Aortic Valve Replacement (AVR)
Updated On: July 23, 2026
Anesthetic Approaches
Pre-bypass hemodynamics are the whole game in stenosis - the hypertrophied ventricle fills poorly and depends on sinus rhythm and diastolic pressure for its own coronary supply. Tachycardia steals filling and perfusion time; hypotension collapses coronary pressure into a thick wall that needs more of it; lost atrial kick drops the cardiac output a stenotic valve can't recover. Slow-ish, sinus, full, and pressure at baseline - induce with that sentence in view.
Regurgitation runs opposite - the failing-forward ventricle wants rate normal-to-high and afterload low. Know which lesion (or mix) is on the table before writing the induction plan.
Induction - titrated and unhurried, arterial line first: the stenotic ventricle punishes both the overdose and the sympathetic surge of a light laryngoscopy. Have a pure alpha agonist drawn up - phenylephrine treats the hypotension without the tachycardia that makes everything worse.
Bypass mechanics - heparin 300-400 units/kg to ACT >=480 before cannulation; anesthesia continues on-pump via vaporizer or propofol drip (awareness risk); protamine 1 mg per 100 units heparin, slowly, at the end.
TEE - sizes the annulus, confirms the diagnosis, then answers the only post-bypass questions that matter: does the prosthesis seat without paravalvular leak, and how does the ventricle look.
Heart block - the conduction system runs through the septum adjacent to the annulus being debrided; complete heart block after AVR is common enough that epicardial pacing wires are routine. Confirm capture before leaving the room.
Separation from bypass - the hypertrophied ventricle stays stiff after the valve is fixed: it still needs preload and rhythm, and an underfilled, hyperdynamic post-AVR ventricle can generate dynamic outflow obstruction - volume and beta-blockade, not more inotrope.
Pressure discipline post-bypass - a fresh aortotomy sits behind every blood pressure decision; treat hypertensive overshoot promptly on the way to the ICU.
Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it's going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient's arms.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
Surgical replacement of the aortic valve on cardiopulmonary bypass, most often for calcific aortic stenosis - the most common valve lesion of the elderly, lethal once symptomatic and untreated - and for aortic regurgitation or endocarditis. The choice of mechanical prosthesis (durable, lifelong anticoagulation) versus bioprosthesis (no anticoagulation, finite lifespan) is made with the surgeon beforehand. TAVR has absorbed most high-risk and many intermediate-risk stenosis patients, so the SAVR population trends younger or has anatomy and pathology (endocarditis, root disease, bicuspid valves) that a catheter can't address.
Access - median sternotomy (or upper hemisternotomy for minimally invasive programs).
Bypass - heparinization, aortic and right atrial cannulation, CPB initiated, cross-clamp, cardioplegic arrest.
Valve - aortotomy, diseased valve excised and the annulus debrided of calcium, prosthesis sized and sutured in.
Wean - aortotomy closed, de-airing under TEE, cross-clamp off, pacing and inotropes as needed to separate from CPB.
Closure - protamine, hemostasis, chest tubes, wires.