General Anesthesia Increased the Risk of Atrial Fibrillation and Acute Kidney Injury in Transcatheter Aortic Valve Replacement
Focus on TAVR Anesthesia
Keywords:anesthesia, transcatheter aortic valve replacement, acute kidney injury, paravalvular leakage, atrial fibrillation, outcomes
Purpose: To examine key impacts of anesthesia on new-onset atrial fibrillation (AF) and acute kidney injury (AKI) in transcatheter aortic valve replacement (TAVR).
Methods: All consecutive patients who underwent transfemoral, transapical, and transaortic TAVR in Fuwai Hospital from 2012 to 2018 were retrospectively analyzed and dichotomized into 2 groups: TAVR under conscious sedation (CS) and under general anesthesia (GA). The primary endpoint was a composite of all-cause mortality, stroke, AF, permanent pacemaker implantation, myocardial infarction, heart failure, high-grade atrioventricular block, and AKI at 1 year. Binary logistic regression and adjusted multilevel logistic regression were performed to analyze the predictors of AF and AKI.
Results: A total of 107 patients were under CS and 66 patients under GA. No significant difference was observed in the composite endpoint (51.5% vs. 41.2%, GA vs. CS, P = .182) and ≥ mild paravalvular leakage (36.4% vs. 31.4%, GA vs. CS, P = .589) at 1 year. However, the GA group had a significantly higher rate of intensive care unit (ICU) admission (84.8% vs. 6.5%, P < .001), AKI (28.8% vs. 14.0%, P = .018), new-onset AF (15.2% vs. 5.5% at 1 year, P = .036). Multivariable analysis revealed GA to be the significant predictor of new-onset AF (odds ratio 3.237, 95% confidence interval 1.059 to 9.894, P = .039) and AKI (odds ratio 2.517, 95% confidence interval 1.013 to 6.250, P = .047).
Conclusion: GA was associated with higher rates of ICU admission, postoperative AKI, and new-onset AF. The results may provide new evidence that CS challenges universal GA.
Aalaei-Andabili SH, Pourafshar N, Bavry AA, et al. Acute kidney injury after transcatheter aortic valve replacement. J Card Surg 2016;31:416-422.
Ahlsson A, Fengsrud E, Bodin L, Englund A. Postoperative atrial fibrillation in patients undergoing aortocoronary bypass surgery carries an eightfold risk of future atrial fibrillation and a doubled cardiovascular mortality. Eur J Cardiothorac Surg 2010;37:1353-1359.
Aranki SF, Shaw DP, Adams DH, et al. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation 1996;94:390-397.
Attard S, Buttigieg J, Galea S, et al. The incidence, predictors, and prognosis of acute kidney injury after transcatheter aortic valve implantation. Clin Nephrol 2018;90:373-379.
Attizzani GF, Alkhalil A, Padaliya B, et al. Comparison of outcomes of transfemoral transcatheter aortic valve implantation using a minimally invasive versus conventional strategy. Am J Cardiol 2015;116:1731-1736.
Attizzani GF, Patel SM, Dangas GD, et al. Comparison of local versus general anesthesia following transfemoral transcatheter self-expanding aortic valve implantation (from the transcatheter valve therapeutics registry). Am J Cardiol 2019;123:419-425.
Bagur R, Rodes-Cabau J, Doyle D, et al. Usefulness of tee as the primary imaging technique to guide transcatheter transapical aortic valve implantation. JACC Cardiovasc Imaging 2011;4:115-124.
Bainbridge D, Martin J, Arango M et al. Perioperative and anaesthetic-related mortality in developed and developing countries: A systematic review and meta-analysis. Lancet 2012;380:1075-1081.
Bartel T, Bonaros N, Muller L, et al. Intracardiac echocardiography: A new guiding tool for transcatheter aortic valve replacement. J Am Soc Echocardiogr 2011;24:966-975.
Ben-Dor I, Looser PM, Maluenda G, et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med 2012;13:207-210.
Butala NM, Chung M, Secemsky EA, et al. Conscious sedation versus general anesthesia for transcatheter aortic valve replacement: Variation in practice and outcomes. JACC Cardiovasc Interv 2020;13:1277-1287.
Cocchieri R, Petzina R, Romano M, et al. Outcomes after transaortic transcatheter aortic valve implantation: Long-term findings from the European ROUTE†. Eur J Cardiothorac Surg 2019;55:737-743.
