Challenges in anesthesiological management of patients undergoing cardiac transapical procedures

Objective: Patients undergoing transapical cardiac procedure are a minority of cardiac surgery patients, but represent a challenge for cardiac anesthesiologists, as they are generally older and have more comorbidities than open heart cardiac surgery patients. The aim of this study is to describe the anesthesiological experience with transapical procedures in a single high volume center, and to analyze the most critical aspects for anesthesiological management. Methods: All patients undergoing cardiac transapical procedure at IRCCS San Raffaele Scientific Institute from January 2009 to April 2018 were included in this case series. Patients were managed by a multidisciplinary heart team: perioperative anesthesiological approach and hemodynamic management were consistent and performed by a group of trained cardiac anesthesiologists. Results: The study population included 143 patients: 81(57%) underwent an aortic valve procedure; 60 (42%) a mitral valve intervention; in one case both aortic and mitral valves were involved; one patient underwent correction of a congenital heart defect. A major intraoperative complication occurred in five (3.5%) patients: the procedure was not technically feasible due to unsuitable anatomy in 3 patients; conversion to open heart surgery was needed in 2 patients. All patients were admitted to the intensive care unit. Intensive care unit stay was 1 (1-3) days and hospital stay was 6 (5-8) days). Hospital survival was 94%. Conclusions: Patients undergoing transapical cardiac procedures are a minority of cardiac surgery patients, but represent a high risk population. An anesthesiological patient-tailored approach, in the context of the therapeutic strategy shared by the heart team, is crucial to improve outcomes.