Virtual ACC 2020 | Conscious Sedation in TAVR

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.

Read also: The Perks of Conscious Sedation in TAVR.

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).

Read also: TAVR in Extremely Large Annuli: Different Patients Might Need Different Prostheses.

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.

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