. 2017; 14: 615-626Crossref PubMed Scopus (23) Google Scholar The two most commonly used technologies for TAVI are balloon- and self-expandable devices. Examples of balloon-expanded devices include SAPIEN XT and SAPIEN 3 (Edwards Lifesciences, Irvine, CA, USA) and of self-expanding devices include CoreValve, Evolut-R (Medtronic, Minneapolis, MN, USA), Portico (St. Jude Medical Inc., St. Paul, MN, USA) and ACURATE (Boston Scientific, Marlborough, MA, USA). The design and materials used differ between devices. For example, the SAPIEN XT is a balloon-expanded valve that is constructed with a radiopaque cobalt–chromium frame and a trileaflet bovine pericardial tissue valve with a polyterephtalate fabric skirt. The Evolut-R is a self-expanding valve constructed from a nitinol frame and a porcine pericardial tissue valve. Valves are available in a range of sizes for different annular sizes. Along with severe aortic stenosis, TAVI might sometimes be indicated in specific patient populations that lie outside the scope of this review, including bicuspid aortic valve stenosis, degenerated surgical bioprosthesis and aortic valve regurgitation/incompetence. The main procedural steps of a TAVI procedure are vascular access, valve deployment and haemostasis of primary interventional access (Fig. 2). Primary interventional access requires sheath insertion that may range from 14 Fr to 20 Fr systems based on the type and size of valve. The most common approach is percutaneous transfemoral, but this may be unfavourable for patients with hostile peripheral vascular or aortic anatomy. A secondary 6 Fr access is required to guide valve deployment, which is usually sited in the right radial artery. Heparin is given i.v. at a bolus dose of ∼3000–5000 units and repeated to achieve an activated clotting time of at least 250 s, which is checked hourly throughout the procedure.9Kalich B.A. Allender J.E. Hollis I.B. Medication management of patients undergoing transcatheter aortic valve replacement.Pharmacother J Hum Pharmacol Drug Ther. 2018; 38: 122-138Crossref PubMed Scopus (4) Google Scholar The valve may be implanted directly, or first dilated by balloon aortic valvuloplasty. This occurs over a super stiff wire placed in the left ventricle. Rapid pacing is required during balloon aortic valvuloplasty and is particularly important when deploying balloon-expandable valves to prevent migration of the valve. This is achieved via rapid right ventricular pacing at a rate of 180–220 beats min−1 to reduce the systolic arterial pressure to below 50 mmHg and lasts for 5–10 s. Specific complications at this step include: device embolisation into the aorta or left ventricle; severe paravalvular regurgitation; coronary ostial obstruction; left ventricular asystole; pulseless electrical activity, especially with poor ventricular function; and atrioventricular block. After deployment, the valve is qualitatively and quantitatively assessed by a physiologist or cardiologist using transthoracic echocardiography. Further steps may be required at this stage. For example, balloon valvuloplasty after dilation may be required in the case of severe paravalvular leak, which will not usually improve with conservative management and may yield clinically significant symptoms in the postoperative period and after discharge from hospital. Ultimately, if the result is unsatisfactory and refractory to further interventions, implantation of a second prosthesis might be necessary as a bailout procedure. The valve delivery system or sheath is removed and in the case of a percutaneous transfemoral approach, devices to close the artery based on sutures or a collagen plug are used for haemostasis. The following general principles of the TAVI procedure remain essential to safe outcomes:•Safety WHO checklist and role allocation;•Patient-specific briefing for preparedness, anticipation of and equipment for potential complications;•Clear communication by all team members;•No barriers to individuals speaking up or alerting the team to problems. The remarkable evolution in assessment, valve technology and technical approaches have led to simplification of the TAVI procedure, accompanied by a remarkable change in intraoperative management and associated implications for the anaesthetist. Previously, most patients would receive general anaesthesia, which would be of a ‘cardiac’ type including high-dose opioids, neuromuscular blockade, tracheal intubation, transoesophageal echocardiography, invasive arterial monitoring and central venous access.10Klein A.A. Webb S.T. Tsui S. Sudarshan C. Shapiro L. Densem C. Transcatheter aortic valve insertion: anaesthetic implications of emerging new technology.BJA Br J Anaesth. 