What would you suggest? AVR or not?

60-something y/o male patient who isn’t physically active but does ADLs.  Scheduled for CABG but has AI, PVD, EF 40%, HTN, HLD.  Would you suggest an AVR or not…. along with the CABG?



What would you suggest?


Transcatheter Mitral Valve Replacement

Our hospital will be partaking in the Medtronic APOLLO study.

The data so far from other hospitals in an easy to read format.


PPT from Duke 2017

Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016 Apr; 6(2): 144–159.

Role of echocardiography for catheter-based management of valvular heart disease. Journal of Cardiology 69 (2017) 66–73.

EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease.  J ASE Sept 2011.

Multimodality Imaging in the Context of Transcatheter Mitral Valve Replacement. JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 10, 2015.

Echo in mitral valve intervention. ESC 2012.

Mitral Valve Morphology Assessment: Three-Dimensional Transesophageal Echocardiography Versus Computed Tomography. Ann Thorac Surg 2010;90:1922–9.

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 69, NO. 4, 2017. 

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Transcatheter Mitral Valve Intervention, An Issue of Interventional Cardiology Clinics, E-Book.

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography.  Can Measurement Lead to Better Management? Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp. 2014.

Transcatheter valve replacement and valve repair: Review of procedures and intraprocedural echocardiographic imaging. Circ Res. 2016;119:341-356.

Philips: TMVR

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.

Transcatheter Mitral Valve Repair. Summer 2014Volume 19, Issue 2, Pages 219–237.


Mitraclip and TEE for MR


Ventricular Assist Devices: Impella

“There’s an emergent case coming for impella placement.”

Impella?  I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement.  But, I’ve never done an Impella on a critically unstable patient.

YouTube video describing the purpose and placement of the Impella

Cath Lab Digest: Overview of Impella 5.0


Anesthesia & Analgesia; January 2012. Echo rounds: The Use of TEE for Confirmation of Appropriate Impella 5.0 Device Placement.

From A&A Echo Rounds

 YouTube video similar to our axillary artery conduit (we had to go left sided bc of a prior AICD in the patient’s right chest) for Impella 5.0

JCVA, June 2010. Review Articles: Percutaneous LVAD: Clinical Uses, Future Applications, and Anesthetic Considerations.

Teeny Tiny Hearts

Diagram of a heart with tricuspid atresia, and...
Image via Wikipedia

Nov 21, 2010

Pediatric cardiac anesthesiologists are pretty much the Gods of anesthesia.  What do I mean by this?  Well, putting kids to sleep and finding IVs and managing their little airways can be tricky.  Now, let’s take that and make it more complex by giving them funky heart anatomy and connections and we’ve got some real tricky anesthesia!

Picture tiny babies, 1-2kg (for the U.S.: 2-4lbs), with teeny tiny hearts…who only have a fightin’ chance in this world with corrective heart surgery.  These tiny hearts are beating away…with some type of pathology that will kill them oftentimes before they reach adulthood.

Sick kids + general anesthesia = possible scary scenario.  Throw in a really good pediatric cardiac anesthesiologist (and pedi heart surgeon)… and that could mean many more years of happy memories!  I’m not sure how these amazing physicians sleep at night (high stress!), but they’re outstanding and certainly have earned my respect!

Some of the cases that I’ve come across:  division of vascular ring; bidirectional Glenn; Fontan; Tetralogy of Fallot repair (extracardiac); hypoplastic aortic arch repair; PDA ligations; modified Blalock-Taussig shunts; AV canal repair; Aortic valve replacement; tricuspid valve repair;  mitral valve repair; Repair of Coarctation.

Some of the pathology I’ve seen: Tetralogy of Fallot, hypoplastic left heart syndrome, coarctation, bicuspid aortic valve, mitral valve prolapse, tricuspid valve prolapse, heterotaxy, unbalanced AV canal, complete vascular ring, patients who were s/p Norwood-Sano, double outlet RV

All I can say is that rotating through pedi hearts for a month was an outstanding experience… one that all adult cardiac anesthesiologists should do.