Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement

Chronic Type A Aortic Dissection After Transcatheter Aortic Valve Replacement

An 87-year-old man with a hostile ascending aorta who underwent transfemoral transcatheter aortic valve replacement (TAVR) using a 26-mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) 2 years earlier presented with chronic type A aortic dissection, which was retrospectively caused by the edge of the pusher of the TAVR implantation system. Redo sternotomy and extraction of the Sapien valve, followed by replacement of the ascending aorta and the aortic valve, were performed successfully. Retrospective image analysis showed the importance of respecting the anatomy of the ascending aorta before considering transfemoral TAVR.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Effect of procedural refinement of transfemoral transcatheter aortic valve implantation on outcomes and costs: a single-centre retrospective study

Objectives

To determine the effect of introducing several procedural refinements of transfemoral transcatheter aortic valve implantation (TAVI) on clinical outcomes and costs.

Design

Retrospective analysis comparing two consecutive 1-year periods, before and after the introduction of procedural refinements.

Setting

Tertiary hospital aortic valve programme.

Participants

Consecutive patients undergoing transfemoral TAVI treated between April 2014 and August 2015 using the initial setup (n=70; control group) or between September 2015 and August 2016 after the introduction of procedural refinements (n=89).

Interventions

Introduction of conscious sedation, percutaneous access and closure, omission of transoesophageal echocardiography during the procedure, and an early discharge procedure.

Outcome measures

Procedural characteristics, complications and outcomes; length of stay in intensive care unit (ICU) and hospital; hospital-related direct costs associated with TAVI.

Results

There were no statistically significant differences in the incidence of complications or mortality between the two groups. The mean length of stay in the ICU was significantly shorter in the procedural-refinement group compared with the control group (5.1 vs 57.2 hours, p<0.001), as was the mean length of hospital stay (4.7 vs 6.6 days, p<0.001). The total cost per TAVI procedure was significantly lower, by £3580, in the procedural-refinement group (p<0.001). This was largely driven by lower ICU costs.

Conclusions

Among patients undergoing transfemoral TAVI, procedural refinement facilitated a shorter stay in ICU and earlier discharge from hospital and was cost saving compared with the previous setup.

Temporal Trends and Clinical Outcomes of Transcatheter Aortic Valve Replacement in Nonagenarians

Background

Contemporary outcomes of transcatheter aortic valve replacement (TAVR) in nonagenarians are unknown.

Methods and Results

We identified 13 544 nonagenarians (aged 90–100 years) who underwent TAVR between 2012 and 2016 using Medicare claims. Generalized estimating equations were used to study the change in short‐term outcomes among nonagenarians over time. We compared outcomes between nonagenarians and non‐nonagenarians undergoing TAVR in 2016. A mixed‐effect multivariable logistic regression was performed to determine predictors of 30‐day mortality in nonagenarians in 2016. A center was defined as a high‐volume center if it performed ≥100 TAVR procedures per year. After adjusting for changes in patients’ characteristics, risk‐adjusted 30‐day mortality declined in nonagenarians from 9.8% in 2012 to 4.4% in 2016 (P<0.001), whereas mortality for patients <90 years decreased from 6.4% to 3.5%. In 2016, 35 712 TAVR procedures were performed, of which 12.7% were in nonagenarians. Overall, in‐hospital mortality in 2016 was higher in nonagenarians compared with younger patients (2.4% versus 1.7%, P<0.05) but did not differ in analysis limited to high‐volume centers (2.2% versus 1.7%; odds ratio: 1.33; 95% CI, 0.97–1.81; P=0.07). Important predictors of 30‐day mortality in nonagenarians included in‐hospital stroke (adjusted odds ratio [aOR]: 8.67; 95% CI, 5.03–15.00), acute kidney injury (aOR: 4.11; 95% CI, 2.90–5.83), blood transfusion (aOR: 2.66; 95% CI, 1.81–3.90), respiratory complications (aOR: 2.96; 95% CI, 1.52–5.76), heart failure (aOR: 1.86; 95% CI, 1.04–3.34), coagulopathy (aOR: 1.59; 95% CI, 1.12–2.26; P<0.05 for all).

Conclusions

Short‐term outcomes after TAVR have improved in nonagenarians. Several procedural complications were associated with increased 30‐day mortality among nonagenarians.