2009; 103: 792-799Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Now, infiltration of local anaesthesia with or without conscious sedation is preferred for transfemoral approaches. When general anaesthesia is required, the general principles of anaesthetising patients with aortic stenosis apply, such as tracheal intubation with neuromuscular blockade; maintaining a low/normal heart rate (∼55 beats.min−1), sinus rhythm and adequate intravascular volume; and high/normal systemic vascular resistance. Inotropic drugs, heavy premedication or rapid i.v. infusion of fluids are not commonly required during induction of anaesthesia for TAVI. The majority of TAVIs are performed by transfemoral approach, which has led to the use of local anaesthesia with conscious sedation in most UK centres. This approach has many potential benefits, including shorter procedural time (∼60 min, though this is variable); direct communication with the patient; reduced need for vasopressor drugs; reduced requirement for ICU; shorter length of stay and lower resource use.11Gurevich S. Oestreich B. Kelly R.F. et al.Outcomes of transcatheter aortic valve replacement using a minimalist approach.Cardiovasc Revasc Med Mol Interv. 2018; 19: 192-195Crossref PubMed Scopus (25) Google Scholar, 12Jensen H.A. Condado J.F. Devireddy C. et al.Minimalist transcatheter aortic valve replacement: the new standard for surgeons and cardiologists using transfemoral access?.J Thorac Cardiovasc Surg. 2015; 150: 833-839Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 13Ribera A. Slof J. Andrea R. et al.Transfemoral transcatheter aortic valve replacement compared with surgical replacement in patients with severe aortic stenosis and comparable risk: cost-utility and its determinants.Int J Cardiol. 2015; 182: 321-328Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 14Ehret C. Rossaint R. Foldenauer A.C. et al.Is local anaesthesia a favourable approach for transcatheter aortic valve implantation? A systematic review and meta-analysis comparing local and general anaesthesia.BMJ Open. 2017; 7e016321Crossref PubMed Scopus (32) Google Scholar There is, however, a paucity of randomised evidence comparing various techniques. One possible explanation for the consistent finding in systematic reviews of observational evidence that local anaesthesia provided better outcomes is that much of this evidence is from when TAVI was first described and later refined; at this time, most patients would receive general anaesthesia by default. Local anaesthesia was introduced later, when there was more familiarity with the procedure and its potential complications. Hence the existing literature might be biased towards local anaesthesia.15Miles L.F. Joshi K.R. Ogilvie E.H. et al.General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before-and-after study.Anaesthesia. 2016; 71: 892-900Crossref PubMed Scopus (23) Google Scholar A recent large RCT found that among patients with aortic stenosis undergoing transfemoral TAVI, outcomes (a composite of all-cause mortality, stroke, myocardial infarction, infection and acute kidney injury at 30 days) were similar between those undergoing general anaesthesia and local anaesthesia with conscious sedation.16Thiele H. Kurz T. Feistritzer H.-J. et al.General versus local anesthesia with conscious sedation in transcatheter aortic valve implantation.Circulation. 2020; 142: 1437-1447Crossref PubMed Scopus (28) Google Scholar This all represents a fertile ground for future research. Transcatheter aortic valve implantation procedures under local anaesthesia may be performed with or without a cardiac anaesthetist present. Increasing experience has emphasised greater importance on a TAVI team member at the patient's ‘head end’ who is dedicated to communicating with the patient, allaying anxiety and where necessary, managing the airway. In our institution, patients are streamlined into one of three anaesthesia pathways once they are found to be suitable for TAVI. These pathways are determined by considering patient-specific and technical factors:1.Local anaesthesia with or without conscious sedation without an anaesthetist present at the team brief or for the procedure. This is the default approach in percutaneous transfemoral access cases (90% of TAVI) and delivered by a standard cardiac catheter laboratory team. In this setting, emergencies are accommodated by the usual emergency pathway for our institution.2.Local anaesthesia with or without conscious sedation with a standby cardiac anaesthetist, who is present for the team brief. This pathway is warranted in the presence of patient-specific factors such as severe musculoskeletal disease or back pain; a significant risk of lack of cooperation; decompensated valve disease and/or a requirement for inotropic drugs; a high risk of valve embolisation or migration (e.g. aortic regurgitation); or a high risk of coronary occlusion.3.General anaesthesia is performed when alternative access routes are used, or when local anaesthesia with or without conscious sedation for percutaneous transfemoral TAVI is unfavourable. The technique of local anaesthetic infiltration used at our institution is by injecting lidocaine 2% around the site of femoral arterial puncture, although others may prefer 1% preparations. Toxic dose thresholds must be avoided, especially where further doses are given or if another longer acting local