Transfemoral aortic valve implantation under sedation and monitored anaesthetic care - a feasibility study

Comparison of Safety and Effectiveness of Local or General Anesthesia after Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

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.

Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement

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.

Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications

Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Cancer in Patients Undergoing Transcatheter Aortic Valve Replacement: A Single-Center Study

Background

The use of transcatheter aortic valve replacement (TAVR) in cancer survivors and patients with active cancer (AC) in cancer survivors and patients with active cancer (AC) is expanding, suggesting a need to adjust the indications and risk assessment pre-TAVR.

Objectives

The purpose of this study was to determine the impact of cancer on peri-procedural complications and survival in a long-term, single-center cohort of patients treated with TAVR.

Methods

Patients treated with TAVR between January 2006 and December 2018 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. The primary endpoints were peri-procedural complications and 30-day survival. A secondary endpoint was 10-year survival.

Results

A total of 1,088 patients (age 81 ± 5 years, 46.6% men) treated with transfemoral TAVR were selected: 839 controls, 196 SC, and 53 AC. Predominant malignancies were breast, gastrointestinal, and prostate cancer. No differences were observed between patients with cancer and controls regarding peri-procedural complications. Patients with AC had similar 30-day survival compared with controls and SC (94.3% vs. 93.3% vs. 96.9%, p = 0.161), but as expected, reduced 10-year survival. AC was associated with a 1.47 (95% CI 1.16 to 1.87) fold increased risk of all-cause 10-year mortality in multivariable adjusted models.

Conclusions

TAVR should be performed in patients with cancer when indicated, considering that patients with cancer have similar periprocedural complications and short-term survival compared with control patients. However, patients with AC have worse 10-year survival. Future studies are needed to define cancer-specific determinants of worse long-term survival.

Clinical experience with trans-catheter aortic valve implantation at a tertiary hospital in the Republic of Ireland

INTRODUCTION

There is a paucity of published data on the clinical experience with trans-catheter aortic valve implantation (TAVI) in the Republic of Ireland. We sought to examine the clinical outcomes of patients with medium-term follow-up treated with TAVI at our institution.

METHODS

A prospective TAVI registry was used to assess the baseline demographics, procedural variables and clinical outcomes of patients treated with TAVI between the inception of the programme in 2008 and November 2017.

RESULTS

A total of 354 patients (mean age 80.9 ± 8.1 years, 58% male, mean STS score 6.1 ± 4.3%) were treated during the study period. Major in-hospital outcomes included in-lab death (n = 2, 0.6%), stroke (n = 8, 2.2%), device embolisation (n = 4, 1.2%), permanent pacemaker implantation (n = 22, 6.2%) and major vascular complication (n = 2, 0.6%). The median length of hospital stay was 4 days (IQR 2-8 days). The Kaplan-Meier estimate of freedom from death at 30 days and 1 year for the entire cohort was 97 ± 1% and 85.4 ± 2.3%, respectively. Trans-femoral access was associated with a significantly lower rate of death and/or stroke at 1 year compared to trans-apical access (84.9 ± 2.4% versus 60 ± 8.9%, p = 0.0005). There was no significant difference in freedom from death and/or stroke at 1 year between balloon-expandable and self-expanding valves (81.6 ± 2.6% versus 84.4 ± 7.4%, p = 0.63).

CONCLUSION

This study documents low complication rates and favourable rates of survival following TAVI in a consecutive series of patients undergoing TAVI at a tertiary referral centre in the Republic of Ireland. These data support the application of this therapy in the Irish context.

A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience

OBJECTIVES

The current 2017 ESC/EACTS guidelines recommend transcatheter aortic valve implantations (TAVIs) as the therapy of choice for inoperable patients with severe symptomatic aortic stenosis. Most of the TAVIs worldwide are performed under general anaesthesia (GA). Although conscious sedation (CS) concepts are increasingly applied in Europe, it is still a matter of debate which concept is associated with highest amount of safety for this high-risk patient population. The aim of this single center, before-and-after study was to investigate feasibility and safety of CS compared with GA with respect to peri-procedural complications and 30-day mortality in patients scheduled for transfemoral TAVI (TF-TAVI).