Significance of echocardiographic evaluation for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is widely accepted as an alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis (AS). Existing scientific evidence demonstrates that TAVI is superior to SAVR, and it is expected that indications for the clinical applications of TAVI will be expanded in the future. Echocardiography plays a key role in perioperative assessment of patients undergoing TAVI. Preprocedural echocardiographic evaluation is important to determine the severity of AS in addition to patients' anatomical suitability for TAVI. Furthermore, echocardiography is essential for intraoperative guidance, assessment of complications, postoperative evaluation, and prognostic prediction. Inaccurate echocardiographic measurements and evaluation can lead to less-than-optimal/inappropriate treatment strategies in patients with AS. Therefore, a thorough understanding of the limitations of echocardiographic evaluation is important. This review summarizes the role of echocardiographic evaluation in patients undergoing TAVI.

Propensity Matched Analysis Comparing Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Implantation

Conscious sedation (CS) has been increasingly utilized in transcatheter aortic valve implantation (TAVI). We aim to compare safety, efficacy, efficiency, and direct cost outcomes of patients who underwent TAVI with general anesthesia (GA) to those with CS. Records for all adult patients undergoing transfemoral TAVI at our institution between February 2012 and September 2018 were retrospectively screened. Patients were grouped by anesthesia treatment (GA or CS) and propensity matched. Safety (in-hospital and 30-day mortality, in-hospital and 30-day stroke, cardiac arrest, need for permanent pacemaker, and composite bleed/vascular adverse events), efficacy (follow-up echocardiographic findings), efficiency (procedure duration, fluoroscopy time, radiation dose, intensive care unit (ICU) stay, hospital length-of-stay, and discharge to home), and direct cost outcomes were compared. A total of 589 patients met our inclusion criteria. Propensity matching yielded 154 GA patients and 154 CS patients. There were no differences in the safety outcomes of in-hospital or 30-day mortality, in-hospital or 30-day stroke, cardiac arrest, and need for permanent pacemaker between GA and CS groups. There was a significant reduction in composite bleeding/vascular events in the CS group (8.4% vs 19.5%, p < 0.01). There were no differences in the follow-up echocardiograms with respect to aortic valve area, left ventricular ejection fraction, and incidence of moderate or severe aortic regurgitation. The CS group had shorter procedural fluoroscopy times and radiation dose, shorter length-of-stay and ICU stay, with similar procedural duration. CS patients were more likely to be discharged to home (59.7% vs 74.7%, p < 0.01). Total direct costs for CS were decreased in almost every departmental category, with a mean 10.4% reduction in overall direct costs (p < 0.001). In conclusion, TAVI with CS is associated with less bleeding and vascular events, lower procedural radiation exposure, reduced length of hospitalization and ICU stay, and lower direct costs in comparison with TAVI with GA. These outcomes occur without sacrificing procedural efficacy or safety.

Minimalist Transcatheter Aortic Valve Replacement: The Right Pathway Forward?

Minimalist transcatheter aortic valve replacement (TAVR) can be implemented with no apparent compromise in patient outcomes. Although this approach is applicable for many patients undergoing TAVR, patient selection by the heart team is critical; one must be cognizant of factors whereby a minimalist approach is unsuitable. In the current era of TAVR, a minimalist approach should encompass the entire process of care and not just the procedure. Streamlining and homogenizing preprocedural workup has potential benefits for patients and health services. Minimalist TAVR is likely the right pathway forward for most patients, but the focus should be patient centered with no compromise to safety.

Current results and remaining challenges of trans-catheter aortic valve replacement expansion in intermediate and low risk patients

TAVR has become the standard treatment in patients at increased surgical risk (STS or EuroSCORE II ≥4% or logistic EuroSCORE I ≥ 10% or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation) and it is increasingly being performed in patients at intermediate to low (STS or EuroSCORE II <4% or logistic EuroSCORE I < 10%) surgical risk. Although non-inferiority has been demonstrated in intermediate and low-risk patients, several challenges need to be addressed before expansion to younger patients. Current trends, trials results, and remaining challenges are summarized and discussed in this review.

Cerebral Embolic Risk During Transcatheter Mitral Valve Interventions: An Unaddressed and Unmet Clinical Need?