anaesthetic agent is used. For this reason, we advise against using mixtures of local anaesthetic agent, in addition to the fact that the duration of anaesthesia with lidocaine alone should be more than sufficient. For cases where there is no anaesthetist present for the procedure, small doses of fentanyl (25–50 μg) or midazolam (1–2 mg) i.v. may be given by catheter laboratory staff as per local protocols. More substantial conscious sedation delivered by an anaesthetist is achieved using standard agents and techniques, but a propofol target-controlled infusion is our standard choice. Getting the plane of sedation wrong in these patients can be disastrous, as hypoxia or hypercarbia could precipitate right ventricular failure and cardiac arrest. Continuous ECG monitoring and pulse oximetry are required, as per minimum standards of perioperative monitoring. If sedative drugs are given, waveform capnography monitoring in conjunction with oxygen delivery through a Hudson mask is recommended. Continuous invasive arterial monitoring is provided via the primary interventional and secondary access sites. One peripheral i.v. access cannula is required for routine TAVI cases via a percutaneous transfemoral approach under local anaesthesia. Femoral venous access may be provided (or taken via the sheath for the transvenous pacing wire if used) in higher-risk cases. Routine urinary bladder catheterisation is not undertaken, to minimise complications such as urinary tract infections and haematuria. Routine use of a balloon-tipped temporary pacing wire potentially reduces the risk of right ventricular perforation with a fixed transvenous pacing wire. A temporary transvenous pacing wire may be avoided by pacing the left ventricle via the stiff guidewire in the left ventricle. In our centre, if a transvenous pacing wire is used (mainly for balloon expandable valve deployment), it is removed in the catheter laboratory in most cases after assessment of the ECG after TAVI and with the help of a prespecified protocol based on studies predicting development of high-degree conduction disturbance. One study showed that patients with a normal PR and QRS interval after TAVI did not develop delayed high-degree conduction disorders, and these patients are naturally the best candidates for removal of the temporary pacing wire in the catheter laboratory.17Toggweiler S. Stortecky S. Holy E. et al.The electrocardiogram after transcatheter aortic valve replacement determines the risk for post-procedural high-degree AV block and the need for telemetry monitoring.JACC Cardiovasc Interv. 2016; 9: 1269-1276Crossref PubMed Scopus (89) Google Scholar If there is a suspicion that a permanent pacemaker will be required after the procedure, a right internal jugular balloon tipped catheter can be used so as to ensure the patient can sit upright during the recovery period. This is then removed if not required or exchanged for a permanent system later on. As TAVI is performed mostly with local anaesthesia with/without conscious sedation, transoesophageal echocardiography is no longer used routinely. Cardiovascular status before and after TAVI, aortography and transthoracic echocardiography enable paravalvular leak to be assessed and complications such as pericardial tamponade to be identified. These can be categorised as relating to: vascular access, conduction abnormalities, coronary artery occlusion and stroke. A recent retrospective observational study suggested increased all-cause in-hospital mortality in females compared with males and increased in-hospital complications apart from acute kidney injury and permanent pacemaker implantation.18Amgai B. Chakraborty S. Bandyopadhyay D. et al.Sex differences in in-hospital outcomes of transcatheter aortic valve replacement.Curr Probl Cardiol. 2020; 46: 100694Crossref PubMed Scopus (2) Google Scholar The influence of sex on differential short-term outcomes after TAVI warrants further study. Computed tomography analysis, routine ultrasound-guided femoral arterial puncture and improved, lower profile valve delivery systems and sheaths have significantly reduced vascular complications to ∼3%.19Klein A.A. Skubas N.J. Ender J. Controversies and complications in the perioperative management of transcatheter aortic valve replacement.Anesth Analg. 2014; 119: 784-798Crossref PubMed Scopus (35) Google Scholar,20Power D. Schäfer U. Guedeney P. et al.Impact of percutaneous closure device type on vascular and bleeding complications after TAVR: a post hoc analysis from the BRAVO-3 randomized trial.Catheter Cardiovasc Interv. 