METHODS

From March 2012 until September 2014, patients scheduled for the TF-TAVI procedure were included in a prospective, observational manner. From the 200 patients finally included, 107 procedures were performed under GA, using either an endotracheal tube or a laryngeal mask, and balanced anaesthesia. CS was performed in 93 patients using low-dose propofol and remifentanil.

RESULTS

Conversion to GA was needed 4 times due to procedural-related complications (4.3%), in one patient due to ongoing agitation (1.1%). The CS-group showed significantly shorter key time courses: anaesthesia time (105 [95-120] minutes vs 115 [105-140] minutes, P-value = 0.009, Mann-Whitney-U-test) and length of stay in the intensive care unit (1.6 [1.0-1.5] d vs 2.1 [1.0-2.0] d, P-value = 0.002, Mann-Whitney-U-test). The lowest mean arterial pressure was significantly higher in the CS-group compared with the GA-group (74.3 mmHg vs 55.2 mmHg, P-value <0.0001, t-test). CS was associated with less requirements of norepinephrine (0.1 μg/kg vs 2.3 μg/kg, P-value <0.0001, Mann-Whitney-U-test).

CONCLUSIONS

Our single-center data demonstrate that CS is a feasible and safe alternative, especially with respect to a higher degree of intra-procedural haemodynamic stability, and a reduced length of stay in the intensive care unit.

Sedation versus general anesthesia for transcatheter aortic valve replacement

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.

Catheterization Laboratory: Structural Heart Disease, Devices, and Transcatheter Aortic Valve Replacement

The cardiac catheterization laboratory is advancing medicine by performing procedures on patients who would usually require sternotomy and cardiopulmonary bypass. These procedures are done percutaneously, allowing them to be performed on patients considered inoperable. Patients have compromised cardiovascular function or advanced age. An anesthesiologist is essential for these procedures in case of hemodynamic compromise. Interventionalists are becoming more familiar with transcatheter aortic valve replacement and the device has become smaller, both contributing to less complications. Left atrial occlusion and the endovascular edge-to-edge mitral valve repair devices were approved. Although these devices require general anesthesia, an invasive surgery and cardiopulmonary bypass machine are not necessary for deployment.

Open Surgical Access for Transfemoral TAVR Should Not Be a Contraindication for Conscious Sedation

OBJECTIVES

The use of monitored anesthesia care (MAC) for transcatheter aortic valve replacement (TAVR) is gaining favor in the United States, although general anesthesia (GA) continues to be common for these procedures. Open surgical cutdown for transfemoral TAVR has been a relative contraindication for TAVR with MAC at most centers. The objective of this study was to review the authors' results of transfemoral TAVR performed in patients with open surgical cutdown with the use of MAC.

DESIGN

Retrospective study design from a prospectively recorded database.

SETTING

Tertiary academic (teaching) hospital.

PARTICIPANTS

Two hundred eighty-two patients undergoing transfemoral TAVR with open surgical cutdown under MAC from 2015 to 2017.

INTERVENTIONS

Transfemoral TAVR under MAC with surgical cutdown for femoral vascular access.

MEASUREMENTS AND MAIN RESULTS

The study cohort consisted of 282 patients with severe aortic stenosis (mean area 0.65 [± 0.16] cm², mean gradient of 48.9 [±13.3] mmHg, and mean age of 82.7 [± 7.31] years). Eleven (3.9%) patients required conversion to GA. First postoperative pain score (0-10) was 2.9 and highest postoperative pain score was 4.6. Major and minor vascular complications occurred in 2 (0.7%) and 6 (2.1%) patients, respectively. Twenty-nine (10.3%) patients were readmitted within 30 days, and 6 (2.1%) patients had in-hospital mortality.

CONCLUSIONS

Open surgical cutdown for transfemoral TAVR can be performed safely using MAC and ilioinguinal block with low rates of conversion to general anesthesia and acceptable postoperative outcomes and pain scores.

Comparison of general anaesthesia and non-general anaesthesia approach in transfemoral transcatheter aortic valve implantation

Objective

Performing transfemoral transcatheter aortic valve implantation (TAVI) without general anaesthesia (GA) has been increasingly adopted. We sought to study the impact of GA and non-GA approaches on procedural outcome and 30-day and 1-year mortality in transfemoral TAVI.

