Clinical Outcome of Asymptomatic Severe Aortic Stenosis With Medical and Surgical Management: Importance of STS Score at Diagnosis

Asymptomatic Aortic Stenosis: From Risk Stratification to Treatment

Our understanding of the natural history of aortic stenosis has significantly increased over the last decade. There have been considerable advances in the diagnosis and risk stratification of patients with aortic stenosis and in surgical and anesthetic techniques. In addition, transcatheter aortic valve replacement has established itself as a viable alternative to surgical management. Inevitably, these developments have raised questions regarding the merits of waiting for symptom onset in asymptomatic patients with severe aortic stenosis before offering treatment. Recent observational and randomized trial data suggest that early intervention in asymptomatic patients with severe aortic stenosis and normal left ventricular function may confer a prognostic advantage to a watchful waiting strategy. In this review, we highlight advances in the management and risk stratification of patients with asymptomatic severe aortic stenosis with particular consideration of recent findings supporting early valvular intervention.

Prognostic impact of main pulmonary artery to ascending aorta diameter ratio in patients with severe aortic stenosis underwent transcatheter aortic valve implantation

BACKGROUND

Pulmonary hypertension (PH) and right ventricular dysfunction are poor prognostic predictors in patients underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS).

AIMS

The prognostic impact of the main pulmonary artery/ascending aorta diameter ratio (MPA/AOr), measured simply by computed-tomographic angiography (CTA), was investigated in this patient group.

METHODS

A total of 374 retrospectively evaluated patients (mean age 78.1 ± 8.4 years, 192 [51.3%] females) who underwent TAVI for severe AS were included. MPA/AOr was measured on preprocedural CTA in all patients and the effect of this measurement on the presence of PH, in-hospital and 2-year-overall long-term mortality was investigated.

RESULTS

The presence of PH was defined as a systolic pulmonary artery pressure (sPAP) >42 mmHg measured by echocardiography. According to multivariate-logistic-regression analysis, MPA/AOr (adjusted [Adj] odds ratio [OR]: 1.188, confidence interval [CI] 95% [1.002-1.410], p = 0.048), tricuspid annular plane systolic excursion (TAPSE) (adj OR:0.736, CI 95% [0.663-0.816], p < 0.001) and left atrial diameter (adj OR:1.051, CI 95% [1.007-1.098], p = 0.024) were identified as independent predictors of PH. In addition, a statistically significant correlation was found between MPA/AOr and TAPSE (r: -0.283, p < 0.001). Furthermore, MPA/AOr was found to be an independent predictor of both in-hospital (adj OR:1.434, CI 95% [1.093-1.881], p = 0.009) and 2-year long-term (adj OR:1.518, CI 95% [1.243-1.853], p < 0.001) mortality in multivariate analysis including TAPSE, STS score and sPAP. In the 2-year Kaplan-Meier survival probability analysis, an MPA/AOr >0.86 was found to have a hazard ratio of 3.697 (95% CI: 2.341-5.840), with a log-rank p < 0.001.

CONCLUSION

MPA/AOr, which can be measured simply by CTA, may be useful as an indicator of the presence of PH and poor prognosis in patients planned for TAVI for severe AS.

Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function

BACKGROUND

A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function.

METHODS AND RESULTS

We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding.

CONCLUSION

We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations.

PROSPERO REGISTRATION NUMBER

CRD42022306132.

Early surgical intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

OBJECTIVE

Timing of intervention for patients with asymptomatic severe aortic stenosis (AS) remains controversial. To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in patients with asymptomatic severe AS.

METHODS

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

RESULTS

Twelve studies were included in which two were randomised clinical trials. A total of 4130 patients were included, providing a 1092 pooled death events. Our meta-analysis showed a significantly lower all-cause mortality for the early AVR compared with WW group, although with a high amount of heterogeneity between studies in the magnitude of the effect (pooled OR 0.40; 95% CI 0.35 to 0.45, p<0.01; I²=61%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR 0.33; 95% CI 0.19 to 0.56, p<0.01; I²=64%) and heart failure hospitalisation (pooled OR 0.19; 95% CI 0.10 to 0.39, p<0.01, I²=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI 0.73 to 2.29, p=0.36, I²=0%) and myocardial infarction (pooled OR 0.49; 95% CI 0.19 to 1.27, p=0.14, I²= 0%).

