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

Jochen Renner, Anna Tesdorpf, Sandra Freitag-Wolf, Helga Francksen, Rainer Petzina, Georg Lutter, Norbert Frey, Derk Frank, Jochen Renner, Anna Tesdorpf, Sandra Freitag-Wolf, Helga Francksen, Rainer Petzina, Georg Lutter, Norbert Frey, Derk Frank

Abstract

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.

Keywords: TAVI; anaesthesia techniques; aortic stenosis; sedation.

Figures

Figure 1
Figure 1
Survival curves of patients scheduled for TF‐TAVI. A, 30‐day survival in TF‐TAVI performed under general anaesthesia (GA) compared with conscious sedation (CS). B, 30‐day survival in TF‐TAVI performed under GA compared with CS in dependency of the logEuroSCORE I
Figure 2
Figure 2
Severity of paravalvular leakage at post‐procedural day 7 in patients receiving general anaesthesia (GA) or conscious sedation (CS). Implanted type of valves in the GA‐group: Sapien XT, 91.5%; Sapien‐3, 6.5%; CoreValve, 2% and in the CS‐group: Sapien XT, 31.2%, Sapien‐3, 66.7%, CoreValve, 2.1%

References

    1. Lindroos M, Kupari M, Heikkila J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21:1220‐1225.
    1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez‐Sarano M. Burden of valvular heart diseases: a population‐based study. Lancet. 2006;368:1005‐1011.
    1. Rosengart TK, Feldman T, Borger MA, et al. Percutaneous and minimally invasive valve procedures: a scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2008;117(13):1750‐1767.
    1. Carabello BA. Clinical practice. Aortic Stenosis N Engl J Med. 2002;346:677‐682.
    1. Cribier A, Eltchaninoff H, Tron C, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end‐stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol. 2004;43(4):698‐703.
    1. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic‐valve replacement in intermediate‐risk patients. N Engl J Med. 2016;374(17):1609‐1620.
    1. Cerrato E, Nombela‐Franco L, Nazif TM, et al. Evaluation of current practices in transcatheter aortic valve implantation: the WRITTEN (WoRldwIde TAVI ExperieNce) survey. Int J Cardiol. 2017;228:640‐647.
    1. Covello RD, Landoni G, Zangrillo A. Anesthetic management of transcatheter aortic valve implantation. Curr Opin Anaesthesiol. 2011;24:417‐425.
    1. Hutchinson N. Sedation vs general anaesthesia for the 'high‐risk' patient‐‐what can TAVI teach us? Anaesthesia. 2011;66:965‐968.
    1. Goren O, Finkelstein A, Gluch A, Sheinberg N, Dery E, Matot I. Sedation or general anesthesia for patients undergoing transcatheter aortic valve implantation‐‐does it affect outcome? An observational single‐center study. J Clin Anesth. 2015;27:385‐390.
    1. Gilard M, Eltchaninoff H, Iung B, et al. Registry of transcatheter aortic‐valve implantation in high‐risk patients. N Engl J Med. 2012;366(18):1705‐1715.
    1. Mack MJ, Brennan JM, Brindis R, et al. Outcomes following transcatheter aortic valve replacement in the United States. JAMA. 2013;310:2069‐2077.
    1. Eggebrecht H, Mehta RH. Transcatheter aortic valve implantation (TAVI) in Germany 2008‐2014: on its way to standard therapy for aortic valve stenosis in the elderly? EuroIntervention. 2016;11:1029‐1033.
    1. Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care—a feasibility study. Anaesthesia. 2011;66:977‐982.
    1. Dehedin B, Guinot PG, Ibrahim H, et al. Anesthesia and perioperative management of patients who undergo transfemoral transcatheter aortic valve implantation: an observational study of general versus local/regional anesthesia in 125 consecutive patients. J Cardiothorac Vasc Anesth. 2011;25:1036‐1043.
    1. Alli OO, Booker JD, Lennon RJ, Greason KL, Rihal CS, Holmes DR Jr. Transcatheter aortic valve implantation: assessing the learning curve. JACC Cardiovasc Interv. 2012;5:72‐79.
    1. Lunardi M, Pesarini G, Zivelonghi C, et al. Clinical outcomes of transcatheter aortic valve implantation: from learning curve to proficiency. Open Heart. 2016;3. e000420
    1. Baumgartner H, Falk V, Bax JJ, et al. ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739‐2791.
    1. Nishimura RA, Otto CM, Bonow RO, et al. AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017. 2017;135:e1159‐e1195.
    1. Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999;16:9‐13.
    1. Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999;15:816‐822. discussion 22‐3
    1. O'Brien SM, Shahian DM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2‐‐isolated valve surgery. Ann Thorac Surg. 2009;88:S23‐S42.
    1. Shahian DM, O'Brien SM, Filardo G, et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3—valve plus coronary artery bypass grafting surgery. Ann Thorac Surg. 2009;88:S43‐S62.
    1. Leon MB, Piazza N, Nikolsky E, et al. Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the valve academic research consortium. J Am Coll Cardiol. 2011;57:253‐269.
    1. Kappetein AP, Head SJ, Genereux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium‐2 consensus document. J Am Coll Cardiol. 2012;60:1438‐1454.
    1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1‐e142.
    1. Goebel N, Ahad S, Schaeufele T, et al. Transcatheter aortic valve implantation in patients at extremely high risk of perioperative mortality. J Heart Valve Dis. 2015;24:635‐639.
    1. Yamamoto M, Meguro K, Mouillet G, et al. Effect of local anesthetic management with conscious sedation in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2013;111:94‐99.
    1. Miles LF, Joshi KR, Ogilvie EH, et al. General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before‐and‐after study. Anaesthesia. 2016;71:892‐900.
    1. Hahn RT, Little SH, Monaghan MJ, et al. Recommendations for comprehensive intraprocedural echocardiographic imaging during TAVR. JACC Cardiovasc Imaging. 2015;8:261‐287.
    1. Glance LG, Dick AW, Mukamel DB, et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011;114:283‐292.
    1. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007;116:2544‐2552.
    1. Mayr NP, Hapfelmeier A, Martin K, et al. Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcomedagger. Br J Anaesth. 2016;116:90‐99.
    1. Motloch LJ, Rottlaender D, Reda S, et al. Local versus general anesthesia for transfemoral aortic valve implantation. Clin Res Cardiol. 2012;101:45‐53.
    1. Lauck SB, Wood DA, Baumbusch J, et al. Vancouver transcatheter aortic valve replacement clinical pathway: minimalist approach, standardized care, and discharge criteria to reduce length of stay. Circ Cardiovasc Qual Outcomes. 2016;9:312‐321.
    1. Brecker SJ, Bleiziffer S, Bosmans J, et al. Impact of anesthesia type on outcomes of transcatheter aortic valve implantation (from the multicenter ADVANCE study). Am J Cardiol. 2016;117:1332‐1338.
    1. Eskandari M, Aldalati O, Dworakowski R, et al. Comparison of general anaesthesia and non‐general anaesthesia approach in transfemoral transcatheter aortic valve implantation. Heart. 2018;104(19):1621‐1628.
    1. Petronio AS, Giannini C, De Carlo M, et al. Anaesthetic management of transcatheter aortic valve implantation: results from the Italian CoreValve registry. EuroIntervention. 2016;12:381‐388.

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