Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone

Background: Transcatheter aortic valve implantation (TAVI) is a valid option for patients with severe aortic stenosis judged to be at high surgical risk. For this procedure, there is no agreement on the appropriate type of anesthesia. Sedation offers several advantages, but general anesthesia (GA) leads to less paravalvular leaks (PVLs) probably because of the transesophageal echocardiography (TEE) guidance. The objective was to compare the incidence of PVL among patients receiving conscious sedation (TAVI-S) and patients receiving GA (TAVI-GA). We made the hypothesis that a referral center does not necessitate TAVI-GA to reduce the incidence of moderate-to-severe PVL. Aim: The primary outcome was the incidence of moderate-to-severe PVL at 30 days after the implantation. Design and Setting: This study design was a retrospective observational trial in a university hospital. Methods: The TAVI-S group underwent the procedure under conscious sedation. In the TAVI-GA group, an endotracheal tube and a TEE probe were inserted. After the valve deployment, PVL was assessed by hemodynamic and fluoroscopic measurements in the TAVI-S group. TEE was also used in the TAVI-GA group to evaluate the presence of PVL. When PVL was moderate or severe according to the Valve Academic Research Consortium criteria. Results: TAVI-S and TAVI-GA were accomplished in 168 (67.5%) and 81 (32.5%) patients, respectively. Our results show no difference between the two groups regarding the incidence and grade of PVL. Conclusion: Performing TAVI under GA with TEE guidance is not associated with a lower incidence of moderate and severe PVL.

Sugammadex - A short review and clinical recommendations for the cardiac anesthesiologist.

This review outlines the basic pharmacodynamic and pharmacokinetic properties of sugammadex for the cardiac anesthesiologist. It describes the different clinical scenarios when sugammadex can be used during cardiac surgery and gives clinical recommendations. Sugammadex is a unique reversal drug that binds a chemical complex with rocuronium and vecuronium, by which the neuromuscular blockade is quickly reversed. It is free of any clinical side-effects and doses of 2 mg/kg or more reliably reverse neuromuscular blockade within 5-15 min, depending on the depth of the neuromuscular blockade. Doses below 2 mg/kg should be avoided at any time because of the inherent risk of recurarization. Sugammadex should not replace good clinical practice - titration of neuromuscular blocking drugs to clinical needs and objective monitoring of neuromuscular blockade in the operating room or intensive care unit. Neuromuscular transmission should be determined in all patients before sugammadex is considered and 5 min after its administration to ensure that extubation is performed with normal neuromuscular transmission.

Sevoflurane causes less arrhythmias than desflurane after off-pump coronary artery bypass grafting: A pilot study.

Background: Volatile anesthetics provide myocardial protection during cardiac surgery. Sevoflurane and desflurane are both efficient agents that allow immediate extubation after off-pump coronary artery bypass grafting (OPCABG). This study compared the incidence of arrhythmias after OPCABG with the two agents. Materials and Methods: Forty patients undergoing OPCABG with immediate extubation and perioperative high thoracic analgesia were included in this controlled, double-blind study; anesthesia was either provided using 1 MAC of sevoflurane (SEVO-group) or desflurane (DES-group). Monitoring of perioperative arrhythmias was provided by continuous monitoring of the EKG up to 72 hours after surgery, and routine EKG monitoring once every day, until time of discharge. Patient data, perioperative arrhythmias, and myocardial protection (troponin I, CK, CK-MB-ratio, and transesophageal echocardiography examinations) were compared using t-test, Fisher's exact test or two-way analysis of variance for repeated measurements; P < 0.05. Results: Patient data and surgery-related data were similar between the two groups; all the patients were successfully extubated immediately after surgery, with similar emergence times. Supraventricular tachycardia occurred only in the DES-group (5 of 20 patients), atrial fibrillation was significantly more frequent in the DES group versus SEVO-group, at five out of 20 versus one out of 20 patients, respectively. Myocardial protection was equally achieved in both groups. Discussion: Ultra-fast track anesthesia using sevoflurane seems more advantageous than desflurane for anesthesia, for OPCABG, as it is associated with significantly less atrial fibrillation or supraventricular arrhythmias after surgery.