Aims 

Conscious sedation instead of general anesthesia has been increasingly adopted in many centers for transfemoral transcatheter aortic valve replacement (TAVR). Improvement of materials and operators’ experience and reduction of periprocedural complications allowed procedural simplification and adoption of a minimalist approach. With this study, we sought to assess the feasibility and safety of transfemoral TAVR routinely performed under local anesthesia without on-site anesthesiology support.

Methods 

The routine transfemoral TAVR protocol adopted at our center includes a minimalist approach, local anesthesia alone with fully awake patient, anesthesiologist available on call but not in the room, and direct transfer to the cardiology ward after the procedure. All consecutive patients undergoing transfemoral TAVR between January 2015 and July 2018 were included. We assessed the rates of actual local anesthesia-only procedures, conversion to conscious sedation or general anesthesia and 30-day clinical outcomes.

Results 

Among 321 patients, 6 received general anesthesia upfront and 315 (98.1%) local anesthesia only. Mean age of the local anesthesia group was 83.2 ± 6.9 years, Society of Thoracic Surgery score 5.8 ± 4.8%. A balloon-expandable valve was used in 65.7%. Four patients (1.3%) shifted to conscious sedation because of pain or anxiety; 6 patients (1.9%) shifted to general anesthesia because of procedural complications. Hence, local anesthesia alone was possible in 305 patients (96.8% of the intended cohort, 95% of all transfemoral procedures). At 30 days, in the intended local anesthesia group, mortality was 1.6%, stroke 0.6%, major vascular complications 2.6%. Median hospital stay was 4 days (IQR 3–7).

Conclusion 

Transfemoral TAVR can be safely performed with local anesthesia alone and without an on-site anesthesiologist in the vast majority of patients.

中文翻译：

---

仅使用局部麻醉的常规常规简约经导管主动脉瓣植入

目的 

在许多经股动脉经导管主动脉瓣置换术（TAVR）的中心中，越来越多地采用自觉镇静代替全身麻醉。改善材料和操作员的经验并减少围手术期并发症，可以简化程序并采用简约方法。通过这项研究，我们试图评估在没有现场麻醉学支持的情况下在局部麻醉下常规行经股动脉TAVR的可行性和安全性。

方法 

我们中心采用的常规经股动脉TAVR方案包括极简方法，仅对完全清醒的患者进行局部麻醉，应召唤但不在房间内的麻醉师，并在手术后直接转移至心脏科病房。纳入了2015年1月至2018年7月期间接受经股动脉TAVR的所有连续患者。我们评估了仅进行局部麻醉的过程，转换为有意识的镇静或全身麻醉的比率以及30天的临床结局。

结果 

在321例患者中，有6例接受了全身麻醉，仅315例（98.1％）接受了局部麻醉。局部麻醉组的平均年龄为83.2±6.9​​岁，胸外科协会评分为5.8±4.8％。气球膨胀阀的使用率为65.7％。四名患者（1.3％）由于疼痛或焦虑而转移到清醒镇静；6例（1.9％）因手术并发症而转为全身麻醉。因此，在305例患者中仅局部麻醉是可能的（预期队列的96.8％，所有经股动脉手术的95％）。在第30天，预期的局麻组死亡率为1.6％，中风为0.6％，主要血管并发症为2.6％。中位住院天数为4天（IQR 3-7）。

结论 

经股动脉TAVR可以仅通过局部麻醉就可以安全地进行，并且在绝大多数患者中无需现场麻醉师。