1. Fast-Track General Anesthesia for Patients Undergoing Transfemoral Transcatheter Aortic Valve Replacement Results In Shorter Intensive Care Unit and Hospital Lengths of Stay and Lower Cost
Andrew Wilkey, MD, Matthew Sundblad, MD, Matthew McMillan, BS, Craig Strauss, MD, MPH
Andrea Sweeney, MBA, R. Saeid Farivar, MD, PhD, Paul Sorajja, MD, Tjorvi E Perry, MD, MMSc
Discussion
Our efforts to implement a fast-track general anesthetic approach and avoid ICU admission in patients undergoing TF-TAVR therapy resulted in a significant decrease in ICU and HLOS and cost. We contend that endotracheal intubation with in-procedure extubation ensures both safety and optimal conditions for device deployment; breath-holding and use of intraprocedural transesophageal echocardiography. Future studies will identify modifiable clinical predictors of post-procedural ICU admission and strategies for further reducing ICU admissions following TF TAVR therapy in our institution.
Introduction / Background
Transcatheter aortic valve replacement (TAVR) therapy has become a viable alternative to surgical aortic valve replacement (SAVR) therapy in otherwise high-risk or inoperable patients. We hypothesized that adopting a fast-track general anesthetic (FTGA) approach would limit post-procedural admission to the intensive care unit (ICU) and significantly decrease hospital length of stay and associated costs.
Figure 1: FTGA vs. HC
(Sedatives / Narcotics)
Figure 2: FTGA vs. HC
(LOS and ICU Admission)
Methods
Using a retrospective study design, we compared demographic data, co-morbidities, aortic valve pathology, intra-procedural management and outcomes in 84 consecutive patients undergoing transfemoral (TF) TAVR procedures using a FTGA approach with 72 consecutive historical controls (HC) undergoing the same procedure type. Anesthetic management was left to the discretion of the anesthesiologist with recommendations to strictly limit perioperative anxiolytics, long-acting narcotics, paralytics and anesthetic agents, use of IV acetaminophen with long-acting local anesthetics infiltration at all groin puncture sites. We encouraged tracheal intubation with immediate post-procedural extubation when appropriate. Descriptive statistics are expressed as means. We defined statistical significance as p≤ 0.05.
Figure 3: FTGA ICU vs. FTGA no ICU (LOS and Cost)
References
Pollak et al. Quality, economics, and national guidelines for transcatheter aortic valve replacement. Prog Cardiovasc Dis 2014; 56:
Babaliaros et al. Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis. JACC Cardiovasc Interv 2014; 7:
Cobey et al. Anesthetic and perioperative considerations for transapical transcatheter aortic valve replacement. J Cardiothorac Vasc Anesth 2014; 28:
Results
There was no statistically significant difference in age, gender, preoperative comorbidities or aortic valve pathology between the FTGA group and HC. The ICU admission rate decreased from 94% in HC to an average of 32% in FTGA patients. On average, the FTGA group received less perioperative sedative and narcotic compared with HC; midazolam 0.3mg vs. 1.0mg (p=0.004), fentanyl 62.7mcg vs mcg (p=0.001), hydromorphone 0.06mg vs. 0.1mg (p=0.56). (Figure 1) FTGA patients admitted to the ICU spent 3.0 days in the ICU and 6.2 days in the hospital vs. 1.7 days in the ICU and 8.3 days in the hospital for HC (p=ns). (Figure 2) On subgroup analysis, FTGA patients who bypassed the ICU spent 4.3 days in the hospital vs days in FTGA patients admitted to the ICU (p=0.001). The variable cost difference between FTGA patients who bypassed the ICU vs. FTGA patients admitted to the ICU was $15, compared with $32,494.95, respectively (p=0.001). (Figure 3)