Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

Toppen, William; Johansen, Daniel; Sareh, Sohail; Fernandez, Josue; Satou, Nancy; Patel, Komal; Kwon, Murray; Suh, William M.; Aksoy, Olcay; Shemin, Richard J.; Benharash, Peyman

doi:10.1371/journal.pone.0173777

Cited by 67 publications

(53 citation statements)

References 14 publications

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“…17 LA/CS was shown to achieve greater improvement of patient's quality of life at 30 days post-TAVR, as assessed by Kansas City Cardiomyopathy Questionnaire compared with general anesthesia. 12 Additionally, for elderly patients, shorter LOS is beneficial, considering the potential reduction in known negative outcomes of longer hospitalization, including reduced functional status, infection, or delirium. 18 There is also lower 1-year mortality rates among patients with severe chronic obstructive pulmonary disease undergoing minimalist approach when compared to the standard procedure.…”

Section: Minimalist Transcatheter Aortic Valve Replacement: Potentialmentioning

confidence: 99%

“…21,26 LA/CS were associated with lower rates of systemic hypertension and subsequent intra and post-procedural inotropic support, and potentially lower pulmonary complications rate, like the incidence of respiratory failure and pneumonia associated with mechanical ventilation. 22,23 As a result, early recovery after the procedure can be achieved, leading to a shorter length of post-procedural ICU stay and LOS, 12,20,22,25,27 e.g. mean 1.5-2.1 days shorter in LOS under LA/CS than under general anesthesia.…”

Section: Local Anesthesia/conscious Sedationmentioning

confidence: 99%

“…CS to general anesthesia was 5.9%, which was consistent with previous reports. 28 According to these prior reports, 12,20,22,25,27 transfemoral TAVR under LA/CS seems to be feasible and safe with the merit of shorter LOS. However, majority of these studies are observational, and randomized, controlled trials are scarce, 29 a potential caveat of which is patient selection bias, e.g.…”

mentioning

confidence: 97%

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Minimalist approach for transcatheter aortic valve replacement

Dallan¹,

Ichibori²,

Attizzani³

2019

J Transcat Intervent

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Transcatheter aortic valve replacement became a routine interventional procedure worldwide, together with improvements in valve technology and optimized implant techniques. The concept of minimalist approach became relevant, aiming at optimal technical implant, fewer perioperative comorbidities, and consequently faster recovery and less associated risks. Compared with surgical aortic valve replacement, reduction of hospital and intensive care unit stay and fewer rates of procedural complications offset the high costs of transcatheter aortic valve replacement valves. The principles of the minimalist approach consist on top performance by experienced structural interventionists, a complete transcatheter basis under local anesthesia and conscious sedation, together with bedside transthoracic echocardiography to access hemodynamic features. It is necessary to customize transcatheter aortic valve replacement optimal procedure by revising how to simplify each aspect of the patient's care process, without losing focus on safety and best outcomes based on individualized patient characteristics, center's expertise, and multidisciplinary care. This review aimed to summarize the current evidence for a minimalist approach to transfemoral transcatheter aortic valve replacement and provide information for its safe and successful implementation and customization.Keywords: Transcatheter aortic valve replacement; Aortic valve/surgery; Aortic valve stenosis; Heart valve prosthesis implantation/methods resumo -O implante transcateter de válvula aórtica tornou-se uma intervenção de rotina em todo o mundo, acompanhando as melhorias na tecnologia das válvulas e a otimização das técnicas de implante. O conceito de abordagem minimalista tornou-se relevante, visando obter um implante tecnicamente ideal, menos comorbidades perioperatórias e, consequentemente, recuperação mais rápida e com menos riscos associados. Em comparação à cirurgia de troca da válvula aórtica, a redução no tempo de hospitalização e na unidade de terapia intensiva, e a menor incidência de complicações do procedimento acabam por compensar os custos mais altos das válvulas para o implante transcateter de válvula aórtica. Os princípios da abordagem minimalista consistem em desempenho superior de intervencionistas estruturais experientes, uma base estrutural completa sob anestesia local e sedação consciente, juntamente da ecocardiografia transtorácica à beira do leito, para avaliar características hemodinâmicas. É necessário customizar um procedimento ideal do implante transcateter de válvula aórtica, procurando simplificar cada um dos aspectos da atenção ao paciente, sem perder o foco na segurança e na obtenção dos melhores desfechos, com base nas características individuais na experiência do centro e no atendimento multidisciplinar. Esta revisão teve como objetivo sintetizar as evidências atuais para uma abordagem minimalista do implante transcateter de válvula aórtica transfemoral, e fornecer informações para garantir a segurança e o sucesso da implementação e customi...

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Section: Minimalist Transcatheter Aortic Valve Replacement: Potentialmentioning

confidence: 99%

Section: Local Anesthesia/conscious Sedationmentioning

confidence: 99%

mentioning

confidence: 97%

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Minimalist approach for transcatheter aortic valve replacement

Dallan¹,

Ichibori²,

Attizzani³

2019

J Transcat Intervent

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“…Comparative studies of the standard and minimalist approaches indicate that in the current era, given the advent of smaller-sized sheaths and valve profiles, the minimalist transfemoral approach can be performed with minimal morbidity and mortality and equivalent effectiveness compared with the standard approach (33,34). Furthermore, a shorter length of hospital stay and lower resource use with the latter approach significantly lowers hospital costs.…”

Section: Minimalistic Approachmentioning

confidence: 99%

Transcatheter aortic valve implantation economics: a grisly reality

Manolis¹

2017

Ann. Cardiothorac. Surg.

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Transcatheter aortic valve implantation (TAVI), an established treatment for inoperable and highrisk operable symptomatic patients with severe aortic stenosis with growing numbers of procedures and expanding indications, is an expensive therapy. Cost-effectiveness analyses rely on the value of the incremental cost-effectiveness ratio (ICER), which is the difference in cost between two possible interventions, divided by the difference in their effect. Several analyses have demonstrated that TAVI is costeffective with an acceptable ICER for the inoperable patient alone and only via the iliofemoral route, while TAVI is more costly and is either less or equally effective as surgery in high-risk operable patients. When use of TAVI is extended to include a larger number of patients suitable for surgery, the overall results become less favorable. Acceptable ICERs should practically equate to the value of the gross domestic product (GDP) per capita in each country; however, the cost of the TAVI kit alone already exceeds the GDP per capita of all moderate-and low-income countries. An overview of the current cost-efficacy issues of TAVI is presented and this grisly reality is discussed, which may hopefully be improved in the future.

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“…Results are expressed as Mantel Haenszel Risk Ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) [1]. In addition to the 26 studies included in our previous analysis, we found 6 new studies (with 12,453 patients) meeting our inclusion criteria [2][3][4][5][6][7].…”

mentioning

confidence: 99%