CONCLUSIONS

This study suggests that for patients with asymptomatic severe AS an early surgical intervention compared with a conservative WW strategy was associated with a lower heart failure hospitalisation and a similar rate of stroke or myocardial infarction, although with significant risk of bias.

PROSPERO REGISTRATION NUMBER

CRD42021291144.

Do all patients with asymptomatic severe aortic stenosis need treatment?

INTRODUCTION

Although guidelines recommend a watchful waiting strategy for patients with asymptomatic severe aortic stenosis, there have been considerable advancements in surgical and anaesthetic techniques along with the success of transcatheter aortic valve replacement (AVR) as a viable alternative to surgical AVR. Inevitably, these developments have raised questions as to whether or not there is still merit in waiting for symptoms to ensue before treatment may offered to these patients.

AREA COVERED

The principal purpose of this paper is to review the data supporting earlier intervention in patients with asymptomatic severe aortic stenosis, and to project the implications these and other ongoing trials will have on indications for AVR in asymptomatic patients in the future.

EXPERT OPINION

The threshold for intervention in certain subgroups of asymptomatic patients with severe AS has already been lowered. The next frontier will inevitably be determining whether all patients with severe AS should undergo AVR irrespective of their symptomatic status.

Management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

OBJECTIVES

The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies.

METHODS

PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'.

RESULTS

Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I2 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I2 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I2 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I2 77%).

CONCLUSION

This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention.

PROSPERO REGISTRATION NUMBER

CRD42022301037.

Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

The purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm² and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

Meta-Analysis of Early Intervention Versus Conservative Management for Asymptomatic Severe Aortic Stenosis

The main objective was to determine the optimal strategy for managing asymptomatic severe aortic stenosis between early intervention versus conservative management. We performed a systematic electronic search of the PubMed and Cochrane databases from the inception of the database to May 31, 2020. The Mantel Haenszel method with the Paule-Mandel estimator of Tau² and Hartung-Knapp adjustment were used to calculate relative risk (RR) with a 95% confidence interval (CI) and 95% prediction interval. P curve analysis was used to assess publication bias and estimate the true effect of an intervention. All analysis was carried out using R version 3.6.2. A total of 9 studies were included in the final analysis, consisting of 1,775 patients with early intervention and 3,040 patients with conservative management. Early intervention as compared with conservative management was associated with reduced risk of all-cause mortality (RR 0.36, 95% CI 0.24 to 0.53), cardiac mortality (RR 0.36, 95% CI 0.27 to 0.48) and noncardiac mortality (RR 0.40, 95% CI 0.28 to 0.56). There was no difference in the risk of sudden cardiac death (RR 0.46, 95% CI 0.15 to 1.40), stroke (RR 0.79, 95% CI 0.17 to 3.64), myocardial infarction (RR 0.44, 95% CI 0.01 to 16.82) or heart failure hospitalization (RR 0.18, 95% CI 0.01 to 5.29) with early intervention compared with conservative management. In conclusion, early intervention is associated with reduced all-cause, cardiovascular, and noncardiovascular mortality without increasing any procedure-related clinical outcomes among asymptomatic severe AS patients. Hence, this meta-analysis supports early intervention instead of watchful waiting for the management of asymptomatic severe AS. This systematic review and meta-analysis was registered with PROSPERO- CRD42020188439.

Natural History of Asymptomatic Severe Aortic Stenosis and the Association of Early Intervention With Outcomes: A Systematic Review and Meta-analysis

Importance

Whether intervention should be performed in patients with asymptomatic severe aortic stenosis (AS) remains debated.

Objective

To meta-analyze the natural history of asymptomatic severe AS and examine the association of early intervention with survival.

Data Sources

PubMed, Embase, and Cochrane databases were searched from inception to February 1, 2020.

Study Selection

Observational studies of adult patients with asymptomatic severe AS.

Data Extraction and Synthesis

Two investigators independently extracted study and patient characteristics, follow-up time, events, and prognostic indicators of events. Random-effects models were used to derive pooled estimates.

