There is global debate how to make TAVR procedures less expensive. Some sites changed from general anesthesia to sedation, some go even beyond that and keep patients fully awake during the procedure. Some sites eliminated anesthesiologists, some even eliminated the surgeons, as well. All this in the name of cost reduction, in exchange of safety, comfort and crucial information if not selected properly. TEE requires general anesthesia, but it can provide invaluable information and we anesthesiologists, can provide tailored and safe anesthesia. In certain situations, like severe lung disease, in experienced hands, sedation could be more appropriate than general anesthesia, even if it means eliminating TEE.
We looked at the cost of TAVR not just as a procedural cost, but as a post-procedural cost. Renal failure following TAVR can occur with underlying renal insufficiency and has significant financial and quality of life consequences. One of the mechanisms for this serious complication is the contrast load administered during preoperative CTA and intra-procedural angiography.
Currently, CTA and angiography are standard of care parts of TAVR procedures. CTA is a 3-dimensional modality clearly required for a 3-dimensional structure’s, like the aortic root, pre-procedural assessment and measurements. That data is used during the procedure applied to 2-dimensional angiography images. With recent 3-dimensional echocardiography advancements, similar assessments and measurements can be provided real-time, in the hybrid room, not needing contrast administration. Moreover, 3D echocardiography can be used intra-procedurally to guide implantation without contrast injections and only with minimal fluoroscopy.
With this approach, we didn’t just decrease the total cost of TAVR, but made the TAVR Heart Team stronger, and more cohesive, as opposed to dismantling it. And if general anesthesia is administered in a tailored and goal directed manner, in most cases, besides to be able to use TEE for better intra-procedural assessment, patients go home the next morning following trans-femoral TAVR, similar to the sedation group.
By GEORGE GELLERT, MD
– Medical Director, Interventional Echocardiography, Structural Heart Program, Cavanagh Heart Center, Banner Good Samaritan Medical Center
– Instructor of Anesthesiology, Mayo Clinic College of Medicine
– Associate Clinical Professor of Anesthesiology, University of Arizona, College of Medicine
– Associate Clinical Professor of Anesthesiology, Creighton University School of Medicine
To read Dr. Gellert’s article in this month’s JIC, visit “TEE-Guided Transcatheter Aortic Valve Implantation With “Zero Contrast” — A Viable Alternative for Patients with Chronic Kidney Disease”