Methods

The UK TAVI registry holds information for every TAVI procedure in the UK. We analysed the data for patients implanted during 2013–2014 using either an Edwards Sapien or a Medtronic CoreValve prosthesis. Propensity score-matching analysis was performed to adjust for confounding factors.

Results

2243 patients were studied (aged 81.4±7.5 years, 1195 males). 1816 (81%) underwent TAVI with GA and 427 (19%) without GA. Transoesophageal echocardiography (TOE) was used in 92.3% of GA and 12.4% of non-GA cases (p<0.001). There was no significant difference in the rate of successful valve deployment (GA 97.2% vs non-GA 95.7%, p=0.104) and in the incidence of more than mild aortic regurgitation (AR) at the end of the procedure (GA 5.6% vs non-GA 7.0%, p=0.295). However, procedure time was longer (131±60 vs 121±60mins, p=0.002) and length of stay was greater (8.0±13.5 vs 5.7±5.5 days, p<0.001) for GA cases. 30-day and 1-year mortality rates did not differ between the GA and non-GA cases. After propensity matching, these results remained unchanged. A second propensity analysis (adjusted for mode of anaesthesia) did not show an association between use of TOE and rate of successful valve deployment or frequency of significant AR. Neither was TOE associated with a longer procedural time or greater length of stay.

Conclusion

Procedure outcome, and 30-day and 1-year mortality are not influenced by mode of anaesthesia. However, GA is associated with longer procedure duration and greater length of stay.

Transfemoral transcatheter aortic valve implantation in patients with end-stage renal disease and kidney transplant recipients

Transcatheter aortic valve implantation (TAVI) has evolved to a treatment of choice in high-risk patients and is therefore ideal for patients with advanced chronic kidney disease, as patients with end-stage renal disease and kidney transplant recipients. Especially, outcome of this special patient group is very important. 22 patients with chronic kidney disease stage 5 undergoing intermittent hemodialysis treatment (CKD 5D) and 8 kidney transplant recipients (KT) with severe aortic valve stenosis underwent transfemoral TAVI. TAVI was successfully performed in all patients. Postinterventional acute kidney injury (AKI) occurred in four kidney transplant recipients (KDIGO grade 1: n = 3, grade 3: n = 1) but creatinine/eGFR returned to baseline values in all patients. Short-term (30-day) mortality was 3% (1 patient in CKD 5D group). KT had a higher 2-year mortality than CKD5D patients (31% vs. 53%; p = 0.309), and cause of death was non-cardiac because of sepsis in all cases. The amount of contrast medium during TAVI was not associated with the development of acute kidney injury. TAVI is feasible in patients with CKD5D and in KT. Postinterventional AKI in these patients is often mild and does not impact renal function at day 30, while infection/ sepsis is the leading cause of mid-term mortality.

Is local anaesthesia a favourable approach for transcatheter aortic valve implantation? A systematic review and meta-analysis comparing local and general anaesthesia

OBJECTIVES

We conducted a systematic review and meta-analysis to identify the potential favourable effects of local anaesthesia plus sedation (LAS) compared with general anaesthesia (GA) in transcatheter aortic valve implantation (TAVI).

METHODS

Electronic databases (PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials) and the reference lists of eligible publications were screened for randomised controlled trials (RCTs) and observational studies published between 1 January 2006 and 26 June 2016 that compare LAS to GA in an adult study population undergoing TAVI. We conducted study quality assessments using the Cochrane risk of bias tool and structured the review according to PRISMA. A meta-analysis calculating the pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) under the assumption of a random-effects model was performed. Statistical heterogeneity was evaluated using the I² statistic and Cochran's Q-test.

RESULTS

After database screening, one RCT and 19 observational studies were included in the review. We found no differences between LAS and GA in terms of 30-day mortality, in-hospital mortality and other endpoints that addressed safety and complication rates. LAS was associated with a shorter ICU and hospital stay and with lower rates of catecholamine administration and red blood cell transfusion. New pacemaker implantations occurred more frequently under LAS. The overall conversion rate from LAS to GA was 6.2%.

CONCLUSION

For TAVI, both LAS and GA are feasible and safe. LAS may have some benefits such as increased haemodynamic stability and shorter hospital and ICU stays, but it does not impact 30-day mortality. Since there is a paucity of randomised trial data and the findings are mainly based on observational study data, this review should be considered as a hypothesis-generating article for subsequent RCTs that are required to confirm the potential favourable effects we detected for LAS.

