Comparison of local versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis

Impact of proficiency in the transcatheter aortic valve implantation procedure on clinical outcomes: a single center retrospective study

BACKGROUND

We used transcatheter aortic valve implantation (TAVI) procedure time to investigate the association between surgical team maturity and outcome.

METHODS

Among patients who underwent TAVI between October 2015 and November 2019, those who had Sapien™ implanted with the transfemoral artery approach were included in the analysis. We used TAVI procedure time and surgery number to draw a learning curve. Then, we divided the patients into two groups before and after the number of cases where the sigmoid curve reaches a plateau. We compared the two groups regarding the surveyed factors and investigated the correlation between the TAVI procedure time and survey factors.

RESULTS

Ninety-nine of 149 patients were analysed. The sigmoid curve had an inflection point in 23.2 cases and reached a plateau in 43.0 cases. Patients in the Late group had a shorter operating time, less contrast media, less radiation exposure, and less myocardial escape enzymes than the Early group. Surgical procedure time showed the strongest correlation with the surgical case number.

CONCLUSION

The number of cases required for surgeon proficiency for isolated Sapien™ valve implantation was 43. This number may serve as a guideline for switching the anesthesia management of TAVI from general to local anesthesia.

Temporal Trends, Outcomes, and Predictors of Next-Day Discharge and Readmission Following Uncomplicated Evolut Transcatheter Aortic Valve Replacement: A Propensity Score-Matched Analysis

BACKGROUND

Next-day discharge (NDD) outcomes following uncomplicated self-expanding transcatheter aortic valve replacement have not been studied. Here, we compare readmission rates and clinical outcomes in NDD versus non-NDD transcatheter aortic valve replacement with Evolut.

METHODS AND RESULTS

Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry patients (n=29 597) undergoing elective transcatheter aortic valve replacement with self-expanding supra-annular valves (Evolut R, PRO, and PRO+) from July 2019 to June 2021 were stratified by postprocedure length of stay: ≤1 day (NDD) versus >1 day (non-NDD). Propensity score matching was used to compare risk adjusted 30-day readmission rates and 1-year outcomes in NDD versus non-NDD, and multivariable regression to determine predictors of NDD and readmission. Between the first and last calendar quarter, the rate of NDD increased from 45.4% to 62.1% and median length of stay decreased from 2 days to 1. Propensity score matching produced relatively well-matched NDD and non-NDD cohorts (n=10 549 each). After matching, NDD was associated with lower 30-day readmission rates (6.3% versus 8.4%; P<0.001) and 1-year adverse outcomes (death, 7.0% versus 9.3%; life threatening/major bleeding, 1.6% versus 3.4%; new permanent pacemaker implantation/implantable cardioverter-defibrillator, 3.6 versus 11.0%; [all P<0.001]). Predictors of NDD included non-Hispanic ethnicity, preexisting permanent pacemaker implantation/implantable cardioverter-defibrillator, and previous surgical aortic valve replacement.

CONCLUSIONS

Most patients undergoing uncomplicated self-expanding Evolut transcatheter aortic valve replacement are discharged the next day. This study found that NDD can be predicted from baseline patient characteristics and was associated with favorable 30-day and 1-year outcomes, including low rates of permanent pacemaker implantation and readmission.

Acute Mitral Valve Regurgitation Caused by Left Ventricular Pacing Wire During Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement is quickly becoming the standard of care for patients with severe aortic stenosis thanks to its minimally invasive nature and favorable outcomes. Recently, left ventricular pacing has been proposed as a safer alternative to traditional right heart pacing, which could simplify the transcatheter aortic valve replacement procedure overall, although procedural complications may still occur. This report describes a rare case of left ventricular pacing wire-induced acute severe mitral valve regurgitation during transcatheter aortic valve replacement.

Safety and feasibility of early discharge after transcatheter aortic valve implantation with ACURATE Neo-the POLESTAR trial

BACKGROUND

Transcatheter aortic valve implantation (TAVI) serves a growing range of patients with severe aortic stenosis (AS). TAVI has evolved to a streamlined procedure minimizing length of hospital stay.

AIMS

To evaluate the safety and efficacy of an early discharge (ED) strategy after TAVI.

METHODS

We performed an international, multi-center, prospective observational single-arm study in AS patients undergoing TAVI with the ACURATE valve platform. Eligibility for ED was assessed prior to TAVI and based on prespecified selection criteria. Discharge ≤ 48 h was defined as ED. Primary Valve Academic Research Consortium (VARC)-3-defined 30-day safety and efficacy composite endpoints were landmarked at 48 h and compared between ED and non-ED groups.

RESULTS

A total of 252 patients were included. The median age was 82 [25th-75th percentile, 78-85] years and the median Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 2.2% [25th-75th percentile, 1.6-3.3]. ED and non-ED were achieved in 173 (69%) and 79 (31%) patients respectively. Monitoring for conduction disturbances was the principal reason for non-ED (33%). Overall, at 30 days, all-cause mortality was 1%, new permanent pacemaker rate was 4%, and valve- or procedure-related rehospitalization was 4%. There was no difference in the primary safety and efficacy endpoint between the ED and non-ED cohorts (OR 0.84 [25th-75th percentile, 0.31-2.26], p = 0.73, and OR 0.97 [25th-75th percentile, 0.46-2.06], p = 0.94). The need for rehospitalization was similarly low for ED and non-ED groups.

CONCLUSION

Early discharge after TAVI with the ACURATE valve is safe and feasible in selected patients. Rhythm monitoring and extended clinical observation protracted hospital stay.

Sedation versus general anesthesia on all-cause mortality in patients undergoing percutaneous procedures: a systematic review and meta-analysis

BACKGROUND

The comparison between sedation and general anesthesia (GA) in terms of all-cause mortality remains a subject of ongoing debate. The primary objective of our study was to investigate the impact of GA and sedation on all-cause mortality in order to provide clarity on this controversial topic.

METHODS

A systematic review and meta-analysis were conducted, incorporating cohort studies and RCTs about postoperative all-cause mortality. Comprehensive searches were performed in the PubMed, EMBASE, and Cochrane Library databases, with the search period extending until February 28, 2023. Two independent reviewers extracted the relevant information, including the number of deaths, survivals, and risk effect values at various time points following surgery, and these data were subsequently pooled and analyzed using a random effects model.

RESULTS

A total of 58 studies were included in the analysis, with a majority focusing on endovascular surgery. The findings of our analysis indicated that, overall, and in most subgroup analyses, sedation exhibited superiority over GA in terms of in-hospital and 30-day mortality. However, no significant difference was observed in subgroup analyses specific to cerebrovascular surgery. About 90-day mortality, the majority of studies centered around cerebrovascular surgery. Although the overall pooled results showed a difference between sedation and GA, no distinction was observed between the pooled ORs and the subgroup analyses based on RCTs and matched cohort studies. For one-year all-cause mortality, all included studies focused on cardiac and macrovascular surgery. No difference was found between the HRs and the results derived from RCTs and matched cohort studies.

