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Your next patient in the preoperative clinic is a 91-year-old man scheduled for transcatheter aortic valve replacement (TAVR). The patient is interested in having the procedure performed under conscious sedation. According to a recent study that used propensity matching to compare TAVR patients who received conscious sedation with those who received general anesthesia, which of the following is MOST likely true? Read the discussion below.
(A) Conscious sedation patients underwent shorter fluoroscopy times.
(B) Total hospital costs were similar between groups.
(C) There was a higher risk of bleeding and vascular complications in the sedation group than in the general anesthesia group.
Discussion
Transcatheter aortic valve replacement (TAVR) for the treatment of aortic stenosis has increased substantially in the past 10 years. While general anesthesia (GA) was frequently administered in the early years of TAVR, conscious sedation is now commonly employed. An early study of TAVR patients found that conscious sedation was superior with respect to procedure time and length of hospitalization while having no effect on mortality rates. A recent study reexamined the safety, efficacy, and efficiency of conscious sedation versus GA for TAVR.
A retrospective, observational study at a tertiary care center compared outcomes between patients who received GA versus those who received conscious sedation for TAVR. Propensity matching, a statistical technique that uses data from a retrospective study to simulate a randomized trial, was used to match patients in the GA group with those in the conscious sedation group. A total of 154 patients who received GA were matched with 154 patients who received conscious sedation. The study found no differences in the rates of in-hospital mortality, 30-day mortality, stroke, or permanent pacemaker implantation. A lower risk of bleeding and vascular events was found in the conscious sedation group compared with the GA group. In the secondary analysis, 100% of patients in the conscious sedation group received newer-generation valves compared to only 65% in the GA group, which may account for the lower bleeding and vascular events in the conscious sedation group. The conscious sedation group also had decreased radiation time and dose, as well as shorter hospital length of stay. There was a 10.4% reduction in overall hospital costs in the conscious sedation group, with most of the cost reductions related to respiratory therapy and pharmacy. No differences were found in ejection fraction, incidence of moderate or severe aortic regurgitation, or aortic valve size at 30 days or 1 year postoperatively. A higher aortic valve mean gradient was found in the conscious sedation group compared to the GA group at 1 year, but an additional analysis that controlled for valve type found no difference in mean gradient between the groups.
In summary, this retrospective study suggests that conscious sedation is a reasonable option for patients undergoing TAVR, but this study was underpowered to make a definitive statement about patient safety. Clinicians should consider individual patient and procedure factors when making the choice of anesthetic technique.
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