Fundación EPIC _ Sedación anestesia general y eco de guiado
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Presentación de la ponencia "Sedación anestesia general y eco de guiado" por el Doctor Moris de la Tasa en los Diálogos EPIC_Retos Clínicos en Válvulas Transcatéter/ Clinical Challenges in TAVR today, el 10 de Mayo de 2018 en Barcelona (España)
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Fundación EPIC _ Sedación anestesia general y eco de guiado
- 1. César Morís Professor of Cardiology Heart Department Director Asturias Central University Hospital Oviedo University OVIEDO -- ESPAÑA SEDACION / ANESTESIA GENERAL EN TAVI
- 4. El mito de la Caverna Platón
- 5. ROW U.S. EU ~55K ROW Japan U.S. EU >120K Japan 4 Expanding Valve Sizes Improving Economics Disease & Therapy Awareness Indication Expansion 0 0 1 1 2 2013 2014 2015 2016 2017 2018 2019 2020 0 5 10 PARTNER Trial (May 2007- Aug 2009) 2012 MedPAR (Oct 2011- Sept 2012) TVT Registry (Nov 2011- May 2013) LOS TAVI Procedure TAVI procedures estimated to double in 5 Years
- 6. The Evolution of TAVI • Continued rapid evolution of TAVR devices, procedural techniques, lower risk populations and better screening and patient selection Sapien 3 Edwards Lifesciences Evolut Pro Medtronic CoreValve
- 7. Bleeding and Major Vascular Complications 0,0 % 0,4 % 0,8 % 1,2 % 1,6 % 2013 2014 2015 2016 1,6 % 1,2 % 1,3 % 1,2 % Major Vascular ComplicaJons 0,0 % 1,8 % 3,5 % 5,3 % 7,0 % 2012 2013 2014 2015 2016 6,9 % 6,0 % 3,8 % 3,0 % 2,4 % Life Threatening Bleed Source: STS/ACC TVT Registry Database as of April 10, 2017
- 8. TAVI Mortality 0,0 % 1,8 % 3,5 % 5,3 % 7,0 % 2012 2013 2014 2015 2016 6,8 % 6,5 % 5,1 % 3,7 % 2,8 % 5,8 % 5,2 % 4,0 % 2,8 % 2,0 % In-hospital 30 day Source: STS/ACC TVT Registry Database as of April 10, 2017 In-hospital mortality after Transvascular, Transapical and Surgical implantation
- 9. The Evolution of TAVI • Continued rapid evolution of TAVR devices, procedural techniques, and populations
- 10. The Evolution of TAVI • Continued rapid evolution of TAVR devices, procedural techniques, and populations • Moving beyond traditional surgical risk models and scores (STS, EuroSCORE, etc.) with TAVR-specific risk scores and individualized risk assessment based on IMAGING (CTA)
- 11. The Evolution of TAVR • Continued rapid evolution of TAVR devices, procedural techniques, and populations • Moving beyond traditional surgical risk models and scores (STS, EuroSCORE, etc.) with TAVR-specific risk scores and individualized risk assessment based on IMAGING (CTA) • Increasingly favor “minimalist” approach with conscious sedation and expedited discharge
- 14. What’s Next • Simplify procedure • Maintain superior outcomes, short and long term • Decrease resource utilization and cost Apr 2018Sept 2007 Efficiency and Economics: Minimalist TF TAVR
- 16. Minimalist TAVI Features – CONSCIOUS SEDATION – Transthoracic echo – No neck line or Swan – Groin access only – No Foley catheter – Avoid ICU admission
- 17. • Femoral puncture and preclosure • Sheath insertion • Temporary pacemaker wire • Valve insertion • Rapid pacing / no rapid pacing • Valve deployment • Closure GA= General Anesthesia, CS= Conscious sedation, LA= Local Anesthesia Needs for TAVI 2017
- 18. GA CS LA - ? ++ - ? ++ - - ++ - - - - - - - - - - - ++ • Femoral puncture and preclosure • Sheath insertion • Temporary pacemaker wire • Valve insertion • Rapid pacing / no rapid pacing • Valve deployment • Closure GA= General Anesthesia, CS= Conscious sedation, LA= Local Anesthesia Needs for TAVI 2017
- 20. General Anesthesia ADVANTAGES • Motionless patient • Intraprocedural confort • Secure airway • No need to manage airway if intra- procedural complications • Facilitates TEE DISADVANTAJES • Greater hemodinamyc inestability • Longer procedures • Longer hospital stay • Grater monitorization needs • More costly
- 21. Advantages • Shorter total room time • Reduced hospital stay • Reduced costs • Minimal invasive lines • Reduced need for vasopressor therapy • Probably reduced delirium risk • Faster return to neurologic baseline • Potencial avoidance of ICU admisión admission or shorter stay in ICU Disadvantages • Less comfort during the procedure • Respiratory depression risk • TEE not easy to use Conscious Sedation
- 23. • Preparation of the implant ? Need for TEE ?
- 24. • Preparation of the implant ? – Done by CT Need for TEE ?
- 25. • Preparation of the implant ? – Done by CT Positioning of valve ? Need for TEE ?
- 26. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Need for TEE ?
- 27. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Assessment of result Need for TEE ?
