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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.
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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.
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Carr ZJ, Li J, Agarkov D, Gazura M, Karamchandani K. Estimates of 30-day postoperative pulmonary complications after gastrointestinal endoscopic procedures: A retrospective cohort analysis of a health system population. PLoS One 2024; 19:e0299137. [PMID: 38394250 PMCID: PMC10889900 DOI: 10.1371/journal.pone.0299137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
The incidence of 30-day postoperative pulmonary complications (PPC) of gastrointestinal endoscopic procedures (GIEP) are not well characterized in the literature. The primary aim of this study was to identify the incidence of 30-day PPC after GIEP within a large healthcare system. We conducted a retrospective cohort study of 5377 patients presenting for GIEP between January 2013 and January 2022. Our primary outcome was the Agency for Healthcare Research and Quality PPC composite (AHRQ-PPC). Secondary outcomes were sub-composites derived from the AHRQ-PPC; including pneumonia (AHRQ-PNA), respiratory failure (AHRQ-RF), aspiration pneumonia/ pneumonitis (AHRQ-ASP) and pulmonary emboli (AHRQ-PE). We performed propensity score matching (PSM) followed by multivariable logistic regression to analyze primary and secondary outcomes. Inpatients had higher 30-day AHRQ-PPC (6.0 vs. 1.2%, p<0.001), as well as sub-composite AHRQ-PNA (3.2 vs. 0.7%, p<0.001), AHRQ-RF (2.4 vs. 0.5%, p<0.001), and AHRQ-ASP (1.9 vs. 0.4%, p<0.001). After PSM adjustment, pre-procedural comorbidities of electrolyte disorder [57.9 vs. 31.1%, ORadj: 2.26, 95%CI (1.48, 3.45), p<0.001], alcohol abuse disorder [16.7 vs. 6.8%, ORadj: 2.66 95%CI (1.29, 5.49), p = 0.01], congestive heart failure (CHF) [22.3 vs. 8.7%, ORadj: 2.2 95%CI (1.17, 4.15), p = 0.02] and pulmonary circulatory disorders [21 vs. 16.9%, ORadj: 2.95, 95%CI (1.36, 6.39), p = 0.01] were associated with 30-day AHRQ-PPC. After covariate adjustment, AHRQ-PPC was associated with upper endoscopy more than lower endoscopy [5.9 vs. 1.0%, ORadj: 3.76, 95%CI (1.85, 7.66), p<0.001]. When compared to gastroenterologist-guided conscious sedation, anesthesia care team presence was protective against AHRQ-PPC [3.7 vs. 8.4%, ORadj: 0.032, 95%CI (0.01, 0.22), p<0.001] and AHRQ-ASP [1.0 vs. 3.37%, ORadj: 0.002, 95%CI (0.00, 0.55), p<0.001]. In conclusion, we report estimates of 30-day PPC after GIEP across inpatient and outpatient settings. Upper endoscopic procedures confer a higher risk, while the presence of an anesthesia care team may be protective against 30-day PPC.
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Affiliation(s)
- Zyad J. Carr
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Judy Li
- Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Daniel Agarkov
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Makenzie Gazura
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, United States of America
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
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Hernando Vela B, Jarén Cubillo P, Bueno Fernández C, Gallego Ligorit L, Ferrer García MC, Diarte JA. Sedation with propofol/remifentanil versus dexmedetomidine / remifentanil for patients undergoing transcatheter aortic valve implant: A retrospective study between 2012 and 2019. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:68-75. [PMID: 38065297 DOI: 10.1016/j.redare.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/26/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous implantation of an aortic valve prosthesis is a therapeutic alternative for patients with severe aortic stenosis. The procedure is traditionally performed under general anaesthesia; however, sedation is now gaining in popularity because it reduces the need for vasoactive drugs and shortens the patient's stay in the critical care unit and on the ward. The aim of this study is to evaluate the clinical efficacy, safety and potential benefits of sedation with dexmedetomidine in patients undergoing percutaneous implantation of an aortic valve prosthesis in terms of haemodynamic and respiratory complications. MATERIALS AND METHODS We performed a retrospective study of 222 patients that had undergone percutaneous implantation of an aortic valve prosthesis between 2012 and 2019 under sedation with either dexmedetomidine plus remifentanil (DEX-RMF) or propofol plus remifentanil (PROPO-RMF). We collected data on complications, mainly haemodynamic and respiratory, during and after the procedure. RESULTS No significant differences were found between sedation with dexmedetomidine and propofol (in combination with remifentanil) in terms of haemodynamic stability and intraprocedural cerebral blood oxygen. In the DEX-RMF group, however, mean blood pressure, midazolam dose, and duration of anaesthesia were lower compared with the PROPO-RMF group, but the incidence of haemodynamic and respiratory complications did not differ significantly between groups. CONCLUSIONS Our results show that sedation, particularly with adjuvant dexmedetomidine, is a valid anaesthetic techniques in percutaneous aortic valve prosthesis implantation.
