Conscious Sedation in TAVR: Is It Advisable?

The fundamental advantage offered by transcatheter aortic valve replacement (TAVR) has always been the fact that it is less invasive than surgical valve replacement. So far, most improvements for these devices have derived in less invasiveness (e.g., by improving the profile of the eluting system). However, there are also cases of “deployment” reduction during the procedure, and the use of transthoracic (instead of transesophageal) echocardiography, percutaneous access closure instead of surgery, and conscious sedation instead of general anesthesia is increasingly frequent.

There have been several single-center experiences proving the safety of conscious sedation during the procedure, which reduces the time spent in the cath lab and in the critical care unit, the global duration of hospital stay, and, obviously, costs.

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The NCDR STS/ACC TVT Registry was designed to characterize the anesthesia choice and outcomes for all U.S. patients undergoing transfemoral TAVR between 2014 and 2015.

Conscious sedation was used in 1737/10,997 (15.8%) cases with a significant trend of increasing usage over time. The conscious sedation group was less likely to suffer in-hospital death (1.6% vs. 2.5%; p = 0.03), and 30-day death (2.9% vs. 4.1%; p = 0.03). Conversion to general anesthesia was necessary in only 5.9% of patients who initially underwent conscious sedation.

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After adjustment for 51 covariates, conscious sedation presented lower technical success (97.9% vs. 98.6%, p < 0.001), but was still associated with lower rates of in-hospital and 30-day death (1.5% vs. 2.4%; p < 0.001 and 2.3% vs. 4.0%; p < 0.001, respectively).

Conclusion

Conscious sedation during TAVR was associated with briefer length of stay and lower short-term mortality compared to TAVR under general anesthesia.

Editorial

Conscious sedation offers a range of varieties impossible to individualize in this work. It may go from local anesthesia only to an endovenous combination of benzodiazepines, opioids, or propofol, offering higher patient comfort; still, invasive ventilation is unnecessary in all cases.

Original title: Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Insights from the NCDR® STS/ACC TVT Registry.

Reference: Hyman MC et al. Circulation. 2017 Sep 1. [Epub ahead of print].

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