Anesthesia Choice and Outcomes After TAVR

Dec 13, 2017
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Authors:
Hyman MC, Vemulapalli S, Szeto WY, et al.
Citation:
Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Insights From the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circulation 2017;136:2132-2140.
Summary By:
Bina Ahmed, MD, FACC

Study Questions:

What is the impact of anesthesia choice on outcomes among patients undergoing transfemoral transcatheter aortic valve replacement (TAVR)?

Methods:

The National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry was used to evaluate outcomes based on type of anesthesia (conscious sedation [CS] vs. general anesthesia [GA]) among patients undergoing transfemoral TAVR from April 2014 to June 2015. Propensity score analysis using 51 different variables was used to control for differences between the two groups. Primary outcome was in-hospital mortality. Secondary outcomes included 30-day mortality, procedural success, intensive care unit and hospital length of stay, and rates of discharge home.

Results:

Of the almost 11,000 patients evaluated, approximately 16% underwent TAVR with CS with increasing trends over the study period. Conversion from CS to GA was noted in 5.9% of patients. After adjusting for differences in clinical covariates, CS was associated with lower procedural success (97.9% vs. 98.6%, p < 0.001), but reduced in-hospital (1.5% vs. 2.4%, p < 0.001) and 30-day (2.3% vs. 4.0%, p < 0.001) mortality. In addition, CS was associated with reductions in procedural inotrope requirement, intensive care unit and hospital length of stay (6.0 vs. 6.5 days, p < 0.001), and combined 30-day death/stroke rates (4.8% vs. 6.4%, p < 0.001). There was no significant difference in the rates of bleeding, vascular complications, or need for pacemaker implantation.

Conclusions:

Among patients undergoing TAVR in the United States from 2014 to 2015, use of CS was associated with lower length of stay and lower in-hospital and 30-day mortality.

Perspective:

These data from the TVT Registry suggest that CS may be better than GA among patients undergoing elective transfemoral TAVR. Although only a minority of patients underwent TAVR with CS (16%) in this analysis, use of CS was increasing over the study period and is anticipated to continue to increase. The reported overall procedural success rate was 0.07% lower, but in-hospital and 30-day mortality was significantly lower in CS patients. In addition, CS patients had slightly lower length of stay. Despite the possibility of unmeasured confounding and selection bias, these data provide support for the use of CS for transfemoral TAVR.

Keywords: Anesthesia, General, Cardiac Surgical Procedures, Conscious Sedation, Heart Valve Diseases, Hospital Mortality, Intensive Care Units, Length of Stay, Pacemaker, Artificial, Stroke, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement, Treatment Outcome


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