title: Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement.
abstract: BACKGROUND
  There is no clear consensus in regard to the optimal anesthesia utilization during transcatheter aortic valve replacement (TAVR). The aim was to compare outcomes of transfemoral (TF) TAVR under monitored anesthesia care (MAC) vs. general anesthesia (GA) and evaluate the rates and causes of intra-procedural MAC failure.
  
  
  METHODS
  All consecutive patients who underwent TF TAVR from April 2007 through March 2015 were retrospectively analyzed and dichotomized into two groups: TAVR under MAC vs. GA. The main endpoints of the study included 30-day and 1-year mortality, the rates and reasons for failure of MAC, in-hospital clinical safety outcomes, and post-procedural hospital and intensive care unit length-of-stays.
  
  
  RESULTS
  A total of 533 patients (51% male, mean-age 83years) underwent TF TAVR under MAC (n=467) or GA (n=66). Fifty-six patients (12%) in the MAC group required conversion to GA. The MAC group had significantly shorter post-procedural hospital (6.0 vs. 7.9, p=0.023) and numerically shorter ICU (2.4 vs. 2.8, p=0.355) mean length-of-stays in days. The clinical safety outcomes were similar in both groups. Kaplan-Meier unadjusted cumulative in-hospital and 30-day mortality rates were higher in the GA group but similar in both groups at 1-year.
  
  
  CONCLUSIONS
  TF TAVR under MAC is feasible and safe, results in shorter hospital stays, can be performed in the majority of cases, and should be utilized as the default strategy. Trans-esophageal echocardiography utilization during TAVR with MAC is safe and feasible. The most common cause for conversion of MAC to GA is cardiac instability and hypotension. The complete heart team should be available at all times in case the need arises for a rapid conversion to GA.
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Sarkis
authors.initials: S
authors.lastname: Kiramijyan
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Itsik
authors.initials: I
authors.lastname: Ben-Dor
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Edward
authors.initials: E
authors.lastname: Koifman
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Romain
authors.initials: R
authors.lastname: Didier
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Marco A
authors.initials: MA
authors.lastname: Magalhaes
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Ricardo O
authors.initials: RO
authors.lastname: Escarcega
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Smita I
authors.initials: SI
authors.lastname: Negi
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Nevin C
authors.initials: NC
authors.lastname: Baker
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Jiaxiang
authors.initials: J
authors.lastname: Gai
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Torguson
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Petros
authors.initials: P
authors.lastname: Okubagzi
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Federico M
authors.initials: FM
authors.lastname: Asch
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Zuyue
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Gaglia
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.affiliation: Section of Interventional Cardiology, MedStar Washington Hospital Center, MedStar Georgetown University Hospital, Washington, D.C.. Electronic address: ron.waksman@medstar.net.
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D000768:Anesthesia, General / Q000009:adverse effects / Q000401:mortality; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D002406:Catheterization, Peripheral; D017548:Echocardiography, Transesophageal; D005260:Female; D005263:Femoral Artery; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic stenosis; General anesthesia; Monitored anesthesia care; Transcatheter aortic valve replacement