CONCLUSIONS

The results suggested a potential superiority of sedation over GA, particularly in the context of cardiac and macrovascular surgery, mitigating the risk of in-hospital and 30-day death. However, for the longer postoperative periods, this difference remains uncertain.

TRIAL REGISTRATION

PROSPERO CRD42023399151; registered 24 February 2023.

Local versus General Anaesthesia for Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomised and Propensity-Score Matched Studies

Transcatheter aortic valve implantation (TAVI) is a common practice for severe aortic stenosis, but the choice between general (GA) and local anesthesia (LA) remains uncertain. We conducted a comprehensive literature review until April 2023, comparing the safety and efficacy of LA versus GA in TAVI procedures. Our findings indicate significant advantages of LA, including lower 30-day mortality rates (RR: 0.69; 95% CI [0.58, 0.82]; p < 0.001), shorter in-hospital stays (mean difference: -0.91 days; 95% CI [-1.63, -0.20]; p = 0.01), reduced bleeding/transfusion incidents (RR: 0.64; 95% CI [0.48, 0.85]; p < 0.01), and fewer respiratory complications (RR: 0.56; 95% CI [0.42, 0.76], p<0.01). Other operative outcomes were comparable. Our findings reinforce prior evidence, presenting a compelling case for LA's safety and efficacy. While patient preferences and clinical nuances must be considered, our study propels the discourse towards a more informed anaesthesia approach for TAVI procedures.

Outcomes of patients undergoing edge-to-edge mitral valve repair with the Edwards PASCAL transcatheter valve repair system under conscious sedation

BACKGROUND

The development of the PASCAL transcatheter valve repair system for treating mitral regurgitation (MR) greatly extends therapeutic options.

AIMS

To assess the safety, efficacy, and time efficiency of the PASCAL system in transcatheter edge-to-edge repair (TEER) under conscious sedation (CS).

METHODS

This is a retrospective, two-center, German registry study consisting of 211 patients who underwent TEER using the PASCAL system under CS. The endpoints were to assess (1) technical, device, and procedural success as per Mitral Valve Academic Research Consortium (MVARC), (2) conversion rate to general anesthesia (GA), (3) hospital length of stay (LoS), (4) New York Heart Association (NYHA) class, and (5) MR compared to baseline at 30-day.

RESULTS

A total of 211 patients with a mean age of 78.4 ± 8.9 years, with 51.4% being female and 86.7% belonging to NYHA functional class III/IV and EuroSCORE II 6.3 ± 4.9%, were enrolled. Procedural success attained was 96.9%, and six patients (2.8%) required conversion from CS to GA. At 30 days follow-up, a significant improvement in MR was found in 96 patients (54.2%) patients with 0/1 grade MR and 45 patients (29.5%) were in NYHA functional class III + IV. Moreover, TEER under CS has a short hospital LoS (6.71 ± 5.29 days) and intensive care unit LoS (1.34 ± 3.49 days) with a 2.8% mortality rate.

CONCLUSIONS

Performing TEER with the PASCAL system under CS resulted in appreciable (96.9%) procedural success with low mortality and is a safe and promising alternative to GA with positive clinical outcomes.

Results of streamlining TAVR procedure towards a minimalist approach: a single center experience in Taiwan

Trans-femoral transcatheter aortic valve replacement (TF-TAVR) performed under conscious sedation (LACS) is not yet become routine practice in Taiwan. We aimed to compared the results between patients received general anesthesia (GA) versus LACS. Our cohort was divided into 3 groups: initial 48 patients received TF-TAVR under routine GA (GA group), subsequent 50 patients under routine LACS (LACS group 1), and recent 125 patients under LACS (LACS group 2). The baseline, procedural characteristics and all outcomes were prospectively collected and retrospectively compared. From Sep 2010 to July 2019, a total of 223 patients were included. The procedure time (157.6 ± 39.4 min vs 131.6 ± 30.3 vs 95.2 ± 40.0, < 0.0001), contrast medium consumption (245.6 ± 92.6 ml vs 207.8 ± 77.9 vs 175.1 ± 64.6, < 0.0001), length of intensive care unit (2 [1-5] days vs 2 [1-3] vs 1 [1-1], P = 0.0001) and hospital stay (9 [7-13] days vs 8 [6-11] vs 6 [5-9], P = 0.0001) decreased significantly with LACS, combined with a trend of less hospital acquired pneumonia (12.5% vs 6.0% vs 5.6%, P = 0.427). 1-year survival rate were also different among 3 groups (83.3% vs 90.0% vs 93.6%, P = 0.053). In our single center experience, a "minimalist" approach of TF-TAVR procedure resulted in less medical resources usage, along with more favorable clinical outcomes.

General Anesthesia Versus Local Anesthesia in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review

OBJECTIVES

For patients with aortic stenosis, transcatheter aortic valve replacement (TAVR) offers a less invasive treatment modality than conventional surgical valve replacement. Although the surgery is performed traditionally under general anesthesia (GA), recent studies have described success with TAVR using local anesthesia (LA) and/or conscious sedation. The study authors performed a pairwise meta-analysis to compare the clinical outcomes of TAVR based on operative anesthesia management.

DESIGN

A random effects pairwise meta-analysis via the Mantel-Haenszel method.

SETTING

Not applicable, as this is a meta-analysis.

PARTICIPANTS

No individual patient data were used.

INTERVENTIONS

Not applicable, as this is a meta-analysis.

MEASUREMENTS AND MAIN RESULTS

The authors comprehensively searched the PubMed, Embase, and Cochrane databases to identify studies comparing TAVR performed using LA or GA. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% CIs. The authors' pooled analysis included 14,388 patients from 40 studies (7,754 LA; 6,634 GA). Compared to GA TAVR, LA TAVR was associated with significantly lower rates of 30-day mortality (RR 0.69; p < 0.01) and stroke (RR 0.78; p = 0.02). Additionally, LA TAVR patients had lower rates of 30-day major and/or life-threatening bleeding (RR 0.64; p = 0.01), 30-day major vascular complications (RR 0.76; p = 0.02), and long-term mortality (RR 0.75; p = 0.009). No significant difference was seen between the 2 groups for a 30-day paravalvular leak (RR 0.88, p = 0.12).

CONCLUSIONS

Transcatheter aortic valve replacement performed using LA is associated with lower rates of adverse clinical outcomes, including 30-day mortality and stroke. No difference was seen between the 2 groups for a 30-day paravalvular leak. These results support the use of minimally invasive forms of TAVR without GA.

In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use

Background

There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR).

Methods

We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O₂ cohort) with 2,313 non-home O₂ patients.

Results

Home O₂ patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV₁) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O₂ cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O₂ patients, home O₂ patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O₂ cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O₂ cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001).

Conclusion

Home O₂ patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.

