Transkateter aort kapak replasmanı için genel anesteziye karşı lokal anestezi

Yıl 2023, Cilt: 3 Sayı: 2, 68 - 75, 21.08.2023

Serhat Günlü Fethullah Kayan Tuncay Güzel Adem Aktan Muhammed Raşit Tanırcan Mehmet Zülkif Karahan

https://doi.org/10.58961/hmj.1317761

Öz

Arka plan/Amaçlar: Transkateter aort kapak replasmanı (TAVR), anestezi yönetimi açısından önemli zorluklar doğurur. TAVR prosedürleri için daha güvenli anestezi türü konusunda fikir birliği yoktur. Sedasyonlu lokal anestezi (LAS) altında transfemoral yaklaşımla yapılan TAVR'nin genel anesteziye (GA) karşı etkinlik ve güvenilirliğini değerlendirmeyi amaçladık.

Yöntemler: Bu gözlemsel ve retrospektif analiz, 2016'dan 2022'ye planlı olarak başvuran ve Transfemoral TAVR uygulanan bireyleri içermektedir. Etkinlik ve güvenlik sonuçları 30 günde değerlendirildi. Bireyler GA ve LAS olmak üzere iki gruba ayrıldı. Hastanede yatışları sırasında demografik özellikler ve prosedürel veriler kaydedildi.
Bulgular: 62'sine (%53.9) LAS, 53'üne GA (%46.1) olmak üzere 115 hasta dahil edildi. Çalışmaya yaş ortalaması 83,2±5,7 olan 59 kadın (%48.8) hasta katıldı. Transfemoral yaklaşımla 115 hastanın 100'üne (%86.9) başarılı TAVR işlemi uygulandı. Ortalama işlem süresi 136.7±46.7 dakika olup GA'ya karşı LAS yapılan hastalarda işlem süresi daha kısaydı (p=0.001). Gruplar arasında floroskopi süresi, kontrast ve radyasyon dozu açısından fark yoktu (p>0.05). 2 hastada (%3.2) önemli vasküler komplikasyonlar acil cerrahi girişim gerektirdi ve anestezi tekniğinde değişiklik yapılmasını gerektirdi. Genel 30 günlük mortalite %5.2 idi ve gruplar arasında önemli bir fark yoktu (GA %7.5'e karşılık LAS %3.2, p =0.28). GA, LAS'tan önemli ölçüde daha uzun YBÜ ve toplam hastanede kalış süresine sahipti (sırasıyla p=0.009 ve p =0.004).
Sonuç: Çalışmamızda LAS kullanılarak transfemoral yoldan TAVR, GA'ya bir alternatifti.

Anahtar Kelimeler

Lokal anestezi, aort stenozu, transfemoral TAVR

Local against general anesthesia for transcatheter aortic valve replacement

Öz

Background/Aims: Transcatheter aortic valve replacement (TAVR) poses significant challenges concerning anesthesia management. There is no consensus on the type of safer anesthesia for TAVR procedures. We aimed to evaluate the effectiveness and safety of TAVR performed with trans-femoral approach under local anesthesia with sedation (LAS) against general anesthesia (GA).
Methods: This observational and retrospective analysis included individuals who were admitted on a planned basis from 2016 to 2022 and underwent Transfemoral TAVR. Effectiveness and safety outcomes were evaluated at 30 days. İndividuals were separated into two groups: GA and LAS. Demographic characteristics and procedural data were recorded during hospitalization.
Results: 115 patients were included, of whom 62 (53.9%) received LAS and 53 received GA (46.1%). 59 female (48.8%) patients with a mean age of 83.2±5.7 participated in the study. Successful TAVR procedure was performed in 100 (86.9%) of 115 patients with the transfemoral approach. The mean procedure time was 136.7±46.7 minutes, and the procedure time was shorter in patients who underwent LAS against GA (p=0.001). There were no differences among the groups including fluoroscopy time, contrast, and radiation dose (p>0.05). In 2 patients (3.2%), significant vascular complications necessitated immediate surgical intervention, necessitating a change in the anesthesia technique. Overall 30-day mortality was 5.2%, with no significant differences among the groups (GA 7.5% vs. LAS 3.2%, p =0.28). GA had substantially longer ICU and total hospitalization stays than LAS (p=0.009 and p =0.004, respectively).
Conclusions: In our study, TAVR via the transfemoral route using LAS was an alternative for GA.

