1
|
Yang L, Hubert J, Gitundu S, Brovman E, Cobey F. Carbon Footprint of Total Intravenous and Inhalation Anesthesia in the Transcatheter Aortic Valve Replacement Procedure. J Cardiothorac Vasc Anesth 2024; 38:1314-1321. [PMID: 38490897 DOI: 10.1053/j.jvca.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/11/2024] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES To quantify and compare the emissions for deep sedation with total intravenous anesthesia (TIVA) and general anesthesia with inhaled agents during the transcatheter aortic valve replacement procedure. DESIGN A retrospective study. SETTING A tertiary hospital in Boston, Massachusetts. PARTICIPANTS The anesthesia records of 604 consecutive patients who underwent the transcatheter aortic valve replacement procedure between January 1, 2018, and March 31, 2022, were reviewed and analyzed. INTERVENTIONS Data were examined and compared in the following 2 groups: general anesthesia with inhaled agents and deep sedation with TIVA. MEASUREMENTS AND MAIN RESULTS The gases, drugs, airway management devices, and anesthesia machine electricity were collected and converted into carbon dioxide emissions (CO2e). The carbon emissions of intravenous medications were converted with the CO2e data for anesthetic pharmaceuticals from the Parvatker et al. study. For inhaled agents, inhaled anesthetics and oxygen/air flow rate were collected at 15-minute intervals and calculated using the anesthetic gases calculator provided by the Association of Anesthetists. The airway management devices were converted based on life-cycle assessments. The electricity consumed by the anesthesia machine during general anesthesia was estimated from the manufacturer's data (Dräger, GE) and local Energy Information Administration data. The data were analyzed in the chi-squared test or Wilcoxon rank-sum test. There were no significant differences in the patients' demographic characteristics, such as age, sex, weight, height, and body mass index. The patients who received general anesthesia with inhaled agents had statistically higher total CO2e per case than deep sedation with TIVA (16.188 v 1.518 kg CO2e; p < 0.001), primarily due to the inhaled agents and secondarily to airway management devices. For deep sedation with TIVA, the major contributors were intravenous medications (71.02%) and airway management devices (16.58%). A subgroup study of patients who received sevoflurane only showed the same trend with less variation. CONCLUSIONS The patients who received volatile anesthesia were found to have a higher CO2e per case. This difference remained after a subgroup analysis evaluating those patients only receiving sevoflurane and after accounting for the differences in the duration of anesthesia. Data from this study and others should be collectively considered as the healthcare profession aims to provide the best care possible for their patients while limiting the harm caused to the environment.
Collapse
Affiliation(s)
- Lei Yang
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA.
| | - Joshua Hubert
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Samwel Gitundu
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Ethan Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Frederick Cobey
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| |
Collapse
|
2
|
Su X, Zhao Z, Zhang W, Tian Y, Wang X, Yuan X, Tian S. Sedation versus general anesthesia on all-cause mortality in patients undergoing percutaneous procedures: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:126. [PMID: 38565990 PMCID: PMC10985877 DOI: 10.1186/s12871-024-02505-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Xuesen Su
- The First College for Clinical Medicine, Shanxi Medical University, No. 56 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Zixin Zhao
- College of Anesthesia, Shanxi Medical University, No. 56 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China
| | - Wenjie Zhang
- Department of Anesthesiology, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China
| | - Yihe Tian
- John Muir College, University of California San Diego, 8775 Costa Verde Blvd, San Diego, CA, USA
| | - Xin Wang
- Department of Anesthesiology, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China
| | - Xin Yuan
- Department of Anesthesiology, First Hospital of Shanxi Medical University, No. 85 Jiefang South Road, Taiyuan, Shanxi, People's Republic of China
| | - Shouyuan Tian
- College of Anesthesia, Shanxi Medical University, No. 56 Xinjian South Road, Taiyuan, Shanxi, People's Republic of China.