Main Outcomes and Measures

The meta-analysis on natural history was performed on the primary end point of all-cause death occurring during a conservative treatment period, with secondary end points consisting of cardiac death, death due to heart failure, sudden death, development of symptoms, development of an indication for aortic valve intervention, and aortic valve intervention. The primary end point for the meta-analysis of early intervention vs a conservative strategy was all-cause death during long-term follow-up. Finally, meta-analysis was performed on the association of prognostic indicators with the composite of death or aortic valve intervention found in multivariable models.

Results

A total of 29 studies with 4075 patients with 11 901 years of follow-up were included. Pooled rates per 100 patients per year were 4.8 (95% CI, 3.6-6.4) for all-cause death, 3.0 (95% CI, 2.2-4.1) for cardiac death, 2.0 (95% CI, 1.3-3.1) for death due to heart failure, 1.1 (95% CI, 0.6-2.1) for sudden death, 18.1 (95% CI, 12.8-25.4) for an indication for aortic valve intervention, 18.5 (95% CI, 13.4-25.5) for development of symptoms, and 19.2 (95% CI, 15.5-23.8) for aortic valve intervention. Early intervention was associated with a significant reduction in long-term mortality (hazard ratio, 0.38; 95% CI, 0.25-0.58). Factors associated with worse prognosis were severity of AS, low-flow AS, left ventricular damage, and atherosclerotic risk factors.

Conclusions and Relevance

Data from observational studies and a recent randomized clinical trial suggest that many patients with asymptomatic severe AS develop an indication for aortic valve intervention, and their deaths are mostly cardiac but not only sudden. Other end points besides sudden death should be considered during the decision to perform early intervention that are associated with improved survival.

Do women benefit more than men from off-pump coronary artery bypass grafting?

Objectives

Outcomes after coronary artery bypass grafting (CABG) are worse in women than in men. This study aims to investigate whether off-pump coronary artery bypass (OPCAB) surgery improves the outcomes in women by comparing different outcome measures in both genders.

Methods

Patients who underwent isolated CABG, either on-pump (ONCAB) or OPCAB, between January 1998 and June 2017 were included. Primary endpoints were 30-day and 120-day mortality. Logistic regression models were constructed to evaluate the effect of the CABG technique on important outcomes such as mortality and the need for blood transfusion.

Results

The data of 17,052 patients were analysed, 3,684 of whom were women (414 OPCAB) and 13,368 men (1,483 OPCAB). The mean number of grafts was lower in the OPCAB group of both genders (p < 0.001). Postoperatively, both men and women undergoing OPCAB surgery received fewer red blood cell transfusions (p < 0.001) and had higher postoperative haemoglobin levels (p < 0.001) than those undergoing ONCAB. Early mortality occurred less frequently after OPCAB surgery in both genders, although the difference was not significant. However, 120-day mortality was significantly lower after OPCAB surgery in women, even after correction for preoperative risk factors [odds ratio (OR) = 0.356, 95% confidence interval (CI) 0.144–0.882, p = 0.026]. The difference in 120-day mortality was not significant in men (OR = 0.787, 95% CI 0.498–1.246, p = 0.307).

Conclusions

Women undergoing CABG benefit more from OPCAB surgery than from ONCAB surgery in terms of 120-day mortality. This difference was not found in men in our patient population.

Natural History, Diagnostic Approaches, and Therapeutic Strategies for Patients With Asymptomatic Severe Aortic Stenosis

Aortic stenosis (AS) is one of the most common valvular diseases encountered in clinical practice. Current guidelines recommend aortic valve replacement (AVR) when the aortic valve is severely stenotic and the patient is symptomatic; however, a substantial proportion of patients with severe AS are asymptomatic at the time of first diagnosis. Although specific morphological valve features, exercise testing, stress imaging, and biomarkers can help to identify patients with asymptomatic severe AS who may benefit from early AVR, the optimal management of these patients remains uncertain and controversial. The current report presents a comprehensive review of the natural history and the diagnostic evaluation of asymptomatic patients with severe AS, and is followed by a meta-analysis from reported studies comparing an early AVR strategy to active surveillance, with an emphasis on the level of evidence substantiating the current guideline recommendations. Finally, perspectives on directions for future investigation are discussed.