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Affiliation(s)
- B Hernando Vela
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario "Miguel Servet", Zaragoza, Spain.
| | - P Jarén Cubillo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario "Miguel Servet", Zaragoza, Spain; Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - C Bueno Fernández
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario "Miguel Servet", Zaragoza, Spain
| | - L Gallego Ligorit
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario "Miguel Servet", Zaragoza, Spain
| | - M C Ferrer García
- Servicio de Cardiología, Hospital Universitario "Miguel Servet", Zaragoza, Spain
| | - J A Diarte
- Servicio de Cardiología, Hospital Universitario "Miguel Servet", Zaragoza, Spain
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Yang L, Hennis L, Patel K, Saccocci MA. Laparoscopic adrenalectomy of pheochromocytoma following management of severe aortic stenosis with transcatheter aortic valve replacement under monitored anesthesia care sedation: a case report. BMC Anesthesiol 2023; 23:18. [PMID: 36631749 PMCID: PMC9832737 DOI: 10.1186/s12871-023-01977-6] [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: 05/06/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Management of a patient with an active pheochromocytoma and severe aortic stenosis remains controversial. Adrenalectomy for a pheochromocytoma poses a high risk for stroke, hypertensive emergency, and mortality, compounded by the cardiovascular instability of severe aortic stenosis. In this case report, successful management of an active pheochromocytoma with concomitant severe aortic stenosis was accomplished by performing transcatheter aortic valve replacement under monitored anesthesia care prior to laparoscopic adrenalectomy. CASE PRESENTATION An 84-year-old woman with severe aortic stenosis (valve area 0.53 cm2) presented with a symptomatic pheochromocytoma. Transcatheter aortic valve replacement was performed under monitored anesthesia care using a judicious approach of 100 mcg fentanyl total, 4 mg total of midazolam, and a background dexmedetomidine infusion. Alpha-blockade was maintained with 10 mg total of phentolamine mesylate. Laparoscopic adrenalectomy was performed after an uncomplicated postoperative course. The perioperative course for the adrenalectomy was unremarkable and the patient was hemodynamically stable. Postoperative course was uncomplicated and the patient was discharged from the hospital after 5 days. CONCLUSION This case report demonstrated the successful approach of managing severe aortic stenosis through a transcatheter aortic valve replacement using monitored anesthesia care sedation prior to laparoscopic adrenalectomy of a symptomatic pheochromocytoma.
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Affiliation(s)
- Leon Yang
- grid.438526.e0000 0001 0694 4940Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Lauren Hennis
- grid.438526.e0000 0001 0694 4940Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Kevin Patel
- grid.438526.e0000 0001 0694 4940Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Michael A. Saccocci
- grid.438526.e0000 0001 0694 4940Virginia Tech Carilion School of Medicine, Roanoke, VA USA ,grid.413420.00000 0004 0459 1303Department of Surgery, Carilion Clinic, Roanoke, VA USA
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5
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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.
