title: Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?
abstract: BACKGROUND
  Transcatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR.
  
  
  METHODS
  Records for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost.
  
  
  RESULTS
  Of the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses.
  
  
  CONCLUSIONS
  Conscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.
authors.affiliation: UCLA Department of Medicine, Los Angeles, California, United States of America.
authors.forename: William
authors.identifier: http://orcid.org/0000-0003-0156-9891
authors.initials: W
authors.lastname: Toppen
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Daniel
authors.initials: D
authors.lastname: Johansen
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Sohail
authors.initials: S
authors.lastname: Sareh
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Josue
authors.initials: J
authors.lastname: Fernandez
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Nancy
authors.initials: N
authors.lastname: Satou
authors.affiliation: UCLA Department of Anesthesia and Preoperative Medicine, Los Angeles, California, United States of America.
authors.forename: Komal D
authors.initials: KD
authors.lastname: Patel
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Murray
authors.initials: M
authors.lastname: Kwon
authors.affiliation: UCLA Division of Cardiology, Los Angeles, California, United States of America.
authors.forename: William
authors.initials: W
authors.lastname: Suh
authors.affiliation: UCLA Division of Cardiology, Los Angeles, California, United States of America.
authors.forename: Olcay
authors.initials: O
authors.lastname: Aksoy
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Shemin
authors.affiliation: UCLA Division of Cardiac Surgery, Los Angeles, California, United States of America.
authors.forename: Peyman
authors.initials: P
authors.lastname: Benharash
mesh_terms: D000369:Aged, 80 and over; D000768:Anesthesia, General / Q000191:economics* / Q000379:methods; D001021:Aortic Valve / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000601:surgery; D016292:Procedural Sedation / Q000191:economics* / Q000379:methods; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D008297:Male; D057216:Propensity Score; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D019616:Thoracic Surgical Procedures / Q000191:economics; D065467:Transcatheter Aortic Valve Replacement / Q000191:economics* / Q000379:methods; D016896:Treatment Outcome