REGISTRATION NUMBER

CRD42016048398 (PROSPERO).

Bispectral index-guided sedation in transfemoral transcatheter aortic valve implantation: a retrospective control study

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for elderly patients with severe aortic valve stenosis who were refused surgical aortic valve replacement because of the high perioperative risk. Traditionally, this procedure has been done under general anesthesia, but more recently local anesthesia and sedation have become popular. This research assessed the effectiveness of transfemoral TAVI under bispectral index (BIS)-guided sedation.

METHODS

In this single-center retrospective control analysis, clinical data, including demographic characteristics, echocardiography, periprocedural data, and main complications, were collected and assessed in 113 patients undergoing TAVI through the femoral artery under general anesthesia (GA group, n=36) and under BIS-guided sedation (SED group, n=77).

RESULTS

The demographic characteristics and echocardiographic parameters between the two groups were similar (P>0.05). Two (2.6%) of patients were moved from BIS-guided sedation to general anesthesia for surgical reasons. Procedures were significantly shorter in the SED group than in the GA group ((127.10±44.43) min vs. (165.90±71.62) min, P=0.004). Patients in the SED group lost less blood and received significantly fewer red blood cells and catecholamines than those in the GA group (5.19% vs. 22.22%, P=0.017 and 67.53% vs. 97.22%, P<0.001). The length of hospital stay was significantly shorter and there were fewer pulmonary complications in the SED group than in the GA group. Thirty-day mortality was similar between the two groups.

CONCLUSIONS

BIS-guided sedation is a feasible and safe approach for transfemoral TAVI. The anesthesiologist should choose the best anesthetic method according to the team's experience.

Anaesthesia Techniques in Transfemoral Transcatheter Aortic Valve Implantation: A Brief Review

Transcatheter aortic valve implantation (TAVI) is an alternative, less invasive method to use for aortic valve replacement in high-risk patients. This operation allows a faster recovery, reduced tissue damage, less postoperative pain, increased patient satisfaction, reduced intensive care unit (ICU) stay, avoidance of ICU admission, reduced hospital stay, and reduced wound infection rates. A retrograde transfemoral approach is commonly used in TAVI procedures. The role of the anaesthetist is important for a successful outcome. General or local anaesthesia, with or without conscious sedation, may be used according to patient characteristics, the presence of comorbidities, and the preference of the surgical team. There is no general consensus regarding which patients should receive general or local anaesthesia during TAVI operations; therefore, the surgical team’s preference has an important influence on the selection of anaesthetic technique. There are many studies in the literature relating to the anaesthesia technique used in TAVI operations. No matter which technique is used, anaesthetists should provide and maintain optimal haemodynamic stability during the procedure. On the other hand, anaesthetists should be cautious of possible procedural complications, such as hypotension, ventricular fibrillation, permanent pacemaker requirement, and emergency aortic valve replacement requirement.

Augmented Reality System for Ultrasound Guidance of Transcatheter Aortic Valve Implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) relies on fluoroscopy and nephrotoxic contrast medium for valve deployment. We propose an alternative guidance system using augmented reality (AR) and transesophageal echocardiography (TEE) to guide TAVI deployment. The goals of this study were to determine how consistently the aortic valve annulus is defined from TEE using different aortic valve landmarks and to compare AR guidance with fluoroscopic guidance of TAVI deployment in an aortic root model.

METHODS

Magnetic tracking sensors were integrated into the TAVI catheter and TEE probe, allowing these tools to be displayed in an AR environment. Variability in identifying aortic valve commissures and cuspal nadirs was assessed using TEE aortic root images. To compare AR guidance of TAVI deployment with fluoroscopic guidance, a TAVI stent was deployed 10 times in the aortic root model using each of the two guidance systems.

RESULTS

Commissures and nadirs were both investigated as features for defining the valve annulus in the AR guidance system. The commissures were identified more consistently than the nadirs, with intraobserver variability of 2.2 and 3.8 mm, respectively, and interobserver variability of 3.3 and 4.7 mm, respectively. The precision of TAVI deployment using fluoroscopic guidance was 3.4 mm, whereas the precision of AR guidance was 2.9 mm, and its overall accuracy was 3.4 mm. This indicates that both have similar performance.