Conscious sedation/monitored anesthesia care versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis

Background

To compare the merits and safety between conscious sedation/monitored anesthesia (CS/MAC) and general anesthesia (GA) for patients receiving transcatheter aortic valve replacement (TAVR).

Measurements

Databases including EMBASE, MEDLINE, and the Cochrane Library databases were searched from inception to October 2022 to identify studies investigating the impact of CS/MAC on peri-procedural and prognostic outcomes compared to those with GA. The primary outcome was the association of CS/MAC with the risk of 30-day mortality, while secondary outcomes included the risks of adverse peri-procedural (e.g., vasopressor/inotropic support) and post-procedural (e.g., stroke) outcomes. Subgroup analysis was performed based on study design [i.e., cohort vs. matched cohort/randomized controlled trials (RCTs)].

Main results

Twenty-four studies (observational studies, n = 22; RCTs, n = 2) involving 141,965 patients were analyzed. Pooled results revealed lower risks of 30-day mortality [odd ratios (OR) = 0.66, p < 0.00001, 139,731 patients, certainty of evidence (COE): low], one-year mortality (OR = 0.72, p = 0.001, 4,827 patients, COE: very low), major bleeding (OR = 0.61, p = 0.01, 6,888 patients, COE: very low), acute kidney injury (OR = 0.71, p = 0.01, 7,155 patients, COE: very low), vasopressor/inotropic support (OR = 0.25, p < 0.00001, 133,438 patients, COE: very low), shorter procedure time (MD = -12.27 minutes, p = 0.0006, 17,694 patients, COE: very low), intensive care unit stay (mean difference(MD) = -7.53 h p = 0.04, 7,589 patients, COE: very low), and hospital stay [MD = -0.84 days, p < 0.00001, 19,019 patients, COE: very low) in patients receiving CS/MAC compared to those undergoing GA without significant differences in procedure success rate, risks of cardiac-vascular complications (e.g., myocardial infarction) and stroke. The pooled conversion rate was 3.1%. Results from matched cohort/RCTs suggested an association of CS/MAC use with a shorter procedural time and hospital stay, and a lower risk of vasopressor/inotropic support.

Conclusion

Compared with GA, our results demonstrated that the use of CS/MAC may be feasible and safe in patients receiving TAVR. However, more evidence is needed to support our findings because of our inclusion of mostly retrospective studies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022367417.

Comparison of Clinical and Economic Outcomes of an Optimized Lean Versus a Standard Transcatheter Aortic Valve Implantation Program (from SOLAR [Safe Outcomes Lean And Resourceful] Study)

The increasing prevalence of aortic stenosis (AS) and the increasing number of patients indicated for transcatheter aortic valve implantation (TAVI) can lead to increased hospital constraints. This study aimed to compare, from the hospital perspective, the costs, resource use, and 30-day clinical outcomes of patients who underwent TAVI under an optimized or standard clinical pathway. A single-center, retrospective study was conducted among patients with native AS who underwent TAVI between January 2018 and March 2021. Patients who underwent optimized lean TAVI were propensity-score matched 1:1 to those who underwent standard TAVI. In-hospital costs and 30-day clinical outcomes were compared between the 2 groups. A total of 182 patients (91 in each group) were included in the final analysis. Baseline covariates were well balanced after matching. Patients who underwent lean TAVI had shorter length of stay (median [interquartile range] 3.0 days [2.0 to 6.0] vs 6.0 days [5.0 to 9.0], p <0.001). Patients in the lean TAVI group incurred lower total costs than did those in the standard TAVI group (mean ± SD: $41,346 ± 10,062 vs $50,471 ± 15,115, p = 0.002). There was no between-group difference in 30-day all-cause mortality (2.2% vs 1.1%, p = 0.573) and pacemaker implantations (5.5% vs 6.6%, p = 0.788). Rates of procedural complications were comparable between groups. In conclusion, lean TAVI leads to hospital efficiencies without compromising patient safety. Efforts to streamline the TAVI procedure should be encouraged to improve access to TAVI for patients with AS, amid resource constraints.

Conscious sedation versus general anesthesia for transcatheter aortic valve implantation in patients with severe chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is considered a major risk factor for postoperative complications after transcatheter aortic valve implantation (TAVI). To date, there is no clear consensus on the best anesthesia management for these patients. We aimed to investigate the effects of types of anesthesia on clinical outcomes in patients with severe COPD undergoing TAVI.

METHODS

This is a single-center, retrospective study comparing conscious sedation (CS) versus general anesthesia (GA) in 72 patients with severe COPD who underwent TAVI. The primary endpoints were 30-day all-cause mortality and postoperative pulmonary complications.

RESULTS

The main outcome of interest of this study was that the frequency of pulmonary complications was statistically higher in the GA group (21.4% vs 3.3%, p = 0.038). These differences are most likely attributed to the GA because of prolonged mechanical ventilation, and longer ICU stay (2 (1.2-3) vs 2.5 (2-4) days, p = 0.029) associated with an increased risk of nosocomial infections. There were no significant differences in procedure complications and 30-day mortality between the two groups (GA; 19% vs CS; 13.3%, p = 0.521). One-year survival rates, compared by Kaplan-Meier analysis, were similar between groups (log-rank p = 0.733).

CONCLUSION

In aortic stenosis patients with severe COPD undergoing TAVI, the use of GA compared with CS was associated with higher incidences of respiratory-related complications, and longer ICU length of stay. CS is a safe and viable option for these patients and should be considered the favored approach.

The safety of early discharge following transfemoral transcatheter aortic valve replacement under general anesthesia

Background

There is growing evidence of the safety of same-day discharge for low-risk conscious sedated TAVR patients. However, the evidence supporting the safety of early discharge following GA-TAVR with routine transesophageal echocardiography (TEE) is limited.

Aims

To assess the safety of early discharge following transcatheter aortic valve replacement (TAVR) using General Anesthesia (GA-TAVR) and identify predictors for patient selection.

Materials and methods

We used data from 2,447 TEE-guided GA-TAVR patients performed at Cedars-Sinai between 2016 and 2021. Patients were categorized into three groups based on the discharge time from admission: 24 h, 24–48 h, and >48 h. Predictors for 30-day outcomes (cumulative adverse events and death) were validated on a matched cohort of 24 h vs. >24 h using the bootstrap model.

Results

The >48 h group had significantly worse baseline cardiovascular profile, higher surgical risk, low functional status, and higher procedural complications than the 24 h and the 24–48 h groups. The rate of 30-day outcomes was significantly lower in the 24 h than the >48 h but did not differ from the 24–48 h (11.3 vs. 15.5 vs. 11.7%, p = 0.003 and p = 0.71, respectively). Independent poor prognostic factors of 30-day outcomes had a high STS risk of ≥8 (OR 1.90, 95% CI 1.30–2.77, E-value = 3.2, P < 0.001), low left ventricle ejection fraction of <30% (OR 6.0, 95% CI 3.96–9.10, E-value = 11.5, P < 0.001), and life-threatening procedural complications (OR 2.65, 95% CI 1.20–5.89, E-value = 4.7, P = 0.04). Our formulated predictors showed a good discrimination ability for patient selection (AUC: 0.78, 95% CI 0.75–0.81).

