GKD Anest Yoð Bak Dern Derg. 2014; 20(2): 129-132 | DOI: 10.5222/GKDAD.2014.129

Anesthetic Management in Aort Valve Surgery with Infective Endocarditis Following Transcatheter Aortic Valve Implantation

Elvin Kesimci¹, Tülin Gümüþ¹, Serkan Taþtan¹, Abdülkadir But², Orhan Kanbak^1
1Anesthesiology And Reanimation Clinic, Ankara Atatürk Education And Research Hospital, Ankara, Turkey
²Anesthesiology And Reanimation Department, Yýldýrým Beyazýt University; Ankara, Turkey

Introduction: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative curative therapy in patients with severe calcific aortic stenosis in aging population, in which there is high operative rate with surgery due to significant co-morbidities. However, problems during and after procedure can seriously complicate the success of TAVI. We present the anesthetic management of a patient with infective endocarditis, undergoing aortic valve replacement surgery following TAVI.
Case Report: A 75-year-old woman who had undergone TAVI five months before was readmitted to hospital with complaints of palpitation, breathlessness and fever. The blood culture was positive for Enterococcus faecalis, so antimicrobial therapy was started with a diagnosis of infective endocarditis. She was intubated due to acute lung edema and acidosis; and also needed dialysis. Transesophagial echocardiography (TEE) showed vegetation on right coronary cusp of the implanted aortic valve. The patient underwent cardiac surgery for removal and replacement of the infected and malfunctioning TAVI valve. At the end of the surgical procedure, she was transferred to the intensive care unit (ICU) on inotropic support. However, in ICU, hemodynamic instability, including rhythm disturbances, persisted and intra-aortic balloon pump was inserted. Postoperative course was complicated with low cardiac output syndrome and organ failure. Unfortunately, the patient died at 10th postoperative hour in spite of all supportive management.
Conclusion: The reported incidence of prosthetic valve endocarditis after TAVI patients is less than 0.5%. However, the mortality rate varies from 30% to 50% and urgent open heart surgery with meticulous anesthesiological planning is required.

Keywords: transcatheter aortic valve implantation (TAVI), infective endocarditis, aort valve surgery

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Transkateter Aort Kapak Ýmplantasyonu Sonrasýnda Geliþen Ýnfektif Endokarditli Aort Kapak Cerrahisinde Anestezi Yönetimi

Elvin Kesimci¹, Tülin Gümüþ¹, Serkan Taþtan¹, Abdülkadir But², Orhan Kanbak^1
1Ankara Atatürk Eðitim Ve Araþtýrma Hastanesi, Anesteziyoloji Ve Reanimasyon Kliniði, Ankara
²Yýldýrým Beyazýt Üniversitesi, Anesteziyoloji Ve Reanimasyon Ana Bilim Dalý, Ankara

Giriþ: Transkateter aort kapak implantasyonu (TAVI) belirgin ko-morbiditeler nedeniyle cerrahi riski oldukça yüksek, ciddi, kalsifik aort stenozu olan yaþlý popülasyonda, alternatif bir tedavi olarak ortaya çýkmýþtýr. Ancak, iþlem sýrasýnda ve sonrasýnda geliþebilecek problemler TAVI' nin baþarýsýný olumsuz etkileyebilir. TAVI sonrasý infektif endokardit geliþen ve cerrahi aort kapak replasmanýna alýnan bir hastada anestezik yaklaþýmýmýzý sunmak istedik.
Olgu Sunumu: : 75 yaþýnda, 5 ay önce TAVI geçirmiþ bayan hasta çarpýntý, nefes darlýðý ve ateþ þikayetleri ile hastaneye baþvurmuþtur. Kan kültürü Enterococcus faecalis için pozitif olan hastaya infektif endokardit tanýsýyla antimikrobiyal tedavi baþlanmýþtýr. Sonrasýnda akut akciðer ödemi ve asidoz nedeniyle entübe edilen hasta diyalize de alýnmýþtýr. Yapýlan transözefageal ekokardiyografide (TEE); implante edilmiþ aortik kapaðýn sað ucunda vejetasyon saptanmasý üzerine hastaya aort kapak replasman cerrahisi uygulanmasýna karar verildi. Operasyon sonunda, hasta inotropik destek tedavisi ile yoðun bakým ünitesine alýndý. Ancak, hastanýn hemodinamik instabilitesi ve ritm bozukluklarý ýsrarla devam edince hastaya intraaortik balon pompasý takýldý. Postoperatif dönemi düþük kardiyak output ve organ yetmezlikleri ile seyreden hasta postoperatif 10. saatte tüm destek tedaviye raðmen kaybedildi.
Sonuç: TAVI sonrasý protez kapak endokarditinin insidansý % 0.5 olarak bildirilmektedir. Ancak bu komplikasyona baðlý mortalite oranlarý % 30-50 arasýnda deðiþmektedir. Bu nedenle bu hastalarda acil açýk kalp cerrahisi için özenli bir anestezi planýna ihtiyaç duyulmaktadýr.

Anahtar Kelimeler: transkateter aort kapak implantasyonu (TAVI), infektif endokardit, aort kapak cerrahisi

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