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A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience.

ABSTRACT: Objectives:The current 2017 ESC/EACTS guidelines recommend transcatheter aortic valve implantations (TAVIs) as the therapy of choice for inoperable patients with severe symptomatic aortic stenosis. Most of the TAVIs worldwide are performed under general anaesthesia (GA). Although conscious sedation (CS) concepts are increasingly applied in Europe, it is still a matter of debate which concept is associated with highest amount of safety for this high-risk patient population. The aim of this single center, before-and-after study was to investigate feasibility and safety of CS compared with GA with respect to peri-procedural complications and 30-day mortality in patients scheduled for transfemoral TAVI (TF-TAVI). Methods:From March 2012 until September 2014, patients scheduled for the TF-TAVI procedure were included in a prospective, observational manner. From the 200 patients finally included, 107 procedures were performed under GA, using either an endotracheal tube or a laryngeal mask, and balanced anaesthesia. CS was performed in 93 patients using low-dose propofol and remifentanil. Results:Conversion to GA was needed 4 times due to procedural-related complications (4.3%), in one patient due to ongoing agitation (1.1%). The CS-group showed significantly shorter key time courses: anaesthesia time (105 [95-120] minutes vs 115 [105-140] minutes, P-value = 0.009, Mann-Whitney-U-test) and length of stay in the intensive care unit (1.6 [1.0-1.5] d vs 2.1 [1.0-2.0] d, P-value = 0.002, Mann-Whitney-U-test). The lowest mean arterial pressure was significantly higher in the CS-group compared with the GA-group (74.3 mmHg vs 55.2 mmHg, P-value <0.0001, t-test). CS was associated with less requirements of norepinephrine (0.1 μg/kg vs 2.3 μg/kg, P-value <0.0001, Mann-Whitney-U-test). Conclusions:Our single-center data demonstrate that CS is a feasible and safe alternative, especially with respect to a higher degree of intra-procedural haemodynamic stability, and a reduced length of stay in the intensive care unit.

SUBMITTER: Renner J

PROVIDER: S-EPMC6346987 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Off-pump transapical aortic valve implantation (TA-TAVI) through mini-thoracotomy was first performed in Vancouver, Canada in October 2005. The objective of this manuscript is to describe the Vancouver experience with 178 TA-TAVI cases in symptomatic severe aortic stenosis (AS) since 2005.Baseline characteristics and in-hospital outcomes were calculated for the overall cohort. To compare pre-procedure and post-procedure echocardiographic measurements, one way analysis of variance was utilized, followed by Tukey's HSD. In-hospital outcomes were compared between early and late cohorts using Z-test and chi-squared test as appropriate. Kaplan-Meier analysis was used to generate 3-year survival curves. The Log-rank test was used to compare survival between low-risk and high-risk groups, based on STS score.Between October 2005-March 2012, TA-TAVI was performed in 178 patients. Mean age was 80.5±8.6 years. Congestive heart failure and renal failure were more common in the late cohort, while previous myocardial infarction was more common in the early cohort (P<0.05). Eleven patients (6.2%) had significant intra-operative complications, including death (1.7%), conversion to CPB (3.9%), and valve embolization (1.1%). In-hospital survival was 87.9%. Mean length of hospital stay was 12.2±17.1 days. In-hospital incidence of stroke was 3.4%. Bleeding (20.2% vs. 4.7%) and vascular (14.6% vs. 3.5%) complications were more common in the early cohort. Echocardiography demonstrated a significant increase in aortic valve area and decrease in mean transvalvular gradient post-procedure. These improvements were maintained throughout the 3-year follow-up period. Overall survival was 72.1% at 6 months, 67.7% at 12 months, 55.5% at 24 months, and 47.3% at 36 months. Repeated Kaplan-Meier analysis for the 2 groups stratified by STS score, demonstrated improved survival in the low-risk group (Log-rank P=0.039).Among patients with symptomatic severe AS at high risk for conventional AVR, TA-TAVI is a reasonable therapeutic option with acceptable risk. Long-term survival appears to be superior in lower-risk patients.