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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,
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Patel P, Jundi L, Li D, Liu H. Is a designated arterial catheter indicated in transcatheter aortic valve replacement procedure? J Biomed Res 2022; 36:73-76. [PMID: 35387903 PMCID: PMC9002161 DOI: 10.7555/jbr.36.20220036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Pooja Patel
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817, USA
| | - Lillian Jundi
- California Northstate University College of Medicine, Sacramento, CA 95757, USA
| | - David Li
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817, USA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA 95817, USA
- Hong Liu, Department of Anesthesiology and Pain Medicine, University of California Davis Health, 4150 V Street, Suite 1200, Sacramento, CA 95817, USA. Tel/Fax: +1-916-734-5031/+1-916-734-7980, E-mail:
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Zhao CB, Yu J, Kong M, Han J, Du H, Huang J. Ketamine for Monitored Anesthesia Care during Transcatheter Aortic Valve Replacement. J Perianesth Nurs 2021; 37:234-237. [PMID: 34972624 DOI: 10.1016/j.jopan.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/02/2021] [Accepted: 06/12/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To study the feasibility and outcomes of ketamine as an anesthetic adjunct during monitored anesthesia care (MAC) in transcatheter aortic valve replacement (TAVR). DESIGN This was a retrospective study. METHODS Data from 155 consecutive TAVR patients at a tertiary care high-volume TAVR medical center were reviewed and analyzed. FINDINGS Among the 155 TAVR cases under MAC, intravenous ketamine was administered as an adjunct in 126 patients. The most common ketamine dose was 20 mg. There was no significant difference for postoperative stroke, intraoperative conversion to general anesthesia, postoperative delirium, need for permanent pacemaker implantation, perivalvular leak and length of stay between the ketamine and non-ketamine groups. The ketamine group demonstrated a statistically significant lower 30-day mortality (P = .0381) and intraoperative cardiac arrest (P = .0025) rate when compared to the nonketamine group. CONCLUSIONS Our results demonstrated that employing ketamine as an adjunct during MAC for TAVR is a feasible option.
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Affiliation(s)
- Chen B Zhao
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
| | - Jianjian Yu
- First Central Clinical College, Tianjin Medical University, Tianjin, China; Department of Anesthesiology, Tianjin Chest Hospital, Tianjin, PR China
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville
| | - Jiange Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin, PR China
| | - Hongyin Du
- First Central Clinical College, Tianjin Medical University, Tianjin, China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY; Department of Cardiovascular & Thoracic Surgery, School of Medicine, University of Louisville, Louisville; Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY; Department of Pharmacology & Toxicology, School of Medicine, University of Louisville, Louisville.
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8
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Musuku SR, Cherukupalli D, Di Capua C, Fitzpatrick M, Sirigaddi K, Bughrara N, Singh C, DeLago A. Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation. Turk J Anaesthesiol Reanim 2020; 48:491-496. [PMID: 33313589 PMCID: PMC7720838 DOI: 10.5152/tjar.2020.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/12/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Surgical aortic valve replacement requires a comprehensive transoesophageal echocardiography (TEE) assessment before and after the intervention by cardiac anaesthesiologists. For patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI), TEE is not routinely used. We started using transthoracic echocardiography (TTE) as a diagnostic and monitoring modality during TF-TAVI procedures. The aim of this study is to examine the usefulness of TTE before and after TF-TAVI. We hypothesised that TTE can serve as a screening tool in TF-TAVI patients and help rule out significant paravalvular leaks (PVLs), and serve as a monitoring tool. METHODS A retrospective, observational study of 24 patients who underwent TF-TAVI with perioperative TTE over a 3-month period was conducted. Intraoperatively, two TTE examinations were performed. The first was a baseline pre-procedural TTE examination after anaesthetic induction, and the second was performed after TAVI valve implantation. Both pre- and post-procedural examinations included five focused TTE views. PVLs were graded as none, non-significant (trace or mild) or significant (moderate or severe). RESULTS The average age and median body mass index of the patients were 82 years and 28.5 kg m-2, respectively. The average time recorded for the pre- and post-TAVI TTE examinations were approximately 4 and 5.5 min, respectively. Non-significant PVL was detected in 6 (25%) patients, and no leak was detected in 18 (75%) patients. CONCLUSION A focused TTE examination was found to be a useful adjunct during TF-TAVI for a cardiac anaesthesiologist in the absence of TEE, and useful in ruling out significant PVLs.
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Affiliation(s)
| | | | | | | | | | - Nibras Bughrara
- Department of Anaesthesiology, Albany Medical Center, Albany, USA
| | | | - Augustin DeLago
- Department of Anaesthesiology, Albany Medical Center, Albany, USA
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Jabbar AA, Hasan M, Jenkins JS, Collins T, Ramee S. Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1291-1298. [PMID: 33246555 DOI: 10.1016/j.carrev.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Ali Abdul Jabbar
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Mohanad Hasan
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - J Stephen Jenkins
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Tyrone Collins
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States of America; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States of America
| | - Stephen Ramee
- John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, United States of America.
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10
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Nampi RG, Law TW, Neuburger PJ. Anesthesiology Research Using Surgical Registries: Consider the Source. J Cardiothorac Vasc Anesth 2020; 35:436-438. [PMID: 33268278 DOI: 10.1053/j.jvca.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Robert G Nampi
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Tina W Law
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY.