Conclusion

Discharge within 24 h following GA-TAVR using TEE is safe for selected patients using our proposed validated predictors.

Transcatheter aortic valve replacement with or without anesthesiologist: results from a high-volume single center

AIMS

Local instead of general anesthesia has become the standard approach in many centers for transfemoral transcatheter aortic valve replacement (TAVR). New generation devices and an increase in operator skills had led to a drastic reduction in periprocedural complications, bringing in the adoption of a minimalist approach. In our study, we aimed to compare patients treated with TAVR under local anesthesia with or without the presence of an anesthesiologist on site (AOS).

METHODS

We compare procedural aspects and results of patients treated with TAVR with an AOS against patients treated with TAVR with an anesthesiologist on call (AOC). From January 2019 to December 2020, all consecutive patients undergoing transfemoral TAVR with either the self-expandable Evolut (Medtronic, MN, USA) or balloon-expandable SAPIEN 3 (Edwards Lifesciences, CA, USA) were collected.

RESULTS

Of 332 patients collected, 96 (29%) were treated with TAVR with AOS, while 236 (71%) were treated with TAVR with AOC. No differences in procedural time, fluoroscopy time and amount of contrast medium were observed. No procedural death and conversion to open-chest surgery was reported. The rate of stroke/transient ischemic attacks and major vascular complications was similar in the two groups. No patients in both groups required conversion to general anesthesia. Two patients (0.8%) in the AOC group required urgent intervention of the anesthesiologist. In the AOC group, there was a greater use of morphine (55.9% vs. 33.3%, P = 0.008), but with a lower dose for each patient (2.0 vs. 2.8 mg, P = 0.006). On the other hand, there was a lower use of other painkiller drugs (3.4% vs. 20.8%, P = 0.001). No difference in inotropic drugs use was observed.

CONCLUSION

In patients at low or intermediate risk undergoing transfemoral TAVR, a safe procedure can be performed under local anesthesia without the presence of an anesthesiologist in the catheterization laboratory.

Procedural Characteristics and Outcomes of Transcatheter Interventions for Aortic Coarctation: A Report From the IMPACT Registry

Background

Although surgical repair was the traditional first-line treatment for native coarctation of the aorta (CoA), balloon angioplasty (BA) and stenting are now increasingly being performed. We aimed to determine the practice patterns and acute outcomes of transcatheter interventions for native coarctation in the largest multicenter registry for congenital catheterization.

Methods

CoA interventions from the IMPACT (IMproving Pediatric and Adult Congenital Treatment) National Cardiovascular Data Registry were analyzed. The procedure choice and acute outcomes were compared among patients with no prior interventions on the aortic isthmus (native CoA). Procedural success was defined as no major adverse events (MAEs) and a final peak gradient of <20 mm Hg and optimal outcome as no MAEs and a final gradient of <10 mm Hg.

Results

Over the 8-year study period, 5928 CoA procedures were performed, of which 1187 were performed in patients with native CoA. In this group, stenting was performed in more then half of children aged >1 year and >90% of those aged >8 years. Procedural success was achieved in >90% of stenting procedures but in only 69% of BAs. Stent implantation was associated with a higher likelihood of optimal gradient (<10 mm Hg) after adjustment for age and baseline characteristics. MAEs were most common in children aged <1 year (14%), occurred in 2% to 2.5% of those aged 1 to 18 years and in 6.6% of adults (P < .001), and were more likely after BA than after stenting (odds ratio, 0.5; 95% CI, 0.28-0.9; unadjusted P = .02).

Conclusions

Catheter interventions for native coarctation are performed safely in older children and adults, with a high degree of immediate procedural success, particularly with stenting.

Predictors of early discharge after transcatheter aortic valve implantation: insight from the CoreValve ClinicalService

AIMS

The aim of this study was to minimize the procedure, and reduce the length of hospital stay (LoS) is the future objective for transcatheter aortic valve replacement (TAVI).Aims of the study are to identify procedural and electrocardiographical predictors of fast-track discharge in patients who underwent TAVI.

METHODS

Patients treated with TAVI included in the One Hospital ClinicalService project were categorized according to the LoS. 'Fast-Track' population, with a postprocedural LoS less than or equal to 3 days, was compared with the 'Slow-Track' population with a postprocedural LoS greater than 3 days.

RESULTS

One thousand five hundred and one patients were collected. Despite single baseline characteristics being almost similar between the two groups, Slow-Track group showed a higher surgical risk (P < 0.001). Patients in the Slow-Track group were more frequently treated with general anaesthesia (P = 0.002) and less frequently predilated (P < 0.001) and received a lower amount of contrast media. No difference between Slow-Track and Fast-Track patients was observed at 30 days in death and in cardiovascular rehospitalization.In the multivariable analysis, STS score of at least 4% [odds ratio (OR): 1.64; P = 0.01], general anaesthesia (OR: 2.80; P = 0.03), predilation (OR: 0.45; P < 001), NYHA 3-4 at baseline (OR: 1.65; P = 0.01), AVB I/LBBB/RBBB onset (OR: 2.41; P < 0.001) and in-hospital new PM (OR: 2.63; P < 0.001) were independently associated with a higher probability of Slow-Track.

CONCLUSION

Fast-Track patients were safely discharged home showing no difference in clinical outcomes after discharge up to 30 days compared with the Slow-Track group. The STS score, general anaesthesia, NYHA 3--4 at baseline, in-hospital onset of conduction disturbances and new PM implantation after TAVI turned out to be predictors of Slow-Track.

Simplified TAVR Procedure: How Far Is It Possible to Go?

Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.

The Impact of Local vs. General Anesthesia in Patients Undergoing Thoracic Endovascular Aortic Surgery

OBJECTIVE

General anesthesia is associated with inherent risks that can be avoided by the use of lesser invasive anesthetic strategies. We hypothesize that examine and compare the use of local or regional anesthesia (LRA to general anesthesia (GA) in patients undergoing thoracic endovascular aortic repair (TEVAR).

METHODS

Patients undergoing TEVAR between 2010-2020 in the Vascular Quality Initiative were analyzed. Exclusion criteria included receipt of branched or physician modified endografts and devices extending distally beyond Zone 5. Patients were categorized as receiving LRA or GA. Center volume was reported by quartile according to annualized TEVAR volume and operative outcomes were compared using appropriate frequentists tests. Univariable and multivariable regression models for anesthesia type and operative outcomes were created to compare unadjusted and adjusted rates of each outcome. Long-term survival was estimated using a Kaplan-Meier survival estimator, while adjusted survival analysis was performed using a Cox proportional-hazards model.

