Cardiology Unit.
Department of Anesthesiology, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.
J Cardiovasc Med (Hagerstown). 2020 Oct;21(10):805-811. doi: 10.2459/JCM.0000000000001030.
Conscious sedation instead of general anesthesia has been increasingly adopted in many centers for transfemoral transcatheter aortic valve replacement (TAVR). Improvement of materials and operators' experience and reduction of periprocedural complications allowed procedural simplification and adoption of a minimalist approach. With this study, we sought to assess the feasibility and safety of transfemoral TAVR routinely performed under local anesthesia without on-site anesthesiology support.
The routine transfemoral TAVR protocol adopted at our center includes a minimalist approach, local anesthesia alone with fully awake patient, anesthesiologist available on call but not in the room, and direct transfer to the cardiology ward after the procedure. All consecutive patients undergoing transfemoral TAVR between January 2015 and July 2018 were included. We assessed the rates of actual local anesthesia-only procedures, conversion to conscious sedation or general anesthesia and 30-day clinical outcomes.
Among 321 patients, 6 received general anesthesia upfront and 315 (98.1%) local anesthesia only. Mean age of the local anesthesia group was 83.2 ± 6.9 years, Society of Thoracic Surgery score 5.8 ± 4.8%. A balloon-expandable valve was used in 65.7%. Four patients (1.3%) shifted to conscious sedation because of pain or anxiety; 6 patients (1.9%) shifted to general anesthesia because of procedural complications. Hence, local anesthesia alone was possible in 305 patients (96.8% of the intended cohort, 95% of all transfemoral procedures). At 30 days, in the intended local anesthesia group, mortality was 1.6%, stroke 0.6%, major vascular complications 2.6%. Median hospital stay was 4 days (IQR 3-7).
Transfemoral TAVR can be safely performed with local anesthesia alone and without an on-site anesthesiologist in the vast majority of patients.
在许多中心，经股动脉经导管主动脉瓣置换术（TAVR）越来越多地采用清醒镇静而非全身麻醉。材料和术者经验的改善以及围手术期并发症的减少，使得手术简化并采用了极简主义方法。本研究旨在评估在没有现场麻醉师支持的情况下，常规在局部麻醉下进行经股 TAVR 的可行性和安全性。
我们中心常规采用经股 TAVR 方案，采用极简主义方法，仅行局部麻醉，使患者完全清醒，麻醉师可随时待命但不在手术室内，术后直接转入心内科病房。纳入 2015 年 1 月至 2018 年 7 月期间连续接受经股 TAVR 的所有患者。评估实际仅行局部麻醉的比例、转为清醒镇静或全身麻醉的比例以及 30 天临床结局。
321 例患者中，6 例患者最初接受全身麻醉，315 例（98.1%）仅行局部麻醉。局部麻醉组的平均年龄为 83.2±6.9 岁，胸外科医师协会评分 5.8±4.8%。使用球囊扩张瓣膜的患者占 65.7%。4 例患者（1.3%）因疼痛或焦虑转为清醒镇静；6 例患者（1.9%）因手术并发症转为全身麻醉。因此，305 例患者（意向性队列的 96.8%，所有经股 TAVR 手术的 95%）可行单纯局部麻醉。在 30 天时，在意向性局部麻醉组中，死亡率为 1.6%，卒中性脑中风 0.6%，大血管并发症 2.6%。中位住院时间为 4 天（IQR 3-7）。
在绝大多数患者中，经股 TAVR 可安全地单独采用局部麻醉，且无需现场麻醉师。
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