Author + information
- Neel M. Butala, MD, MBA1,2,
- Mabel Chung, MD, MPH1,3,
- Eric A. Secemsky, MD, MSc1,
- Pratik Manandhar, MS4,
- Guillaume Marquis-Gravel, MD, MSc4,
- Andrzej S. Kosinski, PhD4,
- Sreekanth Vemulapalli, MD4,
- Robert W. Yeh, MD, MSc1 and
- David J. Cohen, MD, MSc5,∗ ()
- 1Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- 2Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- 3Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- 4Duke Clinical Research Institute, Durham, NC
- 5University of Missouri-Kansas City, Kansas City, MO
- ↵∗Address for Correspondence: David J. Cohen, MD, MSc 824 W. 56th St. Kansas City, MO 64113 Tel: 816-444-5632
Objectives (1) To examine variation in use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time; and (2) to evaluate outcomes of CS compared with general anesthesia (GA) using instrumental variable (IV) analysis, a quasi-experimental method to control for unmeasured confounding.
Background Despite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding.
Methods Among 120,080 patients in the TVT Registry who underwent transfemoral TAVR between 1/2016 and 3/2019, we evaluated the relationship between anesthetic choice and TAVR outcomes using hospital proportional use of CS as an IV.
Results Over the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. Based on IV analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference [aRD] 0.2%; p=0.010) and 30-day mortality (aRD 0.5%; p<0.001), shorter hospital length of stay (adjusted difference 0.8 days; p<0.001), and more frequent discharge to home (aRD 2.8%; p<0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however.
Conclusions In contemporary US practice, use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.
Tweet/handle: @djc795, @nmbutala, @MabelChungMD, @G_MarquisGravel, @rwyeh; Use of conscious sedation for TAVR has increased and is associated with mortality and shorter LOS compared with general anesthesia. Nonetheless, there remains wide variation in use across hospitals.
Dr. Butala is funded by the John S. LaDue Memorial Fellowship at Harvard Medical School, Boston, MA and reports consulting fees and ownership interest in HiLabs, outside the submitted work.
Dr. Guillaume Marquis-Gravel receives honoraria and/or speaking fees from Servier and Novartis (unrelated to study content).
Dr. Secemsky receives grants from AstraZeneca, BD Bard, Boston Scientific, Cook Medical, CSI, Medtronic, Philips, and UCSF. He consults for CSI, Medtronic, and Philips and is on the speaking bureau of BD Bard, Cook Medical and Medtronic
Dr. Yeh reports additional grant support from Abiomed, Astra Zeneca and Boston Scientific and, and consulting fees from Abbott, Boston Scientific, Medtronic, and Teleflex, outside the submitted work.
Dr. Vemulapalli reports Grants/Contracts from: National Institutes of Health, Patient Centered Outcomes Research Institute, Food and Drug Administration (NEST), American College of Cardiology, Society of Thoracic Surgeons, Abbott Vascular, Boston Scientific. Consulting / Advisory Board: Boston Scientific, HeartFlow, Baylabs (Caption Health), Janssen
Dr. Cohen reports institutional grant support from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott and consulting fees from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott
- Received February 28, 2020.
- Revision received March 6, 2020.
- Accepted March 10, 2020.
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