RESULTS

Of the 17,099 patients who underwent TEVAR, 7,299 met the inclusion and exclusion criteria. Of these, 3.8% received LRA. There were no significant differences in the annual proportion of patients who received LRA from 2011 to 2020 (p = 0.49, Chi-square test for trend). Only 18.8% of patients who received LRA were treated at the highest quartile volume centers. Patients who received LRA were older and more comorbid compared to those who received GA. There were no differences in in-hospital mortality (OR = 0.79, 95% CI 0.42 to 1.38, p = 0.44) or composite of any complication (OR = 0.79, 95% CI 0.54 to 1.14, p = 0.22) between patients who received LRA compared to GA. This also applied to patients presenting with rupture. Receipt of LRA was associated with lower odds of post-operative congestive heart failure (OR = 0.19, 95% CI 0.01 to 0.89, p = 0.01) as well as decreased length of ICU (OR = 0.54, 95% CI 0.40 to 0.72, p < 0.01) and hospital length of stay (OR = 0.64, 95% CI 0.46 to 0.84, p < 0.01). LRA was not associated with decreased long-term survival compared to GA (HR 0.95, 95% CI 0.72 to 1.25, p = 0.72).

CONCLUSION

Despite a greater number of baseline comorbidities, patients undergoing TEVAR with LRA experienced shorter ICU and post-operative lengths of stay, with similar operative outcomes and long-term survival compared to patients who received GA.. Similar findings were found amongst the rupture cohort. LRA should be considered more frequently in select patients undergoing TEVAR.

Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.

Institutional infrastructural preconditions and current perioperative anaesthesia practice in patients undergoing transfemoral transcatheter aortic valve implantation: a cross-sectional study in German heart centres

OBJECTIVES

Transfemoral transcatheter aortic valve implantation (TF-TAVI) is an established therapy for patients with symptomatic aortic stenosis, which requires periprocedural anaesthesia care. In 2015, the German Federal Joint Committee released a directive on minimally invasive heart valve interventions which defines institutional infrastructural requirements in German heart centres. But still generally accepted expert consensus recommendations or national or international guidelines regarding periprocedural anaesthesia management for TF-TAVI are lacking. This nationwide cross-sectional study had two major objectives: first to assess the concordance with existing national regulations regarding infrastructural requirements and second to evaluate the status quo of periprocedural anaesthesia management for patients undergoing TF-TAVI in German heart centres.

DESIGN

Multicentre cross-sectional online study to evaluate the periprocedural anaesthesia management.

SETTING

In this nationwide cross-sectional study, electronic questionnaires were sent out to anaesthesia departments at TF-TAVI-performing centres in Germany in March 2019.

PARTICIPANTS

78 anaesthesia departments of German heart centres.

RESULTS

54 (69.2%) centres returned the questionnaire of which 94.4% stated to hold regular Heart Team meetings, 75.9% to have ready-to-use heart-lung machines available on-site, 77.8% to have cardiac surgeons and 66.7% to have perfusionists routinely attending throughout TF-TAVI procedures. Regarding periprocedural anaesthesia management, 41 (75.9%) of the participating centres reported to predominantly use 'monitored anaesthesia care' and 13 (24.1%) to favour general anaesthesia. 49 (90.7%) centres stated to use institutional standard operating procedures for anaesthesia. Five-lead ECG, central venous lines, capnometry and intraprocedural echocardiography were reported to be routine measures in 85.2%, 83.3%, 77.8% and 51.9% of the surveyed heart centres.

CONCLUSIONS

The concordance with national regulations, anaesthesia management and in-house standards for TF-TAVI vary broadly among German heart centres. According to the opinion of the authors, international expert consensus recommendations and/or guidelines would be helpful to standardise peri interventional anaesthesia care.

Comparison of anesthesia management in transcatheter aortic valve implantation: a retrospective cohort study

BACKGROUND AND OBJECTIVES

We aimed to investigate the effects of two different anesthetic techniques in our patients who underwent transcatheter aortic valve implantation (TAVI).

METHODS

In this study, 303 patients who underwent TAVI procedure with a diagnosis of severe aortic stenosis between January 1, 2012 and December 31, 2018 were retrospectively evaluated. The patients were divided according to the type of anesthesia given during each procedure as; general anesthesia (GA), local anesthesia (LA).

RESULTS

LA was preferred in 245 (80.8%) of 303 patients who underwent TAVI, while GA was preferred in 58 patients (19.1%). Median ages ​​of our patients who received LA and GA were 83 and 84, respectively. The procedure and anesthesia durations of the patients in the GA group were longer than the LA group (p< 0.00001, p < 0.00001, respectively). Demographic and pre-operative clinical data were similar in comparison between two groups (p > 0.05) except for peripheral artery disease. Hypertension was the most common comorbidity in both groups. While the number of inotrope use was significantly higher in patients who received GA (p < 0.00001), no significant differences were found between LA and GA patients in terms of major complications and mortality (p > 0.05). Intensive care and hospital stays were significantly shorter in the LA group (p = 0.001, p = 0.023, respectively).

CONCLUSION

The anesthetic technique of TAVI procedure did not have a significant effect on outcomes including; complications, mortality and success of the procedure. LA provides shorter duration of procedure and hospital stay.

Utilization, Costs, and Outcomes of Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement

[Figure: see text].

Same Day Discharge during the COVID-19 Pandemic in Highly Selected Transcatheter Aortic Valve Replacement Patients

Background

Transcatheter aortic valve replacement (TAVR) with a standardized clinical pathway allows most patients to achieve safe next-day discharge. This approach has been successfully implemented across global centers as part of the Benchmark Program. Considering restricted hospital resources resulting from the COVID-19 pandemic, a modified same day discharge (SDD) clinical pathway was implemented for selected TAVR patients at a single Benchmark site.

Methods

All patients accepted for TAVR were assessed for the SDD clinical pathway. Eligibility criteria included adequate social support and accessibility to the TAVR program post-discharge. Patients with preexisting conduction disease were excluded. The clinical pathway comprised of mobilization, bloodwork and electrocardiogram 4 hours post-TAVR and discharge ≥8 hours following groin hemostasis.

Results

From June to December 2020, 142 patients underwent TAVR at a single community Benchmark site. Of those, 29 highly selected patients were successfully discharged the same day using the SDD clinical pathway. There were no vascular access complications, permanent pacemaker (PPM) implantation, or mortality in the SDD group during index admission or at 30-day follow-up. When compared to a standard therapy group, there was no statistically significant difference in 30-day cardiovascular readmission.