As new transcatheter mitral valve (MV) interventions continuously evolve, potential procedure-related adverse events demand careful investigation. The risk of cerebral embolic damage is ubiquitous in any left-sided structural heart intervention (and potentially linked to long-term neurocognitive sequelae); therefore, efforts to evaluate these aspects in the field of catheter-based MV procedures are justified. Given the peculiarities of MV anatomy, MV disease, and MV procedures, the lessons learned from other transcatheter heart interventions (i.e., transcatheter aortic valve replacement) cannot be directly translated to MV applications. Through a systematic assessment of available evidence, the authors present and discuss procedure- and patient-related factors potentially associated with cerebral embolic risk during catheter-based MV interventions. Given the paucity of available data in this field, future large, dedicated studies are needed to understand whether cerebral embolic injury represents a real clinical issue during MV procedures.

Meta-Analysis Comparing Renal Outcomes after Transcatheter versus Surgical Aortic Valve Replacement

Background

Acute kidney injury (AKI) is a common complication of aortic valve replacement. However, comparative on the incidence of (AKI) following transcatheter (TAVR) versus surgical valve replacement (SAVR) is sparse.

Methods

We performed a meta-analysis of the randomized controlled trials (RCT) and propensity-matched observational studies comparing (A) incidence of AKI and (B) incidence of dialysis-requiring AKI at 30 days after TAVR and SAVR.

Results

Twenty-six studies (20 propensity-matched studies; 6 RCTs) including 19,954 patients were analyzed. The incidence of AKI was lower after TAVR than after SAVR (7.1% vs. 12.1%, OR 0.52; 95%CI, 0.39-0.68; p<0.001, I²=57%), but the incidence of dialysis-requiring AKI was similar (2.8% vs. 4.1%, OR 0.78; 95%CI, 0.49-1.25; p=0.31, I²=70%). Similar results were observed in a sensitivity analysis including RCTs only for both AKI ([5 RCTs; 5,418 patients], 2.0% vs. 5.0%, OR 0.39; 95%CI, 0.28-0.53; p<0.001, I²=0%), and dialysis-requiring AKI ([2 RCTs; 769 patients]; 2.9% vs. 2.6%, OR 1.1; 95%CI, 0.47-2.58; p=0.83, I²=0%). However, in studies including low-intermediate risk patients only, TAVR was associated with lower incidence of AKI ([10 studies; 6,510 patients], 7.6% vs. 12.4%, OR 0.55, 95%CI 0.39-0.77, p<0.001, I²=57%), and dialysis-requiring AKI, ([10 studies; 12,034 patients], 2.0% vs. 3.6%, OR 0.57, 95%CI 0.38-0.85, p=0.005, I²=23%).

Conclusions

TAVR is associated with better renal outcomes at 30 days in comparison with SAVR, especially in patients at low-intermediate surgical risk. Further studies are needed to assess the impact of AKI on long-term outcomes of patients undergoing TAVR and SAVR.

Operational and Institutional Recommendations and Requirements for TAVR: A Review of Expert Consensus and the Impact on Health Care Policy

When transcatheter aortic valve replacement (TAVR) was first approved for use in the United States in 2012, multiple leading surgical and cardiology societies were tasked with creating recommendations and requirements for operators and institutions starting and maintaining TAVR programs. Creation of this consensus document was challenging due to limited experience with this new technology, and a lack of robust centralized data that could be used to validate outcome measures and create benchmarks for self-assessment and improvement. Despite these limitations, this document provided government agencies a framework for regulation that ultimately determined requirements for Medicare payment for TAVR and therefore greatly determined how and where care was delivered for patients with aortic stenosis. After the proliferation of TAVR institutions throughout the US and with data from more than 100,000 cases in the STS/ACC Transcatheter Valve Therapies TM Registry, leaders of the same societies reconvened in 2018 to update their consensus document. The new recommendations include suggested personnel, facilities, training, and assessment of outcomes and competencies required to run a safe and efficient TAVR program. This article seeks to detail the changes from the original consensus document with a particular focus on issues relevant to cardiac anesthesiologists as well as important healthcare policy ramifications for patients and providers in the United States.

Risk of spinal cord ischemia after thoracic endovascular aortic repair

Background

Spinal cord ischemia (SCI) is a recognized grave complication after thoracic endovascular aortic repair (TEVAR). The present study aimed to evaluate the incidence and investigate risk of SCI after TEVAR based on current prophylactic strategies designed against established risk factors.

