Conclusion
The use of sedation with or without local anaesthesia appears to be a
safe and effective method to facilitate TAVI. The use of sedation over
general anaesthesia has been shown to reduce length of stay in the ICU
and in hospital, reduce polypharmacy and cause much less haemodynamic
compromise. In those who are high risk; frail, elderly or have severe
co-morbidities the risk of GA may be too great and can outweigh the
benefits intended from TAVI. Experienced centres will have clinicians
trained in how to anaesthetise and deal with these group of patients; a
multidisciplinary team discussion is vital to ensure the appropriate
anaesthetic is chosen for each patient. As TAVI continues to
revolutionise the treatment for symptomatic aortic stenosis, the rise in
cases in inevitable and the use of sedation and local anaesthesia allows
clinicians with a viable option to treat a challenging group of
patients.
References:
1) Imnadze G, Hofmann S, Billion M, et al. Clinical value of the 20%
logistic EuroSCORE cut-off for selecting TAVI candidates: a
single-centre cohort study analysis. Open Heart .
2020;7(1):e001194. Published 2020 Feb 19.
doi:10.1136/openhrt-2019-001194
2) Afshar AH, Pourafkari L, Nader ND. Periprocedural considerations of
transcatheter aortic valve implantation for anesthesiologists. J
Cardiovasc Thorac Res . 2016;8(2):49-55. doi:10.15171/jcvtr.2016.10
3) Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR,
Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ,
Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE,
Sacco RL, Smith D, Thomas JD. 2012 ACCF/AATS/SCAI/STS expert consensus
document on transcatheter aortic valve replacement. J Am Coll Cardiol.
2012 Mar 27;59(13):1200-54. doi: 10.1016/j.jacc.2012.01.001. Epub 2012
Jan 31. PMID: 22300974.
4) Debry N, Delhaye C, Azmoun A, Ramadan R, Fradi S, Brenot P, Sudre A,
Moussa MD, Tchetche D, Ghostine S, Mylotte D, Modine T. Transcarotid
Transcatheter Aortic Valve Replacement: General or Local Anesthesia.
JACC Cardiovasc Interv. 2016 Oct 24;9(20):2113-2120. doi:
10.1016/j.jcin.2016.08.013. PMID: 27765304
5) Gauthier C, Astarci P, Baele P, et al. Mid-term survival after
transcatheter aortic valve implantation: Results with respect to the
anesthetic management and to the access route (transfemoral versus
transapical). Ann Card Anaesth . 2015;18(3):343-351.
doi:10.4103/0971-9784.159804
6) Renner J, Tesdorpf A, Freitag-Wolf S, et al. A retrospective study of
conscious sedation versus general anaesthesia in patients scheduled for
transfemoral aortic valve implantation: A single center
experience. Health Sci Rep . 2018;2(1):e95. Published 2018 Nov 1.
doi:10.1002/hsr2.95
7) Husser O, Fujita B, Hengstenberg C, Frerker C, Beckmann A, Möllmann
H, Walther T, Bekeredjian R, Böhm M, Pellegrini C, Bleiziffer S, Lange
R, Mohr F, Hamm CW, Bauer T, Ensminger S; GARY Executive Board.
Conscious Sedation Versus General Anesthesia in Transcatheter Aortic
Valve Replacement: The German Aortic Valve Registry. JACC Cardiovasc
Interv. 2018 Mar 26;11(6):567-578. doi: 10.1016/j.jcin.2017.12.019.
PMID: 29566803.
8) Miles LF, Joshi KR, Ogilvie EH, Densem CG, Klein AA, O’Sullivan M,
Martinez G, Sudarshan CD, Abu-Omar Y, Irons JF. General anaesthesia vs.
conscious sedation for transfemoral aortic valve implantation: a single
UK centre before-and-after study. Anaesthesia. 2016 Aug;71(8):892-900.
doi: 10.1111/anae.13522. Epub 2016 Jun 29. PMID: 27353456.
9) Goren O, Finkelstein A, Gluch A, Sheinberg N, Dery E, Matot I.
Sedation or general anesthesia for patients undergoing transcatheter
aortic valve implantation–does it affect outcome? An observational
single-center study. J Clin Anesth. 2015 Aug;27(5):385-90. doi:
10.1016/j.jclinane.2015.03.025. Epub 2015 Apr 24. PMID: 25912486.
