A logistic regression analysis comparing minimalistic approach and intubation anaesthesia in patients undergoing transfemoral transcatheter aortic valve replacement.

Alexander Maier,Constantin Von Zur Mühlen,Wolfgang Bothe,Klaus Kaier,Holger Schröfel,Benedikt Hammerich,Thomas Brieschal,Timo Heidt,Manfred Zehender,Christoph Bode,Jochen Reinöhl,Peter Stachon,Frank Humburger,Marc W Merx

doi:10.1371/journal.pone.0227345

Alexander Maier, Constantin Von Zur Mühlen + Show 12 more

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https://doi.org/10.1371/journal.pone.0227345

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Abstract

AimsPatients with postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR) are ventilated and hospitalized longer and suffer increased in-hospital mortality. This study hypothesized that a minimalistic approach with conscious sedation during transfemoral aortic valve replacement (TF-AVR) protects against delirium, time of mechanical ventilation, and increased length of stay in intensive care unit (ICU) compared to intubation anaesthesia.Methods and results308 patients which underwent TF-AVR in our centre between 01/2013 and 08/2017 were retrospectively evaluated regarding postoperative delirium, time of mechanical ventilation, and days in ICU. TF-AVR was performed with intubation anaesthesia in 245 patients and with conscious sedation in 63. The operative risk estimated by the logEUROScore was similar in both groups (intubation: 13.28 +/-9.06%, conscious sedation: 12.24 +/-6.77%, p = 0.395). In the conscious sedation group procedure duration was shorter (0.61 +/-0.91h vs. 1.75 +/-0.96h, p<0.001). The risk for intraprocedural complications was not influenced by the anaesthesia method (OR conscious sedation instead of intubation 1.66, p = 0.117), but days on ICU (-2.21 days, p<0.0001) and minutes of mechanical ventilation (-531.2 min, p < 0.0001) were reduced. Furthermore, the risk of POD was decreased when TF-AVR was performed under conscious sedation (6.35% vs. 18.18%, OR 0.29, p = 0.021).ConclusionsTime of mechanical ventilation, risk of POD, and days on ICU were substantially reduced in patients who underwent TF-AVR under conscious sedation. Our data suggest that TF-AVR with conscious sedation is safe with a beneficial postoperative course in clinical practice, and should be considered the favoured approach.

Highlights

Transcatheter aortic valve replacement (TAVR) is the standard care for patients with highgrade aortic valve stenosis at increased operative risk
Risk of postoperative delirium (POD), and days on intensive care unit (ICU) were substantially reduced in patients who underwent transfemoral aortic valve replacement (TF-AVR) under conscious sedation
Our data suggest that TF-AVR with conscious sedation is safe with a beneficial postoperative course in clinical practice, and should be considered the favoured approach

Summary

Introduction

Transcatheter aortic valve replacement (TAVR) is the standard care for patients with highgrade aortic valve stenosis at increased operative risk. Patients with severe aortic valve stenosis often are at high risk for postoperative delirium (POD) due to pre-existing conditions such as dementia, advanced age, heart failure, or atrial fibrillation [8]. POD is defined as a potentially lethal state caused by acute or subacute brain failure with disturbance of consciousness, hyper- or hypoactivity, and disorientation or perceptual disturbance. It may trigger cognitive decline and lasting dementia [9,10,11]. Higher NYHA class, and atrial fibrillation are risk factors for POD [8]. Patients with POD after TAVR were ventilated and hospitalized longer and suffered an increased risk for in-hospital mortality [8]

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Conclusion