CONCLUSIONS

Aortic valve commissures can be identified more reliably than cuspal nadirs from TEE. The AR guidance system achieved similar deployment accuracy to that of fluoroscopy while eliminating the use and consequences of nephrotoxic contrast and radiation.

Risk Assessment of Patients Undergoing Transfemoral Aortic Valve Implantation upon Admission for Post-Interventional Intensive Care and Surveillance: Implications on Short- and Midterm Outcomes

Background

Several studies have found that standard risk scores inaccurately reflect risk in TAVI cohorts. The assessment of mortality risk upon post-interventional ICU admission is important to optimizing clinical management. This study sought to determine outcomes and factors affecting mortality in patients admitted to the intensive care unit (ICU) after transcatheter aortic valve implantation (TAVI), and to analyze and compare the predictive values of SAPS II and EuroSCORE.

Methods and Findings

214 consecutive patients treated with transfemoral TAVI (2006–2012) admitted to the ICU in an academic tertiary-care university hospital, were included in this retrospective data analysis. The overall 30-day mortality rate was 7%. Non-survivors at 30-days and survivors showed differences in the rates of catecholamine therapy upon ICU admission (93 vs. 29%; p<0.001), stroke (20 vs. 1%;p<0.001), sepsis (27 vs. 2%;p<0.001), kidney injury (83 vs. 56%; log-rank p<0.001), catecholamine therapy (88 vs. 61%;log-rank p<0.001) and vascular complications (60 vs. 17%; p<0.001). Mean SAPS II score and predicted mortality were higher in non-survivors (38.1±7.0 vs. 29.9±6.2;p<0.001 and 23.1±11.7 vs. 10.5±8.2;p<0.001, retrospectively), whereas the logistic EuroSCORE could not discriminate between the groups (p = 0.555). Among the biochemical parameters, the maximum values of creatinine, procalcitonin, and troponin I during the first 48 h after ICU admission were significantly higher in non-survivors. Multivariate analysis of baseline characteristics and complications associated with two-year mortality showed no significant results.

Conclusions

The SAPS II is a good tool for estimating ICU mortality immediately after performing the TAVI procedure and provides valuable information for other known predictors of mortality.

Cardio-anesthesiology considerations for the trans-catheter aortic valve implantation (TAVI) procedure

Transcatheter aortic valve implantation (TAVI) has become the mainstay for high-risk or inoperable patients with symptomatic aortic valve stenosis, and research regarding the use of transcatheter valves in intermediate or low-risk patients is currently ongoing. The aim of this article is to provide comprehensive insight into the anesthetic management of patients undergoing TAVI and to highlight possible gaps in the current knowledge. One important procedural characteristic that is imperative to consider is the type of anesthesia being used and its possible complications. Increasingly, experienced centers have changed from general anesthesia with endotracheal intubation to local anesthesia with sedation, especially when the transfemoral access route is used for TAVI. There is still debate regarding what type of anesthesia should be used in the procedure, and the lack of randomized data makes it even more challenging for the operators.

Monitored anesthesia care in and outside the operating room

Monitored anesthesia care (MAC) is an anesthesia technique combining local anesthesia with parenteral drugs for sedation and analgesia. The use of MAC is increasing for a variety of diagnostic and therapeutic procedures in and outside of the operating room due to the rapid postoperative recovery with the use of relatively small amounts of sedatives and analgesics compared to general anesthesia. The purposes of MAC are providing patients with safe sedation, comfort, pain control and satisfaction. Preoperative evaluation for patients with MAC is similar to those of general or regional anesthesia in that patients should be comprehensively assessed. Additionally, patient cooperation with comprehension of the procedure is an essential component during MAC. In addition to local anesthesia by operators or anesthesiologists, systemic sedatives and analgesics are administered to provide patients with comfort during procedures performed with MAC. The discretion and judgment of an experienced anesthesiologist are required for the safety and efficacy profiles because the airway of the patients is not secured. The infusion of sedatives and analgesics should be individualized during MAC. Many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction.

Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement

BACKGROUND

There is no clear consensus in regard to the optimal anesthesia utilization during transcatheter aortic valve replacement (TAVR). The aim was to compare outcomes of transfemoral (TF) TAVR under monitored anesthesia care (MAC) vs. general anesthesia (GA) and evaluate the rates and causes of intra-procedural MAC failure.

