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Purpose of Review The purpose of this chapter is to provide a brief review on current anesthesia techniques for transfemoral transcatheter aortic valve implantation (TF-TAVI). Recent Findings TF-TAVI has become a standard treatment option for high risk patients with severe aortic stenosis. Increasing experience with prosthetic durability and equivalent or superior outcomes of transcatheter over surgical aortic valve replacement will boost the caseload of high- and intermediate-risk patients. For TF-TAVI, general anesthesia (GA) had initially been widely preferred over local anesthesia with monitored anesthesia care (LA-MAC), but with large national practice variation. Institutional routines are changing now since evidence from large registries accrues that LA-MAC represents a feasible, safe, and economically sound alternative to GA, if no contraindications apply. Although prospective randomized TAVI anesthesia trials are lacking, observational data show that GA is associated with higher patient risk, longer procedural time, more vasopressor and transfusion requirement, and more resource use and costs, whereas periprocedural mortality is comparable or non-significantly better with LA-MAC. In summary, GA remains a robust solution for specific situations and teams. In many experienced centers, however, LA-MAC has become first choice whenever possible. Whether LA-MAC is an option should be decided upon by the anesthesiologist and the heart team in consultation with the patient, following prospectively defined decision pathways. With increasing caseload and decreasing invasiveness of TAVI technology, anesthesia providers must meet the challenge to reduce resource use and costs without compromising patient safety and satisfaction.

Introduction Levosimendan is a potent inodilator agent. The net effect of haemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. To assess the haemodynamic effects in cardiac surgery patients treated with levosimendan we conducted a systemic review. Our hypothesis was that levosimendan improves cardiac function, but also triggers a systemic vasodilatation. Methods Systematic review with meta-analysis. English-language literature with access to full texts and supplements in US National Library of Medicine (PUBMED), MEDLINE, EMBASE, and CENTRAL was searched systematically from 2006 until July 2018. Included randomized controlled trials, case-matched or retrospective studies providing at least two sequentially measured haemodynamic variables in adult patients undergoing cardiac surgery with cardio pulmonary bypass and treated with levosimendan in comparison to alternative drugs or devices. Results Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardised mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference (SMD) at baseline by a multivariate mixed effects meta-analysis model. With the correction for baseline differences, other haemodynamic variables, especially the systemic vascular resistance did not significantly differ until POD 1 [-0.17 (-0.64 to 0.30), p=0.48] and POD 7 [-0.13 (-0.61 to 0.34), p=0.58] between the levosimendan and the comparator group. Discussion Levosimendan increased cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome. Hypotension seems not to be statistically relevant.

Levosimendan is a potent non-adrenergic inodilator agent. The net effect of hemodynamic changes may result in a hyperdynamic state with low systemic vascular resistance. We conducted a systematic review and meta-analysis assessing hemodynamics in cardiac surgery patients treated with levosimendan. English-language literature was searched systematically from 2006 until October 2018, including randomized controlled trials and case-matched or retrospective studies providing at least two sequentially measured hemodynamic variables in adult patients who underwent cardiac surgery with cardiopulmonary bypass and were treated with levosimendan in comparison to alternative drugs or devices. Cardiac index significantly increased in the levosimendan group by 0.74 (0.24 to 1.23) [standardized mean difference (95% CI); p = 0.003] from baseline to postoperative day (POD) 1, and by 0.75 (0.25 to 1.25; p = 0.003) from baseline to POD 7, when corrected for the standardized mean difference at baseline by a multivariate mixed effects meta-analysis model. With this correction for baseline differences, other hemodynamic variables including systemic vascular resistance did not significantly differ until POD 1 [−0.17 (−0.64 to 0.30), p = 0.48] and POD 7 [−0.13 (−0.61 to 0.34), p = 0.58] between the levosimendan and the comparator group. Levosimendan increases cardiac index in patients undergoing cardiac surgery. Although levosimendan has inodilator properties, this meta-analysis finds no clinical evidence that levosimendan produces vasopressor-resistant vasoplegic syndrome.

We present the case of a patient with infective endocarditis anesthetized for replacement of severely regurgitant aortic valve. Intraoperative transesophageal echocardiography revealed a new diagnosis of severe secondary mitral regurgitation. After aortic valve replacement and tricuspid valve repair, severe mitral regurgitation resolved rapidly without any intervention. In multivalvular disease, instant spontaneous resolution of secondary mitral regurgitation is possible after surgical correction of an aortic regurgitation causing left ventricular volume overload.

Current guidelines on postcardiotomy veno-arterial extracorporeal oxygenation ECMO (vaECMO) do not mention the assessment of pulmonary function, especially prior to the weaning procedure in the operation room (OR). Mucociliary dysfunction, a nearly ubiquitous finding among mechanically ventilated patients, might put these patients at risk for potential airway problems and associated weaning failure at the time of vaECMO weaning in the OR. In conformity to veno-venous ECMO management, we suggest routine bronchoscopy with bronchial hygiene in the ICU prior to vaECMO weaning in the OR. Likewise, an assessment of patient pleura for effusions should be routinely performed. Although cardiac and respiratory failure often co-exist and there are multiple causes of respiratory failure in patients who require vaECMO, we anticipate that vaECMO patients would significantly benefit from an expanded focus on the pulmonary function and possible respiratory mucous congestion. A routine preweaning bronchoscopy would reduce the frequency of weaning failures in this particular setting, especially in those patients with successfully restored cardiac function.