Sedation or general anesthesia for patients undergoing transcatheter aortic valve implantation--does it affect outcome? An observational single-center study.

UNLABELLED: Aortic stenosis is one of the most common valvular lesions. Nowadays, a new treatment is emerging: the transcatheter aortic valve implantation (TAVI). It is considered a suitable alternative for the surgical approach in selected high-risk patients. This procedure may be performed under sedation (SED) or under general anesthesia (GEA). STUDY OBJECTIVE: Assess the feasibility and safety of TAVI under sedation. DESIGN: Observational study. SETTING: Single-center study conducted between the years 2009 and 2012. PATIENTS: A total of 204 American Society of Anesthesiologists physical status 3 to 4 patients who underwent TAVI in the study period and for whom complete data were obtained were included. Demographic and periprocedural data were acquired from the patients' files. The patients were divided into SED and GEA groups. INTERVENTIONS: The study was not an interventional study. MEASUREMENTS: The study did not include measurements. MAIN RESULTS: The 2 groups had similar demographic characteristics and echocardiographic parameters. The rate of conversion from SED to GEA was 4.6%. The SED group received significantly less catecholamines and intravenous fluids during the procedure. The total procedural time was significantly shorter for the SED group. There was a trend toward more postprocedural pulmonary complications in the GEA group. In-hospital mortality and total length of stay were similar between the groups. CONCLUSIONS: The results of the current study, which included a relatively large number of patients, suggest that both anesthetic modalities are safe for patients undergoing TAVI. The anesthesiologist should thus tailor the anesthetic approach to the patient, taking into account the team's experience as well as the hemodynamic status of the patient. With growing experience, our team recommends performing TAVI under SED and in selected cases under GEA.

Transcatheter aortic valve implantation: a single-center experience of 300 cases.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has recently become an alternative to surgical aortic valve replacement in selected patients with high operative risk. OBJECTIVES: To investigate the 30 day clinical outcome of the first 300 consecutive patients treated with transfemoral TAVI at the Tel Aviv Medical Center. METHODS: The CoreValve was used in 250 patients and the Edwards-Sapien valve in 50. The mean age of the patients was 83 +/- 5.3 years (range 63-98 years) and the mean valve area 0.69 +/- 0.18 cm2 (range 0.3-0.9 cm2); 62% were women. RESULTS: The procedural success rate was 100%, and 30 day follow-up was done in all the patients. The average Euro-score for the cohort was 26 +/- 13 (range 1.5-67). Total in-hospital mortality and 30 day mortality were both 2.3% (7 patients). Sixty-seven patients (22%) underwent permanent pacemaker implantation after the TAVI procedure, mostly due to new onset of left bundle brunch block and prolonged PR interval or to high degree atrioventricular block. The rate of stroke was 1.7% (5 patients). Forty-one patients (13.7%) had vascular complications, of whom 9 (3%) were defined as major vascular complications (according to the VARC definition). CONCLUSIONS: The 30 day clinical outcome in the first 300 consecutive TAVI patients in our center was favorable, with a mortality rate of 2.3% and low rates of stroke (1.7%) and major vascular complications (3%).

Higher levels of serum cytokines and myocardial tissue markers during on-pump versus off-pump coronary artery bypass surgery.

Increased Troponin I levels and pro-inflammatory cytokines have been reported in most patients undergoing cardiac surgery, ascribed to the type and extent of surgery, reperfusion injury, and the method of myocardial protection. We investigated their levels in patients undergoing on-pump (CCAB) or off-pump (OPCAB) coronary artery bypass surgery and whether these correlated with the extent of myocardial injury. One hundred twenty patients were prospectively randomized to undergo OPCAB (n = 60) or CCAB (n = 60). Hemodynamic and respiratory data, as well as serum CK-MB mass fraction, Troponin I, and interleukin (IL)-6, IL-8, and IL-10 levels, were collected perioperatively. Demographic, hemodynamic, and respiratory parameters were similar between the two groups. Troponin I was significantly lower in the OPCAB than in the CCAB group, either at the end of ischemia, end of surgery, 6-hour and 24-hour postoperatively (4 +/- 3, 5 +/- 3, 7 +/- 5, and 8 +/- 3 microg/L, vs. 19 +/- 18, 27 +/- 19, 28 +/- 13.5, and 33 +/- 8.5 microg/L, respectively, p < 0.05). Serum cytokine levels in the OPCAB patients were lower compared to the CCAB group at the end of surgery (32 +/- 35, 25 +/- 30, and 40 +/- 30 pg/ml for IL-6, IL-8, and IL-10 vs. 230 +/- 30, 140 +/- 70, and 125 +/- 50 pg/ml, respectively, p < 0.05). Plasma IL-6 levels correlated with the Troponin I levels at the end of surgery in both groups (r = 0.45, p = 0.01). Thus, OPCAB surgery is associated with reduced levels of Troponin I and activation of cytokines, compared to those in the CCAB group. High levels of these factors could correlate with myocardial damage during coronary artery bypass surgery. This finding warrants further laboratory and clinical confirmation in the future.