Comparison of Outcomes of Transfemoral Transcatheter Aortic Valve Implantation Using a Minimally Invasive Versus Conventional Strategy

Some centers, mostly in Europe, have demonstrated the feasibility of a minimally invasive strategy (MIS; i.e., local anesthesia and conscious sedation, performed in the cath laboratory without transesophageal echocardiography guidance). Nonetheless, the experience of MIS for TAVI using both commercially available valves is lacking in the United States. We, therefore, retrospectively studied all transfemoral TAVI cases performed at our institution between March 2011 and November 2014 to assess the safety and efficacy of MIS. Patients were dichotomized according to the strategy (MIS vs conventional strategy [CS]) used for the procedure. One hundred sixteen patients were included in the MIS group and 91 patients were included in the CS group. Baseline characteristics were similar, and procedural success was comparable (99.1% in MIS and 98.9% in CS, p = 1). One intraprocedural death occurred in each group, whereas conversion rates to general anesthesia were low (3.4%). Comparable device success was obtained. Rates of complications and >mild paravalvular leak before discharge were low and comparable. Length of hospital stay was significantly reduced in the MIS (median, 3.0 [2.0 to 5.0] days) compared with than that in CS group (median 6.0 days [3.5, 8.0]). At a median follow-up of 230 days, no significant difference in survival rate was detected (89% vs 88%, p = 0.9). On average, MIS was associated with remarkable cost saving compared with CS ($16,000/case). In conclusion, TAVI through MIS was associated with a shorter postprocedural hospital stay, lower costs, and similar safety profile while keeping procedural efficacy compared with CS.

Cardiac Mechanics in Isolated Bicuspid Aortic Valve Disease With Normal Ejection Fraction: A Study of Various Valvular Lesion Types

Aortic stenosis (AS) and aortic regurgitation (AR) are associated with congenital isolated bicuspid aortic valve (BAV) disease. The chronic pressure overload of AS and the volume overload of AR are known to impair the left ventricular function. This study assessed whether two-dimensional speckle tracking echocardiography (2D-STE) is capable of detecting the myocardial dysfunction associated with BAV caused by various aortic valve lesions in patients retaining normal ejection fraction (EF).Thirty-two isolated BAV patients and 20 healthy tricuspid aortic valve (TAV) volunteers were recruited. BAV patients were divided into 4 subgroups based on aortic valvular lesion types: normal function (NF) group, isolated AS group, isolated AR group, and a group who had both AS&AR. Myocardial strain and degree of twist were analyzed and compared between the BAV and TAV groups, as well as between valvular lesion groups and the NF group.Compared with healthy TAV controls, global radial strain (GRS), global circumferential strain (GCS), global longitudinal strain (GLS), and twist angle absolute values were lower in the BAV group (P < 0.05). The AS, AR, and AS&AR groups all demonstrated a significant decrease in GRS and GCS when compared with the TAV group. The AS and AS&AR groups demonstrated lower GLS than the TAV group, and the smallest degree of twist was detected in the AR group. There were no significant differences between the NF and TAV groups. The AR and AS&AR groups demonstrated significant differences in multiple parameters of cardiac mechanics compared with the NF group.2D-STE is able to detect altered cardiac mechanics associated with aortic lesion types in BAV patients with normal EF compared with normal TAV controls, and so can provide valuable information for clinical decision-making.

Almanac 2012: adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Association of myocardial deformation with outcome in asymptomatic aortic stenosis with normal ejection fraction

BACKGROUND

Current guidelines recommend intervention for symptomatic aortic stenosis, but the management of asymptomatic aortic stenosis remains controversial. As left ventricular global longitudinal strain (GLS) has been shown to predict cardiovascular outcome, we sought to find whether its use could guide the assessment of risk in these patients.

METHODS AND RESULTS

We prospectively followed 79 patients with severe asymptomatic aortic stenosis (39 men; mean age, 77 ± 12 years; aortic valve [AV] area index, 0.36 cm(2)/m(2)). In addition to standard echocardiography, speckle strain was measured to assess GLS. Patients were followed for cardiac death and AV replacement driven by symptom development. A multivariable Cox regression was performed to identify associations with events. During 23 ± 20 months, 3 patients had cardiac death and 49 underwent AV replacement. Event-free survival was 72 ± 5% at 1 year, 50 ± 5% at 2 years, and 24 ± 5% at 4 years. Death and AV replacement were predicted by GLS (hazard ratio [HR], 1.14 [95% CI, 1.01-1.28]; P=0.037), as well as extent of AV calcification (HR, 2.44 [95% CI, 1.17-5.12]; P=0.018), peak transaortic pressure gradient (HR, 1.03 [95% CI, 1.01-1.04]; P<0.001), valvulo-arterial impedance (HR, 1.32 [95% CI, 1.04-1.67]; P=0.045), and Society of Thoracic Surgeons Predicted Risk of Morbidity and Mortality (HR, 0.95 [95% CI, 0.90-1.00]; P=0.052). A mean absolute GLS <15% was associated with a significant excess mortality, and this measurement added incremental prognostic value to the Society of Thoracic Surgeons Predicted Risk of Morbidity and Mortality, transaortic peak pressure gradient, AV calcification, and valvulo-arterial impedance.

