Double-lumen oropharyngeal cannula for sedation in percutaneous aortic valve implant with transesophageal echocardiography. Case report

Abstract

Introduction: The prevalence and severity of aortic valve disease increases in the elderly population. Transfemoral transcatheter aortic valve implantation (TAVI) has been gaining space as an alternative method even in mild cases to conventional open aortic valve replacement surgery. In many centers, conscious sedation as an alternative to general anesthesia to these procedures. Therefore, the use transesophageal echocardiography (TEE) is a concern when conscious sedation is performed. In this case report, we describe for the first time the use of a double‐lumen oropharyngeal cannula to support sedation in a patient undergoing TAVI and TEE monitoring. Methods: Case report: 72‐year‐old male patient, 58kg, 178 cm tall, physical status ASA 3, Euroescore II 1,81%, with severe aortic stenosis (Aortic valve orifice area = 0.5cm2, maximum and mean gradient = 58mmHg and 31mmHg, respectively) underwent elective percutaneous aortic valve implantation with transfemoral vascular access. After standard monitoring, sedation was started with intravenous infusion of dexmedetomidine and propofol titrated to effect. The cannula was inserted right after loss of consciousness, connecting one of its lines to the capnograph and the other one to the supplemental oxygen source with a continuous flow of 3L/min. Right after, TEE probe was passed through the cannula to the upper esophagus.(Figure 1) A: CO2 exhaled line monitoring; B: O2 line administration; C: Lumen used to keep a better patency of the airway during spontaneous ventilation; D: Lumen used to pass the TEE probe. Throughout the procedure, patient was maintained on spontaneous ventilation, maintaining BIS values below 60. Data collection includes: ETCO2, mean arterial pressure, heart rate, BIS values, SatO2 and arterial blood gases. The examiner was also questioned subjectively the comfort of handling the TEE probe during the exam (easy, moderate or difficult) and also checking for possible oral cavity trauma due use of the cannula during procedure. Results: The procedure went without any complications. No soft tissue lesions were found The examiner considered the handling of the probe with the presence of the cannula easy. Discussion: The oropharyngeal cannula was feasible to support sedation in this patient for TAVI with TEE monitoring. However, further studies with a larger number of patients and randomized trials comparing different techniques are still needed to confirm our results.