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Structural Heart & EP Cases

These cases occur in the hybrid OR or EP lab rather than the main CVOR. The environment is different — more proceduralists, less surgical exposure, C-arm in the room, and patients are often sicker than your CABG population. General setup principles from the CVOR Guide apply. Obviously way less versed, fentanyl, rocuronium, but still consider all push dose pressers and drips as required. Specific case notes below.

General Setup for All Structural Cases

Arterial line, fluid warmer with blood tubing and stopcocks, phenylephrine and norepi syringes, norepi drip spiked but not connected, nitroglycerin syringe, pacer box and Zoll on and ready. Consider 5% albumin or blood in the room.

Structural Heart (EP/Hybrid)

  • General Set up: Standard GETA set up with arterial line set up. Fluid warmer with blood tubing and stopcocks for bolusing drugs ready to go. Phenylephrine syringe, norepi syringe, norepi drip spiked but not hooked up to the patient, nitroglycerin syringe. - Heparin and protamine will be given to you.
  • Consider having some 5% albumin available or blood in the room
  • Pacer box and zoll available and turned on. TAVRs require two pacer boxes.
  • Discuss plan for access and procedure with all providers involved. In some cases we can use their radial or femoral access for BP monitoring.
  • Induction: Gentle and then get lines in quickly. TEE probe follows if necessary. Aline will be pre sedation for tavrs.
  • Maintenance: Maintain the BP and monitor EBL and any ectopy. Be ready to give immediate emergency drugs and or zoll therapy. Sometimes the proceduralist needs to be reminded that there is significant ectopy and they can back off on what they are doing and things stabilize without additional treatment. Best practice is to keep communicating and give very small amounts of drugs due to the potential for proceduralist induced hypotension with rapid resolution.
  • These are not overly stimulating procedures. It is generally accepted to keep the patient paralyzed and keep the anesthetics to a minimum. Any movement can prove deadly due to the intracardiac devices present in the heart.
  • Emergence: Smooth with minimal coughing. Be mindful of the access points. Patients should not move their legs etc.

PFA Pulse Frequency Ablations

  • Intro to PFA from the Cleveland Clinic
  • Scietific Study PFA
  • These are not cryo or RFA ablations :
  • No arterial line required
  • Dr Ali will have you inject 12000 unit of heparin and 1mg of atropine IV once he crosses the septum. The dose is 10000 units if the pt is on coumadin.
  • Dr. Mageed will have you inject 10000+ units of heparin only as he uses the catheter to pace if the patients become asystolic. I give atropine or glyco depending on their age on induction. I don't like asystole. He is starting to allow atropine use
  • These cases last around 30-40min
  • There may be a need to administer 2mg or more of nitroglycerin : Nitro Protocol PFA

Other EP Cases

Extravascular and subq ICD

  • GETA
  • Tunneling is stimulating
  • May induce VF to test the device

BiV Upgrade or Original Insertion

  • Usually GETA

A Flutter and SVT Ablation

  • Can do whatever anesthesia appropriate including MAC and LMA
  • May require TEE

TAVR

  • Antibioitcs are usually ancef.
  • Usually MAC (75%) Many different cocktails including propofol drip, midazolam/fentanyl, precedex bolus and drip, remifentanil drip, precedex/midazolam/fentanyl bolus etc etc. Be ready for potential conversion to open cardiac surgery. Be prepared and have heparin available for CPB.
  • During the valve deployment there needs to be rapid ventricular pacing. Heart rates are typically 150-220bpm. If you are doing a mac the patient may and will feel dizzy, woozy, lightheaded, and have crushing chest pain. Try to warn them and console them if they feel this.
  • Also be prepared for brief but extreme hypotension: MAP < 50. Do not treat as this will cause a large overshoot after the valve is deployed and the HR returns to normal.
  • Once the valve is in, keep the BP <160. You may need to turn off or titrate up/down some vasoactives.
  • Rapid pacing and valve deployment can cause rhythm disturbances after the valve is in. This is partly due to the proximity of the aortic valve annulus and the conduction system. Have two pacer boxes ready so that you can quickly pace at a rate of 60-80bpm if the patient is in heart block or asystole.
  • TAVR insertion sites can also include carotid, subclavian, aortic, apical
  • These sites need GETA

Watchman

  • These normally require arterial lines. Usually post induction. These can go fast so stay efficient.
  • Standard GETA tailored to the patient

Mitral Clips/Triscupid Clips

  • These cases are for patients with severe regurgitation but are not surgical candidates. They will get groin access and have a transseptal puncture (Mitral). A clip is then guided with TEE in order to help the leaflets close better to hopefully reduce the regurgitant flow.
  • These cases take time or they can be over very quickly.
  • Anesthesia is general with an ETT, TEE, arterial line, sometimes extra lines for pacing as needed. Use the standard cath lab anesthesia set up adding drips as needed (some of these patients are very sick and already lined up, intubated etc in the unit).
  • The best way to do these cases is keep them paralyzed and as close to their normals as possible.
  • Usually very judicious fluid management, again think their normal.

Tanscatheter Mitral Valve

See clipping info above. It is all the same except instead of a clip they insert a valve.

Lead Extractions

  • These cases are general with an ETT and arterial line. Sometimes temporary venous pacing wires are needed which necessitate an IJ introducer. Have all of these ready.
  • These patients can be very sick from their infection so ensure you have all of the drips as stated above ready.
  • These patients can lose lots of volume quickly from SVC damage, subclavian damage, and direct cardiac damage. There is always a CT surgeon and operative team on standby. You should have blood available and/or 5% albumin in the room.
  • In terms of volume, often these patients have a very poor EF so that will hamper significant resuscitative efforts.
  • Communicate with the surgical and procedural team if you are struggling.
  • The proceduralist will place a balloon in the superior vena cava in the event the subclavian vein is severely damaged or ripped off. This will be the first step of the procedure.
  • The next step will be to excise the pacemaker device and then isolate the leads. Extraction will then commence.
  • This happens with two devices: a tightrail and a laser. Your attending should be in the room when the laser comes on, or the tighrail is being used. Both devices need to have the leads be pulled tight to work, both devices can result in catastrophic damage. When the leads are pulled tightly there can be invagination of the heart tissues. This can cause a drastic decrease in RV output and therefore decrease in cardiac output and blood pressure. Watch the monitors during this time and alert the proceduralist to rapid loss in blood pressure. Be careful to treat this as the blood pressure can be quickly corrected by letting off the lead. Communicate with the proceduralist!!! If the blood pressure is starting to trend down be communicative as this can mean bleeding from the subclavian, vena cava, and/or the heart. Be vigilant and communicate!
  • The final piece of this case is what will the patient have for a pacemaker after the device is removed? Ensure that there is a plan in place before the device is removed!!!

Other cases involving ECMO and Impella insertion/removal

  • These patients often are intubated with drips and lines but you may need to add something. Drips will be different depending on if the device is being inserted or removed.
  • Some impella removals are done with just local/light mac. It is good practice to have all lines, GETA things ready to go in case things do not proceed according to plan.
  • ECMO circuit review