- Shanxi Province Cancer Hospital/Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences No. 3, Workers' New Village, Xinghualing District, Taiyuan, Shanxi, People's Republic of China.
| |
Collapse
|
3
|
Jaffar-Karballai M, Al-Tawil M, Roy S, Kayali F, Vankad M, Shazly A, Zeinah M, Harky A. 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. Curr Probl Cardiol 2024; 49:102360. [PMID: 38128636 DOI: 10.1016/j.cpcardiol.2023.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Sakshi Roy
- School of Medicine, Queen's University Belfast, Northern Ireland, UK
| | | | | | - Ahmed Shazly
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
| |
Collapse
|
4
|
Ko CC, Hung KC, Chang YP, Liu CC, Cheng WJ, Wu JY, Li YY, Lin TC, Sun CK. Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review. Sci Rep 2023; 13:16241. [PMID: 37758810 PMCID: PMC10533830 DOI: 10.1038/s41598-023-43548-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.
Collapse
Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung City, Taiwan
| | - Yang-Pei Chang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Wan-Jung Cheng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yu-Yu Li
- Department of Anesthesiology, Chi Mei Medical Center, Chiali, Tainan City, Taiwan
| | - Tso-Chou Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Dachang Hospital, I-Shou University, No. 305, Dachang 1St Road, Sanmin District, Kaohsiung City, Taiwan.
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung City, Taiwan.
| |
Collapse
|
5
|
Fan J, Hudson JL, Fan KC, Gayer S, Flynn HW. Evolving Use of Regional versus General Anesthesia for the Surgical Repair of Open Globe Injuries. Am J Ophthalmol 2023; 251:71-76. [PMID: 36822572 PMCID: PMC10247446 DOI: 10.1016/j.ajo.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE The purpose of the current study is to report outcomes with the evolving use of regional anesthesia with monitored anesthesia care (RA-MAC) vs general anesthesia (GA) in the repair of open globe injuries. DESIGN Retrospective, consecutive, comparative, nonrandomized clinical study. METHODS The study includes 507 eyes of 507 patients with open globe injuries treated with either RA-MAC or GA at a tertiary referral center between 2015 and 2020. There was no predetermined protocol for selection of anesthesia method. However, based on experience and findings of prior research by this group, regional anesthesia with monitored anesthesia care was typically selected initially and changed to general anesthesia if warranted after evaluation of the patient and discussion with the surgeon. The main outcome measure was visual acuity at last follow-up. Results were compared to previously published study groups between 1995 and 2014. RESULTS Primary closure of open globe injury was performed under RA-MAC anesthesia in 462 patients (91%) and under GA in 45 patients (9%). Zone 1, 2, and 3 injuries were recorded in 251, 170, and 86 patients, respectively. Zone 1 (96%, 240 of 251 patients) or zone 2 (92%, 156 of 170 patients) (P < .001) were more likely to be repaired under RA-MAC vs zone 3 injuries (76%, 65 of 86 patients). The improvement from presenting visual acuity was similar for the 2 anesthesia groups, 0.52 logMAR and 0.46 logMAR for RA-MAC and GA, respectively (P = .68, CI -0.3 to 0.2). The use of RA-MAC anesthesia for open globe injuries has increased at our institution from 64% in 1995-1999 to 91% in the present study, 2015-2020 (P < .00001). CONCLUSION The current study demonstrates that with anesthesiologists experienced in ophthalmic regional anesthesia techniques, and appropriate case selection, RA-MAC can be safely used as an alternative to general anesthesia for open globe repair. Considerations when employing RA-MAC include a patient's ability to cooperate, position, and communicate for the duration of the globe repair.
Collapse
Affiliation(s)
- Jason Fan
- From the Department of Ophthalmology (J.F., J.L.H., K.C.F., S.G., H.W.F.)
| | - Julia L Hudson
- From the Department of Ophthalmology (J.F., J.L.H., K.C.F., S.G., H.W.F.)
| | - Kenneth C Fan
- From the Department of Ophthalmology (J.F., J.L.H., K.C.F., S.G., H.W.F.)
| | - Steven Gayer
- From the Department of Ophthalmology (J.F., J.L.H., K.C.F., S.G., H.W.F.); Department of Anesthesiology (S.G.), Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA
| | - Harry W Flynn
- From the Department of Ophthalmology (J.F., J.L.H., K.C.F., S.G., H.W.F.).
