The number of TAVR procedures performed under local anesthesia with or without conscious sedation is rising (3,11). According to Transcatheter Valve Therapy Registry analyzing 120,080 TF-TAVR patients between January 2016 and March 2019 in the U.S., the use of LACS increased substantially from 33–64%, but 17% of the U.S. centers continued to use GA exclusively (11). In Taiwan, TF-TAVR procedures performed under LACS were still less than 50%. Which anesthetic management is more favorable for TF-TAVR is now a subject of intense debate, leading to a considerable variation in clinical practice. Based on the results of this single center study, LACS is not only a feasible alternative to conventional GA for TF-TAVR, but also results in less resource usage, comparable with the observations in previous registries (4–6,11). Practicing this “minimalist” approach, improved clinical outcomes with very limited 30-days (4/175, 2.2%) and 1-year mortality (13/175, 7.4%) could be achieved in a center with an annual TAVR case number less than 100.
Most centers started TAVR procedure with GA. But with increasing experience and familiarity with devices, operators tend to switch from GA to LACS (13). The results of previous registries (2–6,11,13,14) investigating LACS versus GA in TF-TAVR were therefore unavoidably confounded by experiential heterogeneity (2). Despite statistical maneuvers such as propensity matching, these results may merely reflect differences in patient selection and learning curve over time, instead of the switching from GA to LACS itself. To clarify the effect of TAVR experience and background heterogeneity, we divided 175 LACS TF-TAVR patients in the present analysis into 2 groups. With similar experiential and risk background (STS mortality score: GA group vs LACS group 1 = 7.4 ± 4.6 vs 6.8 ± 4.4, P = 0.548) as compared to GA group, significantly less contrast medium consumption (245.6 ± 92.6 ml vs 207.8 ± 77.9 ml, P = 0.05), shorter procedure time (157.6 ± 39.4 mins vs 131.6 ± 30.3 mins, P = 0.001), ICU stay (2 [1–5] days vs 2 [1–3] days, P = 0.009) and less in-hospital medical fee (267906 [193116–380331] vs 209398 [151889–314497], P = 0.0297) were still observed in LACS group 1. Although the effect of improvement in technical skills can never be ruled out, the results could still be attributed to the “minimalist” approach: simplification of the anesthetic strategies and access pre-closure.
Tracheal intubation with mechanical ventilation, indwelling urinary tract catheters, hemodynamic instability, and prolonged hospitalization associated with GA may increase the risk of infection. Interestingly, TAVR peri-procedural infections were never reported in previous single center reports (15,16), or registry studies (4–6, 11, 12, 14) comparing of anesthetic managements. Peri-procedural infection is not part of the endpoints in Valve Academic Research Consortium (VARC), except for infective endocarditis after TAVR (8,9). In the SOLVE-TAVI trial, infections requiring antibiotic treatment occurred in one-fifth of the patients, mainly attributable to pneumonia and urinary tract infection. The incidences of overall infections were reported similar between GA & LACS groups, but the risk of pneumonia was not mentioned specifically (7). In our cohort, the incidence of hospital acquired pneumonia (HAP) in GA group was 2-times higher than that in LACS group 1 and 2, although not statistically significant due to sample size. Significantly lower HAP rate, however, was seen in LACS group 2 comparing to that in GA group, but this was probably confounded by the different risk profile of the patient populations.
Lower incidence of in-hospital gastro-intestinal (GI) bleeding was also found in the LACS groups in the present study, which was never reported in previous registries or randomized trial comparing GA versus LACS in TAVR. GI bleeding was included in major and minor bleeding complications in VARC definition, and was not counted independently (7,8). Stanger et al reported a retrospective single center evaluation of 841 TAVR patients, and overall risk of upper GI bleeding following TAVR was found to be 2.0% (17/841) (17). Patients on triple antithrombotic therapy are at highest risk for severe upper GI bleeding. Upper endoscopy evaluation or treatment was done in 12 patients, and the most common lesion was a distal esophageal or gastroesophageal junction ulceration with active bleeding. They postulated that the use of intraoperative TEE, which may cause local mechanical and thermal trauma, was the reason for these findings. The mechanism and impact of in-hospital GI bleeding following TAVR should be studied further in the future.
The present study has a number of limitations. Firstly, this is a single center study with a relatively small consecutive cohort. The 2 discussed anesthetic strategies were chosen arbitrarily over time without randomization. Secondly, because of the chronological nature of the study, the results may be confounded by differences in procedure experience and patient risk profiles, as well as the simultaneous introduction of other technological advances in TAVR, such as newer generation of valve systems. Thirdly, the actual anesthetic agents and dosages applied in LACS or GA were not pre-specified or controlled, and their potential influence on the outcome was difficult to be examined by the present study.