Less is More. Less What?
“Less is More,” a reference to a phrase from the Robert Browning poem, Andrea Del Sarto. The phrase also has been adopted in architecture to reflect the artistic opinion that a simplistic or minimalist design is more aesthetically pleasing. We seem to have evolved into a “less is more” dogma in the world of transcatheter aortic valve replacement (TAVR), where increasingly centers are documenting improved outcomes and reduced resource utilization when TAVR is performed using a minimally invasive approach.
Giri and colleagues, from University of Pennsylvania1, presented their study at the Society for Cardiovascular Angiography and Interventions 2016 Scientific Sessions. They queried the STS/ACC TVT Registry from 2014 to 2015, seeking to compare the use of general anesthesia for TAVR with that of moderate sedation. The database included 10,997 elective TAVR patients, in whom moderate sedation was used in 15.8%. Procedural success was comparable between the two modalities, yet moderate sedation patients had lower rates of 30-day mortality and stroke. These advantages remained even with a propensity matched comparison.
It is true that with smaller introducer sheaths, improved deployment technologies, increasingly experienced operators, and “enhanced recovery” pathways, a large subset of TAVR procedures can be managed without general endotracheal anesthesia. Some reports claim procedural success and economic advantages a result of using “little to no anesthesia.” In truth, these centers are implementing a team-based, minimally invasive approach to TAVR in which one strategy involves the move toward monitored anesthesia care. However, the other components of this pathway also are highly contributory to the success of the minimally invasive TAVR. These other strategies include the elimination of invasive monitors, urinary catheters, and transesophageal echocardiography (TEE) from the standard monitoring, removal of femoral vein pacing wires at the end of the procedure, and a large emphasis on early ambulation. In essence, it is an enhanced recovery protocol after surgery (ERAS) for TAVR. Some, like the Emory University team, have moved TAVR procedures into a standard cardiac catheterization laboratory, with no anesthesiologist present, and offer nurse-administered conscious sedation as part of the TAVR procedure. They aim for discharge of the patient in one day and have termed this a “minimalist approach.” At TVT 2016, Dr. Babaliaros and colleagues reported similar rates of complications to standard protocol patients, even hinting at improvements in rates of vascular complications, pacemaker implantation, and paravalvular leak. Needless to say, this “minimalist” strategy resulted in a cost savings of nearly $10,000 per patient.2
We appreciate the successes of these rapid transit protocols; however, is “minimalist approach” the ideal term? The Merriam-Webster dictionary defines minimalist as “a person who favors a moderate approach to the achievement of a set of goals or who holds minimal expectations for the success of a program.” A second definition includes “being or offering no more than what is required or essential.” Clearly there is a more positive message to be imparted.
It is critical that one does not misinterpret the phrase “less anesthesia” to mean without the services or input of the anesthesiologist. The cardiac anesthesiologist is and should be an integral part of the planning team, determining which patients are candidates for conscious sedation, and helping to create and implement the expedient clinical care pathways that now exist. Other large TAVR centers have created “fast track” TAVR protocols that employ monitored anesthesia care with an anesthesiologist and discharge routinely on post-procedure day 2. In published work from the Italian CoreValve registry, Drs. Petronio and Giannini also realized a similar reduction in adverse events, including a reduction in acute kidney injury, when patients were managed using a local anesthesia protocol.3 They concluded that in selected patients, “local anesthesia can be used with excellent clinical outcomes, however since severe procedural complications are possible, an anesthesiologist should always be present as part of the team.”
It behooves us and our TAVR patients to ensure that the first time a patient comes into contact with an anesthesiologist it is not during rescue from a catastrophe. SCA is committed to excellence in patient care and to creating the educational, research, and administrative support to lead this charge. SCA has collaboratively approached the structural heart disease team in conjunction with our colleagues at the American Society of Echocardiography (ASE). In May, we hosted a Structural Heart Disease Symposium at our Echo Week Conference and course directors Dr. Burkhard Mackensen and Dr. Sunil Mankad presented an outstanding interdisciplinary live program. SCA will continue to offer cutting-edge education in the management of structural heart disease with offerings at our Annual Meetings, Echo Week meetings, and future multidisciplinary symposia. We will ensure that the headlines do not read “TAVR outcomes improved without anesthesia!” but rather “TAVR outcomes improved using enhanced recovery protocols implemented by the structural heart disease team.”
Linda Shore-Lesserson, MD
- Giri, J. Moderate vs. general anesthesia for transcatheter aortic valve replacement: An STS/ACC Transcatheter Valve Therapy Registry Analysis. SCAI, May 2016.
- Babaliaros V, Devireddy C, Lerakis S, et al. Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): outcomes and cost analysis. JACC Cardiovasc Interv. 2014;7(8):898-904.
- Petronio AS, Giannini C, De Carlo M. Anaesthetic management of transcatheter aortic valve implantation: results from the Italian CoreValve registry. EuroIntervention 2016; 12:381-388.