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11
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Abbett SK, Urman RD, Resor CD, Brovman EY. The Effect of Anesthesia Type on Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2020; 35:429-435. [PMID: 33023815 DOI: 10.1053/j.jvca.2020.09.083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess postoperative outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) either under general anesthesia (GA) or monitored anesthesia care (MAC) as the primary anesthetic. DESIGN A retrospective, propensity-matched, cohort study, with univariate logistic regression to assess postoperative outcomes. SETTING Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). PARTICIPANTS The study comprised 559 patients who underwent a TAVR procedure under GA or MAC. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After propensity score matching, there were no significant differences between the two cohorts in age, sex, race, body mass index, functional status, American Society of Anesthesiologists physical status, and other comorbidities. There were no significant differences in 30-day mortality between the two cohorts, or in the number of complications at 30 days. However, hospital length of stay was significantly shorter in the MAC cohort compared with the GA cohort. CONCLUSIONS Patients undergoing TAVR under MAC may have similar 30-day mortality and complications, but shorter hospital length of stay, than patients undergoing TAVR under GA.
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Affiliation(s)
- Sarah K Abbett
- Department of Anesthesiology, Milford Regional Medical Center, Milford, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA
| | | | - Ethan Y Brovman
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA.
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12
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Musuku SR, Capua CAD, Doshi I, Cherukupalli D, Byun Y, Shapeton AD. Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed With General Anesthesia Using a Supraglottic Airway Versus Monitored Anesthesia Care. J Cardiothorac Vasc Anesth 2020; 35:1760-1768. [PMID: 32980257 DOI: 10.1053/j.jvca.2020.09.086] [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: 07/15/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Compare general anesthesia with a supraglottic airway versus monitored anesthesia care for transfemoral transcatheter aortic valve replacement (TF-TAVR) in patients with aortic stenosis. The authors hypothesized that the supraglottic airway group would have similar operating room and procedure times, postanesthesia care unit (PACU) and hospital stays, and similar rates of intraprocedural and postprocedural complications compared with the monitored anesthesia care group. STUDY DESIGN Retrospective chart review with 1:1 propensity score matching of supraglottic airway to monitored anesthesia care patients. SETTING Tertiary care academic medical center. PARTICIPANTS TF-TAVR patients between 2017 and 2019. INTERVENTIONS Supraglottic airway or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS One hundred forty-eight supraglottic airway patients were matched with 148 monitored anesthesia care patients. Monitored anesthesia care patients had slightly shorter operating room (p < 0.001) and procedure times (p = 0.015). No difference was observed in hospital length of stay (p = 0.34). Fewer patients in the supraglottic airway group required a PACU stay >2 hours (p < 0.001). Use of intraprocedural vasopressors (p < 0.001) and fentanyl dosage (p < 0.001) was higher in the supraglottic airway group. No differences were observed in postoperative complications or procedural success rates. CONCLUSIONS In this, the first study to compare these 2 modalities, supraglottic airway use was demonstrated to be a safe, feasible alternative to monitored anesthesia care during TF-TAVR and did not increase organ-specific morbidity, 30-day mortality, hospital length of stay, or PACU length of stay. Even though supraglottic airway was associated with slight increases in procedure and operating room times, these were not clinically significant.
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Affiliation(s)
- Sridhar R Musuku
- Department of Anesthesiology and Perioperative Medicine, Albany Medical Center, Albany, NY.
| | | | | | - Divya Cherukupalli
- Department of Anesthesiology and Perioperative Medicine, Albany Medical Center, Albany, NY
| | | | - Alexander D Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, MA; Tufts University School of Medicine, Boston, MA
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13
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Kronfli AP, Lehman E, Yamane K, Roberts SM, Cios TJ. Dexmedetomidine Is an Equal Cost Alternative to Propofol in Transcatheter Aortic Valve Replacement, With Equivalent In-Hospital and 30-Day Outcomes. J Cardiothorac Vasc Anesth 2020; 35:439-445. [PMID: 33004269 DOI: 10.1053/j.jvca.2020.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Transcatheter aortic valve replacement (TAVR) with monitored anesthesia care (MAC) is well-tolerated and is growing in popularity. Differences in outcomes based on anesthetic agent choice with MAC has received less attention. The authors sought to determine whether differences in outcomes and cost exist based on whether patients receive dexmedetomidine or propofol when undergoing TAVR with MAC. DESIGN Retrospective cohort study. SETTING The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. PARTICIPANTS The study comprised 161 patients who underwent TAVR with MAC between May 2014 and March 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A propofol-only (n = 58) group and dexmedetomidine-only (n = 103) group were identified. No differences in in-hospital mortality or complication rate were identified when evaluating for stroke, transfusion, new arrhythmia, cardiac arrest, or bleeding and vascular complications (p > 0.05, all). Thirty-day outcomes were also equivalent, with no differences in mortality, stroke, vascular complication, new arrhythmia, or myocardial infarction (p > 0.05, all). The average amount of epinephrine, norepinephrine, or phenylephrine used intraoperatively was not significantly different. Overall median hospitalization costs were equivalent ($57,554.31 with dexmedetomidine v $58,538.08 with propofol, p = 0.97). CONCLUSIONS There were no significant differences in in-hospital outcomes, 30-day outcomes, or total cost of the patient's hospitalization, based on the use of dexmedetomidine versus propofol in patients undergoing TAVR.