CONCLUSIONS

GLS is associated with outcomes in patients with severe asymptomatic aortic stenosis, incremental to other clinical and echocardiographic variables.

The year in review: the surgical treatment of valvular disease-2011

This review highlights important advances in techniques, guidelines, outcomes and innovations in valve surgery during 2011.

Predictors of early and mid-term results in contemporary aortic valve replacement for aortic stenosis

BACKGROUND

The purpose of this study was to evaluate clinical risk factors and assess the impact of the Society of Thoracic Surgeons (STS) scores on outcomes after contemporary aortic valve replacement (AVR) for aortic stenosis (AS).

METHODS

We retrospectively analyzed the data from 209 consecutive patients with AS (mean 69 ± 9 years) who underwent AVR. The outcomes measured included operative mortality, postoperative complications, postoperative prolonged length of stay (PLOS), discharge to nonhome location, and mid-term mortality.

RESULTS

Operative mortality was 3.8%, and five-year survival was 88.6 ± 2.8%. Multivariable analysis revealed preoperative New York Heart Association (NYHA) class as a significant predictor of both operative mortality (p = 0.03; odds ratio [OR]: 8.5) and mid-term mortality (p = 0.02; OR: 10.5). NYHA class also emerged as an independent predictor for postoperative complications (p = 0.002; OR: 5.8) and PLOS (p = 0.01; OR: 2.5). Other preoperative independent predictors included dialysis for PLOS (p = 0.04; OR: 2.9), age (p = 0.03; OR: 1.1), and left ventricular ejection fraction (EF; p = 0.03; OR: 0.9) for nonhome discharge, and EF for mid-term mortality (p = 0.01; OR: 0.9). The mean STS-PROM (predicted risk of mortality) was 4.6% ± 6.1%, and thus, the observed-to-expected (O/E) ratio of operative mortality in our series was 0.82.

CONCLUSIONS

Advanced NYHA class, older age, dialysis, and lower EF are significant independent preoperative risk factors for early and mid-term results of AVR for AS. Consideration of these predictors should be used to identify high-risk patients requiring AVR for AS.

Local versus general anesthesia for transfemoral aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) represents a novel option for elderly with severe aortic valve stenosis who are denied surgical aortic valve replacement due to high perioperative risk. While transfemoral TAVI generally is being performed in general anesthesia (GA), TAVI under local anesthesia plus mild sedation (LAPS) might be an effective and safe alternative.

METHODS

In a single-centre analysis, we assessed clinical data, preoperative risk scores (STS-Score), echocardiography, periprocedural data and labor costs in 74 patients undergoing transfemoral TAVI under GA (n = 33) and LAPS (n = 41).

RESULTS

Patients who underwent TAVI in LAPS presented significantly more often with pulmonary hypertension and impaired renal function, and tended to have a higher STS score and more severe symptoms (higher NYHA class) versus the GA group. There were no significant differences in procedure-related 30-day mortality or complications between groups. The peak systolic and mean central aortic pressure were significantly higher in the LAPS group, while at the same time these patients required significantly less often periprocedural adrenergic support. Intervention time was shorter in the LAPS group due to avoidance of surgical cut-down of the access site. Moreover, total procedure time was significantly shorter and labor costs were lower in the LAPS group. Patients who underwent TAVI in LAPS could be mobilized significantly earlier.

CONCLUSION

Our study indicates that TAVI under LAPS is as effective and safe as TAVI under GA. Furthermore, total procedure time, intervention time and labor costs could be reduced by LAPS. Mobilization of patients could be achieved earlier. We therefore consider LAPS to be favorable in patients undergoing transfemoral TAVI.