Conclusions

This study demonstrates the safety and feasibility of same day discharge post-TAVR in a highly selected cohort of patients, with no observable difference in safety outcomes when compared to patients who were discharged according to standard institutional practice.Abbreviations: AS: aortic stenosis; ACT: Activated clotting time; AV: atrioventricular; AVB: atrioventricular block; BBB: bundle branch block; CAIC: Canadian Society for Cardiovascular Angiography; CCL: cardiac catheterization laboratory; CT: Computed topography; CV: cardiovascular; IQR: Interquartile Range; IVCD: intraventricular conduction delay; LBBB: left bundle branch block; LOS: length of stay; NDD: next day discharge; PPM: permanent pacemaker; RBBB: right bundle branch block; SCAI: Society for Cardiovascular Angiography and Intervention; SD: standard deviation; SDD: same day discharge; ST: standard therapy; STS PROM: society of thoracic surgeons predicted risk of mortality; TAVR: transcatheter aortic valve replacement; TF: transfemoral; THV: transcatheter heart valve; TTE: transthoracic echocardiogram; VARC: Valve Academic Research Consortium

Meta-analysis of minimalist versus standard care approach for transcatheter aortic valve replacement

BACKGROUND

The change in practice of transcatheter aortic valve replacement (TAVR) to a minimalist approach is a debate.

METHODS

Online database search for studies that compared the minimalist approach with the standard approach for TAVR were searched from inception through September 2020. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the fixed or random-effects model.

RESULTS

A total of 9 studies with 2,880 TAVR patients (minimalist TAVR;1066 and standard TAVR; 1,814) were included. Compared to standard approach, there were no significant differences in in-hospital mortality, 30-day mortality, or hospital readmissions. However, there was a reduced risk of acute kidney injury (OR0.49;95%CI0.27-0.89), major bleeding (OR0.21;95%CI0.12-0.38) and major vascular complications (OR0.60,95%CI0.39-0.91) associated with the minimalist TAVR group. There was comparatively shorter hospital length of stay (mean difference -2.41;95%CI-2.99,-1.83) days, procedural time (mean difference -43.99;95%CI-67.25,-20.75) minutes, fluoroscopy time (mean difference -2.69;95%CI-3.44,-1.94) minutes and contrast volume (mean difference -26.98;95%CI-42.18,-11.79) ml in the minimalist TAVR group.

CONCLUSIONS

This meta-analysis demonstrated potential benefits of the minimalist TAVR approach over the standard approach regarding some adverse clinical outcomes as well as procedural outcomes without significant differences in mortality or readmission rates.

Impact of Anesthesia Strategy and Valve Type on Clinical Outcomes After Transcatheter Aortic Valve Replacement

BACKGROUND

The randomized SOLVE-TAVI (compariSon of secOnd-generation seLf-expandable vs. balloon-expandable Valves and gEneral vs. local anesthesia in Transcatheter Aortic Valve Implantation) trial compared newer-generation self-expanding valves (SEV) and balloon-expandable valves (BEV) as well as local anesthesia with conscious sedation (CS) and general anesthesia (GA) in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). Both strategies showed similar outcomes at 30 days.

OBJECTIVES

The purpose of this study was to compare clinical outcomes during 1-year follow-up in the randomized SOLVE-TAVI trial.

METHODS

Using a 2 × 2 factorial design 447 intermediate- to high-risk patients with severe, symptomatic aortic stenosis were randomly assigned to transfemoral TAVR using either the SEV (Evolut R, Medtronic Inc., Minneapolis, Minnesota) or the BEV (Sapien 3, Edwards Lifesciences, Irvine, California) as well as CS or GA at 7 sites.

RESULTS

In the valve-comparison strategy, rates of the combined endpoint of all-cause mortality, stroke, moderate or severe paravalvular leakage, and permanent pacemaker implantation were similar between the BEV and SEV group (n = 84, 38.3% vs. n = 87, 40.4%; hazard ratio: 0.94; 95% confidence interval: 0.70 to 1.26; p = 0.66) at 1 year. Regarding the anesthesia comparison, the combined endpoint of all-cause mortality, stroke, myocardial infarction, and acute kidney injury occurred with similar rates in the GA and CS groups (n = 61, 25.7% vs. n = 54, 23.8%; hazard ratio: 1.09; 95% confidence interval: 0.76 to 1.57; p = 0.63).

CONCLUSIONS

In intermediate- to high-risk patients undergoing transfemoral TAVR, newer-generation SEV and BEV as well as CS and GA showed similar clinical outcomes at 1 year using a combined clinical endpoint. (SecOnd-generation seLf-expandable Versus Balloon-expandable Valves and gEneral Versus Local Anesthesia in TAVI [SOLVE-TAVI]; NCT02737150).

Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes

Transcatheter aortic valve replacement (TAVR) has revolutionized the percutaneous management of valvular heart disease and has evolved to progressively minimalist techniques over the past decade. This review discusses the impact of minimalist TAVR, explores the alternative approaches when transfemoral (TF) TAVR is not possible, and analyzes the current outcomes of transcarotid (TC) versus transaxillary/subclavian (TAx) TAVR, which are the two leading nonfemoral (NF) approaches emerging as the preferred alternatives to TF TAVR.

Single-center experience of 105-minimalistc transfemoral transcatheter aortic valve replacement and its outcome

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) increases worldwide, and indications expand from high-risk aortic stenosis patients to low-risk aortic stenosis. Studies have shown that minimalistic TAVR done under conscious sedation is safe and effective. We report single-operator, the single-center outcome of 105 minimalist transfemoral, conscious sedation TAVR patients, analyzed retrospectively.

METHODS

All patients underwent TAVR in cardiac catheterization lab via percutaneous transfemoral, conscious sedation approach. A dedicated cardiac anesthetist team delivered the conscious sedation with a standard protocol described in the main text. The outcomes were analyzed as per VARC-2 criteria and compared with the latest low-risk TAVR trials.

RESULTS

A total of 105 patients underwent transcatheter aortic valve replacement between July 2016 to February 2020. The mean age of the population was 73 years, and the mean STS score was 3.99 ± 2.59. All patients underwent a percutaneous transfemoral approach. Self-expanding valve was used in 40% of cases and balloon-expandable valve in 60% (Sapien3™ in 31% and MyVal™ in 29%) of cases. One patient required conversion to surgical aortic valve replacement. The success rate was 99 percent. The outcomes were: all-cause mortality: 0.9%, stroke rate 1.9%, New pacemaker rate 5.7%, 87.6% had no paravalvular leak. The mild and moderate paravalvular leak was seen in 2.8% and 1.9%, respectively. The mean gradient decreased from 47.5 mmHg to 9 mmHg. The average ICU stay was 26.4 h, and the average hospital stay was 5.4 days. Our outcomes are comparable with the latest published low-risk trial.

CONCLUSION

Minimalist, conscious sedation, transfemoral transcatheter aortic valve replacement when done following a standard protocol is safe and effective.

General anesthesia vs. sedation in transcatheter aortic valve implantation (TAVI): retrospective study of the incidence of acute kidney injury

INTRODUCTION AND OBJECTIVES

Anesthetic techniques have been reported as having an impact on acute kidney injury (AKI) incidence in the postoperative period in patients undergoing transcatheter aortic valve implantation (TAVI). This study aimed to assess whether exists an association between anesthetic approach in patients undergoing TAVI and the post-operative AKI incidence. The existence of association between anesthetic approach and mortality was also assessed.

