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26

Chapter 2

curves.

12

Two experienced cardiac anaesthetists were assigned to the procedures, with

one only responsible for the study documentation. As the primary end-point the authors

have chosen a surrogate parameter, probably reflecting one aspect of patient outcome:

perioperative cumulative cerebral oxygen desaturation, which was comparable between

groups, as were the results of a secondary endpoint, the neurocognitive function. However,

more respiratory adverse events were registered in the sedation group. Looking in more

detail at the anaesthetic procedure, the author’s state that moderate to deep sedation was

performed to provide optimal implantation conditions. One might question whether we

still can expect a favourable difference in patient outcome between general anaesthesia

and deep sedation? Deep sedation for sure has several disadvantages, as are described in

the respective adverse respiratory events of the present study. But is deep sedation really

needed to facilitate this procedure in an optimal manner? In our centre, TF-TAVI is performed

with reasonable results in unsedated or only light sedated patients.

13

However, these results

might also have signi cant bias, as they come from an observational cohort database and

not from a randomised trial. As in other hospitals, we performed GA in the beginning

and then switched to sedation and later to LA only, after learning our lessons concerning

patient selection, vascular screening, team training, and after gaining more experienced

with the procedure. However, although the TAVI procedures are constantly improved,

all these interventions are associated with potentially life-threatening complications, and

therefore - although the procedure is performed by a cardiologist under local analgesia

– a cardiac anaesthetist is part of the multidisciplinary team. Performing TF-TAVI under

LA without sedation has another advantage: communication with the patient is the best

neurologic monitor we have, and in case of any cerebrovascular event, immediate further

diagnostic and possible treatment strategies can be initiated. This advantage will be lost in

situations where deep sedation is used, as described in the study by Mayr and colleagues.

11

These authors have chosen cerebral desaturation as the primary outcome parameter;

in both groups, cerebral oxygenation decreased during pacing-induced cardiac arrest

for balloon valvuloplasty and hypotension during valve release. However, these periods

of cerebral desaturation were obviously too short to have any effect on neurocognitive

function. The current study is too small to allow a more distinct answer on whether the

respective anaesthetic technique influences patient outcome after TF-TAVI. As most of the

current reviews on this topic conclude, we need randomised trials to de ne the role of

anaesthesia in the treatment of patients with severe aortic stenosis undergoing TF-TAVI.

As the number of patients treated with this technique increases,

14,15

we should be able to

answer this question with evidence-based data from randomised trials. The study from

Mayr and colleagues

11

is a rst step on a long way to further evaluate the optimal treatment

strategies for TF-TAVI. It is attractive for cardiologists and cardiac surgeons to demonstrate

that these procedures can be performed without anaesthesia support. Therefore, we clearly