Conscious sedation better than general anesthesia for TAVR
USA: The use of conscious sedation (CS) in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with improved outcomes compared with general anesthesia (GA), according to a recent study. The study, published in the journal JACC: Cardiovascular Interventions found that compared with GA, CS was associated with reduced in-hospital mortality and 30-day mortality, as well as shorter hospital length of stay and more frequent discharge to home.
The proportion of TAVR using conscious sedation has increased from 33% to 64% between January 2016 and March 2019. Despite this, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding. Neel M. Butala, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and colleagues examined variation in the use of CS for TAVR across hospitals and over time and to evaluate outcomes of CS compared with GA using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding.
The researchers evaluated the relationship between anesthesia choice and TAVR outcomes using hospital proportional use of CS as an instrumental variable among 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019.
Key findings of the study include:
- 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%) and 30-day mortality (adjusted risk difference: 0.5%), shorter length of hospital stay (adjusted difference: 0.8 days), and more frequent discharge to home (adjusted risk difference: 2.8%) compared with GA.
- The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach.
"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," concluded the authors.
The study, "Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Variation in Practice and Outcomes," is published in the journal JACC: Cardiovascular Interventions.