Author + information
- Partho P. Sengupta, MD∗ (, )
- Brandon M. Wiley, MD,
- Sandeep Basnet, MD,
- Anitha Rajamanickman, MD,
- Jason C. Kovacic, MD, PhD,
- Gregory W. Fischer, MD,
- Annapoorna S. Kini, MD and
- Samin K. Sharma, MD
- ↵∗Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, New York 10029
Two- and three-dimensional transesophageal echocardiography (TEE) has played a vital role in transcatheter aortic valve replacement (TAVR) procedures for evaluating aortic annulus and root geometry, device selection, procedural guidance, and assessment of prosthetic valve function. The use of intraprocedural TEE, however, often necessitates the use of general anesthesia (GA) with endotracheal intubation, which may increase procedural time and the potential risks of complications associated with GA. An alternate strategy is the use of transthoracic echocardiography (TTE) so that the TAVR procedure is completed under controlled sedation and analgesia, also referred to as monitored anesthesia care (MAC) (1). In this letter, we summarize our initial experience in performing TTE-guided TAVR under MAC. The procedural outcomes from a group of patients who underwent TEE-guided TAVR under GA were matched on the basis of the mean EuroSCORE II values and used as a comparison cohort.
We included all patients who underwent TAVR through the transfemoral approach (either percutaneous or direct arterial cut down) from May 1, 2012 to August 30, 2014. Both TEE and TTE were performed with the use of a Vivid 9 imaging platform (GE Healthcare, Waukesha, Wisconsin). Valve sizing was determined by means of multidetector computed tomography. Fluoroscopic guidance was used in all cases. Anesthesia was administered and monitored by a cardiac anesthesiologist. General anesthesia consisted of tracheal intubation facilitated with a paralytic and induction agent. Anesthesia was maintained with inhaled anesthetics and intravenous opioids. MAC was administered with the use of infusions of either dexmedetomidine or propofol in combination with intravenous opioids and local anesthesia (2.0% lidocaine with 0.5% bupivacaine) applied to the femoral access site. Both cohorts were monitored with insertion of a central venous catheter, pulmonary artery catheter, temporary right ventricular pacemaker, and invasive arterial blood pressure catheter. The 2 groups were compared by use of standard statistical methods for continuous and categorical variables, with differences considered statistically significant at p < 0.05.
The study population included 111 patients, of whom 64 underwent TAVR with TEE (GA) and 47 underwent TTE (MAC). The Edwards-SAPIEN THV (Edwards Lifesciences, Irvine, California) was placed in 50 of the TEE cohort and in 9 of the TTE cohort. The remainder of the patients received the CoreValve prosthesis. Two patients in the TTE cohort were converted to TEE because of inadequate transthoracic windows. The baseline characteristics are presented in Table 1.
Outcome data were statistically similar between the cohorts with regard to procedural success, degree of paravalvular regurgitation, need for additional valve implantation, or complications such as peri-procedural stroke or death (Table 1). Procedural time was longer in the TEE (GA) cohort (p < 0.001) and related to the time needed for weaning off the ventilator. The median length of stay was 6 days in both groups and was not affected by type of valve. The similar length of stay was related to our institutional policy that required monitoring for 48 h in the intensive care unit, irrespective of the type of anesthesia or valve implanted.
Although this is a retrospective study with a modest sample size and relative heterogeneity with respect to type of valve implanted, our data suggest that TAVR can be safely performed with the use of TTE guidance under MAC. These findings require larger, prospective, multicenter studies to more clearly define potential benefits such as shorter procedural times, decreased length of stay, and reduced hospital costs.
Please note: Dr. Kovacic has received grant support from AstraZeneca. Dr. Sharma has received speaker’s fees from Boston Scientific Corporation, Abbott Vascular Inc., AngioScore, DSI/Lilly Inc., and ABIOMED, CSI. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Sherif Nagueh, MD, has served as the Guest Editor for this article.
- American College of Cardiology Foundation