10) Thiele H, Kurz T, Feistritzer HJ, Stachel G, Hartung P, Lurz P,
Eitel I, Marquetand C, Nef H, Doerr O, Vigelius-Rauch U, Lauten A,
Landmesser U, Treskatsch S, Abdel-Wahab M, Sandri M, Holzhey D, Borger
M, Ender J, Ince H, Öner A, Meyer-Saraei R, Hambrecht R, Fach A,
Augenstein T, Frey N, König IR, Vonthein R, Rückert Y, Funkat AK, Desch
S, Berggreen AE, Heringlake M, de Waha-Thiele S; SOLVE-TAVI
Investigators. General Versus Local Anesthesia With Conscious Sedation
in Transcatheter Aortic Valve Implantation: The Randomized SOLVE-TAVI
Trial. Circulation. 2020 Oct 13;142(15):1437-1447. doi:
10.1161/CIRCULATIONAHA.120.046451. Epub 2020 Aug 21. PMID: 32819145.
11) Romano SM, Ristalli F, Giglioli C, et al. Deep sedation vs femoral
block anesthesia: beat-by-beat hemodynamic impact on TAVI
procedure. Am J Cardiovasc Dis . 2020;10(4):340-349. Published
2020 Oct 15.
12) Durand E, Borz B, Godin M, Tron C, Litzler PY, Bessou JP, Bejar K,
Fraccaro C, Sanchez-Giron C, Dacher JN, Bauer F, Cribier A, Eltchaninoff
H. Transfemoral aortic valve replacement with the Edwards SAPIEN and
Edwards SAPIEN XT prosthesis using exclusively local anesthesia and
fluoroscopic guidance: feasibility and 30-day outcomes. JACC Cardiovasc
Interv. 2012 May;5(5):461-467. doi: 10.1016/j.jcin.2012.01.018. Epub
2012 May 9. PMID: 22560979.
13) Oguri A, Yamamoto M, Mouillet G, Gilard M, Laskar M, Eltchaninoff H,
Fajadet J, Iung B, Donzeau-Gouge P, Leprince P, Leguerrier A, Prat A,
Lievre M, Chevreul K, Dubois-Rande JL, Chopard R, Van Belle E, Otsuka T,
Teiger E; FRANCE 2 Registry Investigators. Clinical outcomes and safety
of transfemoral aortic valve implantation under general versus local
anesthesia: subanalysis of the French Aortic National CoreValve and
Edwards 2 registry. Circ Cardiovasc Interv. 2014 Aug;7(4):602-10. doi:
10.1161/CIRCINTERVENTIONS.113.000403. Epub 2014 Jul 8. PMID: 25006175
14) Jain R, O’Hair DP, Bajwa TK, et al. Transthoracic echocardiography
is adequate for intraprocedural guidance of transcatheter aortic valve
implantation. Echo Res Pract . 2017;4(4):63-72.
doi:10.1530/ERP-17-0050
15) Zaouter C, Smaili S, Leroux L, Bonnet G, Leuillet S, Ouattara A.
Transcatheter aortic valve implantation: General anesthesia using
transesophageal echocardiography does not decrease the incidence of
paravalvular leaks compared to sedation alone. Ann Card Anaesth .
2018;21(3):277-284. doi:10.4103/aca.ACA_204_17
16) Sherifi I, Omar AMS, Varghese M, et al. Comparison of
transesophageal and transthoracic echocardiography under moderate
sedation for guiding transcatheter aortic valve replacement. Echo
Res Pract . 2018;5(2):79-87. doi:10.1530/ERP-17-0080
17) He W, Huang RR, Shi QY, Liu XB, Wang JA, Yan M. Bispectral
index-guided sedation in transfemoral transcatheter aortic valve
implantation: a retrospective control study. J Zhejiang Univ Sci
B . 2017;18(4):353-359. doi:10.1631/jzus.B1600522
18) Toppen W, Johansen D, Sareh S, et al. Improved costs and outcomes
with conscious sedation vs general anesthesia in TAVR patients: Time to
wake up?. PLoS One . 2017;12(4):e0173777. Published 2017 Apr 5.
doi:10.1371/journal.pone.0173777
19) Ahmad M, Patel JN, Vipparthy SC, et al. Conscious Sedation Versus
General Anesthesia in Transcatheter Aortic Valve Replacement: A Cost and
Outcome Analysis. Cureus . 2019;11(6):e4812. Published 2019 Jun 3.
doi:10.7759/cureus.4812
20) Mosleh W, Mather JF, Amer MR, Hiendlmayr B, Kiernan FJ, McKay RG.