| |
Collapse
|
6
|
Hung KC, Chen JY, Hsing CH, Chu CC, Lin YT, Pang YL, Teng IC, Chen IW, Sun CK. Conscious sedation/monitored anesthesia care versus general anesthesia in patients undergoing transcatheter aortic valve replacement: A meta-analysis. Front Cardiovasc Med 2023; 9:1099959. [PMID: 36704470 PMCID: PMC9872395 DOI: 10.3389/fcvm.2022.1099959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/26/2022] [Indexed: 01/11/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kuo-Chuan Hung
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan,Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan,Department of Medical Research, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yu-Li Pang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Chia Teng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan,College of Medicine, I-Shou University, Kaohsiung City, Taiwan,*Correspondence: Cheuk-Kwan Sun,
| |
Collapse
|
7
|
Wang L, Liu Y, Gao H, Zhang B, Zhou S, Xie M, Sun X. Comparison of Safety and Effectiveness of Local or General Anesthesia after Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12020508. [PMID: 36675437 PMCID: PMC9866516 DOI: 10.3390/jcm12020508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023] Open
Abstract
It remains controversial to choose anesthesia for transcatheter aortic valve implantation (TAVI). A meta-analysis of cohort studies was conducted to assess the efficacy and safety of local anesthesia (LA) compared to general anesthesia (GA) in TAVI. All relevant studies published from 1 January 2002, to 31 June 2022, were searched in Ovid, PubMed, Embase, Web of Science, and Cochrane Library. A total of 34 studies involving 23,480 patients were included in the meta-analysis. TAVI with LA was associated with a significant reduction in hospital stay [WMD = −2.48, 95% CI (−2.80, −2.16), p < 0.00001], operative [WMD = −12.25, 95% CI (−13.73, −10.78), p < 0.00001] and fluoroscopy time [WMD = −3.30, 95% CI (−5.40, −1.19), p = 0.002], and an increased risk of acute kidney injury [OR = 1.31, 95% CI (1.01, 1.69), p = 0.04] and a reduced incidence of major bleeding [OR = 0.59, 95% CI (0.46, 0.75), p < 0.0001] and the use of cardiovascular drugs [OR = 0.17, 95% CI (0.05, 0.57), p = 0.004]. No differences were found between LA and GA for 30-day mortality, procedural success rate, myocardial infarction, permanent pacemaker implantation, paravalvular leak, shock, and cerebrovascular events. Overall, 4.4% of LA converted to GA. Based on current evidence, our results suggested that LA strategies reduced hospital stay, operative time, fluoroscopy time, cardiovascular drug consumption, and major bleeding rates in patients undergoing TAVI but led to increased acute kidney injury rates. Further studies and randomized trials are required to verify the presented findings and to identify patients who might benefit from LA.
Collapse
|
8
|
Holmes HR, Falasa M, Neal D, Choi CY, Park K, Bavry AA, Freeman KA, Manning EW, Stinson WW, Jeng EI. Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:401-408. [PMID: 36217748 DOI: 10.1177/15569845221124113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Monitored anesthesia care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a Veterans Affairs Medical Center. METHODS A single-center retrospective review was performed of 349 patients who underwent transfemoral TAVR (MAC, n = 244 vs GA, n = 105) from January 2014 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs. RESULTS In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs 198 min, P < 0.001), ICU LOS (1.4 vs 1.8 days, P < 0.001), total hospital LOS (3.4 vs 5.4 days, P < 0.001), and lower index total cost ($81,300 vs $85,400, P = 0.010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs 196 min, P < 0.05), ICU LOS (1.2 vs 1.7 days, P = 0.006), total LOS (3.5 vs 5.1 days, P = 0.001), and 180-day mortality (2.4% vs 12%, P < 0.03). There was no difference in total hospitalization cost or total cost. CONCLUSIONS In propensity-matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality but no significant difference in cost.
