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Conscious Sedation vs. General Anesthesia in TAVR
Study Questions:
What is the use of local anesthesia or conscious sedation (LACS) and general anesthesia (GA) in transcatheter aortic valve replacement (TAVR), and its impact on outcome?
Methods:
The investigators analyzed a total of 16,543 patients from the German Aortic Valve Registry from 2011-2014, and propensity-matched analyses were performed to correct for potential selection bias. The endpoints of the present study were 30-day and 1-year mortality. The association of LACS versus GA with time to 30-day and 1-year mortality was assessed using Cox proportional hazard models. Hazard ratios (HRs) with their respective 95% confidence intervals (CIs) were computed.
Results:
LACS was used in 49% of patients (8,121 of 16,543). In the hospital, LACS was associated with lower rates of low-output syndrome, respiratory failure, delirium, cardiopulmonary resuscitation, and death. There was no difference in paravalvular leakage (II+) between LACS and GA in the entire population (5% vs. 4.8%; p = 0.76) or in the matched population (3.9% vs. 4.9%; p = 0.13). The risk for prolonged intensive care unit stay (≥3 days) was significantly reduced with LACS (odds ratio, 0.82; 95% CI, 0.73-0.92; p = 0.001). Thirty-day mortality was lower with LACS in the entire population (3.5% vs. 4.9%; HR, 0.72; 95% CI, 0.60-0.86; p < 0.001) and in the matched population (2.8% vs. 4.6%; HR, 0.6; 95% CI, 0.45-0.8; p < 0.001). However, no differences in 1-year mortality between both groups in the entire population (16.5% vs. 16.9%; HR, 0.93; 95% CI, 0.85-1.02; p = 0.140) and in the propensity-matched population (14.1% vs. 15.5%; HR, 0.90; 95% CI, 0.78-1.03; p = 0.130) were observed.
Conclusions:
The authors concluded that use of LACS in TAVR is safe, with fewer post-procedural complications and lower early mortality.
Perspective:
This national registry study reports that almost one-half of TAVR procedures were performed using LACS in Germany, primarily at high-volume centers. LACS was associated with faster procedure times, fewer procedural complications, and a more favorable post-procedural course. Furthermore, 30-day mortality was lower with LACS, an effect that persisted after multivariate adjustment and propensity matching. While these data support broad application of LACS by experienced teams, additional randomized studies are needed to confirm these findings and determine the true value of LACS versus GA in TAVR.
Keywords: Anesthesia, General, Anesthesia, Local, Cardiopulmonary Resuscitation, Conscious Sedation, Delirium, Heart Valve Diseases, Intensive Care Units, Length of Stay, Respiratory Insufficiency, Risk, Transcatheter Aortic Valve Replacement, Treatment Outcome
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