The Munich Valsalva Implantation Technique (MuVIT) for Cardiac Output Reduction During TEVAR: Vena Cava Occlusion With the Valsalva Maneuver

Abstract

Purpose To demonstrate a physiologically induced alternative to the typical methods of reducing cardiac output during deployment of stent-grafts in the aortic arch and proximal aorta. Technique A modified Valsalva maneuver, the Munich Valsalva implantation technique (MuVIT), to raise the intrathoracic pressure, minimize backflow, and reduce the cardiac output is illustrated in a patient undergoing a triple-branch thoracic endovascular aortic repair (TEVAR). During manual mechanical ventilation, the adjustable pressure-limiting valve is carefully closed to 25 mm Hg, creating “manual bloating” of the lungs and sustained apnea. The increased intrathoracic pressure causes compression of the vena cava and pulmonary veins, reducing the venous backflow and gradually decreasing the arterial pressure. Once the desired pressure is obtained, the stent-graft is accurately deployed. The airway pressure is thereupon slowly reduced, and the patient is taken back to normal ventilation. The procedure is then finished following standard practice. Conclusion The MuVIT is a simple, noninvasive technique for cardiac output reduction during aortic arch TEVAR, eliminating the need for other invasive techniques.

Partial Right Atrial Inflow Occlusion for Transient Systemic Hypotension During Deployment of Thoracic Stentgrafts

“…Recently, the MuVIT technique has been published by Tsilimparis et al [ 3 ] describing reduced cardiac output by a modified Valsalva maneuver due to controlled manual ventilation performed by the anesthesiologist. This technique needs to be evaluated but seems promising and eliminates the need for additional venous access.…”

“…Concurrently, the more TEVAR indications are extended to hemodynamic and anatomically challenging landing zones, and the more inaccurate stentgraft deployment becomes an issue. For this reason, several techniques to manage this downstream migration have been described including pharmacologically induced systemic hypotension, rapid right ventricular pacing, and recently the Munich Valsalva Implantation Technique (MuVIT) [1][2][3]. The technique of partial atrial inflow occlusion to rapidly achieve reversible systemic hypotension has been described previously by few other authors in animal studies and case series [4][5][6] and in one patient cohort study [7], but detailed information about the blood pressure over time during this maneuver is lacking.…”

Technical Aspects of Fenestrated Arch TEVAR With Preloaded Fenestration

“…To achieve a precise and controlled delivery, this step should optimally be performed under fusion guidance and cardiac output reduction, either with the Munich Valsalva Implantation Technique, ventricular rapid over-pacing, vena cava (VC) balloon occlusion or adenosine-induced cardiac arrest. 9 The endograft should be positioned with the fenestration in front of the target vessel and its correct location should be confirmed with angiography. First, under gentle tension on the through-and-through guidewire to maintain constant retraction of the wire as the endograft is unsheathed, the 2 initial stents should be deployed, taking care not to pull back the delivery system; followed by confirmation via angiography of correct positioning of the fenestration.…”

Aorta ascendens und Arcus aortae – endovaskuläre Therapie heute und in der Zukunft

“…Fortwährende Verbesserungen und Verfeinerungen der Implantationstechniken, wie z. B. die Implantation während eines Valsalva-Manövers (MuVIT genannt) [9], und auch des implantierten Materials führten dazu, dass heutzutage im Bereich der deszendierenden thorakalen und abdominellen Aorta die endovaskuläre Therapie eine immer bedeutsamere Option im Vergleich zu den offenen chirurgischen Verfahren darstellt und diese teils als Goldstandard abgelöst hat. Dennoch stellen der Aortenbogen und die damit assoziierten Landezonen nicht nur in anatomischer Hinsicht eine besondere Herausforderung für die endovaskuläre Therapie dar.…”