Background

In many centers, transfemoral TAVR is performed under general anesthesia (GA) with TEE guidance and monitoring. However, the use of lighter sedation and analgesia, known as monitored anesthesia care or MAC and the use of TTE imaging might have similar procedural success rates in select patients.

Methods

This was a single center retrospective study 111 patients undergoing transfemoral TAVR from 2012 to 2014. Of these, 64 had GA with TEE and 47 had MAC with TTE. Patients in each group were matched by mean EuroSCORE II values and then used as a comparison cohort.

Results

Most (50 of 64) of the GA/TEE patients and few (9 of 47) of the MAC/TTE patient had Edwards-SAPIEN THV valves. CoreValve was used in the remainder. After matching, comparison of the two groups demonstrated similar rates and severity of paravalvular regurgitation. Procedural time was longer with TEE due to need to wean from the ventilator, though overall hospital lenght of stay was similar.

Conclusions

In patients undergoing transfemoral TAVR, MAC with TTE may be safely performed in carefully selected patients with outcomes that appear similar to those undergoing GA and TEE.

Commentary/Perspective

It has been known for some time that TAVR can be performed with moderate sedation as the first TAVR was actually done under moderate sedation¹. Durand and colleagues in 2012 published a prospective registry showing favorable procedural success rates with MAC². This paper attempts to directly compare procedural outcomes in those with MAC vs. GA by matching patients based by EuroScore II. However, because of the retrospective study design, it is not easy to control for all of the factors that led to the decision to have a patient undergo MAC/TTE as opposed to GA/TEE. Another caveat is that the population studied was heterogeneous and the CoreValve was disproportionately used in those undergoing MAC/TTE. In addition, length of stay was affected by a required hospital policy to monitor all patients in the ICU for 48 hrs post procedure.

As TAVR technology has become smaller and safer, and as the bar for thinking about TAVR over surgical AVR gets lower and lower, it is important to study sedation and imaging techniques which are less invasive and incur less patient risk. Experienced operators now have become quite good at using fluoroscopy for valve positioning and for identification of common procedural complications. Randomized trials are needed to compare the two sedation and imaging strategies and to help us inform patient selection for each group.

References

1. Cribier A., Eltchaninoff H., Bash A.; Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 106 2002:3006-3008.
2. Durand E., Borz B., Godin M.; Transfemoral aortic valve replacement with the Edwards SAPIEN and Edwards SAPIEN XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: feasibility and 30-day outcomes. J Am Coll Cardiol Intv. 5 2012:461-467.

Clinical Topics: Noninvasive Imaging, Valvular Heart Disease, Nuclear Imaging

Keywords: Analgesia, Anesthesia, Anesthesia, General, Conscious Sedation, Fluoroscopy, Humans, Intensive Care Units, Length of Stay, Pain Management, Patient Care, Patient Selection, Prospective Studies, Registries, Retrospective Studies, Heart Valve Diseases

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