Fröhlich Georg M, Lansky Alexandra J, Webb John, Roffi Marco, Toggweiler Stefan, Reinthaler Markus, Wang Duolao, Hutchinson Nevil, Wendler Olaf, Hildick-Smith David, Meier Pascal
The Heart Hospital, University College London Hospitals, London, UK.
BMC Med. 2014 Mar 10;12:41. doi: 10.1186/1741-7015-12-41.
The hypothesis of this study was that local anesthesia with monitored anesthesia care (MAC) is not harmful in comparison to general anesthesia (GA) for patients undergoing Transcatheter Aortic Valve Implantation (TAVR).TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Traditionally, in most centers, this procedure is done under GA, but more recently procedures with MAC have been reported.
This is a systematic review and meta-analysis comparing MAC versus GA in patients undergoing transfemoral TAVR. Trials were identified through a literature search covering publications from 1 January 2005 through 31 January 2013. The main outcomes of interest of this literature meta-analysis were 30-day overall mortality, cardiac-/procedure-related mortality, stroke, myocardial infarction, sepsis, acute kidney injury, procedure time and duration of hospital stay. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals.
Seven observational studies and a total of 1,542 patients were included in this analysis. None of the studies were randomized. Compared to GA, MAC was associated with a shorter hospital stay (-3.0 days (-5.0 to -1.0); P = 0.004) and a shorter procedure time (MD -36.3 minutes (-58.0 to -15.0 minutes); P <0.001). Overall 30-day mortality was not significantly different between MAC and GA (RR 0.77 (0.38 to 1.56); P = 0.460), also cardiac- and procedure-related mortality was similar between both groups (RR 0.90 (0.34 to 2.39); P = 0.830).
These data did not show a significant difference in short-term outcomes for MAC or GA in TAVR. MAC may be associated with reduced procedural time and shorter hospital stay. Now randomized trials are needed for further evaluation of MAC in the setting of TAVR.
本研究的假设是，对于接受经导管主动脉瓣植入术（TAVR）的患者，与全身麻醉（GA）相比，监护下麻醉（MAC）进行局部麻醉并无危害。TAVR是治疗严重主动脉瓣狭窄的一种迅速普及的治疗选择。传统上，在大多数中心，该手术在全身麻醉下进行，但最近已有采用监护下麻醉进行手术的报道。
这是一项比较经股动脉TAVR患者采用监护下麻醉与全身麻醉的系统评价和荟萃分析。通过文献检索确定试验，检索范围涵盖2005年1月1日至2013年1月31日发表的文献。该文献荟萃分析关注的主要结局为30天总死亡率、心脏/手术相关死亡率、中风、心肌梗死、败血症、急性肾损伤、手术时间和住院时间。采用随机效应模型计算合并相对风险（RR）及95%置信区间。
本分析纳入了7项观察性研究，共1542例患者。所有研究均非随机对照研究。与全身麻醉相比，监护下麻醉与较短的住院时间（-3.0天（-5.0至-1.0）；P = 0.004）和较短的手术时间（MD -36.3分钟（-58.0至-15.0分钟）；P <0.001）相关。监护下麻醉与全身麻醉的30天总死亡率无显著差异（RR 0.77（0.38至1.56）；P = 0.460），两组的心脏和手术相关死亡率也相似（RR 0.90（0.34至2.39）；P = 0.830）。
这些数据未显示TAVR中监护下麻醉或全身麻醉的短期结局有显著差异。监护下麻醉可能与手术时间缩短和住院时间缩短相关。现在需要进行随机试验以进一步评估TAVR中监护下麻醉的效果。