METHODS

All consecutive patients who underwent TF TAVR from April 2007 through March 2015 were retrospectively analyzed and dichotomized into two groups: TAVR under MAC vs. GA. The main endpoints of the study included 30-day and 1-year mortality, the rates and reasons for failure of MAC, in-hospital clinical safety outcomes, and post-procedural hospital and intensive care unit length-of-stays.

RESULTS

A total of 533 patients (51% male, mean-age 83years) underwent TF TAVR under MAC (n=467) or GA (n=66). Fifty-six patients (12%) in the MAC group required conversion to GA. The MAC group had significantly shorter post-procedural hospital (6.0 vs. 7.9, p=0.023) and numerically shorter ICU (2.4 vs. 2.8, p=0.355) mean length-of-stays in days. The clinical safety outcomes were similar in both groups. Kaplan-Meier unadjusted cumulative in-hospital and 30-day mortality rates were higher in the GA group but similar in both groups at 1-year.

CONCLUSIONS

TF TAVR under MAC is feasible and safe, results in shorter hospital stays, can be performed in the majority of cases, and should be utilized as the default strategy. Trans-esophageal echocardiography utilization during TAVR with MAC is safe and feasible. The most common cause for conversion of MAC to GA is cardiac instability and hypotension. The complete heart team should be available at all times in case the need arises for a rapid conversion to GA.

A Practical Approach to Managing Transcatheter Aortic Valve Replacement With Sedation

Transcatheter aortic valve replacement is increasingly performed as a minimally invasive treatment option for aortic valve disease. The typical anesthetic management for this procedure was traditionally similar to surgical aortic valve replacement and involved general anesthesia and transesophageal echocardiography. In this review, we discuss the technological advances in transcatheter valve systems that have improved outcomes and allow for use of sedation instead of general anesthesia. We describe an anesthetic protocol that avoids general anesthesia and utilizes transthoracic echocardiography for procedural guidance.

Sedation or general anesthesia for transcatheter aortic valve implantation (TAVI)

Transfemoral transcatheter aortic valve implantation (TAVI) is nowadays a routine therapy for elderly patients with severe aortic stenosis (AS) and high perioperative risk. With growing experience, further development of the devices, and the expansion to "intermediate-risk" patients, there is increasing interest in performing this procedure under conscious sedation (TAVI-S) rather than the previously favoured approach of general anesthesia (TAVI-GA). The proposed benefits of TAVI-S include; reduced procedure time, shorter intensive care unit (ICU) length of stay, reduced need for intraprocedural vasopressor support, and the potential to perform the procedure without the direct presence of an anesthetist for cost-saving reasons. To date, no randomized trial data exists. We reviewed 13 non-randomized studies/registries reporting data from 6,718 patients undergoing TAVI (3,227 performed under sedation). Patient selection, study methods, and endpoints have differed considerably between published studies. Reported rates of in-hospital and longer-term mortality are similar for both groups. Up to 17% of patients undergoing TAVI-S require conversion to general anesthesia during the procedure, primarily due to vascular complications, and urgent intubation is frequently associated with hemodynamic instability. Procedure related factors, including hypotension, may compound preexisting age-specific renal impairment and enhance the risk of acute kidney injury. Hypotonia of the hypopharyngeal muscles in elderly patients, intraprocedural hypercarbia, and certain anesthetic drugs, may increase the aspiration risk in sedated patients. General anesthesia and conscious sedation have both been used successfully to treat patients with severe AS undergoing TAVI with similar reported short and long-term mortality outcomes. The authors believe that the significant incidence of complications and unplanned conversion to general anesthesia during TAVI-S mandates the start-to-finish presence of an experienced cardiac anesthetist in order to optimize patient outcomes. Good quality randomized data is needed to determine the optimal anesthetic regimen for patients undergoing TAVI.

Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome†

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a treatment strategy for patients with severe aortic stenosis. Although general anaesthesia (TAVI-GA) and sedation (TAVI-S) have previously been described for TAVI, the difference in safety and efficacy of both methods has not been studied in a randomized trial.