Anahtar Kelimeler

Local anesthesia, aortic stenosis, trans-femoral TAVR

Kaynakça

• Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, et al; PARTNER Trial Investigators. Trans- catheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011; 364: 2187–2198. doi: 10.1056/NEJMoa1103510
• Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25): e1159-e1195. doi:10.1161/CIR.0000000000000503
• Abud MA, Candıello GÑA, Padılla LT, Pıccınını F, Trıvı M, Castro MF, Cura FA. Eficacia y seguridad del implante valvular aórtico percutáneo por vía transfemoral bajo anestesia general vs. anestesia local más sedación consciente. Revista argentina de cardiología. 2018; 86(1): 35-41.
• Hamid N, Ranard LS, Khalique OK, et al. Commissural Alignment After Transfemoral Transcatheter Aortic Valve Replacement With the JenaValve Trilogy System. JACC Cardiovasc Interv. 2021;14(18):2079-2081. doi:10.1016/j.jcin.2021.07.025
• Wood DA, Lauck SB, Cairns JA, et al. The Van-Cover 3M (Multidisciplinary, Multimodality, but Minimalist) clinical pathway facilitates safe next-day discharge home at low-, medium-, and high-volume transfemoral transcatheter aortic valve replacement centers: the 3M TAVR study. J Am Coll Cardiol Intv. 2019; 12: 459–69.
• Gheorghe L, Brouwer J, Gutierrez A, et al. Can TAVR Be Effectively and Safely Performed Without Intraprocedural TEE? Curr Cardiol Rep. 2020;22(9):80. Published 2020 Jul 9. doi:10.1007/s11886-020-01344-8
• Krishnaswamy A, Isogai T, Agrawal A, et al. Feasibility and Safety of Same-Day Discharge Following Transfemoral Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv. 2022;15(6):575-589. doi:10.1016/j.jcin.2022.01.013
• Kaneko S, Morimoto T, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effect of remimazolam on the incidence of delirium after transcatheter aortic valve implantation under general anesthesia: a retrospective exploratory study. J Anesth. 2023;37(2):210-218. doi:10.1007/s00540-022-03148-2
• Petronio SA, Giannini C, De Carlo M, Bedogni F, Colombo A, Tamburino C, et al. Anesthetic management of transcatheter aortic valve implantation: Results from the Italian CoreValve registry. EuroIntervention 2016; 12: 381-8. http://doi.org/f8wtw7
• Carl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller AR, et al. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. Ger Med Sci. 2010; 8: Doc12. doi: 10.3205/000101
• Kappetein AP, Head SJ, Généreux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoints definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg 2012;42:S45-S60. http://doi.org/cnnj
• Camuglia AC, Cole CMW, Boyne N, et al. 30-Day Outcomes With the Portico Transcatheter Heart Valve: Insights From a Multi-Centre Australian Observational Study. Heart Lung Circ. 2023;32(2):224-231. doi:10.1016/j.hlc.2022.09.012
• Mork C, Twerenbold R, Gahl B, et al. Similar 5-Year Survival in Transfemoral and Transapical TAVI Patients: A Single-Center Experience. Bioengineering (Basel). 2023;10(2):156. Published 2023 Jan 24. doi:10.3390/bioengineering10020156
• Lancellotti P, Petitjean H, Postolache A, Cosyns B. Focus on valvular heart disease. Acta Cardiol. 2022;77(10):861-863. doi:10.1080/00015385.2022.2159193
• D’ErrigoP,RanucciM,CovelloRD,BiancariF,RosatoS,Barbanti M, et al. Outcome After General Anesthesia Versus Monitored Anes- thesia Care in Transfemoral Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth. 2016; 30: 1238-43. http://doi.org/cnnk
• Barbanti M. Early Discharge After Transcatheter Aortic Valve Replacement: Mature Times. JACC Cardiovasc Interv. 2019;12(5):431-432. doi:10.1016/j.jcin.2018.12.017
• Cheng DR. Local or general anesthesia for TAVI surgery? An updated systematic review and meta-analysis. European Heart Journal. 2021; 42.Supplement_1: ehab724. 1670.
