Page 74 - Critical Care Notes

4223_Tab02_045-106 29/08/14 10:00 AM Page 68

CV
Management
■ Routine postoperative care: Maintain airway patency; monitor pulmonary
status.
■ Monitor vital signs and intake and output.
■ Monitor dressing and incision for drainage, erythema.
■ Perform peripheral and neurovascular assessments hourly for first 8 hr
after surgery.
■ Monitor neurological status for first 8 hr postoperatively.
■ Titrate medications, vasopressors, and inotropes to optimize cardiac
function and BP.
■ Monitor chest tube drainage.
■ Watch for signs of bleeding by monitoring Hgb and Hct every 4 hr.
■ Monitor for pain.
■ Start on anticoagulation therapy when approved by cardiac surgeon.
Transcatheter Aortic Valve Replacement (TAVR)
■ TAVR was developed for the treatment of severe, symptomatic aortic stenosis,
for patients at very high surgical risk for traditional valve replacement surgery,
or for patients with technical issues with surgery (i.e., porcelain aorta or signif-
icant mediastinal radiation).
■ Bilateral femoral arteries are prepped, the femoral artery is cannulated
with a sheath, and the vessel is dilated. The sheath is replaced by a larger
sheath, which is used to accommodate the stent-valve delivery system.
An arterial catheter is placed in the left femoral artery for hemodynamic
monitoring.
■ A guide wire and valvuloplasty balloon catheter are used to steer and
deploy the stent-valve. Aortic balloon valvuloplasty is performed to sepa-
rate the leaflets. Contrast is injected, and fluoroscopy is used to visualize
the stent placement.
■ When the position of the stent-valve is confirmed, the device is then
deployed. Rapid right ventricular pacing reduces cardiac wall motion and
prevents the stent-valve from slipping from the correct position during bal-
loon inflation. A temporary pacing lead is placed in the right ventricle via
the femoral vein, and temporary pacing is initiated. This is followed by
rapid inflation and deflation of the stent-deployment valvuloplasty balloon,
and termination of pacing and a return of a normal rhythm.
■ Once the catheter is pulled back, the stent-valve will cover the native aortic
leaflets and fit tightly in the aortic annulus. Angiography of the right and
left coronary arteries is performed to assess blood flow. The femoral artery
is repaired, and the sheath is removed.
Pathophysiology
Aortic stenosis. See under cardiac valve replacement
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