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

The association between different anesthetic techniques and outcomes in patients undergoing transfemoral aortic valve replacement

Background

There is an increasing number of patients undergoing transfemoral aortic valve replacement (TAVR) with sedation. There is limited data assessing the efficacy and safety of the different types of sedative drugs. The objective was to compare two sedation techniques with regard to the need for vasoactive support, respiratory support, rate of conversion to general anesthesia (GA), common perioperative morbidities, intensive care unit (ICU) stay, and in-hospital mortality.

Methods

A retrospective chart review study conducted among patients who underwent TAVR at a specialized cardiac center between January 2016 and December 2019. Data collection included patient diagnosis, preoperative comorbidities, intraoperative outcomes, and postoperative outcomes.

Results

A total of 289 patients received local anesthesia; 210 received propofol infusion and 79 received a mixed propofol-ketamine infusion (Ketofol). The average age was 75.5 ± 8.9 years and 58.1% of the patients were females. Comparing propofol and ketofol groups, 31.2% and 34.2% of the patients required drug support, 7.6% and 6.3% required conversion to GA, 46.7% and 59.5% required respiratory support, respectively. These intraoperative outcomes were not significantly different between groups, P = 0.540, P = 0.707, and P = 0.105, respectively. In-hospital 30-day mortality in propofol and ketofol groups were 1.9% and 3.8%, respectively, P = 0.396. In both groups, the median post-procedure coronary care unit stay was 26 hours while post-procedure hospital stay was 3 days.

Conclusions

There were no significant differences in perioperative or postoperative outcomes in TAVR patients receiving either propofol or ketofol. Propofol infusion, either alone or with ketamine, is reliable and safe, with minimal side effects.

High-flow nasal oxygen vs. standard oxygen therapy for patients undergoing transcatheter aortic valve replacement with conscious sedation: a randomised controlled trial

BACKGROUND

Minimally invasive surgery is becoming more common and transfemoral transcatheter aortic valve replacement is offered to older patients with multiple comorbidities. Sternotomy is not required but patients must lie flat and still for up to 2-3 h. This procedure is increasingly being performed under conscious sedation with supplementary oxygen, but hypoxia and agitation are commonly observed.

METHODS

In this randomised controlled trial, we hypothesised that high-flow nasal oxygen would provide superior oxygenation as compared with our standard practice, 2 l min^-1 oxygen by dry nasal specs. This was administered using the Optiflow THRIVE Nasal High Flow delivery system (Fisher and Paykel, Auckland, New Zealand) at a flow rate of 50 l min^-1 and FiO₂ 0.3. The primary endpoint was the change in arterial partial pressure of oxygen (pO₂) during the procedure. Secondary outcomes included the incidence of oxygen desaturation, airway interventions, the number of times the patient reached for the oxygen delivery device, incidence of cerebral desaturation, peri-operative oxygen therapy duration, hospital length of stay and patient satisfaction scores.

RESULTS

A total of 72 patients were recruited. There was no difference in change in pO₂ from baseline using high-flow compared with standard oxygen therapy: median [IQR] increase from 12.10 (10.05-15.22 [7.2-29.8]) to 13.69 (10.85-18.38 [8.5-32.3]) kPa vs. decrease from 15.45 (12.17-19.33 [9.2-22.8]) to 14.20 (11.80-19.40 [9.7-35.1]) kPa, respectively. The percentage change in pO2 after 30 min was also not significantly different between the two groups (p = 0.171). There was a lower incidence of oxygen desaturation in the high-flow group (p = 0.027). Patients in the high-flow group assigned a significantly higher comfort score to their treatment (p ≤ 0.001).

CONCLUSION

This study has demonstrated that high flow, compared with standard oxygen therapy, does not improve arterial oxygenation over the course of the procedure. There are suggestions that it may improve the secondary outcomes studied.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number (ISRCTN) 13,804,861. Registered on 15 April 2019. https://doi.org/10.1186/ISRCTN13804861.

Assessing the Safety of Total Intravenous Anesthesia with Remimazolam in General Anesthesia for Transcatheter Aortic Valve Implantation of Severe Aortic Valve Stenosis: A Case Series

Background and Objectives: In patients with severe aortic stenosis (sAS), it is crucial to maintain hemodynamic stability during the induction and maintenance of general anesthesia for transcatheter aortic valve implantation (TAVI). In this study, we assessed the efficacy and safety of remimazolam in maintaining hemodynamic stability during anesthetic induction and maintenance. Cases: TAVI was performed on seven patients with sAS, and remimazolam was administered for total intravenous anesthesia (TIVA) of general anesthesia with induction (3.0 mg/kg/h) and maintenance (1.0 mg/kg/h). All patients underwent TAVI without major hemodynamic concerns and later recovered. Conclusions: Remimazolam can be safely used for induction and maintenance of general anesthesia in patients with sAS when performing TAVI.

