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Chen T, Asher S, Apruzzese P, Owusu-Dapaah H, Gonzalez G, Maslow A. Hypercapnia during transcatheter aortic valve replacement under monitored anaesthesia care: a retrospective cohort study. Open Heart 2024; 11:e002801. [PMID: 39214537 PMCID: PMC11367353 DOI: 10.1136/openhrt-2024-002801] [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: 06/24/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Acute intraoperative hypercapnia and respiratory acidosis, which can occur during monitored anaesthesia care (MAC), pose significant cardiopulmonary risks for patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The goal of the present study is to assess the incidence, risk factors and impact of intraoperative hypercapnia during MAC for patients undergoing transfemoral TAVR. METHODS Data was collected retrospectively from the electronic medical record of 201 consecutive patients with available intraoperative arterial blood gas (ABG) data who underwent percutaneous transfemoral TAVR with MAC using propofol and dexmedetomidine. ABGs (pH, arterial partial pressure of carbon dioxide (PaCO2) and arterial partial pressure of oxygen) were performed at the start of each case (baseline), immediately prior to valve deployment (ValveDepl), and on arrival to the postanaesthesia care unit. Data was analysed using Fisher's exact test, unpaired Student's t-test, Wilcoxon rank sum or univariate linear regression as appropriate based on PaCO2 and pH during ValveDepl (PaCO2-ValveDepl, pH-ValveDepl) and change in PaCO2 and pH from baseline to ValveDepl (PaCO2-%increase, pH-%decrease) to determine their association with preoperative demographic data, intraoperative anaesthetic and vasoactive medications and postoperative outcomes. RESULTS PaCO2 increased by a mean of 28.4% and was higher than baseline in 91% of patients. Younger age, male sex, increased weight and increased propofol dose contributed to higher PaCO2-ValveDepl and greater PaCO2-%increase. Patients with PaCO2-ValveDepl>60 mm Hg, pH≤7.2 and greater pH-%decrease were more likely to receive vasoactive medications, but perioperative PaCO2 and pH were not associated with adverse postoperative outcomes. CONCLUSIONS Transient significant hypercapnia commonly occurs during transfemoral TAVR with deep sedation using propofol and dexmedetomidine. Although the incidence of postoperative outcomes does not appear to be affected by hypercapnia, the need for vasopressors and inotropes is increased. If deep sedation is required for TAVR, hypercapnia and the need for haemodynamic and ventilatory support should be anticipated.
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Affiliation(s)
- Tzonghuei Chen
- Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Shyamal Asher
- Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Patricia Apruzzese
- Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Harry Owusu-Dapaah
- Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Gustavo Gonzalez
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew Maslow
- Department of Anesthesiology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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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.
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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.
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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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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.
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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
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Bodmer NJ, Fielding-Singh V, Vanneman MW. Transcatheter Aortic Valve Dissemination: The More the Merrier or Too Much of a Good Thing? J Cardiothorac Vasc Anesth 2021; 36:925-928. [PMID: 34974961 DOI: 10.1053/j.jvca.2021.11.023] [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: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Natalie J Bodmer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Anaesthesia for minimally invasive cardiac procedures in the catheterization lab. Curr Opin Anaesthesiol 2021; 34:437-442. [PMID: 34184641 DOI: 10.1097/aco.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures. RECENT FINDINGS The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting. SUMMARY Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.
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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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