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Affiliation(s)
- Anthony P Kronfli
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.
| | - Erik Lehman
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Kentaro Yamane
- Department of Surgery, Penn State Heart and Vascular Institute, The Pennsylvania State University College of Medicine, Hershey, PA
| | - S Michael Roberts
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Theodore J Cios
- Department of Anesthesiology, The Pennsylvania State University, College of Medicine, Hershey, PA
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14
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Abstract
New developments in transcatheter valve technologies including aortic valve replacement and mitral valve and tricuspid valve interventions are described. Recent studies evaluating the success rate, patient outcomes, and anesthesiologic management of the procedures are discussed.
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Affiliation(s)
- Michael A Ackermann
- Department of Anesthesiology and Intensive Care Medicine, Heart Centre Leipzig, Struempellstr 39, Leipzig 04289, Germany
| | - Jörg K Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Centre Leipzig, Struempellstr 39, Leipzig 04289, Germany.
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15
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Cook SA, Navas-Blanco JR, Acho C, Han X, Wyman J, Szymanski TJ. Comparison of Patient Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Using Pre-Sedation Radial Versus Post-Sedation Femoral Arterial Sites for Blood Pressure Monitoring. J Cardiothorac Vasc Anesth 2019; 33:3303-3308. [DOI: 10.1053/j.jvca.2019.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/11/2022]
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16
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Marino M, Lilie CJ, Culp WC, Schepel SR, Tippett JC. The Evolution of Echocardiographic Type and Anesthetic Technique for Transcatheter Aortic Valve Replacement at a High-Volume Transcatheter Aortic Valve Replacement Center. J Cardiothorac Vasc Anesth 2019; 33:29-35. [DOI: 10.1053/j.jvca.2018.06.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/11/2022]
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17
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Sato K, Jones PM. Sedation versus general anesthesia for transcatheter aortic valve replacement. J Thorac Dis 2018; 10:S3588-S3594. [PMID: 30505539 DOI: 10.21037/jtd.2018.08.89] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is currently significant controversy regarding the best anesthesia management for patients undergoing transcatheter aortic valve replacement (TAVR). Some institutions primarily use general anesthesia (GA) but many institutions primarily use moderate sedation. Much of the controversy is due to the limited evidence base available to inform this decision and the strong feelings and pre-conceived notions about the optimal anesthesia technique which exist amongst anesthesiologists, cardiologists, and cardiac surgeons. In this article and in the context of TAVR, we will define the salient differences between GA and sedation, review the results and limitations of the currently available data, and discuss the priority questions for future research.