Project description:AimsSystemic inflammatory response, identified by increased total leucocyte counts, was shown to be a strong predictor of mortality after transcatheter aortic valve implantation (TAVI). Yet the mechanisms of inflammation-associated poor outcome after TAVI are unclear. Therefore, the present study aimed at investigating individual inflammatory signatures and functional heterogeneity of circulating myeloid and T-lymphocyte subsets and their impact on 1 year survival in a single-centre cohort of patients with severe aortic stenosis undergoing TAVI.Methods and resultsOne hundred twenty-nine consecutive patients with severe symptomatic aortic stenosis admitted for transfemoral TAVI were included. Blood samples were obtained at baseline, immediately after, and 24 h and 3 days after TAVI, and these were analysed for inflammatory and cardiac biomarkers. Myeloid and T-lymphocyte subsets were measured using flow cytometry. The inflammatory parameters were first analysed as continuous variables; and in case of association with outcome and area under receiver operating characteristic (ROC) curve (AUC) ≥ 0.6, the values were dichotomized using optimal cut-off points. Several baseline inflammatory parameters, including high-sensitivity C-reactive protein (hsCRP; HR = 1.37, 95% CI: 1.15-1.63; P < 0.0001) and IL-6 (HR = 1.02, 95% CI: 1.01-1.03; P = 0.003), lower counts of Th2 (HR = 0.95, 95% CI: 0.91-0.99; P = 0.009), and increased percentages of Th17 cells (HR = 1.19, 95% CI: 1.02-1.38; P = 0.024) were associated with 12 month all-cause mortality. Among postprocedural parameters, only increased post-TAVI counts of non-classical monocytes immediately after TAVI were predictive of outcome (HR = 1.03, 95% CI: 1.01-1.05; P = 0.003). The occurrence of SIRS criteria within 48 h post-TAVI showed no significant association with 12 month mortality (HR = 0.57, 95% CI: 0.13-2.43, P = 0.45). In multivariate analysis of discrete or dichotomized clinical and inflammatory variables, the presence of diabetes mellitus (HR = 3.50; 95% CI: 1.42-8.62; P = 0.006), low left ventricular (LV) ejection fraction (HR = 3.16; 95% CI: 1.35-7.39; P = 0.008), increased baseline hsCRP (HR = 5.22; 95% CI: 2.09-13.01; P < 0.0001), and low baseline Th2 cell counts (HR = 8.83; 95% CI: 3.02-25.80) were significant predictors of death. The prognostic value of the linear prediction score calculated of these parameters was superior to the Society of Thoracic Surgeons score (AUC: 0.88; 95% CI: 0.78-0.99 vs. 0.75; 95% CI: 0.64-0.86, respectively; P = 0.036). Finally, when analysing LV remodelling outcomes, ROC curve analysis revealed that low numbers of Tregs (P = 0.017; AUC: 0.69) and increased Th17/Treg ratio (P = 0.012; AUC: 0.70) were predictive of adverse remodelling after TAVI.ConclusionsOur findings demonstrate an association of specific pre-existing inflammatory phenotypes with increased mortality and adverse LV remodelling after TAVI. Distinct monocyte and T-cell signatures might provide additive biomarkers to improve pre-procedural risk stratification in patients referred to TAVI for severe aortic stenosis.

Project description:ObjectivesTransfemoral transcatheter aortic valve implantation (TF-TAVI) is an established therapy for patients with symptomatic aortic stenosis, which requires periprocedural anaesthesia care. In 2015, the German Federal Joint Committee released a directive on minimally invasive heart valve interventions which defines institutional infrastructural requirements in German heart centres. But still generally accepted expert consensus recommendations or national or international guidelines regarding periprocedural anaesthesia management for TF-TAVI are lacking. This nationwide cross-sectional study had two major objectives: first to assess the concordance with existing national regulations regarding infrastructural requirements and second to evaluate the status quo of periprocedural anaesthesia management for patients undergoing TF-TAVI in German heart centres.DesignMulticentre cross-sectional online study to evaluate the periprocedural anaesthesia management.SettingIn this nationwide cross-sectional study, electronic questionnaires were sent out to anaesthesia departments at TF-TAVI-performing centres in Germany in March 2019.Participants78 anaesthesia departments of German heart centres.Results54 (69.2%) centres returned the questionnaire of which 94.4% stated to hold regular Heart Team meetings, 75.9% to have ready-to-use heart-lung machines available on-site, 77.8% to have cardiac surgeons and 66.7% to have perfusionists routinely attending throughout TF-TAVI procedures. Regarding periprocedural anaesthesia management, 41 (75.9%) of the participating centres reported to predominantly use 'monitored anaesthesia care' and 13 (24.1%) to favour general anaesthesia. 49 (90.7%) centres stated to use institutional standard operating procedures for anaesthesia. Five-lead ECG, central venous lines, capnometry and intraprocedural echocardiography were reported to be routine measures in 85.2%, 83.3%, 77.8% and 51.9% of the surveyed heart centres.ConclusionsThe concordance with national regulations, anaesthesia management and in-house standards for TF-TAVI vary broadly among German heart centres. According to the opinion of the authors, international expert consensus recommendations and/or guidelines would be helpful to standardise peri interventional anaesthesia care.

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A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience.

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