Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation

Abstract

Most transcatheter aortic valve replacement (T-AVR) using the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA) is done under general anesthesia. The present study aimed to examine the feasibility and safety of T-AVR under monitored anesthesia care and aimed to compare the clinical outcome to the outcome of patients who underwent general anesthesia. The analysis included 92 consecutive patients undergoing T-AVR via the transfemoral approach guided by transesophageal echocardiography using the Edwards SAPIEN valve. The cohort was divided into two groups: I, monitored anesthesia care (n=70; 76.1%) and II, intubation (n=22; 23.9%). Monitored anesthesia care was given by anesthesiologists in one of two protocol regimens: Ketamine & Propofol or Dexmedetomidine. The crossover rate to general anesthesia and the clinical outcome of these two groups were compared. Baseline clinical characteristics of the two groups were similar, except for higher logistic EuroSCORE and prior stroke in the monitored anesthesia care group. Surgical access of the femoral artery was performed in 15 (68.1%) from the general anesthesia group and in 24 (34.2%) from the monitored anesthesia care group, p=0.05. The median procedure duration was significantly lower in the monitored anesthesia care group (91 vs. 155min, p=0.008) and there was a trend to lower median intensive care unit stay and hospital stay (27 vs. 72h, p=0.07 and 5 vs. 7.5days, p=0.06, respectively). Of the patients with monitored anesthesia care, 8 (11.4%) converted to general anesthesia. T-AVR using the Edwards SAPIEN valve can be performed in the majority of cases with controlled monitored anesthesia care, thereby avoiding the necessity of general anesthesia and resulting in shorter procedure time and in-hospital length of stay.