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Affiliation(s)
- Keita Sato
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, ON, Canada.,Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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18
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Berthoud V, Ellouze O, Bièvre T, Konstantinou M, Jazayeri S, Bouchot O, Girard C, Bouhemad B. Serratus Anterior Plane Block for Apical TAVR in an Awake Patient. J Cardiothorac Vasc Anesth 2018; 32:2275-2277. [DOI: 10.1053/j.jvca.2017.12.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Indexed: 11/11/2022]
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19
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Transcatheter Valve Procedures and the Anesthesiologist. Int Anesthesiol Clin 2018; 56:74-97. [PMID: 30204609 DOI: 10.1097/aia.0000000000000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Ates I, Cilingiroglu M. Percutaneous access versus surgical cut down for TAVR: Where do we go from here? Catheter Cardiovasc Interv 2018; 91:1363-1364. [DOI: 10.1002/ccd.27653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 04/15/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Mehmet Cilingiroglu
- Arkansas Heart Hospital; Little Rock Arkansas
- Koc University School of Medicine; Istanbul Turkey
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21
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Goeddel LA, Serini J, Steyn JW, Evans AS, Dwarakanath S, Ramakrishna H, Augoustides J, Brady MB. Transcatheter Aortic Valve Replacements: Current Trends and Future Directions. Semin Cardiothorac Vasc Anesth 2018; 23:282-292. [PMID: 29871563 DOI: 10.1177/1089253218779389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since the 1960s when the first aortic surgical aortic valve replacement (SAVR) was performed, continuous growth in the field of valvular technology has occurred. Although SAVR remains a lifesaving procedure, minimally invasive transcatheter aortic valve replacement has revolutionized and expanded aortic valve replacement to patients who were not previously SAVR candidates, increasing their quality of life and survival. Since its introduction in the United States in 2011, the technology and practice have rapidly expanded. Hybrid techniques have been developed that combine surgical access to the vasculature with valvular deployment over transcatheter systems. This literature review aims to describe the differences between the current available valve technologies, review approaches to surgical technique, discuss anesthetic considerations, and look forward to future directions, trends, and challenges.
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Affiliation(s)
- Lee A Goeddel
- 1 Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | - Adam S Evans
- 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Sherifi I, Omar AMS, Varghese M, Weiner M, Anyanwu A, Kovacic JC, Sharma S, Kini A, Sengupta PP. Comparison of transesophageal and transthoracic echocardiography under moderate sedation for guiding transcatheter aortic valve replacement. Echo Res Pract 2018; 5:79-87. [PMID: 29743180 PMCID: PMC5987181 DOI: 10.1530/erp-17-0080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 05/09/2018] [Indexed: 11/10/2022] Open
Abstract
The optimal periprocedural imaging strategy during transcathether aortic valve replacement (TAVR) performed under moderate sedation is debated. Transthoracic echocardiography (TTE) provides suboptimal views due to poorer resolution and patient positioning, whereas use of transesophageal echocardiography (TEE) under moderate sedation is not widely utilized. The aim of our study was to compare the value of TTE in comparison with TEE guidance under moderate sedation during TAVR. The study population included 144 consecutive patients (mean age 83 ± 11 years, 78 (54%) females) who had TAVR under moderate sedation using either a TTE (n = 96) or TEE (n = 48). We compared procedural outcomes using propensity score matching. There were no significant inter-group differences in age, sex, ejection fraction, aortic valve area, pressure gradients, creatinine or type of valve used. The procedural time was significantly shorter in the TEE group (P < 0.001) and associated with a lower need for periprocedural aortograms (7.7 ± 1.9 vs 8.2 ± 1.9, P = 0.022) and a lower occurrence of acute kidney injury (1 vs 11, P = 0.047). The 1:1 propensity score matching also showed a lower procedural time (P = 0.032), number of aortograms (P = 0.014) and a trend toward lower acute kidney injury in the TEE group (P = 0.077). TAVR guidance using TEE is associated with a lower fluoroscopic time, a lower need for additional aortograms and trend in lower occurrence of post-TAVR acute kidney injury.
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Affiliation(s)
- Ines Sherifi
- Division of Cardiology, Weill Cornell Medical Center, New York, New York, USA.,Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alaa Mabrouk Salem Omar
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Internal Medicine, Bronx Lebanon Hospital Center, New York, New York, USA.,Department of Internal Medicine, Medical Division, National Research Center, Cairo, Egypt
| | - Mithun Varghese
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Menachem Weiner
- Division of Anesthesia, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ani Anyanwu
- Division of Cardiothoracic Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason C Kovacic
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samin Sharma
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Annapoorna Kini
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Partho P Sengupta
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA .,WVU Heart & Vascular Institute, University of West Virginia, Morgantown, West Virginia, USA
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23
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Villablanca PA, Mohananey D, Ramakrishna H. Comparison of local versus general anesthesia in patients undergoing transcatheter aortic valve replacement: An updated meta-analysis. Catheter Cardiovasc Interv 2018; 92:1018-1019. [DOI: 10.1002/ccd.27639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 03/27/2018] [Indexed: 11/07/2022]
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24
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Lester L, Brady MB, Brown CH. Sedation Versus General Anesthesia for TAVR: Where Do We Go From Here? J Cardiothorac Vasc Anesth 2017; 31:2055-2057. [DOI: 10.1053/j.jvca.2017.05.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Indexed: 11/11/2022]
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