Advertisement

Current Anesthesiology Reports

, Volume 7, Issue 3, pp 283–290 | Cite as

General Anesthesia or Monitored Anesthesia Care for Transfemoral Transcatheter Aortic Valve Implantation: Current Trends and Future Directions

  • Jan-Oliver Friess
  • Kalgini Durrer Ariyakuddy
  • Balthasar Eberle
  • Gabor ErdoesEmail author
Cardiovascular Anesthesia (J Fassl, Section Editor)
  • 94 Downloads
Part of the following topical collections:
  1. Topical Collection on Cardiovascular Anesthesia

Abstract

Purpose of Review The purpose of this chapter is to provide a brief review on current anesthesia techniques for transfemoral transcatheter aortic valve implantation (TF-TAVI). Recent Findings TF-TAVI has become a standard treatment option for high risk patients with severe aortic stenosis. Increasing experience with prosthetic durability and equivalent or superior outcomes of transcatheter over surgical aortic valve replacement will boost the caseload of high- and intermediate-risk patients. For TF-TAVI, general anesthesia (GA) had initially been widely preferred over local anesthesia with monitored anesthesia care (LA-MAC), but with large national practice variation. Institutional routines are changing now since evidence from large registries accrues that LA-MAC represents a feasible, safe, and economically sound alternative to GA, if no contraindications apply. Although prospective randomized TAVI anesthesia trials are lacking, observational data show that GA is associated with higher patient risk, longer procedural time, more vasopressor and transfusion requirement, and more resource use and costs, whereas periprocedural mortality is comparable or non-significantly better with LA-MAC. In summary, GA remains a robust solution for specific situations and teams. In many experienced centers, however, LA-MAC has become first choice whenever possible. Whether LA-MAC is an option should be decided upon by the anesthesiologist and the heart team in consultation with the patient, following prospectively defined decision pathways. With increasing caseload and decreasing invasiveness of TAVI technology, anesthesia providers must meet the challenge to reduce resource use and costs without compromising patient safety and satisfaction.

Keywords

Transfemoral TAVI General anesthesia Sedation Vasopressor Transfusion Outcome 

Notes

Compliance with Ethical Standards

Conflict of Interest

Jan-Oliver Friess declares that he has no conflict of interest.

Kalgini Durrer Ariyakuddy declares that she has no conflict of interest.

Balthasar Eberle has received speaker’s honoraria from Medtronic.