• Hillenbrand KD, Racine CL, McNeil JS, Kleiman AM. Difficult TEE Probe Placement: The Evidence, Troubleshooting Techniques, and a Guide to Alternative Monitoring Options for Intraoperative Physicians. Semin Cardiothorac Vasc Anesth. 2019;23(4):369-378. doi:10.1177/1089253219842836
• von Scheidt W, Welz A, Pauschinger M, et al. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI): Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments. Clin Res Cardiol. 2020;109(1):1-12. doi:10.1007/s00392-019-01528-5
• D’ErrigoP,RanucciM,CovelloRD,BiancariF,RosatoS,Barbanti M, et al. Outcome After General Anesthesia Versus Monitored Anes- thesia Care in Transfemoral Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2016; 30: 1238-43. http://doi.org/cnnk
• Gilard M, Eltchaninoff H, Iung B, et al. FRANCE2 Investigators. Registry of transcatheter aortic valve implantation in high-risk patients. N Engl J Med.2012; 366: 1705-1715.
• Breitbart P, Minners J, Pache G, et al. Long-term follow-up of patients with contained annulus ruptures after TAVI: the EuropeaN COntained RupturE (ENCORE) registry. EuroIntervention. 2020;16(1):83-88. doi:10.4244/EIJ-D-19-00740
• Takamura T, Kobayashi S, Inoue R, Izumi D, Seko T, Tokui T, Kasai A. Transcatheter Aortic Valve Implantation Following Permanent Pacemaker Implantation for Severe Aortic Stenosis Complicated with Hypertrophic Obstructive Cardiomyopathy. Journal of Transcatheter Valve Therapies. 2020; 2(1): 19-23.
• Martins A, Castro ML, Fragata I. Experiência Inicial de um Programa de TAVI: Análise da Decisão Anestésica e sua Evolução [Initial Experience of a TAVI Program: Analysis of the Anesthetic Decision and its Evolution]. Acta Med Port. 2019;32(2):126-132. doi:10.20344/amp.10982
• Akbaş S, Özkan AS, General anesthesia versus local anesthesia plus sedation in high risk patients underwent transcatheter aortic valve implantation (TAVI) A retrospective chorort study. GKDA Derg. 2019;25(1):43-51
• Nilsson K, Buccheri S, Christersson C, et al. Causes, pattern, predictors, and prognostic implications of new hospitalizations after transcatheter aortic valve implantation: a long-term nationwide observational study. Eur Heart J Qual Care Clin Outcomes. 2022;8(2):150-160. doi:10.1093/ehjqcco/qcab026
• van Ginkel DJ, Brouwer J, van Hemert ND, et al. Major threats to early safety after transcatheter aortic valve implantation in a contemporary cohort of real-world patients. Neth Heart J. 2021;29(12):632-642. doi:10.1007/s12471-021-01638-8
• Kaneko S, Morimoto T, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effect of remimazolam on the incidence of delirium after transcatheter aortic valve implantation under general anesthesia: a retrospective exploratory study. J Anesth. 2023;37(2):210-218. doi:10.1007/s00540-022-03148-2
• Amin R, Arunothayaraj S, Kirtchuk D, et al. Mobility aids predict mortality after transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2022;99(1):E31-E37. doi:10.1002/ccd.29981
• Ma X, Chu H, Han K, et al. Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis. J Am Geriatr Soc. 2023;71(2):646-660. doi:10.1111/jgs.18104
• Ruge H, Burri M, Erlebach M, Lange R. Propensity matched analysis of vascular complications using integrated or expandable sheaths for TAVR. Catheter Cardiovasc Interv. 2022;99(5):1611-1618. doi:10.1002/ccd.30088
• Barbe T, Levesque T, Durand E, et al. Transcatheter aortic valve implantation: The road to a minimalist "stent-like" procedure. Arch Cardiovasc Dis. 2022;115(4):196-205. doi:10.1016/j.acvd.2022.03.004
• Holmes DR, Nishimura RA, Grover FL, Brindis RG, Carrol JD, Edwards FH, et al. Annual Outcomes With Transcatheter Valve Therapy: From the STS/ACC TVT Registry. J Am Coll Cardiol 2015;66:2813-23. http://doi.org/f74jrv