Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Catheter Cardiovasc Interv. 2021 Sep;98(3):E436-E443. doi: 10.1002/ccd.29496. Epub 2021 Jan 29.
Monitored anesthesia care (MAC) has become more widely used during transcatheter aortic valve replacement (TAVR) to avoid the complications of general anesthesia (GA).
We included consecutive patients who underwent transfemoral-TAVR at our institution between January 2012 and April 2017. We compared outcomes with GA versus MAC.
Of 998 patients, MAC was used in 43.9%. MAC was associated with shorter procedural time (96.9 ± 30.9 vs. 135 ± 64.6 mins; p < .001), fluoroscopy time (20.4 ± 8.9 vs. 29 ± 18.7 mins; p < .001), lower contrast volume (45.5 ± 27 vs. 60.4 ± 43 cc; p < .001), and decreased radiation exposure (12,869 ± 8,099 vs. 20,630 ± 16,276 cGy-cm ; p < .001). Patients who underwent MAC had a briefer median (IQR) intensive care unit stay [23.3 (21-24) vs. 23.4 (20.8-26) hrs; p < .001], and hospital stay [2 (2, 3) vs. 3 (2-6) days; p < .001], and were more frequently discharged to home (93.4% vs. 82.9%; p < .001). MAC was associated with lower mortality at 30 days (0.5% vs. 2.9%; log-rank p = .012; adjHR 0.22, 95% CI 0.06-0.82; p = .024), but not at 1 year (11.7% vs. 14.6%; log-rank p = .157) or 3 years (36.8% vs. 38.4%; log-rank p = 0.433). There were no differences in major adverse cardiac and cerebrovascular events (MACCE) at either 30 days (4.6% vs. 9.3%; log-rank p = .14) or 1 year (21.1% vs. 21.5%; log-rank p = .653). Similar findings were seen among patients who received newer-generation SAPIEN-3 valves.
Utilizing MAC and omitting intraprocedural transesophageal echocardiography during TAVR seems to be more efficient without compromising safety. Better TAVR outcomes can be achieved with newer generation valves without needing GA.
在经导管主动脉瓣置换术（TAVR）中，使用监测麻醉护理（MAC）以避免全身麻醉（GA）的并发症的情况越来越多。
我们纳入了 2012 年 1 月至 2017 年 4 月期间在我院接受经股动脉 TAVR 的连续患者。我们比较了 GA 与 MAC 的结果。
在 998 例患者中，MAC 的使用率为 43.9%。MAC 与更短的手术时间（96.9±30.9 分钟与 135±64.6 分钟；p<0.001）、透视时间（20.4±8.9 分钟与 29±18.7 分钟；p<0.001）、较低的造影剂用量（45.5±27 毫升与 60.4±43 毫升；p<0.001）和减少的辐射暴露（12,869±8,099 与 20,630±16,276 戈瑞厘米；p<0.001）相关。接受 MAC 的患者 ICU 中位（IQR）停留时间更短[23.3（21-24）分钟与 23.4（20.8-26）分钟；p<0.001]，住院时间更短[2（2，3）天与 3（2-6）天；p<0.001]，更常出院回家（93.4%与 82.9%；p<0.001）。MAC 在 30 天死亡率较低（0.5%与 2.9%；log-rank p=0.012；调整后 HR 0.22，95%CI 0.06-0.82；p=0.024），但在 1 年（11.7%与 14.6%；log-rank p=0.157）或 3 年（36.8%与 38.4%；log-rank p=0.433）时无差异。在 30 天（4.6%与 9.3%；log-rank p=0.14）或 1 年（21.1%与 21.5%；log-rank p=0.653）时主要不良心脑血管事件（MACCE）无差异。在接受新一代 SAPIEN-3 瓣膜的患者中也观察到了类似的结果。
在 TAVR 过程中使用 MAC 并省略术中经食管超声心动图似乎更有效，而不会影响安全性。使用新一代瓣膜可以实现更好的 TAVR 结果，而无需 GA。