MATERIALS AND METHODS

A retrospective, single-center, observational study was conducted at the Centro Hospitalar Universitário de São João, a Portuguese reference center. All patients undergoing TAVI from January 2015 to June 2018 were recruited and were divided into two groups for analysis: general anesthesia (GA) and sedation.

RESULTS

One hundred and seven patients underwent TAVI (GA: n = 24; sedation: n = 83) and the overall incidence of AKI was 14.02%. We found a higher incidence of intraoperative hypotension in the GA group (83.3 vs. 33.7%, p < 0.001). Regarding postoperative outcomes, there were no significant differences in AKI incidence (20.8 vs. 12.0%, p = 0.319) and mortality. A significant association was found between postoperative AKI and preexisting chronic kidney disease (CKD), preoperative heart failure functional class, intraoperative hypotension, longer length of stay in level II unit, longer hospital stay and worsening of previous CKD stage.

CONCLUSIONS

It was not possible to established association between the anesthetic approach for TAVI procedures and postoperative AKI and mortality. Our study reinforces the importance of preventing AKI incidence, considering its impact on the worsening of baseline CKD and on the length of stay, leading to higher hospitalization costs.

Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes

BACKGROUND

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valves that are detected up to 18% of all implanted surgical valves. Perioperative morbidity is thought to be lower in percutaneous compared to surgical PVL repair. However, a direct comparison of PVL closure techniques has never been performed. Our study is the first to demonstrate that elective PVL closure with monitored anesthesia care can be achieved with high success and low complications rates resulting in short hospital stays.

METHODS

This is a retrospective cohort of patients admitted electively for catheter-based treatment of symptomatic prosthetic paravalvular regurgitation from Jan 2013 to April 2018. Both mitral and aortic PVLs were included. Patients' demographics, risk factors, procedural outcomes, In-hospital and thirty-day mortality were all reported. We followed the Valve Academic Research Consortium (VARC) criteria to define device and procedural technical success. In-hospital and 30- day outcomes were assessed by retrospective chart review.

RESULTS

A total of 54 PVLs in thirty-seven patients were repaired (65% aortic & 35% mitral). The mean-age in the mitral cohort was lower than the aortic cohort (61 vs 72years, P<0.0001) but the two groups shared similar clinical risk factors (P>0.05). Average hospital stay was 1-2days (<1.5days overall cohort) which was significantly lower in the aortic compared to the mitral cohort (P=0.009). All procedures were guided by TEE under conscious sedation with monitored anesthesia care. Procedural technical success defined as any significant residual shunt was 81% in the overall cohort and 88% in the aortic group. No procedural deaths were reported. Short-term mortality during the first 30days was 5.4% (two patients).

CONCLUSION

Elective catheter-based repair of symptomatic prosthetic paravalvular regurgitation appears to be safe and effective. The use of conscious sedation with monitored anesthesia care resulted in short hospital stay.

Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study

AIM

Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI.

METHODS

This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up.

RESULTS

The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome.

CONCLUSION

In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.

General Versus Local Anesthesia With Conscious Sedation in Transcatheter Aortic Valve Implantation

Background:

In clinical practice, local anesthesia with conscious sedation (CS) is performed in roughly 50% of patients undergoing transcatheter aortic valve replacement. However, no randomized data assessing the safety and efficacy of CS versus general anesthesia (GA) are available.

Methods:

The SOLVE-TAVI (Comparison of Second-Generation Self-Expandable Versus Balloon-Expandable Valves and General Versus Local Anesthesia in Transcatheter Aortic Valve Implantation) trial is a multicenter, open-label, 2×2 factorial, randomized trial of 447 patients with aortic stenosis undergoing transfemoral transcatheter aortic valve replacement comparing CS versus GA. The primary efficacy end point was powered for equivalence (equivalence margin 10% with significance level 0.05) and consisted of the composite of all-cause mortality, stroke, myocardial infarction, infection requiring antibiotic treatment, and acute kidney injury at 30 days.

Results:

The primary composite end point occurred in 27.2% of CS and 26.4% of GA patients (rate difference, 0.8 [90% CI, −6.2 to 7.8]; P equivalence =0.015). Event rates for the individual components were as follows: all-cause mortality, 3.2% versus 2.3% (rate difference, 1.0 [90% CI, −2.9 to 4.8]; P equivalence <0.001); stroke, 2.4% versus 2.8% (rate difference, −0.4 [90% CI, −3.8 to 3.8]; P equivalence <0.001); myocardial infarction, 0.5% versus 0.0% (rate difference, 0.5 [90% CI, −3.0 to 3.9]; P equivalence <0.001), infection requiring antibiotics 21.1% versus 22.0% (rate difference, −0.9 [90% CI, −7.5 to 5.7]; P equivalence =0.011); acute kidney injury, 9.0% versus 9.2% (rate difference, −0.2 [90% CI, −5.2 to 4.8]; P equivalence =0.0005). There was a lower need for inotropes or vasopressors with CS (62.8%) versus GA (97.3%; rate difference, −34.4 [90% CI, −41.0 to −27.8]).

Conclusions:

Among patients with aortic stenosis undergoing transfemoral transcatheter aortic valve replacement, use of CS compared with GA resulted in similar outcomes for the primary efficacy end point. These findings suggest that CS can be safely applied for transcatheter aortic valve replacement.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02737150.

Transcatheter aortic valve replacement: potential use in lower-risk aortic stenosis

INTRODUCTION

The widespread use of transcatheter aortic valve implantation (TAVI) is expanding to low-risk patients. Nevertheless, a low clinical risk does not always correspond to a low procedural risk for the percutaneous approach.

AREAS COVERED

The initial trials on TAVI in low-risk populations had encouraging results, showing non-inferiority in comparison to surgical aortic valve replacement (SAVR). However, the low-risk definition is based on risk score calculators developed for the surgical setting and not including other specific features that are more relevant to TAVI and can affect procedural outcomes. For example, the presence of bicuspid aortic valves, high calcific burden, low coronary height or conduction disturbances is all potentially associated with suboptimal results or even procedural complications. In addition, the lack of longer follow-up prevents us to draw conclusions about long-term outcomes, including data about valve durability and coronary re-access.

EXPERT OPINION

Although current evidence suggest similar results for TAVI and SAVR in low-risk populations, there are some technical and procedural limitations that still need to be addressed in order to close the gap between TAVI and surgery. Optimal, lasting results with a low rate of procedural complications are highly expected in low-risk, otherwise healthy subjects, with potential for longevity.

Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe: Results of an Online Survey

OBJECTIVES

Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe.

DESIGN

Structured web-based, anonymized, voluntary survey.

SETTING

Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018.

PARTICIPANTS

Physicians.

MEASUREMENTS AND MAIN RESULTS

The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%.

CONCLUSION

The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.

