Conscious Sedation Compared With General Anesthesia for TAVR

December 1, 2017—A study comparing conscious sedation versus general anesthesia for transcatheter aortic valve replacement (TAVR) was published by Matthew C. Hyman, MD, et al in Circulation (2017;136:2132–2140).

The investigators found that in United States practice, TAVR with conscious sedation is associated with a briefer length of stay and lower in-hospital and 30-day mortality when compared to TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, although comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another, concluded the investigators in Circulation.

The background of the study is that conscious sedation is used during TAVR with limited evidence as to the safety and efficacy of this practice.

In the study, the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to characterize the anesthesia choice and clinical outcomes of all patients in the United States undergoing elective percutaneous transfemoral TAVR between April 1, 2014 and June 30, 2015.

The investigators performed raw and inverse probability of treatment-weighted analyses to compare patients undergoing TAVR with general anesthesia to patients undergoing TAVR with conscious sedation on an intention-to-treat basis for the primary outcome of in-hospital mortality. Secondary outcomes included 30-day mortality, in-hospital and 30-day death/stroke, procedural success, intensive care unit and hospital length of stay, and rates of discharge to home. Post hoc falsification endpoint analyses were performed to evaluate for residual confounding.

As summarized in Circulation, conscious sedation was used in 1,737 of 10,997 (15.8%) cases with a significant trend of increasing usage over the time period studied (P for trend < .001). In raw analyses, intraprocedural success with conscious sedation and general anesthesia was similar (98.2% vs 98.5%; P = .31). The conscious sedation group was less likely to experience in-hospital (1.6% vs 2.5%; P = .03) and 30-day death (2.9% vs 4.1%; P = .03).

Conversion from conscious sedation to general anesthesia was noted in 102 of 1,737 (5.9%) conscious sedation cases. After inverse probability of treatment-weighted adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% vs 98.6%; P < .001) and a reduced rate of mortality at the in-hospital (1.5% vs 2.4%; P < .001) and 30-day (2.3% vs 4%; P < .001) time points. Conscious sedation was associated with reductions in procedural inotrope requirement, intensive care unit and hospital length of stay (6 vs 6.5 days; P < .001), and combined 30-day death/stroke rates (4.8% vs 6.4%; P < .001). Falsification endpoint analyses of vascular complications, bleeding, and new pacemaker/defibrillator implantation demonstrated no significant differences between groups after adjustment, reported the investigators in Circulation.