Durand E, Borz B, Godin M et al. Transfemoral aortic valve replacement with the Edwards Sapien and Edwards Sapien XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: Feasibility and 30-day outcomes. JACC Cardiovasc Interv 2012;5:461-467.
Helgadottir S, Sigurdsson MI, Ingvarsdottir IL, et al. Atrial fibrillation following cardiac surgery: Risk analysis and long-term survival. J Cardiothorac Surg 2012;7:87.
Hellhammer K, Piayda K, Afzal S et al. The latest evolution of the Medtronic CoreValve system in the era of transcatheter aortic valve replacement: Matched comparison of the Evolut PRO and Evolut R. JACC Cardiovasc Interv 2018;11:2314-2322.
Hyman MC, Vemulapalli S, Szeto WY et al. Conscious sedation versus general anesthesia for transcatheter aortic valve replacement: Insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology transcatheter valve therapy registry. Circulation 2017;136:2132-2140.
Kadakia MB, Silvestry FE, Herrmann HC. Intracardiac echocardiography-guided transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2015;85:497-501.
Kappetein AP, Head SJ, Genereux P et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 consensus document (varc-2). Eur J Cardiothorac Surg 2012;42:S45-S60.
Kiramijyan S, Ben-Dor I, Koifman E, et al. Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med 2016;17:384-390.
Konigstein M, Ben-Shoshan J, Zahler D et al. Outcome of patients undergoing TAVR with and without the attendance of an anesthesiologist. Int J Cardiol 2017;241:124-127.
Kumar N, Garg N. Acute kidney injury after aortic valve replacement in a nationally representative cohort in the USA. Nephrol Dial Transplant 2019;34:295-300.
Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597-1607.
Leon MB, Smith CR, Mack MJ et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016;374:1609-1620.
Maier A, Hammerich B, Humburger F, et al. A logistic regression analysis comparing minimalistic approach and intubation anaesthesia in patients undergoing transfemoral transcatheter aortic valve replacement. PLoS One 2020;15:e0227345.
Manoharan G, Van Mieghem NM, Windecker S, et al. 1-year outcomes with the evolut r self-expanding transcatheter aortic valve: From the international forward study. JACC Cardiovasc Interv 2018;11:2326-2334.
Marcantuono R, Gutsche J, Burke-Julien M, et al. Rationale, development, implementation, and initial results of a fast track protocol for transfemoral transcatheter aortic valve replacement (TAVR). Catheter Cardiovasc Interv 2015;85:648-654.
Mathew JP, Fontes ML, Tudor IC, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004;291:1720-1729.
Mosleh W, Mather JF, Amer MR, et al. Propensity matched analysis comparing conscious sedation versus general anesthesia in transcatheter aortic valve implantation. Am J Cardiol 2019;124:70-77.
Nuis RJ, Rodes-Cabau J, Sinning JM, et al. Blood transfusion and the risk of acute kidney injury after transcatheter aortic valve implantation. Circ Cardiovasc Interv 2012;5:680-688.
Oguri A, Yamamoto M, Mouillet G, et al. Clinical outcomes and safety of transfemoral aortic valve implantation under general versus local anesthesia: Subanalysis of the French Aortic National Corevalve and Edwards 2 registry. Circ Cardiovasc Interv 2014;7:602-610.
Saia F, Ciuca C, Taglieri N, et al. Acute kidney injury following transcatheter aortic valve implantation: Incidence, predictors and clinical outcome. Int J Cardiol 2013;168:1034-1040.
Thiele H, Kurz T, Feistritzer HJ, et al. General versus local anesthesia with conscious sedation in transcatheter aortic valve implantation: The randomized SOLVE-TAVI trial. Circulation 2020;142:1437-1447.
Van Mieghem NM, Tchetche D, Chieffo A, et al. Incidence, predictors, and implications of access site complications with transfemoral transcatheter aortic valve implantation. Am J Cardiol 2012;110:1361-1367.
Villareal RP, Hariharan R, Liu BC, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004;43:742-748.
Yagasaki H, Goto Y, Mori Y, Noda T. Transcatheter aortic valve replacement with intracardiac echocardiography from the right internal jugular vein. Cardiovasc Diagn Ther 2018;8:525-529.
Zaouter C, Smaili S, Leroux L, et al. Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone. Ann Card Anaesth 2018;21:277-284.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).