- 28. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Assessment of result – TTE / Aortogram / Pressures Need for TEE ?
- 29. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Assessment of result – TTE / Aortogram / Pressures • Detection of Complications: Tamponade Need for TEE ?
- 30. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Assessment of result – TTE / Aortogram / Pressures • Detection of Complications: Tamponade -TTE Need for TEE ?
- 31. • Preparation of the implant ? – Done by CT Positioning of valve ? – X Ray guided Assessment of result – TTE / Aortogram / Pressures • Detection of Complications: Tamponade -TTE Need for TEE ? LIMITED BENEFIT OF TEE IN TAVI
- 40. BMJ Open 2017;7:e016321 One RCT and 19 observational studies were included Favours LAS Favours GA 30 Days mortality In-hospital mortality Intraprocedural catecholamine Postprocedural catecholamine Transfusion requierements New pacemaker Stroke Neumonia Length hospital stay Length ICU stay + ++ + + + + + + - - - + + + GA= General Anesthesia, LAS= Local Anesthesia+Sedation
- 41. 16,543 patients from the German Aortic Valve Registry from 2011 to 2014 Number of procedures In HospitalIn ICU
- 42. 30 and 1-Year Mortality According to Local Anesthesia or Conscious Sedation Versus General Anesthesia Survival According to Local Anesthesia or Conscious Sedation Versus General Anesthesia 16,543 patients from the German Aortic Valve Registry from 2011 to 2014 J Am Coll Cardiol Intv 2018;11:567–78
- 44. Odds ratios adjusted for variables associated with 1-year mortality Women and in patients with pulmonary hypertension
- 45. 10.997 TAVR between April 1, 2014, and June 30, 2015 from TVT Registry ▪ Black, ▪ Less BMI, ▪ Prior AV surgery, ▪ Greater AV grd, ▪ No PAD, ▪ Greater STS, ▪ Self Expandable Valve % Centros % CS
- 47. In-hospital outcomes 30-days outcomes CONCLUSIONS: Conscious sedation is associated with briefer length of stay and lower in- hospital and 30-day mortality. These results suggest the safety of conscious sedation in this population
- 48. ▪ NO General Anesthesic as a default procedure ▪ Screening patients for GA ▪ Inmediate anesthesic support avalaible during the procedure ▪ Radial line for pressure ▪ Right jugular neck line for temp pacemaker, on table ▪ Sedation with Midazolan + ▪ Temporary wire for 24 hours only if AV conduction disturbances What we do at HUCA
- 49. 2017 - ACTUALIDAD 140 Transfemoral Patients General Anesthesia 10 Pts. 7,1 % • Lack of experience 4 Pts. • TEE need 4 Pts • Already OTI 2 Pts
- 57. • Should be reserved for patients unable to tolerate a procedure awake Role for GA ? • In my view
- 58. • Should be reserved for patients unable to tolerate a procedure awake • There is no role for GA in routine TAVI Role for GA ? • In my view
- 59. • Should be reserved for patients unable to tolerate a procedure awake • There is no role for GA in routine TAVI • ‘Conscious ‘ sedation carries the risk of paradox reactions Role for GA ? • In my view
- 60. • Should be reserved for patients unable to tolerate a procedure awake • There is no role for GA in routine TAVI • ‘Conscious ‘ sedation carries the risk of paradox reactions • Local anesthesia can deal with discomfort from puncture and sheath insertion Role for GA ? • In my view
- 61. • Should be reserved for patients unable to tolerate a procedure awake • There is no role for GA in routine TAVI • ‘Conscious ‘ sedation carries the risk of paradox reactions • Local anesthesia can deal with discomfort from puncture and sheath insertion • Monitored Anesthetic Control is important ! Role for GA ? • In my view
- 62. • It has proven to be a valid and safe option. Concious Sedation
- 63. • It has proven to be a valid and safe option. • Proven advantages in terms of hemodynamic stability, stays and costs. Concious Sedation
- 64. • It has proven to be a valid and safe option. • Proven advantages in terms of hemodynamic stability, stays and costs. • Proven advantages its role in reducing short term mortality. Concious Sedation
- 65. • It has proven to be a valid and safe option. • Proven advantages in terms of hemodynamic stability, stays and costs. • Proven advantages its role in reducing short term mortality. • Its implementation is clearly increasing as the teams gain experience, although there are still large differences between centers and countries. Concious Sedation
- 66. • It has proven to be a valid and safe option. • Proven advantages in terms of hemodynamic stability, stays and costs. • Proven advantages its role in reducing short term mortality. • Its implementation is clearly increasing as the teams gain experience, although there are still large differences between centers and countries. • It is part of a minimalist approach. Important the preoperative selection. Concious Sedation
- 67. Conclusions • Minimalist TAVI is the strategy on which early discharge and lower costs will be more common.
- 68. Conclusions • Minimalist TAVI is the strategy on which early discharge and lower costs will be more common. • Minimalist TAVI has proven a short term mortality benefit
- 69. Conclusions • Minimalist TAVI is the strategy on which early discharge and lower costs will be more common. • Minimalist TAVI has proven a short term mortality benefit • Anatomical Risk (not clinical risk) will be the dividing line on whether patients are done Minimalist TAVI (>80%)
- 70. Muchas gracias