Hung Kuo-Chuan, Chen Jen-Yin, Hsing Chung-Hsi, Chu Chin-Chen, Lin Yao-Tsung, Pang Yu-Li, Teng I-Chia, Chen I-Wen, Sun Cheuk-Kwan
School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan.
Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan.
Front Cardiovasc Med. 2023 Jan 10;9:1099959. doi: 10.3389/fcvm.2022.1099959. eCollection 2022.
To compare the merits and safety between conscious sedation/monitored anesthesia (CS/MAC) and general anesthesia (GA) for patients receiving transcatheter aortic valve replacement (TAVR).
Databases including EMBASE, MEDLINE, and the Cochrane Library databases were searched from inception to October 2022 to identify studies investigating the impact of CS/MAC on peri-procedural and prognostic outcomes compared to those with GA. The primary outcome was the association of CS/MAC with the risk of 30-day mortality, while secondary outcomes included the risks of adverse peri-procedural (e.g., vasopressor/inotropic support) and post-procedural (e.g., stroke) outcomes. Subgroup analysis was performed based on study design [i.e., cohort vs. matched cohort/randomized controlled trials (RCTs)].
Twenty-four studies (observational studies, = 22; RCTs, = 2) involving 141,965 patients were analyzed. Pooled results revealed lower risks of 30-day mortality [odd ratios (OR) = 0.66, < 0.00001, 139,731 patients, certainty of evidence (COE): low], one-year mortality (OR = 0.72, = 0.001, 4,827 patients, COE: very low), major bleeding (OR = 0.61, = 0.01, 6,888 patients, COE: very low), acute kidney injury (OR = 0.71, = 0.01, 7,155 patients, COE: very low), vasopressor/inotropic support (OR = 0.25, < 0.00001, 133,438 patients, COE: very low), shorter procedure time (MD = -12.27 minutes, = 0.0006, 17,694 patients, COE: very low), intensive care unit stay (mean difference(MD) = -7.53 h = 0.04, 7,589 patients, COE: very low), and hospital stay [MD = -0.84 days, < 0.00001, 19,019 patients, COE: very low) in patients receiving CS/MAC compared to those undergoing GA without significant differences in procedure success rate, risks of cardiac-vascular complications (e.g., myocardial infarction) and stroke. The pooled conversion rate was 3.1%. Results from matched cohort/RCTs suggested an association of CS/MAC use with a shorter procedural time and hospital stay, and a lower risk of vasopressor/inotropic support.
Compared with GA, our results demonstrated that the use of CS/MAC may be feasible and safe in patients receiving TAVR. However, more evidence is needed to support our findings because of our inclusion of mostly retrospective studies.
https://www.crd.york.ac.uk/prospero/, identifier CRD42022367417.
比较清醒镇静/监护麻醉（CS/MAC）与全身麻醉（GA）在接受经导管主动脉瓣置换术（TAVR）患者中的优缺点及安全性。
检索了包括EMBASE、MEDLINE和Cochrane图书馆数据库在内的数据库，检索时间从建库至2022年10月，以确定研究CS/MAC与GA相比对围手术期和预后结果影响的研究。主要结局是CS/MAC与30天死亡率风险的关联，次要结局包括围手术期不良事件（如血管升压药/正性肌力药支持）和术后不良事件（如中风）的风险。根据研究设计[即队列研究与匹配队列/随机对照试验（RCT）]进行亚组分析。
分析了24项研究（观察性研究22项；RCT 2项），涉及141,965例患者。汇总结果显示，与接受GA的患者相比，接受CS/MAC的患者30天死亡率风险较低[比值比（OR）=0.66，P<0.00001，139,731例患者，证据确定性（COE）：低]、一年死亡率（OR =0.72，P =0.001，4,827例患者，COE：极低）、大出血（OR =0.61，P =0.01，6,888例患者，COE：极低）、急性肾损伤（OR =0.71，P =0.01，7,155例患者，COE：极低）、血管升压药/正性肌力药支持（OR =0.25，P<0.00001，133,438例患者，COE：极低）程序时间较短（平均差（MD）=-12.27分钟，P =0.0006，17,694例患者，COE：极低）、重症监护病房住院时间（平均差（MD）=-7.53小时，P =0.04，7,589例患者，COE：极低）和住院时间[MD=-0.84天，P<0.00001，19,019例患者，COE：极低]，手术成功率、心血管并发症（如心肌梗死）和中风风险无显著差异。汇总转化率为3.1%。匹配队列/RCT的结果表明，使用CS/MAC与较短的手术时间和住院时间以及较低的血管升压药/正性肌力药支持风险相关。
与GA相比，我们的结果表明，在接受TAVR的患者中使用CS/MAC可能是可行且安全的。然而，由于我们纳入的大多是回顾性研究,需要更多证据来支持我们的发现。