[Perioperative stroke]

Perioperative stroke is defined as an ischemic cerebrovascular event that occurs during or within 30 days after surgery and is associated with an increased perioperative risk of morbidity and mortality. Depending on the type of surgery stroke is diagnosed in up to 11% of all patients in the perioperative period. Patients with a history of ischemic stroke or transitory ischemic attack have an increased risk for perioperative stroke. Therefore, a critical assessment of indications and the timing of surgery are crucial to prevent recurring stroke in this patient population. Importantly, individualized blood pressure management is essential for optimization of cerebral perfusion during the perioperative period.This article provides a summary of the epidemiology, risk factors, and etiology of perioperative stroke. Moreover, possible preventive strategies relevant for the anesthesiologist are reviewed.

Recent advances in nonoperating room anesthesia for cardiac procedures

PURPOSE OF REVIEW

The number of complex procedures performed in the cardiac catheterization laboratory (CCL) is rapidly increasing. Because of their complexity, they frequently require the assistance of an anesthesiologist. The CCL is primarily designed to facilitate a percutaneous cardiac intervention; therefore, it might be a challenging workplace for an anesthesiologist. The aim of this review is to briefly present tasks and challenges of providing anesthesia in the CCL and to provide a concise description of common cardiac procedures performed there.

RECENT FINDINGS

Recent literature indicates that many complicated cardiac procedures can be performed in CCL under monitored anesthesia care. At the same time several of them (e.g. transcatheter aortic valve replacement) are quickly becoming a viable alternative for surgical valve replacement. The most recent expansion of CCL procedures is related to rapidly growing population of grown-ups with congenital heart disease. All aforementioned developments present new challenges to an anesthesiologist.

SUMMARY

New and fast development of percutaneous cardiac interventions has created a new working place for the anesthesiologist - the CCL. Our expertise in complex cardiac pathophysiology allows conduct of complicated procedures outside of the operating theater. For the same reasons, there is ongoing discussion whether anesthesia support in CCL should be provided by a general or cardiac anesthesiologist.

Supraglottic Airway Use for Transfemoral-Transcatheter Aortic Valve Replacement

OBJECTIVE

Examine outcome differences in patients managed either with a supraglottic airway or an endotracheal tube for general anesthesia during transcatheter aortic valve replacement. The authors hypothesized that patients managed with a supraglottic airway would have shorter post-anesthesia care unit and hospital stays and receive fewer opioids, norepinephrine equivalents, and neuromuscular blocking agents, without an increase in 30-day major adverse cardiovascular events.

DESIGN

Retrospective chart review with 1:2 supraglottic airway-to-endotracheal tube patient propensity score matching.

SETTING

Single, urban, tertiary care, academic medical center.

PARTICIPANTS

Patients undergoing transfemoral- transcatheter aortic valve replacement between 2017 and 2019.

INTERVENTIONS

Supraglottic or endotracheal tube airway management during general anesthesia.

MEASUREMENTS AND MAIN RESULTS

Thirty-one supraglottic airway patients were propensity score matched with 62 endotracheal tube patients. There was no significant difference for postanesthesia care unit (p = 0.58) or hospital (p = 0.16) lengths of stay. Supraglottic airway patients received significantly fewer neuromuscular blockers (p < 0.0001) and trended toward fewer opioids (p = 0.05), but received a similar number of norepinephrine equivalents (p = 0.76). The major adverse cardiovascular event odds ratio between groups was 1.39 (p = 0.51). The time under general anesthesia (p = 0.02) and total time in the operating room (p = 0.04) were significantly shorter for supraglottic airway patients.

CONCLUSIONS

Supraglottic airway management in transcatheter aortic valve replacement was feasible without an increase in major adverse cardiovascular outcomes compared with endotracheal tube management during general anesthesia. Supraglottic airway patients trended toward receiving fewer opioids and received significantly fewer neuromuscular blockers while also having significantly shorter time under general anesthesia and total time in the operating room.

Comparing sedation vs. general anaesthesia in transoesophageal echocardiography-guided percutaneous transcatheter mitral valve repair: a meta-analysis

AIMS

Transoesophageal echocardiography-guided percutaneous transcatheter mitral valve repair (TOE-guided PMVR) using edge-to-edge leaflet plication is typically performed under general anaesthesia (GA). Increasing evidence supports the efficacy and safety of PMVR performed under conscious sedation (CS) or deep sedation (DS). We performed a meta-analysis comparing safety and efficacy of CS/DS vs. GA in PMVR.

METHODS AND RESULTS

A comprehensive search was performed using PubMed, CINAHL, Ovid MEDLINE, Embase, and the Cochrane Library. Study characteristics, participant demographics, and procedural outcomes with both types of anaesthesia were analysed. Out of 73 articles, five met inclusion criteria. Overall, there was no significant difference in the primary outcome of procedural success rate [odds ratio (OR) 0.75; 95% confidence interval (CI) 0.30-1.88, I2= 0.0%, P = 0.538] or post-procedure in-hospital mortality (OR 1.02; 95% CI 0.38-2.71, I2= 0.0%, P = 0.970) in the patients undergoing PMVR under CS/DS vs. GA. The secondary endpoint of intensive care unit (ICU) length of stay (LOS) was significantly shorter in patients under CS/DS vs. GA (standardized mean difference, SMD = -0.97; 95% CI -1.75 to -0.20; P = 0.014), but the hospital LOS (SMD = 0.36; 95% CI -0.77 to 0.04, P = 0.078) did not show a statistically significant difference between the groups, although it was shorter in the CS/DS group. No difference was observed between CS/DS and GA in fluoroscopy time, procedure time, or complications, including pneumonia, stroke/transient ischaemic attack, and major bleeding.

CONCLUSION

CS or DS has lower ICU LOS, but comparable procedural success rate and in-hospital mortality, making it a potential alternative to GA for TOE-guided PMVR.

Embolization of aortic valve leaflet during valve-in-valve transcatheter aortic valve implantation: a case report

Background 

Aortic stenosis (AS) is one of the most common valvular disorders worldwide. An increasing number of transcatheter aortic valve implantation (TAVI) procedures are being performed yearly for managing AS. This, along with the occurrence of common complications, makes timely diagnosis essential to manage rare complications and improve patient outcomes.

Case summary 

We present a case of a 77-year-old Caucasian male with severe AS with a dysfunctional bioprosthetic valve following previous surgical valve replacement. During valve-in-valve TAVI, we noted bioprosthetic valve leaflet avulsion and embolization causing a major vascular occlusion that resulted in vascular insufficiency of the left lower extremity. This condition was managed successfully via immediate diagnosis using transoesophageal echocardiogram, angiogram, and vascular surgical intervention for retrieving the embolized valve to re-establish circulation.

Discussion 

To our knowledge, this is the first case of aortic valve leaflet embolization during TAVI resulting in significant vascular insufficiency. Vascular complications are common during TAVI. However, not all vascular complications are the same. Our case highlights an embolic vascular complication from an avulsed prosthetic material during a challenging valve-in-valve TAVI procedure.