METHODS

The INSERT trial was a single centre, controlled parallel-group trial with balanced randomization. Sixty-six patients (68-94 yr) with acquired aortic stenosis undergoing transfemoral CoreValve™ were assigned to TAVI-GA or TAVI-S. Comparable operative risk was determined from risk-scores (EUROscore, STS-Score). Monitoring and anaesthetic drugs were standardized. Near-Infrared-Spectroscopy was used to monitor cerebral-oxymetry blinded. Primary outcome was the perioperative cumulative cerebral desaturation. As secondary outcomes, changes in neurocognitive function and respiratory and haemodynamic adverse events were evaluated.

RESULTS

Of 66 included patients, 62 (TAVI-GA: n=31, TAVI-S: n=31) were finally analysed. Baseline characteristics were comparable. In 24 patients (39%) cerebral desaturation was observed. Cumulative cerebral desaturation was comparable (TAVI-GA:(median [IQR]) (0[0/1308] s%) vs. TAVI-S:(0[0/276] s%); P=0.505) between the groups. Neurocognitive function did not change within and between groups. Adverse events were more frequently observed in TAVI-S patients (P<0.001). Bradypnoea (n=16, 52%) and the need for airway manoeuvres (n=11, 36%) or bag-mask-ventilation (n=6, 19%) were the most common respiratory adverse events.

CONCLUSIONS

Cerebral desaturation occurred in both patient groups, but there was no significant difference between the two groups. Based on primary outcome, both methods were shown to be comparable. Neurocognitive outcome was similar. The higher incidence of adverse events in the sedation group suggests a potential advantage of general anaesthesia.

CLINICAL TRIAL REGISTRATION

NCT 01251328.

The Anesthetic Management of Transcatheter Aortic Valve Implantation

An increasing number of patients with a high risk for surgery because of advanced age and associated comorbidities that significantly increase the perioperative risk successfully undergo transcatheter aortic valve implantation (TAVI). TAVI is commonly performed under general or local anesthesia or local anesthesia plus mild sedation to achieve a conscious sedation. The anesthetic regimen generally depends on the patient’s clinical profile and the procedural technical characteristics, but the center’s experience and internal organization likely play an important role in anesthetic decision making. The large variation in anesthetic management among various centers and countries likely depends on the different composition of the operating team and institutional organization. Therefore, a tight interaction among the various members of the TAVI team, including the cardiac anesthetist, provides the proper anesthetic management using the chosen procedural technique.

Transcatheter Aortic Valve Implantation: First Applications and Short Term Outcomes in Our Clinic

OBJECTIVE

The objective of this study is to evaluate the first applications and short term outcomes of transcatheter aortic valve implantation (TAVI) in our clinic, which is a new technology for the patients with high risk for surgical aortic valve replacement (SAVR).

MATERIALS AND METHODS

Between January 2010 and December 2012, twenty five patients (16 males, 9 females; mean age 74.04±8.86 years) diagnosed with severe aortic stenosis, who were at high risk for surgery (EuroSCORE II: 5.58±4.20) and underwent TAVI in our clinic, were evaluated. The demographic and clinical characteristics of patients, anaesthetic management, complications during pre- and post-operative periods and the mortality rate in the first 30 days and six months were recorded.

RESULTS

Edwards SAPIEN Valve prostheses were implanted by transfemoral approach (percutaneously in 10 patients and surgically in 15 patients) in all patients. The TAVI procedure was performed under general anaesthesia. The success rate of the TAVI procedure was 100%. Three patients had limited dissection of the femoral artery; however, intervention was not needed due to good distal perfusion rate. Permanent pacemaker was implanted to four patients because of long-term atrioventricular blockage. After the procedure, all patients were transferred to the Intensive Care Unit (ICU) and all patients were extubated in the ICU. The mean mechanical ventilation duration (minutes) was 166.20±39.32, the mean critical care unit stay (day) was 5.64±2.99 and the mean hospital stay (day) was 11.92±5.54. Acute renal failure was observed in one patient and stroke was observed in two patients on the first postoperative day. The mortality rate in the first 30 days and 6 months was found to be 4% and 16%, respectively.

CONCLUSION

Transcatheter aortic valve implantation is a great option for patients with severe aortic stenosis who are at high risk for SAVR. In our institute, procedural success and short term outcomes for patients underwent TAVI were found to be similar to the other studies in the national and international literature.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.