Local Anesthesia ‘Preferable’ Over General for Transfemoral TAVR

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Local anesthesia is a better option than general for reducing complications and increasing comfort in patients undergoing transcatheter aortic valve replacement (TAVR), according to a registry study published online July 8, 2014, ahead of print in Circulation: Cardiovascular Interventions. However, researchers highlight the heightened risk of aortic regurgitation with local anesthesia and advocate for increased monitoring and transesophageal echocardiography (TEE) support when using this approach.

Similar Outcomes

Procedural success was similar for both general (97.6%) and local (97.0%) anesthesia, but hospital length of stay tended to be longer in the latter cohort (P = .030). Postprocedural aortic regurgitation classified as at least mild was less likely after TAVR with general vs local anesthesia (15.0% vs 19.1%; P = .015), but there were no differences in the incidence of VARC-defined complications. After propensity matching, baseline and procedural characteristics between the groups were similar.

Overall mortality after a median follow-up of 137 days was 15.1%, and slightly more than half of deaths (53.1%) occurred in the first 30 days. Of those that occurred beyond 30 days, 37.0% were from cardiovascular causes. Both 30-day and 1-year survival, according to Kaplan-Meier analysis, did not differ based on anesthetic strategy. Propensity matching confirmed these results (table 1).

Table 1. Mortality Outcomes

Mortality outcomes were similar in all prespecified subgroup analyses. Among COPD patients, cumulative 30-day mortality related to respiratory failure trended higher with general anesthesia (HR 2.83; 95% CI 0.93-8.39).

Local Anesthesia Preferred  

Dr. Yamamoto and colleagues attribute the higher risk of aortic regurgitation after TAVR with local anesthesia to the less frequent use of TEE support. 

Initiating the procedure with local anesthesia is preferable over general anesthesia, the authors observe, as the former involves less invasive measures and is better tolerated by elderly and high-risk patients who are ineligible for surgical valve replacement. Keeping patients awake with local anesthesia also allows for the “rapid detection of stroke and vascular complications,” they write.

Because of this, it is “acceptable” to change to general anesthesia “when serious problems are encountered, to manage any complication in the best possible manner,” the authors comment. “It might be different if the use of [local anesthesia] itself was associated with a higher rate of complications.”

Focus on Aortic Regurgitation

The authors further stress the importance of TEE guidance as procedures done without it “do not allow for the precise evaluation of paravalvular [aortic regurgitation]. If the operators did not use TEE during [TAVR], the assessment of paravalvular leak after aortic valve replacement had to be made on the basis of multimodality approaches, including aortic root angiography, transthoracic echocardiography, and hemodynamic methods.”

Findings gleaned from TEE “may influence operators to opt for more frequent postdilatation immediately after prosthesis implantation and may contribute to the lower incidence of postprocedural [aortic regurgitation],” they add.

Future research should focus on this and other efforts to reduce procedural complications, the authors suggest, and include longer follow-up as 137 days “was insufficient for analyzing midterm mortality.”

Source: 
Oguri A, Yamamoto M, Mouillet G, et al. Clinical outcomes and safety of transfemoral aortic valve implantation under general versus local anesthesia: subanalysis of the French Aortic National CoreValve and Edwards 2 Registry. Circ Cardiovasc Interv. 2014;Epub ahead of print.

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