Transcarotid TAVR Safety: Local or General Anesthesia?

Courtesy of Dr. Agustín Vecchia.

Early transcatheter aortic valve replacement (TAVR) was characterized by high vascular complication rates associated to elevated device diameter (e.g. 22-24 Fr. in the first PARTNER) and less operator experience typical of new techniques.

This study shows the progress of TAVR field in these last years, the experience gained by some groups, and the positive impact of valve technology enhancement.

The aim of this study was to assess the safety and efficacy of transcarotid TAVR (surgical approach at common carotid level) and to compare two anesthesia strategies:

• One minimally invasive, with conscious sedation (MIS)
• The other with general anesthesia (GA)

The study included 174 TAVR patients between 2009 and 2014 from two centers in France that had been ruled out for femoral TAVR due to severe vascular peripheral disease.

52 (29.8%) patients were intervened with MIS and 122 (70.1%) with GA.

Overall outcomes were available at one year, and end points were defined by VARC-2 consensus (Valve Academic Research Consortium-2).

Multislice CT was used to assess the carotid, subclavian and vertebral arteries, along with MRI to the circle of Willis to assess collateral blood flow.

During procedure, brain oxygen saturation was monitored using infrared spectroscopy (Equanox 7600, Nonnin Medical Inc., North Plymouth).

Results

• Procedure and valve deployment were 100% successful
• 30 day mortality was 7.4% (13 patients)
• All-cause mortality at one year was 12.6% (n = 22)
• All cause cardiovascular mortality was 8.0% (n = 14)
• When dividing patients according to anesthesia strategy, there were no differences in 30 day mortality (GA 7.3% vs. MIS 7.6%; p=0.94), or one year mortality (GA 13.9% vs. MIS 9.6%; p=0.43).
• Neither were there differences in clinical efficacy or safety end points at one month (85.2% vs. 94.2%; p=0.09 and 77.8% vs. 86.5%; p = 0.18 respectively).
• In the GA group, there were 10 cerebrovascular events (5.7%): 4 strokes (2.2%) and 6 transient ischemic attacks (3.4%). There were no cerebrovascular events in the MIS group (p<0.001).

Conclusion

The authors concluded that TAVR is safe with both strategies, despite there were a minimal number of cerebrovascular events in the GA group.

Editorial Comment

Despite the current TAVR systems allow insertion with 14 Fr catheters, which increases the number of procedures via transfemoral approach, alternative access sites will always be necessary. This is the largest series on transcarotid access published so far, and it shows it is safe and effective.

We should consider, on one hand, that patients underwent extra screening and costly procedures, such as MRI; on the other hand, hospitalization was reduced by nearly 50%: 11.3 vs. 6 days (p < 0.001).

As regards stroke rate reduction with MIS, the authors think this phenomenon could be secondary to the learning curve of operators, since the first transcarotid TAVR procedures were done under GA and the most recent, done by more experienced operators, even when using GA, saw no cerebrovascular events.

Another reason is that, currently, balloon predilation is not as frequently used, and last but no less important, there is chance, especially keeping in mind the number of events is small. It would have been interesting to try rule out any other associated factors.

Courtesy of Dr. Agustín Vecchia. German Hospital, Buenos Aires, Argentina.

Original Title: Transcarotid Transcatheter Aortic Valve Replacement. General or Local Anesthesia

Reference: Debry N et al. J Am Coll Cardiol Intv. 2016;9(20):2113-2120.

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