Romano Salvatore Mario, Ristalli Francesca, Giglioli Cristina, Meucci Francesco, Stolcova Miroslava, Baldereschi Giorgio Jacopo, Cecchi Emanuele, Squillantini Giovanni, Ciappi Francesco, Marchionni Niccolò, Di Mario Carlo, Payen Didier
Experimental and Clinical Medicine Department, University Hospital Florence Italy.
Structural Interventional Cardiology, Cardio-Thoraco-Vascular Department, Careggi University Hospital Florence, Italy.
Am J Cardiovasc Dis. 2020 Oct 15;10(4):340-349. eCollection 2020.
In spite of the increased use of Trans-catheter Aortic Valve Implantation (TAVI) due to the better patient selection, well-trained operators and improved technology, the choice of the best anesthesia regimen remains an open question. In particular, it remains to be clarified whether deep sedation (DS) in spontaneous breathing or femoral local anesthesia (LA) is best.
This study compared the hemodynamic variations determined by deep sedation (DS) with spontaneous breathing and local femoral anesthesia (LA) in 2 groups of patients submitted to TAVI with two different kinds of anesthesia, using a beat-by-beat pulse contour method (MostCare).
82 patients with severe aortic stenosis and similar baseline characteristics and indications underwent trans-femoral TAVI: 50 with LA and 32 with DS. All patients were submitted to minimally invasive hemodynamic monitoring. The following parameters were measured: : systolic, diastolic, mean (SysP, DiaP, MAP) and dicrotic (DicP) pressures; : cardiac output (CO), stroke volume (SV); (VAC): peripheral arterial elastance (Ea), systemic vascular resistance (SVR); : cardiac cycle efficiency (CCE), dP/dt.
The TAVI procedure was successful in 89% of patients (VARC-2 criteria) with no difference between the 2 groups. Anesthesia induction determined a higher decrease of pressures in DS than in LA (P<0.01) with no differences in CO. The VAC parameters (Ea, SVR) decreased (P<0.01) in DS with an improvement in CCE (P<0.001); these parameters did not change in LA. The post-TAVI flow and VAC parameters, especially Ea, increased (P<0.05) more significantly in the LA group than in the DS group (P<0.001). Using logistic regression, the occurrence of the post-TAVI aortic regurgitation was correctly associated with the pressure gradient MAP-DicP in 63% of the study population (P=0.033). This association was more effectively detected in the LA group (78%, P=0.011) with a ROC AUC=0.779, than the DS group.
The use of the pulse contour method to track the fast-hemodynamic changes during the TAVI procedure proved suitable for the aim. As expected, LA and DS induced different pre-TAVI hemodynamic conditions, which influenced the post-TAVI hemodynamic changes. The hemodynamic conditions induced by LA, enabled the occurrence of post-TAVI aortic regurgitation to be detected more effectively.
尽管由于患者选择更优、操作人员训练有素以及技术改进，经导管主动脉瓣植入术（TAVI）的应用有所增加，但最佳麻醉方案的选择仍是一个悬而未决的问题。特别是，自主呼吸下的深度镇静（DS）与股部局部麻醉（LA）哪种最佳仍有待阐明。
本研究使用逐搏脉搏轮廓法（MostCare），比较了两组接受两种不同麻醉方式的TAVI患者，自主呼吸下深度镇静（DS）与股部局部麻醉（LA）所引起的血流动力学变化。
82例具有相似基线特征和适应症的严重主动脉瓣狭窄患者接受了经股动脉TAVI：50例采用LA，32例采用DS。所有患者均接受了微创血流动力学监测。测量了以下参数：收缩压、舒张压、平均压（SysP、DiaP、MAP）和重搏压（DicP）；心输出量（CO）、每搏输出量（SV）；外周动脉弹性（Ea）、全身血管阻力（SVR）；心循环效率（CCE）、dP/dt。
89%的患者TAVI手术成功（符合VARC-2标准），两组之间无差异。麻醉诱导时，DS组的压力下降幅度高于LA组（P<0.01），而CO无差异。DS组的VAC参数（Ea、SVR）下降（P<0.01），CCE有所改善（P<0.001）；LA组这些参数未发生变化。TAVI术后，LA组的血流和VAC参数，尤其是Ea，升高幅度（P<0.05）比DS组更显著（P<0.001）。使用逻辑回归分析，在63%的研究人群中（P=0.033），TAVI术后主动脉瓣反流的发生与压力梯度MAP-DicP正确相关。与DS组相比，LA组更能有效检测到这种相关性（78%，P=0.011），ROC曲线下面积（AUC）为0.779。
使用脉搏轮廓法追踪TAVI手术期间的快速血流动力学变化被证明适用于该目的。正如预期的那样，LA和DS在TAVI术前引起了不同的血流动力学状况，这影响了TAVI术后的血流动力学变化。LA所诱导的血流动力学状况能够更有效地检测到TAVI术后主动脉瓣反流的发生。
