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ENGLISH SUMMARY
The aim of this thesis was to analyse
analgo-sedation procedures outside the operation
room (OR) focussing on feasibility, patient safety as well as satisfaction of patients and
operators.
In the first part we focused on special procedures discussing their suitability for sedation
outside the operation room in the specific situation.
Transfemoral implantation of aortic valves (TAVI) – discussed in
chapters 2
1
and 3
2
- is an
example of such a procedure.
It is a complex interventionasking for specific technical skills of the interventional cardiologist,
together with a nearly motionless patient. This combination usually necessitates general
anaesthesia or deep sedation. However, by means of risk stratification of individual patients
before the procedure, growing experience of the operators, continuous improvement of
implantation devices, and the option to renounce transoesophageal ultrasound control,
TAVI has become a short-lasting, painless procedure no longer requiring general anaesthesia
or deep sedation.
The overall complication rate of this procedure is indeed low, but one single complication
such as aortic dissection, severe aortic regurgitation, major vascular damage, bleeding, or
stroke can be serious and even lethal. Additionally, we should not neglect that we have to
deal with a high-risk patient group. Most patients are elderly and have several comorbidities
that increase periprocedural morbidity and mortality.
Hence, this is the group of patients in which we would like to avoid general anaesthesia
or even sedation: the awake patient is still the best monitor we have to diagnose possible
vascular or neurological complications as early as possible. Not only to diagnose, but also to
treat these complications immediately, is it necessary to work with a multidisciplinary team.
In the AMC, we started in October 2007 with TAVI procedures under general anaesthesia.
Three years later in 2010, our local standard for TAVI procedures had become the fully
awake patient with local wound infiltration, monitored and accompanied by a cardiac
anaesthesiologist.
Our data show that this approach to transfemoral TAVI is safe and feasible with a very low
rate of conversion to general anaesthesia. In our population, 2% (4 patients) of all procedures
had to be converted from local anaesthesia to general anaesthesia: one was converted to
cardiac surgery due to dislocation of the valve in the left ventricle, another one due to
severe restlessness of the patient, and the other two patients developed peripheral vascular
complications making immediate general anaesthesia necessary.
Although the conversion rate was low, these data show that a procedure, which can easily
be performed under local anaesthesia, regardless needs the multidisciplinary approach with
an anaesthesiologist responsible not only for intraprocedural haemodynamic monitoring