Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

Abstract

BackgroundTranscatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR.MethodsRecords for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost.ResultsOf the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses.ConclusionConscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.

Minimalist approach for transcatheter aortic valve replacement

“…17 LA/CS was shown to achieve greater improvement of patient's quality of life at 30 days post-TAVR, as assessed by Kansas City Cardiomyopathy Questionnaire compared with general anesthesia. 12 Additionally, for elderly patients, shorter LOS is beneficial, considering the potential reduction in known negative outcomes of longer hospitalization, including reduced functional status, infection, or delirium. 18 There is also lower 1-year mortality rates among patients with severe chronic obstructive pulmonary disease undergoing minimalist approach when compared to the standard procedure.…”

“…21,26 LA/CS were associated with lower rates of systemic hypertension and subsequent intra and post-procedural inotropic support, and potentially lower pulmonary complications rate, like the incidence of respiratory failure and pneumonia associated with mechanical ventilation. 22,23 As a result, early recovery after the procedure can be achieved, leading to a shorter length of post-procedural ICU stay and LOS, 12,20,22,25,27 e.g. mean 1.5-2.1 days shorter in LOS under LA/CS than under general anesthesia.…”

“…CS to general anesthesia was 5.9%, which was consistent with previous reports. 28 According to these prior reports, 12,20,22,25,27 transfemoral TAVR under LA/CS seems to be feasible and safe with the merit of shorter LOS. However, majority of these studies are observational, and randomized, controlled trials are scarce, 29 a potential caveat of which is patient selection bias, e.g.…”

Transcatheter aortic valve implantation economics: a grisly reality

“…Comparative studies of the standard and minimalist approaches indicate that in the current era, given the advent of smaller-sized sheaths and valve profiles, the minimalist transfemoral approach can be performed with minimal morbidity and mortality and equivalent effectiveness compared with the standard approach (33,34). Furthermore, a shorter length of hospital stay and lower resource use with the latter approach significantly lowers hospital costs.…”

TCT-664 Comparison of General versus Local Anesthesia in Patients Undergoing Transcatheter Aortic Valve Replacement (TAVR): A Meta-analysis

“…Results are expressed as Mantel Haenszel Risk Ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) [1]. In addition to the 26 studies included in our previous analysis, we found 6 new studies (with 12,453 patients) meeting our inclusion criteria [2][3][4][5][6][7].…”