Optimal use of anesthetics in nonagenarians undergoing TAVR

Torres, Pedro

Optimal use of anesthetics in nonagenarians undergoing TAVR

Tuesday, May 21, 2019

Belmont Ballroom 2-3 (The Cosmopolitan of Las Vegas)

Jesus pino Moreno , 1. University Of Miami/JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Fergie medical Ramos , 1. University Of Miami/JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Pedro medical Torres , University of Miami/ JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Pradeep Dayanand, M.D. , 1. University Of Miami/JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Nakeya Dewaswala, M.D. , 1. University Of Miami/JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Kai Chen , University of Miami/ JFK Medical Center Palm Beach Regional Consortium, Atlantis, FL

Lawrence Lovitz, M.D. , JFK Medical Center, Atlantis, FL

Mark Rothemberg, M.D. , JFK Medical Center, Atlantis, FL

Roberto J. Cubeddu, M.D., FSCAI , Cleveland Clinic Florida, Weston, FL

Robert Chait, M.D. , University of Miami Palm Beach Regional Campus, Atlantis, FL

Marcos Nores, MD , JFK Medical Center, Atlantis, FL

Background
Transcatheter Aortic valve replacement (TAVR) is the standard treatment for patients with severe aortic stenosis that are inoperable. The data about optimal use of anesthesia in nonagenarians undergoing TAVR is limited.

Methods
This is a retrospective cohort study of nonagenarians (age 90-99 years) that underwent TAVR between April 2012 and December 2016 in a tertiary cardiovascular center. Optimal use of anesthesia was defined as the administration of ≤3 anesthetic agents (excluding Ketamine). Evaluated outcomes included: 30-day mortality and 1-year mortality, in-hospital infection, prolonged Foley catheter use, length of stay (LOS) and stroke.

Results
Out of 570 patients that underwent TAVR in our institution, 136 were nonagenarians with a mean age of 92±2 years and mean STS score of 8.3 ± 4.8. A total of 68 (50%) patients were female with a mean aortic valve area of 0.62 ± 0.18 cm2 and mean AV gradient of 52±12 mmHg. Trans-femoral approach was performed in 70 (75%) of the patients. The average number of anesthetics administered was 3.3. Propofol was used in 38(28%) of the patients, Dexmedetomidine in 97 (71%), Midazolam in 84 (61%), Lidocaine/Bupivacaine in 110 (80%), Fentanyl in 121 (89%) and Ketamine in 0 (0%). Optimal use of anesthesia was performed in 70 (52%) nonagenarians. There was a strong correlation between the number of anesthetics and LOS. For every anesthetic used, LOS increased 0.61 days (p-value <0.0001). Additionally, non-optimal anesthesia (≥4 agents) was associated with prolonged Foley catheter use (>24 hours post-procedure), OR: 3.09 CI 95% (1.37 - 6.96) p-value- 0.0067. In-hospital infections occurred in 5 (7.14%) of patients with optimal use of anesthesia vs. 10 (15%) for the non-optimal group, p-value 0.174. The number of anesthetics used did not correlate with the rate of stroke, 1 (1.4%) for optimal group vs. 1 (1.5%) for the non-optimal group, (p-value 1.000). Thirty-day mortality was 4 (5.7%) for the optimal group vs 2 (3.0%) for the non-optimal group, (p-value 0.6813); one-year mortality was 10 (14%) vs 7(11%), p-value 0.6082, respectively.

Conclusions
This study suggests that optimal anesthesia use (3 or lesser agents) in nonagenarians undergoing TAVR decreases morbidity significantly but not mortality.