The current practice of transcatheter aortic valve replacement in China

OBJECTIVE

The purpose of this study is to summarize the current practice and experience of transcatheter aortic valve replacement in China.

METHODS

The relevant articles were identified through computerized searches of the CNKI, WANFANG, VIP, and PubMed databases through February 1, 2022, using the search terms: "transcatheter aortic valve replacement," "transcatheter aortic valve implantation," "China."

RESULTS

The database searches identified 22 articles, 2092 patients, 57.65% were male, with a mean age of 74.2 ± 6.0 years, 71.51% of patients were classified by New York Heart Association as class Ⅲ/Ⅳ, Society of Thoracic Surgeons score 8.4 ± 4.1, mean left ventricular ejection fraction 52.8 ± 14.2%, mean transvalvular aortic pressure gradient 59.9 ± 18.9 mmHg. The overall procedural success rate was 97.85%, and 2.15% of patients were converted to sternotomy, mainly due to transcatheter aortic bioprosthesis dislocation. The most common vascular access approach was transfemoral (1071 patients, 51.20%). General anesthesia (48.90%) was the commonly used anesthesia technique. The incidence of postprocedural complications was as follows: permanent pacemaker implantation (10.47%), bleeding events (8.60%), mild paravalvular leakage (17.73%), moderate and severe paravalvular leakage (4.16%), vascular complications (3.30%), stroke (1.43%), respectively. The overall periprocedural period and postprocedural 30-day mortality was 2.72%.

CONCLUSIONS

Among patients undergoing transcatheter aortic valve replacement in China, device implantation success was achieved in 97.85% of cases. The most common vascular access approach was transfemoral. General anesthesia was the most commonly used anesthetic technique. Paravalvular leakage (458 patients, 21.89%) was the most common complication.

Continuous Noninvasive Arterial Pressure Monitoring for Transcatheter Aortic Valve Replacement

OBJECTIVES

The objective of the present study, which was conducted in patients undergoing transcatheter aortic valve replacement, was to compare continuous noninvasive arterial pressure measured with the ClearSight device (Edwards Lifesciences, Irvine, CA) with invasive radial artery pressure used as the reference method. The authors hypothesized that the ClearSight device is an accurate, precise, safe, and efficient method for arterial blood pressure measurement comparable with an invasive radial arterial line.

DESIGN

The study included the retrospective review of 20 consecutive patients scheduled for elective transcatheter aortic valve replacement with the SAPIEN 3 transcatheter heart valve (Edwards Lifesciences) at a single tertiary academic hospital, who underwent monitoring with both the ClearSight device and an invasive radial arterial pressure line. The patients underwent transcatheter aortic valve replacement from October to December 2019.

SETTING

Single tertiary academic medical center.

PARTICIPANTS

The study comprised 20 patients, with 2,243 unique blood pressure data points.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A statistically significant correlation between the invasive radial arterial pressure line and the ClearSight device was observed for systolic blood pressure (correlation coefficient 0.86; p < 0.001), diastolic blood pressure (correlation coefficient 0.56; p < 0.001), and mean arterial pressure (correlation coefficient 0.78; p < 0.001). Bland-Altman analysis was used to assess the agreement of systolic blood pressure, diastolic blood pressure, and mean arterial pressure between the two methods. Results for systolic blood pressure between the arterial line and ClearSight device were as follows: bias = 9.8 ± 10.1, percentage bias = 7.6%, and mean error = 15.8%. Results for diastolic blood pressure between the arterial line and ClearSight device were as follows: bias = -5.9 ± 7.8, percentage bias = 10.7%, and mean error = 28.4%. Results for mean arterial pressure between the arterial line and ClearSight device were as follows: bias = 0.3 ± 7.4, percentage bias = 0.4%, and mean error = 18.3%. The concordance rates of systolic blood pressure, diastolic blood pressure, and mean arterial pressure were 100%, 95.1%, and 98.8%, respectively.

CONCLUSIONS

The accuracy, agreement, and precision of the ClearSight device were convincing for mean arterial pressure, systolic blood pressure, and diastolic blood pressure for patients with severe aortic stenosis undergoing elective transcatheter aortic valve replacement.