Methods

The study retrospectively reviewed a prospectively maintained database to investigate patients who underwent TEVAR successfully between January 2009 and December 2012 in a single cardiovascular center. Detailed assessment of SCI risk was routinely performed for all patients before TEVAR was carried out. Prophylactic measures, including left subclavian artery (LSA) revascularization, blood pressure augmentation and cerebrospinal fluid (CSF) pressure control after TEVAR, were employed in high-risk patients and physical neurological examinations were regularly done to evaluate SCI after TEVAR. Patients were further divided into SCI group and non-SCI group.

Results

A total of 650 patients were enrolled in the study. Eleven patients (1.69%) developed SCI after TEVAR. Baseline level of hemoglobin was significantly lower in the SCI group (113.00 vs. 128.50, P=0.023). More patients in the SCI patients in the SCI group underwent TEVAR under general anesthesia (45.5% vs. 17.7%, P=0.033). A significantly higher incidence of post TEVAR hypotension was found in the SCI group (2.7% vs. 27.3%, P=0.004). Logistic regression analysis revealed that post-TEVAR hypotension (OR, 8.379; 95% CI, 1.833-38.304; P=0.006) was strongly associated with development of SCI and high normal baseline hemoglobin was a protective factor (OR, 0.969; CI, 0.942-0.998; P=0.037). The mortality in hospital and mortality at 1 year were not significant different between the SCI and the non-SCI group (0% vs. 1.6% P=1.000; 9.1% vs. 3.0%, P=0.294, respectively). While length of post-TEVAR stay (13.00 vs. 7.00 days, P=0.000) and length of hospital stay (20.00 vs. 13.00 days, P=0.001) were significantly greater in the SCI group.

Conclusions

Our study revealed that, based on current prophylactic measures to curtail SCI, including LSA revascularization, blood pressure augmentation and CSF pressure control after TEVAR, post-TEVAR hypotension remains a major and independent risk factor for SCI and high normal baseline hemoglobin level is protective. SCI results in longer post-TEVAR stay and hospital stay, but not associated with increased mortality. Robust precautions should be taken against underlying causes for post-TEVAR hypotension and low level of hemoglobin should be avoided.

Sedation versus general anesthesia for transcatheter aortic valve replacement

There is currently significant controversy regarding the best anesthesia management for patients undergoing transcatheter aortic valve replacement (TAVR). Some institutions primarily use general anesthesia (GA) but many institutions primarily use moderate sedation. Much of the controversy is due to the limited evidence base available to inform this decision and the strong feelings and pre-conceived notions about the optimal anesthesia technique which exist amongst anesthesiologists, cardiologists, and cardiac surgeons. In this article and in the context of TAVR, we will define the salient differences between GA and sedation, review the results and limitations of the currently available data, and discuss the priority questions for future research.

Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors

INTRODUCTION

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI.

METHODS

A retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed.

RESULTS

Eleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2±1.2, P<.001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P<.03) CONCLUSIONS: In our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.

The Benefits of Enhanced Recovery After Surgery Programs and Their Application in Cardiothoracic Surgery

The perioperative care of the surgical patient is undergoing a paradigm shift. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of care and best practice in many surgical specialties throughout the world. ERAS is a multimodal, multidisciplinary, evidence-based approach to care of the surgical patient that aims to optimize perioperative management and outcomes. Implementation, however, has been slow because it challenges traditional surgical doctrine. The key elements of ERAS Pathways strive to reduce the response to surgical stress, decrease insulin resistance, and maintain anabolic homeostasis to help the patient return to baseline function more quickly. Data suggest that these pathways have produced not only improvements in clinical outcome and quality of care but also significant cost savings. Large trials reveal an increase in 5-year survival and a decrease in immediate complication rates when strict compliance is maintained with all pathway components. Years of success using ERAS in colorectal surgery have helped to establish a body of evidence through a number of randomized controlled trials that encourage application of these pathways in other surgical specialties.

Relationships Between Intraoperative Hemodynamic Parameters and Delayed Hemodynamic Recovery After Valve Deployment in Transcatheter Aortic Valve Replacement

OBJECTIVE

To determine the relationships between intraoperative hemodynamic parameters and delayed hemodynamic recovery after valve deployment and identify the predictive factors of delayed hemodynamic recovery by focusing on intraoperative hemodynamics in patients with transcatheter aortic valve replacement (TAVR).

