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A 77-year-old woman presents for preoperative evaluation prior to a transcatheter aortic valve replacement. According to a recent meta-analysis, risk of which of the following 30-day outcomes will MOST likely be reduced if the procedure is performed with local anesthesia versus general anesthesia?
(A) Paravalvular leak X(B) Acute kidney injury X
(C) Mortality ✔
Gain insight on this topic, and many others, with Summaries of Emerging Evidence (SEE) 2024 – now available. The content is aggregated from 30 international medical journals to streamline your learning and improve your practice.
Over the past decade, transcatheter aortic valve replacement (TAVR) has become the predominant therapy for treating aortic valve stenosis. With advances in technical aspects, delivery systems, and operator and center experience, many institutions have moved from general anesthesia to local anesthesia with conscious sedation or conscious sedation alone for placement of the aortic valve via a percutaneous route. Distinct advantages of general anesthesia include patient unawareness, motion control during the procedure, transesophageal echocardiogram for precision valve placement, and periprocedural pain management. The advantages of conscious sedation are reduced recovery time, fewer adverse effects and risks related to general anesthesia, and lower costs.
Recently, a meta-analysis was performed to compare clinical outcomes of TAVR with general anesthesia versus local anesthesia with conscious sedation or conscious sedation alone. Of the 544 studies screened, 40 were included in the final cohort (1 randomized controlled trial, 7 propensity-matched observational studies, and 32 nonmatched observational cohort studies). The final analysis included 14,388 patients. The local anesthesia/conscious sedation group included 7,700 patients and the general anesthesia group included 6,688 patients. Of note, patients in the local anesthesia/conscious sedation group had a lower Society of Thoracic Surgeons risk score (standard mean difference, –0.23; 95% CI, –0.38 to –0.08) and a lower proportion of diabetic patients (relative risk, 0.91; 95% CI, 0.84–0.98). The primary outcome of the study was 30-day mortality and stroke. Secondary outcomes included 30-day myocardial infarction, acute kidney injury, paravalvular leak, major and life-threatening bleeding, and major vascular complications. Other secondary outcomes included a need for a new pacemaker, new conduction abnormalities, long-term mortality, intraoperative mortality, and length of stays in the hospital and intensive care unit (ICU).
The primary analyses revealed lower 30-day mortality rates when TAVR was performed with local anesthesia/conscious sedation (risk ratio [RR], 0.69; 95% CI, 0.58–0.82) and lower rates of 30-day stroke compared to the general anesthesia group (RR, 0.78; 95% CI, 0.63–0.96). Compared to the general anesthesia group, the local anesthesia/conscious sedation group demonstrated a lower risk of 30-day major bleeding (RR, 0.64; 95% CI, 0.47–0.89), lower rates of 30-day major vascular complications (RR, 0.76; 95% CI, 0.61–0.96), lower risk for need for inotropes (RR, 0.52; 95% CI, 0.39–0.69), shorter ICU stay (SMD, –0.99 days; 95% CI, –1.86 to –0.13 days), shorter hospital stay (SMD, –0.66 days; 95% CI, –0.86 to –0.47 days), and lower rates of long-term mortality (RR, 0.75; 95% CI, 0.61–0.92). No differences were observed in 30-day myocardial infarction (RR, 0.85; 95% CI, 0.25–2.93), 30-day acute kidney injury (RR, 0.92; 95% CI, 0.78–1.10), 30-day paravalvular leak (RR, 0.88; 95% CI, 0.73–1.05), intraoperative mortality (RR, 0.61; 95% CI, 0.33–1.1), new pacemaker implantation (RR, 1.05; 95% CI, 0.94–1.17), or new conduction abnormality (RR, 0.86; 95% CI, 0.58–1.27).
In summary, this meta-analysis revealed that TAVR performed with local anesthesia and conscious sedation or conscious sedation alone was associated with a reduced risk of adverse outcomes and 30-day mortality compared with general anesthesia. Also, the lack of perioperative transesophageal echocardiography in this group of patients was not associated with increased paravalvular leak. While local anesthesia and conscious sedation may be considered acceptable as a primary anesthetic technique for standard TAVR, the final decision needs to be individualized according to patient profile, operator experience, and center facilities.
References
Date of last update: July 9, 2024