Collapse
Affiliation(s)
- Henry R Holmes
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Matheus Falasa
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Daniel Neal
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Calvin Y Choi
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Ki Park
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kirsten A Freeman
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eddie W Manning
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Wade W Stinson
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eric I Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| |
Collapse
|
9
|
Berkovitch A, Finkelstein A, Barbash IM, Kornowski R, Fefer P, Steinvil A, Vaknin Assa H, Danenberg H, Maor E, Guetta V, Segev A. Local Anesthesia versus Conscious Sedation among Patients Undergoing Transcatheter Aortic Valve Implantation-A Propensity Score Analysis. J Clin Med 2022; 11:jcm11113134. [PMID: 35683525 PMCID: PMC9181727 DOI: 10.3390/jcm11113134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Conscious sedation (CS) has been used successfully to treat patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) and as such is considered the standard anesthesia method. The local anesthesia (LA) only approach may be feasible and safe thanks to improvements in operators' experience. OBJECTIVE To evaluate differences between LA only versus CS approaches on short- and long-term outcomes among patients undergoing TAVI. METHODS We performed a propensity score analysis on 1096 patients undergoing TAVI for severe AS. Two hundred and seventy-four patients in the LA group were matched in a ratio of 1:3 with 822 patients in the CS group. The primary outcome was a 1-year mortality rate. Secondary outcomes included procedural and peri-procedural complication rates and in-hospital mortality. RESULTS Patients in the CS group had significantly higher rates of grade 2-3 acute kidney injury and were more likely to have had new left bundle branch block and high-degree atrioventricular block. Patients who underwent TAVI under CS had significantly higher in-hospital and 1-year mortality rates compared to LA (1.6% vs. 0.0% p-value = 0.036 and 8.5% vs. 3.3% p-value = 0.004, respectively). Kaplan-Meier's survival analysis showed that the cumulative probability of 1-year mortality was significantly higher among subjects undergoing CS compared to patients LA (p-value log-rank = 0.024). Regression analysis indicated that patients undergoing CS were twice more likely to die of at 1-year when compared to patients under LA (HR 2.18, 95%CI 1.09-4.36, p-value = 0.028). CONCLUSIONS As compared to CS, the LA-only approach is associated with lower rates of peri-procedural complications and 1-year mortality rates.
Collapse
Affiliation(s)
- Anat Berkovitch
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
| | - Ariel Finkelstein
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
- Division of Cardiology, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Israel M. Barbash
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
- Division of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Paul Fefer
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
| | - Arie Steinvil
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
- Division of Cardiology, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Hana Vaknin Assa
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
- Division of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel
| | - Haim Danenberg
- The Heart Institute, Hadassah Ein-Karem Medical Center, The Hebrew University, Jerusalem 91120, Israel;
| | - Elad Maor
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
| | - Victor Guetta
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
| | - Amit Segev
- Division of Cardiology, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Tel-Hashomer 5262000, Israel; (A.B.); (I.M.B.); (P.F.); (E.M.); (V.G.)
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel; (A.F.); (R.K.); (A.S.); (H.V.A.)
- Correspondence: ; Tel.: +972-52-666-7581; Fax: +972-3-530-2683
| |
Collapse
|
10
|
Kanda H, Takahashi Y, Sugawara A, Takahoko K, Shirasaka T, Saijo Y, Kamiya H. Comparing Conscious Sedation With Regional Anesthesia Versus General Anesthesia in Minimally Invasive Mitral Valve Surgery With Right-Sided Minithoracotomy: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 36:452-460. [PMID: 34332841 DOI: 10.1053/j.jvca.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/02/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aims of the present study were to evaluate and compare the safety and feasibility, including hospitalization, intensive care unit (ICU) stay, frequency of conversion to general anesthesia (GA), pH, PaCO2, and PaO2, of selected patients who underwent minimally invasive mitral valve surgery (MIMVS) via a right minithoracotomy under conscious sedation (CS) to avoid GA. The authors also aimed to evaluate the perioperative management of spontaneous breathing. DESIGN A retrospective, observational study. SETTING Single-center. PARTICIPANTS This study enrolled 101 patients who underwent MIMVS under CS or GA. INTERVENTIONS The patients who underwent MIMVS were managed under CS or GA according to indication criteria. MEASUREMENTS AND MAIN RESULTS ICU stay (p = 0.010), postoperative time until first fluid intake (p < 0.0001), and duration of mechanical ventilation (p = 0.004) were shorter in the CS group than in the GA group. No patients converted to GA from CS. PaCO2 during cardiopulmonary bypass (CPB) in the CS group was significantly lower than that in the GA group. However, PaCO2 at the termination of CPB in the CS group was significantly higher than that in the GA group. CONCLUSIONS In the CS group, advanced-age patients with comorbidities underwent mitral surgery without postoperative complications. The authors' findings suggested that MIMVS under CS could be a potentially less-invasive method, providing a quicker recovery than MIMVS under GA.
