Impact of Anesthesia Type on Outcomes of Transcatheter Aortic Valve Implantation (from the Multicenter ADVANCE Study)

Abstract

Transcatheter aortic valve implantation (TAVI) has become the standard of care for many patients with symptomatic severe aortic stenosis who are at increased risk of morbidity and mortality during surgical aortic valve replacement. However, there is still no general consensus regarding the use of general anesthesia (GA) versus local anesthesia with sedation (non-GA) during the TAVI procedure. Using propensity score matching analysis, we analyzed the characteristics and outcomes of patients undergoing TAVI with either GA (n=245) or non-GA (n=245) in the fully monitored, international, CoreValve ADVANCE Study. No statistically significant differences existed between the non-GA and GA groups in all-cause mortality (25.4% vs. 23.9%, p=0.78), cardiovascular mortality (16.4% vs. 16.6%, p=0.92), or stroke (5.2% vs. 6.9%, p=0.57) through 2-year follow up. Major vascular complications were more common in the non-GA group. Total hospital stay was similar between the 2 groups. Conversion from non-GA to GA occurred in 13 patients (5.3%) due to procedural complications in 9 patients and discomfort or restlessness in 4 patients. The majority of the procedural complications were related to valve positioning or vascular issues. Two of the 13 converted patients died during the procedure. Both GA and non-GA are widely used in real-world TAVI practice, and the decision appears to be guided by only a few patient-related factors and dominated by local and national practice. The outcomes of both anesthesia modes are equally good. When conversion from non-GA did occur, the complication requiring GA affected outcomes.Key words: severe aortic stenosis, transcatheter aortic valve replacement; anesthesia; real-world clinical trial 3 Transcatheter aortic valve implantation (TAVI) has become standard of care for patients with symptomatic severe aortic stenosis at extreme or high risk for surgery. 1 In practice, even lower risk patients are already being treated, while at least 3 TAVI clinical trials are assessing the role of the therapy in patients considered at only intermediate risk from surgical AVR. It is therefore likely the number of patients treated with TAVI will increase, requiring additional numbers of operators and hospitals. Concurrently, the procedure is becoming less complex. Smaller sheath sizes, a reduced need for rapid pacing and balloon valvuloplasty, availability of repositionable and recapturable valves, and decreased reliance upon intraprocedural transesophageal echocardiography will herald a new era of TAVI. A significant proportion of procedures are already being performed using local anesthesia with sedation. Others have reported potential benefits of using local anesthesia, including shorter intensive care unit and overall hospital stays, less hemodynamic instability, and less need for vasopressors. [2][3][4][5] It is likely that the proportion of patients treated in this manner will increase. In the ADVANCE study 6 , patients were treated according to best local practice in experienced centers, and a signif...

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

“…Similar to our report, in Transcatheter Valve Treatment Sentinel (TCVT) registry, the patients in the non-GA group were older, and the rate of previous coronary artery bypass grafting (CABG) surgery was higher in the GA group, whereas in contrast to our study they observed no difference in the BMI, left ventricular ejection fraction and eGFR between the GA and non-GA groups 4 16. In keeping with our report, there were higher rate of patients with previous CABG and impaired left ventricular function in the GA group in ADVANCE registry 14. A higher logistic EuroSCORE was observed in the GA cases in the ADVANCE, Italian CoreValve and TCVT registries but not in the French Aortic National CoreValve and Edwards 2 (FRANCE 2) registry.…”

“…Acute kidney injury stage III and bleeding, even after propensity score matching, was higher in the GA patients in the Italian CoreValve registry 15. The report from the TCVT registry also showed a higher rate of renal replacement therapy in the GA TAVI group,4 and there was a higher rate of vascular complications in the non-GA TAVI cohort in the ADVANCE registry 14…”

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

“…We reviewed 35 full-text articles and identified 20 articles for inclusion in our review (figure 1). [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] All the studies were observational studies except one RCT. 32 Table 1 shows the baseline clinical characteristics of the included studies.…”

Predictors of Thrombocytopenia after Self-Expandable Transcatheter Aortic Valve Replacement: A Single-Center Experience from China

“…Anesthetic agents, such as fentanyl, propofol, dexmedetomidine, and midazolam, have never been reported to influence blood platelets. Recent data, using propensity score-matching analysis, showed less procedural duration, less fluoroscopic time, and more postprocedural complications in a non-GA cohort [17,18]. Longer X-ray exposure, longer procedural time, and larger contrast amounts have been reported to be associated with TP, which might help to elucidate this correlation between TP and anesthesia techniques [9].…”