According to the TVT Registry, patients who undergo transcatheter aortic valve replacement (TAVR) with conscious sedation have better outcomes, including lower mortality rates. A minimalist strategy always (sooner or later) proves to be superior across our whole range of procedures, from a simple diagnostic study with local anesthesia and a 4-Fr transradial access, to a transcatheter aortic valve replacement with percutaneous closure and conscious sedation.
This strategy is growing in the US, but in Europe it was adopted a while back.
Among interventional cardiologists, its adoption is as diverse as its definitions. However, pretty much everybody agrees on the use of transthoracic echocardiography and light sedation as a minimalist approach, as opposed to general anesthesia with an invasive management of the airway.
Only one trial to date, SOLVE-TAVI, randomized patients to one of the aforementioned strategies or the other, and it proved the noninferiority of a minimalist strategy. Such study, however, was underpowered to detect other events.
The analysis herein outlined was meant to be presented at the American College of Cardiology 2020 Scientific Session and simultaneously published in JACC: Cardiovascular Interventions. However, given the current worldwide pandemic, the event is unlikely to take place; in consequence, we can access this work digitally.
This study included 120,080 patients from over 500 sites, who underwent TAVR between 2016 and 2019. Globally, the proportion of patients managed through a minimalist strategy increased from 33% to 63%. Variation across sites was significant; one fourth of hospitals used conscious sedation in over 80% of procedures, and up to 13% of sites used general anesthesia in absolutely all cases.
Conscious sedation was associated with modestly lower in-hospital mortality (1.1% vs. 1.3% with general anesthesia; p = 0.01) and 30-day mortality (2.0% vs. 2.5%; p < 0.001).
The percentage of patients discharged home (88.9% vs. 86.1%; p < 0.001) and hospital length of stay (3.5 vs. 4.3 days; p < 0.001) were also significantly better with a minimalist approach.
Original Title: Conscious sedation versus general anesthesia for transcatheter aortic valve replacement: variation in practice and outcomes.
Reference: Butala NM et al. J Am Coll Cardiovasc Intv. 2020; Epub ahead of print.
We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.