Local versus general anesthesia for transfemoral aortic valve implantation

Motloch, Lukas J.; Rottlaender, Dennis; Reda, Sara; Larbig, Robert; Bruns, M.; Müller‐Ehmsen, Jochen; Strauch, Justus; Madershahian, Navid; Erdmann, Erland; Wahlers, Thorsten; Hoppe, Uta C.

doi:10.1007/s00392-011-0362-8

Cited by 151 publications

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“…First, GA is defined by the patient having been placed in a state of "unconsciousness" such that they are Previous studies have suggested potential advantages of a non-GA procedure, including shorter procedure times, shorter intensive care unit and overall hospital stays, lower vasopressor requirements, and equally good outcomes in terms of mortality. [2][3][4][5] Others have identified that a non-GA approach may require conversion to GA in up to 5% of cases for cardiac arrest, tamponade, myocardial infarction, or procedural stroke. 10 A higher incidence of paravalvular regurgitation has been recorded in 1 study of patients treated with non-GA, perhaps reflecting a reluctance of operators to prolong the procedure to undertake further post-deployment valvuloplasty or second valve deployment.…”

Section: Discussionmentioning

confidence: 99%

“…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 significant proportion was treated with local rather than general anesthesia.…”

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confidence: 99%

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

Brecker

Bleiziffer

Bosmans

et al. 2016

The American Journal of Cardiology

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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...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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

Brecker

Bleiziffer

Bosmans

et al. 2016

The American Journal of Cardiology

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“…There are numerous studies including the results of TAVI applications in many countries [10][11][12][13][14]. However, there are a limited number of studies on TAVI procedure in Turkey [15][16][17].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2015

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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. Bulgular: Tüm hastalarda Edwards SAPIEN Valve protez transfemoral yaklaşımla (10 hastada perkutanöz, 15 hastada cerrahi yöntemle) yerleştirildi. Tüm hastalarda TAVI işlemi genel anestezi altında yapıldı ve transözefagial ekokardiyografi tüm hastalara uygulandı. TAVI işleminin başarı oranı %100 idi. İşlem süresince mortalite ve ciddi komplikasyon izlenmedi. Üç hastada femoral arterde sınırlı disseksiyon görüldü, ancak distal perfüzyonun iyi olması nedeniyle herhangi bir müdahale gerekmedi. Uzun süreli atriyoventriküler blokaj nedeniyle dört hastaya kalıcı pacemaker takıldı. İşlem sonrası, tüm hastalar Yoğun Bakım Ünitesi'ne (YBÜ) gönderildi ve tüm hastalar YBÜ'de ekstübe edildi. Ortalama mekanik ventilasyon süresi (dakika): 166,20±39,32, ortalama yoğun bakımda kalış süresi (gün): 5,64±2,99 ve ortalama hastanede kalış süresi (gün): 11,92 ±5,54 idi. Postoperatif birinci gün, bir hastada akut renal yetmezlik ve iki hastada inme izlendi. İlk 30 gündeki mo...

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“…5 Furthermore, general anesthesia may increase costs and reduce the number of procedures that can be performed daily. 6 Continuous TEE is an essential tool to help the interventional cardiologist perform the procedure, and it allows for the administration of lower doses of contrast medium and an overall lower exposure to radiation for the patient and the operating team. Nevertheless, it can be challenging for the patient to tolerate what can be a protracted TEE examination.…”

Section: Résumémentioning

confidence: 99%

Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask

Zangrillo

Mazzone

Votta

et al. 2016

Can J Anesth/J Can Anesth

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Purpose Left atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia. Clinical features Percutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H 2 O; positive end-expiratory pressure = 7 cm H 2 O; FIO 2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent. ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure. RésuméObjectif La fermeture de l'appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l'anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transoesophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d'une ETO prolongée pour la fermeture Electronic supplementary material The online version of this article

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Local versus general anesthesia for transfemoral aortic valve implantation

Cited by 151 publications

References 16 publications

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

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

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

Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask

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