经导管主动脉瓣置换术中的清醒镇静与全身麻醉：实践与结局的差异。
Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Variation in Practice and Outcomes.
机构信息
Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
出版信息
JACC Cardiovasc Interv. 2020 Jun 8;13(11):1277-1287. doi: 10.1016/j.jcin.2020.03.008.
OBJECTIVES
The aims of this study were to examine variation in the use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time and to evaluate outcomes of CS compared with general anesthesia (GA) using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding.
BACKGROUND
Despite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding.
METHODS
Among 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019, the relationship between anesthesia choice and TAVR outcomes was evaluated using hospital proportional use of CS as an instrumental variable.
RESULTS
Over the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. On the basis of instrumental variable analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference: 0.2%; p = 0.010) and 30-day mortality (adjusted risk difference: 0.5%; p < 0.001), shorter length of hospital stay (adjusted difference: 0.8 days; p < 0.001), and more frequent discharge to home (adjusted risk difference: 2.8%; p < 0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however.
CONCLUSIONS
In contemporary U.S. practice, the use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.
目的
本研究旨在考察医院间和时间推移过程中经导管主动脉瓣置换术（TAVR）中使用清醒镇静（CS）的差异，并使用工具变量分析（一种控制未测量混杂因素的准实验方法）评估 CS 与全身麻醉（GA）相比的结局。
背景
尽管 TAVR 中 CS 的使用不断增加，但目前缺乏有关使用模式的最新数据，而且评估镇静选择对结局影响的现有研究可能存在未测量的混杂因素。
方法
在 2016 年 1 月至 2019 年 3 月 TVT（经导管瓣膜治疗）登记处接受经股 TAVR 的 120080 例患者中，使用医院 CS 比例作为工具变量评估麻醉选择与 TAVR 结局的关系。
结果
在研究期间，使用 CS 进行 TAVR 的比例从 33%增加到 64%，CS 在医院 CS 使用量最低和最高四分位数的中位数分别为 0%和 91%的病例中使用。基于工具变量分析，CS 与住院死亡率降低相关（校正风险差异：0.2%；p=0.010）和 30 天死亡率降低相关（校正风险差异：0.5%；p<0.001）、住院时间缩短（校正差异：0.8 天；p<0.001）和更频繁地出院回家（校正风险差异：2.8%；p<0.001），与 GA 相比。然而，大多数结局的获益幅度小于传统倾向评分匹配方法。
结论
在美国，TAVR 中 CS 的使用继续增加，尽管医院间仍存在较大差异。与 GA 相比，TAVR 中 CS 的使用与更好的结局相关（包括死亡率降低），尽管获益幅度似乎小于之前的研究。
Zotero 插件