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

Abstract

ObjectivesWe 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).MethodsElectronic 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.ResultsAfter 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%.ConclusionFor 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 numberCRD42016048398 (PROSPERO).

Severe structural deterioration of small aortic bioprostheses treated with valve-in-valve transcatheter aortic valve implantation

“…Fröhlich et al in a meta‐analysis described the conversion rate from local to general anesthesia being as high as 6.3% and showed that local anesthesia was associated with significantly shorter procedure time and in‐hospital stay. Ehret et al suggested that local anesthesia is associated with favorable effects such as a reduced need for inotropic support and packed red blood cells transfusions. Having gained enough experience in the field of TAVI, it was possible to reduce the rate of general anesthesia to below 8%.…”

Minimalist approach for transcatheter aortic valve replacement

“…Another meta-analysis published in the same year, with 19 studies, showed no differences between the two anesthetic techniques (RR: 0.91; 95%CI 0.70-1.18; p=0.48). 25 One-year or long-term survival, as well as procedure-related complications, such as stroke, myocardial infarction, acute kidney injury, vascular and bleeding complications also did not differ between LA/CS and general anesthesia in several studies. 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.…”

“…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.…”

“…mean 1.5-2.1 days shorter in LOS under LA/CS than under general anesthesia. 5,25 However, emergent conversion from LA/CS to general anesthesia is not rare, showing a wide range of incidence rates between 2.9% and 12% in large clinical studies. 22 The predominant reasons for the conversion are patient uncooperativeness or discomfort, as well as procedural complications, such as vascular complications, hemodynamic compromise, and cardiac tamponade.…”

“…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.…”