Collapse
Affiliation(s)
- Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan.
| | - Yukako Takahashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Ami Sugawara
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kenichi Takahoko
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yasuaki Saijo
- Department of Social Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| |
Collapse
|
11
|
Kleinecke C, Allakkis W, Buffle E, Liu XX, Mohrez Y, Gloekler S, Brachmann J, Schnupp S, Achenbach S, Yu J. Impact of conscious sedation and general anesthesia on periprocedural outcomes in Watchman left atrial appendage closure. Cardiol J 2021; 28:519-527. [PMID: 33438184 DOI: 10.5603/cj.a2020.0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transcatheter left atrial appendage closure (LAAC) is performed either in conscious sedation (CS) or general anesthesia (GA), and limited data exist regarding clinical outcomes for the two approaches. The aim of the study was to analyze the effect of CS versus GA on acute outcomes in a large patient cohort undergoing LAAC with a Watchman occluder. METHODS A cohort of 521 consecutive patients underwent LAAC with Watchman occluders at two centers (REGIOMED hospitals, Germany) between 2012 and 2018. One site performed 303 consecutive LAAC procedures in GA, and the other site performed 218 consecutive procedures in CS. The safety endpoint was a composite of major periprocedural complications and postoperative pneumonia. The efficacy endpoint was defined as device success. RESULTS After a 1:1 propensity score matching, 196 (CS) vs. 115 (GA) patients could be compared. In 5 (2.6%) cases CS was converted to GA. The primary safety endpoint (3.5% [CS] vs. 7.0% [GA], p = 0.18) and its components (major periprocedural complications: 2.5% vs. 3.5%, p = 0.73; postoperative pneumonia: 2.6% vs. 4.3%, p = 0.51) did not differ between the groups. Also, device success was comparable (96.9% vs. 93.9%, p = 0.24). CONCLUSIONS In patients undergoing LAAC with the Watchman device, conscious sedation and general anesthesia showed comparable device success rates and safety outcomes. The type of anesthesia for LAAC may therefore be tailored to patient comorbidities, operator experience, and hospital logistics.
Collapse
Affiliation(s)
- Caroline Kleinecke
- Department of Cardiology, REGIOMED Klinikum Lichtenfels, Lichtenfels, Germany.
| | - Wasim Allakkis
- Department of Cardiology, REGIOMED Klinikum Coburg, Coburg, Germany
| | - Eric Buffle
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Xiao-Xia Liu
- Department of Cardiology, REGIOMED Klinikum Coburg, Coburg, Germany.,Department of Cardiology, Beijing Anzhen Hospital, Beijing, China
| | - Yamen Mohrez
- Department of Cardiology, REGIOMED Klinikum Coburg, Coburg, Germany
| | - Steffen Gloekler
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | | | - Steffen Schnupp
- Department of Cardiology, REGIOMED Klinikum Coburg, Coburg, Germany
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander University Erlangen-Nuernberg, Erlangen, Germany
| | - Jiangtao Yu
- Department of Cardiology, REGIOMED Klinikum Lichtenfels, Lichtenfels, Germany.,Department of Cardiology, Klinikum Koblenz-Montabaur, Koblenz, Germany
| |
Collapse
|
12
|
Simplification of Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2019; 12:2460-2461. [DOI: 10.1016/j.jcin.2019.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 11/21/2022]
|