Gabor Erdoes declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135:e146–603. doi: 10.1161/CIR.0000000000000485.CrossRefPubMedGoogle Scholar
  2. 2.
    Danielsen R, Aspelund T, Harris TB, Gudnason V. The prevalence of aortic stenosis in the elderly in Iceland and predictions for the coming decades: the AGES-Reykjavík study. Int J Cardiol. 2014;176:916–22. doi: 10.1016/j.ijcard.2014.08.053.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Chizner MA, Pearle DL, deLeon AC. The natural history of aortic stenosis in adults. Am Heart J. 1980;99:419–24.CrossRefPubMedGoogle Scholar
  4. 4.
    Leon MB, Smith CR, Mack M. et al; PARTNER trial investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.CrossRefPubMedGoogle Scholar
  5. 5.
    Sharabiani MTA, Fiorentino F, Angelini GD, Patel NN. Long-term survival after surgical aortic valve replacement among patients over 65 years of age. Open Heart. 2016;3:e000338. doi: 10.1136/openhrt-2015-000338.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Authors/Task Force Members, Vahanian A, Alfieri O, et al. Guidelines on the management of valvular heart disease (version 2012): the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012;33:2451–96. doi: 10.1093/eurheartj/ehs109.CrossRefGoogle Scholar
  7. 7.
    Cribier A. Development of transcatheter aortic valve implantation (TAVI): a 20-year odyssey. Arch Cardiovasc Dis. 2012;105:146–52. doi: 10.1016/j.acvd.2012.01.005.CrossRefPubMedGoogle Scholar
  8. 8.
    Saji M, Lim DS. Transcatheter aortic valve replacement in lower surgical risk patients: review of major trials and future perspectives. Curr Cardiol Rep. 2016;18:103. doi: 10.1007/s11886-016-0772-3.CrossRefPubMedGoogle Scholar
  9. 9.
    Mylotte D, Osnabrugge RLJ, Windecker S, et al. Transcatheter aortic valve replacement in Europe: adoption trends and factors influencing device utilization. J Am Coll Cardiol. 2013;62:210–9. doi: 10.1016/j.jacc.2013.03.074.CrossRefPubMedGoogle Scholar
  10. 10.
    Osnabrugge RLJ, Mylotte D, Head SJ, Van Mieghem NM, Nkomo VT, LeReun CM, et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J Am Coll Cardiol. 2013;62:1002–12. doi: 10.1016/j.jacc.2013.05.015.CrossRefPubMedGoogle Scholar
  11. 11.
    Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–20. doi: 10.1056/NEJMoa1514616.CrossRefPubMedGoogle Scholar
  12. 12.
    Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017;376:1321–31. doi: 10.1056/NEJMoa1700456.CrossRefPubMedGoogle Scholar
  13. 13.
    Mayr NP, Michel J, Bleiziffer S, Tassani P, Martin K. Sedation or general anesthesia for transcatheter aortic valve implantation (TAVI). J Thorac Dis. 2015;7:1518–26. doi: 10.3978/j.issn.2072-1439.2015.08.21.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Fröhlich GM, Lansky AJ, Webb J, Roffi M, Toggweiler S, Reinthaler M, et al. Local versus general anesthesia for transcatheter aortic valve implantation (TAVR)—systematic review and meta-analysis. BMC Med. 2014;12:41. doi: 10.1186/1741-7015-12-41.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Mayr NP, Hapfelmeier A, Martin K, Kurz A, van der Starre P, Babik B, et al. Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome. Br J Anaesth. 2016;116(1):90–9. doi: 10.1093/bja/aev294.CrossRefPubMedGoogle Scholar
  16. 16.
    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;27:385–90. doi: 10.1016/j.jclinane.2015.03.025.CrossRefPubMedGoogle Scholar
  17. 17.
    Petronio AS, Giannini C, De Carlo M, et al. Anaesthetic management of transcatheter aortic valve implantation: results from the Italian CoreValve registry. EuroIntervention. 2016;12:381–8. doi: 10.4244/EIJY15M03_05.CrossRefPubMedGoogle Scholar
  18. 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:e0173777. doi: 10.1371/journal.pone.0173777. Cost analysis of a single center with retrospective evidence for cost effectiveness of LA-MAC CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    • Kiramijyan S, Ben-Dor I, Koifman E, et al. Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med. 2016;17:384–90. doi: 10.1016/j.carrev.2016.02.003. Single center experience with retrospective analysis of indications for intraprocedural conversion from LA-MAC to GA CrossRefPubMedGoogle Scholar
  20. 20.
    • Brecker SJD, Bleiziffer S, Bosmans J, Gerckens U, Tamburino C, Wenaweser P, et al. ADVANCE study investigators. Impact of anesthesia type on outcomes of transcatheter aortic valve implantation (from the multicenter ADVANCE study). Am J Cardiol. 2016;117:1332–8. doi: 10.1016/j.amjcard.2016.01.027. A multicenter, secondary analysis showing that there are large national differences in utilization of LA-MAC vs. GA. CrossRefPubMedGoogle Scholar
  21. 21.
    D'Errigo P, Ranucci M, Covello RD, et al. Outcome after general anesthesia versus monitored anesthesia care in transfemoral transcatheter aortic valve replacement. J Cardiothorac Vasc Anesth. 2016;30:1238–43. doi: 10.1053/j.jvca.2016.05.034.CrossRefPubMedGoogle Scholar
  22. 22.
    Jabbar A, Khurana A, Mohammed A, Das R, Zaman A, Edwards R. Local versus general anesthesia in transcatheter aortic valve replacement. Am J Cardiol. 2016;118:1712–6. doi: 10.1016/j.amjcard.2016.08.051.CrossRefPubMedGoogle Scholar
  23. 23.
    Roten L, Wenaweser P, Delacrétaz E, et al. Incidence and predictors of atrioventricular conduction impairment after transcatheter aortic valve implantation. Am J Cardiol. 2010;106:1473–80. doi: 10.1016/j.amjcard.2010.07.012.CrossRefPubMedGoogle Scholar
  24. 24.
    Cribier A, Eltchaninoff H, Bash A, Borenstein N. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis. Circulation Circulation. 2002;106(24):3006–8. doi: 10.1161/01.CIR.0000047200.36165.B8.CrossRefPubMedGoogle Scholar
  25. 25.
    Cerrato E, Nombela-Franco L, Nazif TM, et al. Evaluation of current practices in transcatheter aortic valve implantation: the WRITTEN (WoRldwIde TAVI ExperieNce) survey. Int J Cardiol. 2017;228:640–7. doi: 10.1016/j.ijcard.2016.11.104.CrossRefPubMedGoogle Scholar
  26. 26.
    Bufton KA, Augoustides JG, Cobey FC. Anesthesia for transfemoral TAVR in North America and Europe. J Cardiothor Vasc Anesth. 2013;27:46–9. doi: 10.1053/j.jvca.2012.08.008.CrossRefGoogle Scholar
  27. 27.
    Kappetein AP, Head SJ, Généreux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the valve academic research consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg. 2012;42:S45–60. doi: 10.1093/ejcts/ezs533.CrossRefPubMedGoogle Scholar
  28. 28.
    GALA Trial Collaborative Group, Lewis SC, Warlow CP, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372:2132–42. doi: 10.1016/S0140-6736(08)61699-2.CrossRefGoogle Scholar
  29. 29.
    Bruder EA, Ball IM, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015;1:CD010225. doi: 10.1002/14651858.CD010225.pub2.PubMedGoogle Scholar
  30. 30.
    Lamperti M. Adult procedural sedation: an update. Curr Opin Anaesthesiol. 2015;28:662–7. doi: 10.1097/ACO.0000000000000244.CrossRefPubMedGoogle Scholar
  31. 31.
    Wutzler A, Huemer M, Boldt L-H, Parwani AS, Attanasio P, Tscholl V, et al. Effects of deep sedation on cardiac electrophysiology in patients undergoing radiofrequency ablation of supraventricular tachycardia: impact of propofol and ketamine. Europace. 2013;15:1019–24. doi: 10.1093/europace/eut025.CrossRefPubMedGoogle Scholar
  32. 32.
    Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;77:1125–1. doi: 10.1093/europace/eut025.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Jan-Oliver Friess
    • 1
  • Kalgini Durrer Ariyakuddy
    • 1
  • Balthasar Eberle
    • 1
  • Gabor Erdoes
    • 1
    Email author
  1. 1.Department of Anesthesiology and Pain Therapy, InselspitalUniversity Hospital Bern, University of BernBernSwitzerland

Personalised recommendations