2019; 93: 1374-1381PubMed Google Scholar A secondary access catheter via the radial artery reduces the morbidity associated with additional femoral arterial access. Suture-mediated or collagen plug femoral artery closure devices enable effective haemostasis and are often used in combination with i.v. protamine. A final iliofemoral angiogram may be needed to exclude femoral artery complications. Bailout equipment and an occlusion balloon should be readily accessible in the event of a vascular complication. Transcatheter aortic valve implantation-related conduction abnormalities result from direct damage of the atrioventricular node or His bundle on prosthesis deployment. Left bundle branch block is the most common conduction abnormality, and complete atrioventricular block is the most important conduction abnormality requiring permanent pacemaker insertion.21Buellesfeld L. Stortecky S. Heg D. et al.Impact of permanent pacemaker implantation on clinical outcome among patients undergoing transcatheter aortic valve implantation.J Am Coll Cardiol. 2012; 60: 493-501Crossref PubMed Scopus (171) Google Scholar,22Shreenivas S. Schloss E. Choo J. Sarembock I. Lilly S. Kereiakes D. Transcatheter aortic valve replacement and cardiac conduction.Expert Rev Cardiovasc Ther. 2019; 17: 293-304Crossref PubMed Scopus (2) Google Scholar The frequency of pacemaker implantation depends on several factors including pre-existing conduction disturbance, the transcatheter heart valve used, depth of prosthesis and length of membranous septum. In the presence of significant baseline conduction disturbances and very high risk of atrioventricular block, a permanent pacing system may be implanted before TAVI. The incidence of coronary artery obstruction is generally <1%, yet is associated with a very poor outcome.23Webb J.G. Mack M.J. White J.M. et al.Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry.J Am Coll Cardiol. 2017; 69: 2253-2262Crossref PubMed Scopus (213) Google Scholar The most common mechanism in 98% of cases is displacement of the native calcified valve leaflet over the coronary ostium. Low take-off of the coronary artery in relation to the aortic annulus is an important risk factor for this complication. Additional predictors include a narrow sinotubular junction and effacement of the aortic root with sinuses of Valsalva measuring <30 mm in diameter. Coronary artery obstruction has also been associated with a three-fold increased risk in valve-in-valve TAVI compared with native aortic valve TAVI.23Webb J.G. Mack M.J. White J.M. et al.Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry.J Am Coll Cardiol. 2017; 69: 2253-2262Crossref PubMed Scopus (213) Google Scholar A common strategy when the risk of coronary obstruction is high is to protect the coronary artery and insert a wire and balloon or stent in advance, and then perform TAVI. If coronary obstruction occurs, emergency stenting can be performed. The incidence of aortic root or annulus rupture is <1% but is associated with a poor acute prognosis.23Webb J.G. Mack M.J. White J.M. et al.Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry.J Am Coll Cardiol. 2017; 69: 2253-2262Crossref PubMed Scopus (213) Google Scholar Moderate to severe left ventricular outflow tract or subannular calcification and transcatheter heart valve oversizing, in which the prosthetic valve is larger than the aortic annulus, are associated with aortic root rupture and para-aortic haematoma. It can be prevented by carefully choosing the transcatheter heart valve type and size. This and other (now rare) injuries to major intrathoracic blood vessels may necessitate major unplanned cardiac surgery with sternotomy and cardiopulmonary bypass. The incidence of stroke continues to decrease, with rates now ∼2% as compared with ∼8% when TAVI was first pioneered.24Kahlert P. Al-Rashid F. Plicht B. et al.Incidence, predictors, origin and prevention of early and late neurological events after transcatheter aortic valve implantation (TAVI): a comprehensive review of current data.J Thromb Thrombolysis. 2013; 35: 436-449Crossref PubMed Scopus (13) Google Scholar,25Latif A. Lateef N. Ahsan M.J. et al.Transcatheter versus surgical aortic valve replacement in patients with cardiac surgery: meta-analysis and systematic review of the literature.J Cardiovasc Dev Dis. 2020; 7: 36Crossref Google Scholar Nevertheless, the use of a minimalist TAVI approach, with local anaesthesia in awake patients, allows for intraoperative and immediate postoperative neurological assessment. The incidence of stroke is not associated with the type of device or approach, or the anaesthetic strategy used. The aetiology is multifactorial and could be related to embolic atheroma, embolic valvular calcific material, thromboembolism from the introduction of wires and devices into the vasculature, and significant hypotension. When the anaesthetist is not physically present but assigned to the list, they must be on standby and available to attend at short notice. For low-risk cases where there has been no anaesthetist assigned to the list or present at the team brief, assistance is provided by the cardiothoracic critical care team. The patient may require sedation or general anaesthesia, and the interventional cardiologist may require assistance with any of the complications listed above. In the case of vascular injury, a vascular radiology and vascular surgical team should be available to attend and offer support. If it is necessary to convert to general anaesthesia, the general principles