Propensity Matched Analysis Comparing Conscious Sedation Versus General
Anesthesia in Transcatheter Aortic Valve Implantation. Am J Cardiol.
2019 Jul 1;124(1):70-77. doi: 10.1016/j.amjcard.2019.03.042. Epub 2019
Apr 10. PMID: 31064667.
21) Melidi E, Latsios G, Toutouzas K, Vavouranakis M, Tolios I, Gouliami
M, Gerckens U, Tousoulis D. Cardio-anesthesiology considerations for the
trans-catheter aortic valve implantation (TAVI) procedure. Hellenic J
Cardiol. 2016 Nov-Dec;57(6):401-406. doi: 10.1016/j.hjc.2016.10.001.
Epub 2016 Oct 6. PMID: 28375080.
22) Mayr NP, Wiesner G, Husser O, Joner M, Michel J, Knorr J, Pellegrini
C, Bleiziffer S, Schunkert H, Lange R, Tassani-Prell P. Critical adverse
events during transfemoral TAVR in conscious sedation. Is an
anesthesiologic support mandatory? Cardiovasc Revasc Med. 2018
Sep;19(6S):41-46. doi: 10.1016/j.carrev.2018.06.014. Epub 2018 Jun 21.
PMID: 30327095.
23) Goldfuss S, Wittmann S, Würschinger F, et al. Anaesthesia-related
complications and side-effects in TAVI: a retrospective study in
Germany. BMJ Open . 2019;9(4):e025825. Published 2019 May 1.
doi:10.1136/bmjopen-2018-025825
24) Mayr NP, Hapfelmeier A, Martin K, Kurz A, van der Starre P, Babik B,
Mazzitelli D, Lange R, Wiesner G, Tassani-Prell P. Comparison of
sedation and general anaesthesia for transcatheter aortic valve
implantation on cerebral oxygen saturation and neurocognitive outcome†.
Br J Anaesth. 2016 Jan;116(1):90-9. doi: 10.1093/bja/aev294. Epub 2015
Sep 29. PMID: 26424178.
25) van der Wulp K, van Wely M, van Heijningen L, et al. Delirium After
Transcatheter Aortic Valve Implantation Under General Anesthesia:
Incidence, Predictors, and Relation to Long-Term Survival. J Am
Geriatr Soc . 2019;67(11):2325-2330. doi:10.1111/jgs.16087
26) Goudzwaard JA, de Ronde-Tillmans MJAG, de Jager TAJ, et al.
Incidence, determinants and consequences of delirium in older patients
after transcatheter aortic valve implantation. Age Ageing .
2020;49(3):389-394. doi:10.1093/ageing/afaa001
27) Yamamoto M, Meguro K, Mouillet G, Bergoend E, Monin JL, Lim P,
Dubois-Rande JL, Teiger E. Effect of local anesthetic management with
conscious sedation in patients undergoing transcatheter aortic valve
implantation. Am J Cardiol. 2013 Jan 1;111(1):94-9. doi:
10.1016/j.amjcard.2012.08.053. Epub 2012 Oct 12. PMID: 23068861.
28) Hyman MC, Vemulapalli S, Szeto WY, Stebbins A, Patel PA, Matsouaka
RA, Herrmann HC, Anwaruddin S, Kobayashi T, Desai ND, Vallabhajosyula P,
McCarthy FH, Li R, Bavaria JE, Giri J. Conscious Sedation Versus General
Anesthesia for Transcatheter Aortic Valve Replacement: Insights from the
National Cardiovascular Data Registry Society of Thoracic
Surgeons/American College of Cardiology Transcatheter Valve Therapy
Registry. Circulation. 2017 Nov 28;136(22):2132-2140. doi:
10.1161/CIRCULATIONAHA.116.026656. Epub 2017 Sep 1. PMID: 28864443.
29) Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E.
Transfemoral aortic valve implantation under sedation and monitored
anaesthetic care–a feasibility study. Anaesthesia. 2011
Nov;66(11):977-82. doi: 10.1111/j.1365-2044.2011.06788.x. Epub 2011 Sep
20. PMID: 21933156.