Critical adverse events during transfemoral TAVR in conscious sedation. Is an anesthesiologic support mandatory?

Background: Transfemoral TAVR (tf-TAVR) under conscious sedation (CS) has become popular. The need of anesthesiologic support during tf-TAVR has been questioned. Critical events during the procedure might require immediate action. We analyzed the frequency of periprocedural critical adverse events (CAE) during tf-TAVR with CS in our institution.

Methods: Tf-TAVR has been performed at our institution since 2007. We excluded patients from the first four years to minimize the influence of any learning curve. CAE were defined as occurrence of 1.) "CPR", 2.) "defibrillation", 3.) "emergency extracorporeal circulation (ECC)" and 4.) "conversion to general anesthesia (GA) not related to 1.)-3.)". Data was prospectively collected in our AVIATOR TAVR registry.

Results: 601 patients were analyzed retrospectively. Overall, CAE were recorded in 54 patients (9%). CPR was necessary in 12 patients (2%) and defibrillation in 10 patients (1.6%). ECC was rarely needed (n = 2, 0.3%). Conversion to GA was necessary in 34 patients (5.65%). Procedure-related conversion was necessary in 10 patients. With 24 patients, sedation-related conversion occurred more frequently. Unrest and pain were the most common reasons for conversion (n = 13, 2%) and respiratory distress in 11 patients (2%). Catecholaminergic support was needed in 269 (45%) patients. Vasopressors were more often applied (n = 249, 41%) than inotropes (n = 59, 10%).

Conclusion: Even in a high-volume center, CAE may occur in nearly every tenth patient. Conversion to GA was the most common CAE. Catecholaminergic support (primary vasopressor support) was needed in nearly every second patient. These points underline the necessity of a cardiac anaesthesiologist to be in the room during the procedure.

Summary: Despite experience, critical adverse events (CAE) still occur in TAVR patients. We analyzed the occurrence of CAE and the need for catecholaminergic support in sedated TAVR patients.