of anaesthetising a patient with aortic stenosis apply.26Charlesworth M. Martinovsky P. The principles of cardiac anaesthesia.Anaesth Intensive Care Med. 2018; 19: 335-338Abstract Full Text Full Text PDF Scopus (2) Google Scholar These include: ensuring application of defibrillator pads, which should already be in place from the start of the procedure; maintaining myocardial oxygen delivery via adequate systemic pressure and diastolic time; maintenance of contractility; optimising preload for a non-compliant left ventricle; and defending sinus rhythm at a rate of ∼55 beats min−1. An opioid-based technique minimises vasodilation and negative inotropy, and can be supported with i.v. doses of an alpha adrenergic agonist. Inotropic drugs may be required for patients with a poorly performing ventricle, necessitating central venous access. Previously, most patients would be cared for after TAVI in the critical care unit. Now, most patients can be safely cared for on a coronary care unit or monitored cardiology ward. Postoperative critical care is only required for specific indications or if unexpected major complications occur. Some patients may require a temporary or permanent pacemaker system after the procedure. Analgesia requirements are minimal, and oral paracetamol is usually sufficient. All patients should be routinely assessed for their risk of venous thromboembolism. Inpatient prophylactic low-molecular-weight heparin is required, but patients do not require long-term anticoagulation. Patients are discharged usually from hospital after a short period of recovery of approximately 2–3 days. To set priorities for the future, we must first consider what the key advances were that made this once high-risk invasive procedure a safe minimally invasive option. These include the PARTNER (Placement of Aortic Transcatheter Valve) trials, which were first to show the benefit for TAVI over other options; the use of preoperative CT to avoid valve mismatch and postoperative paravalvular leak; the manufacture of low-profile transvenous delivery systems; and the use of preformed super-stiff guidewires to reduce the risk of ventricular perforation. Arguably, the move from general to local anaesthesia has only been possible with these advances, but more evidence is required on the benefits of different anaesthetic techniques. Future advances might include the use of TAVI in asymptomatic patients or those with moderate to severe disease; the need for fewer staff in the catheter laboratory; shorter hospital stay (including possible same-day discharge); and reduced overall financial costs associated with the procedure. More challenging might be the use of TAVI in younger patients, as durability, the incidence of paravalvular leak, and the need for permanent pacemaker implantation have to be at least equivalent to surgical options. The authors declare that they have no conflicts of interest. The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education. Mike Charlesworth MSci PGCert FRCA MSc FFICM is a consultant in cardiothoracic anaesthesia, critical care and ECMO at Wythenshawe Hospital, Manchester. He is also an editor of Anaesthesia and Anaesthesia Reports. Brian G. Williams FRCA FFICM is a consultant in cardiothoracic anaesthesia, critical care and ECMO at Wythenshawe Hospital, Manchester. He is clinical lead for perioperative care in the cardiac catheter laboratory at Wythenshawe Hospital. Mamta Buch PhD FRCP is a consultant interventional cardiologist at Wythenshawe Hospital, Manchester and clinical lead for the transcatheter heart valve services. She has extensive experience of developing the transcatheter aortic valve implantation service at Wythenshawe Hospital, and is also very engaged in all aspects of clinical practice." @default.
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• W3135972890 title "Advances in transcatheter aortic valve implantation, part 2: perioperative care" @default.
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• W3135972890 cites W2059665832 @default.
• W3135972890 cites W2103242305 @default.
• W3135972890 cites W2149609916 @default.
• W3135972890 cites W2164987168 @default.
• W3135972890 cites W2165258820 @default.
• W3135972890 cites W2324073140 @default.
• W3135972890 cites W2463213207 @default.
• W3135972890 cites W2464376081 @default.
• W3135972890 cites W2596188051 @default.
• W3135972890 cites W2605849388 @default.
• W3135972890 cites W2611230830 @default.
• W3135972890 cites W2729050341 @default.
• W3135972890 cites W2743671140 @default.
• W3135972890 cites W2751630023 @default.
• W3135972890 cites W2760060928 @default.
• W3135972890 cites W2767245397 @default.
• W3135972890 cites W2806812164 @default.
• W3135972890 cites W2924856181 @default.
• W3135972890 cites W2938393404 @default.
• W3135972890 cites W2946655127 @default.
• W3135972890 cites W3081389099 @default.
• W3135972890 cites W3082161162 @default.
• W3135972890 cites W3086059167 @default.
• W3135972890 cites W3136472765 @default.
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