DESIGN

A retrospective study.

SETTING

A single university hospital.

PARTICIPANTS

Sixty-four patients who underwent elective TAVR between 2015 and 2017.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

The 64 patients were divided into the following 2 groups according to the time for recovery: systolic arterial pressure exceeded 90 mmHg and central venous oxygen saturation (ScvO₂) exceeded 65%-delayed recovery (DR) (n = 36) group, and early recovery (ER) (n = 28) group. ScvO₂ in the DR group was not lower than that in the ER group after induction of anesthesia. However, ScvO₂ in the DR group gradually decreased and was lower than that in the ER group before valve deployment, despite improvement in blood pressure through the administration of vasopressor agents.

CONCLUSION

ScvO₂ monitoring during TAVR is useful to predict delayed recovery greater than 60 seconds after valve deployment in TAVR.

Feasibility and Outcomes of Transcatheter Aortic Valve Implantation Using the Left Axillary Artery as Primary Access Site

BACKGROUND

The femoral artery is generally used as primary access for transcatheter aortic valve implantation. However, peripheral artery disease often precludes femoral access. The purpose of this study was to describe clinical outcome of transcatheter aortic valve implantation using the left axillary artery (LAA) as primary access site.

METHODS

From December 2008 until June 2016, data on all consecutive patients treated with a Medtronic device through the LAA at our hospital were registered, and outcome was prospectively collected according to the updated Valve Academic Research Consortium-2 criteria. Mortality check was performed nationally.

RESULTS

In total, 362 patients were included (median age 80 years [range, 76 to 84]; logistic European System for Cardiac Operative Risk Evaluation 17% ± 12%). Successful axillary access was achieved in 99%. Medtronic CoreValve (86%) and Evolut R (14% [Medtronic, Minneapolis, MN]) were implanted. Major vascular complications occurred in 5% of patients, 1% was LAA related. Life-threatening bleeding and major bleeding were observed in 2% and 10%, respectively. Additional complications were new left bundle branch blood (30%), new permanent pacemaker (11%), and stroke (1%). There were 6 procedural deaths (2%) and 19 deaths (5%) within 30 days. One-year mortality rate was 19%.

CONCLUSIONS

This is the first study reporting outcome after transcatheter aortic valve implantation using the LAA as default access. We conclude that it is highly feasible and safe with low rates of major vascular complications, bleeding, and stroke.

Outcomes and Safety of Transcatheter Aortic Valve Implantation With and Without Routine Use of Transesophageal Echocardiography

Transesophageal echocardiography (TEE) has been extensively used historically for Transcatheter aortic valve implantation (TAVI) but focus is shifting from routine use of TEE and general anesthesia to "as needed" use. We evaluated patients who had TAVI in our institution from September 2012 to February 2017. Decision for implantation and use of TEE during procedure was made by the structural heart team on a case-to-case basis, based on FDA approved indications. Data including procedural details, length of stay and rehospitalizations were obtained from all patients. TAVI was performed on 178 patients during the study period of which 104 of 178 had TEE during TAVI. Baseline characteristics were fairly comparable in both groups. Similar proportion of self-expanding and balloon expanding valves were deployed. Patients in TEE group had longer overall procedure time (107 minute vs 83 minute, p = 0.0002) and longer length of stay (5.01days vs 2.49days, p < 0.0001). Echocardiographic study postprocedure showed similar incidence of paravalvular leak and similar gradients and velocities across aortic valve. Rates of 30-day readmissions were similar in both groups. In conclusion, in this single-center retrospective analysis-TAVI without the 'routine use' of TEE was comparable with those done with TEE guidance in terms of periprocedural complications and 30-day readmissions. Overall procedure length and length of stay was predictably higher in the TEE group.

Transcatheter aortic valve replacement: The year in review 2017

This article is a continuation of our previously published annual reviews of transcatheter aortic valve replacement (TAVR). In 2017, TAVR further established a foothold in the management of intermediate risk patients with the publication of SURTAVI trial. Randomized trials also addressed the use of cerebral protection during TAVR and single versus dual antiplatelet therapy after TAVR. Newer generation valve systems continued to be studied for their efficacy and safety. This paper summarizes the major studies published in 2017.