2020 FSA Posters

P081: MAC FOR TAVR REDUCES HOSPITAL LENGTH-OF-STAY AND OVERALL COST OF CARE
Devon Cole, MD; Director Cardiac Anesthesia, HealthPark Medical Center, Lee Health

Background: To optimize efficiency, the transcatheter aortic valve replacement (TAVR)  perioperative pathway was reviewed at our institution and updated by review of literature, then measured for quality improvement. Prior to 2017, we performed all TAVRs via general endotracheal anesthesia with TEE by cardiac anesthesia, followed by direct ICU admit.  In July 2018, we began primarily using MAC anesthesia for TAVR via multimodality, multidisciplinary but minimalist (3M) approach (ref 1), using TTE to assess for paravalvular leak by echo tech.  General anesthesia and ICU admit were always an acceptable plan, at any point, according to the Anesthesiologist's assessment.  There was a wash in period preceeding the perioperative pathway change.  In the 12 months prior to change, 210 TAVRs were completed compared to 224 TAVRs in the 12 months following the change; the postop ICU admission rates were 70.0% (147/210) compared to 21.9% (49/224), respectively.  

Methods: MAC TAVR patients were recovered at PACU for observation and assessment prior to surgical progressive care unit (SPCU) transfer.  Intraop infusions of precedex and simplified blood pressure support with NE were used, and overal goal of minimal lines and minimal infusions necessary to maintain safety given the patient's comorbidities (refs 2-3).  This routinely includes, arterial line and CVP access for temporary venous pacer placed by anesthesia and intraop CPAP/BIPAP.  Training of PACU and SPCU nurses was done by the Director of Cardiac Anesthesia and he remained as key contact for protocol issues as they arose.  Coordination with surgical team, and confirmation of patient safety was based on the following criteria:  (a) absence of persistent (>3 hr) intraventricular conduction delay, (b) absence of clinically important changes in hemoglobin and renal function, (c) return to baseline mobilization, and (d) availability of support person to remain with patients for 24 hrs once discharged.  This pathway is based on the well-established standards (refs 4-5).

Results:

Percent next day discharge, 12.4% (26/210)  compared to 26.3% (59/224)

Percent discharge < 48 hours,  37.1% (78/210) compared to 55.4% (124/224)

30-day All-Cause Readmission, 11.0% (23/210) compared to 10.7% (24/224)

30-day Mortality or Stroke,  6.7% (14/210) compared to 1.8%  (4/224)

**We began low-risk TAVR enrollment March 2016, with baseline group prior to change, July 2017 thru June 2018 = 6 low-risk patients, compared to latter group, July 2018 thru June 2019 = 4 low-risk patients (bicuspid study patients only).

Discussion:

Learning objectives for this presentation with full literature review include:  

• Is MAC for TAVR safe?
• Is there a ‘recommended' anesthetic technique for TAVR?
• Is a randomized-controlled trial (RCT) required to address potential confounders or do we just accept the observed data of improved patient surgical experience to justify the change of MAC anesthesia for TAVR?

References:

1.  Catheter Cardio Inter 2019;1–9 (available online ahead of print)

2.  J Cardiothor Vasc An 2018; 32:1426-1438

3.  Kor J Anes 2014; 66:317

4. Can J Cardiol  2014;30(12):1583-1587

5.  JAMA Surg 2019;154(8):755-766