Transcarotid TAVR Worked Well, Often Avoided General Anesthesia in French Experience

Pam Harrison

October 18, 2016

LILLE, FRANCE — The transcarotid approach for transcatheter aortic-valve replacement (TAVR) appears to be a good option for patients who are not candidates for transfemoral access, suggests a report on the largest series of patients undergoing the procedure[1]. It also suggests local anesthesia may be the safer strategy, as it was associated with fewer periprocedural strokes compared with general anesthesia.

Dr Brian P O'Neill (Temple Heart and Vascular Institute, Philadelphia, PA), editorialist[2] for the report published October 17, 2016 in JACC: Cardiovascular Interventions, lauded the analysis for its large cohort size given the unusual TAVR approach: 174 patients seen over 5 years.

"Most of the previous data presented for the transcarotid access has been in fewer than 10 patients," he told heartwire from Medscape. So this large experience "shows us that you get very similar results with the transcarotid approach as with the transfemoral approach, and it also suggests that the minimalist approach is an effective way of doing the procedure."

As reported by Dr Nicolas Debry (Institut Cardiopulmonaire, CHRU Lille, France) and colleagues, the patients, with severe peripheral vascular disease, making them poor candidates for transfemoral access, underwent transcarotid TAVR at two centers in France between 2009 and 2014.

All had severe aortic-valve disease and multiple comorbidities, the group notes; their mean age was 80.5 years with an average STS mortality score of 8.4.

About 70% received general anesthesia and the remainder had the procedure by a minimally invasive strategy (MIS) consisting of local anesthesia and conscious sedation.

Patients treated with the minimally invasive approach had significantly more coronary artery disease (P<0.001) and prior revascularization (P=0.001) than those who underwent general anesthesia, but otherwise the two groups were similar.

The Medtronic CoreValve was used in approximately 80% of patients, vascular access was achieved in all patients, and there were no instances of valve embolization, the group notes. The device was successfully positioned in 88% of the MIS group and 93% of the general-anesthesia group.

Thirty-day mortality across the whole cohort was 7.4%, and all-cause mortality at 1 year was 12.6%, with no differences between the MIS and general-anesthesia groups. Nor were there differences in other important outcomes, with the exception of periprocedual stroke and transient ischemic attacks (TIAs), both of which were more common with general anesthesia (P<0.001).

Outcomes of Minimally Invasive Treatment vs General Anesthesia

Outcome Minimally invasive strategy, n=52 (%) General anesthesia, n=122 (%)
30-d mortality 7.6 7.3
1-y mortality 9.6 13.9
Strokes 0 2.2*
TIA 0 3.4*
* P<0.001 vs MIS; no other significant differences.

The proximity of the transcarotid access to the patient's head can be difficult for both patients and operators, the group writes. For example, accessing the carotid can be uncomfortable for patients, and there is a risk that the patient might move as the valve is being deployed. "Generous local anesthesia and an appropriate level of sedation is therefore fundamental."

Only 5.7% of those planned for MIS had to cross over to general anesthesia, according to the group.

O'Neill pointed out for heartwire that, as these French centers gained more experience with the transcarotid approach, complication rates decreased. "Patients who developed strokes in this cohort did so early on in investigators' experience, so this goes to show that practice makes perfect and experience goes a long way to making the procedure even safer for patients."

He also said that the French experience suggests that a minimalist approach—meaning without intubation, at most centers—is an effective way of doing transcarotid TAVR. "Intubation, particularly if patients are sicker, does have deleterious effects, and patients can develop complications from it," O'Neill explained.

"And given the data from these authors, it would appear that there are advantages to doing transcarotid TAVR under moderate as opposed to general sedation, and that primarily has to do with the fact that you are able to assess the patient's consciousness when they are under moderate sedation," he added.

"I think their data would suggest a minimalist or moderate sedation approach may be the approach of choice with this particular access."

Debry had no relevant financial relationships; disclosures for the coauthors are listed in the article. O'Neill reports receiving research support from Edwards Lifesciences.

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