TAVI for patients with pulmonary arterial hypertension – impact of the anesthesia regime on the short-term outcome
Authors: Mayr P , Rheude T R , Pellegrini C , Alvarez Covarrubia H , Xhepa E , Cassese S , Tassani-Prell P , Joner M 
Published: October 2021

Abstract

Objectives and background
Pulmonary Arterial Hypertension (PAH) has been independently associated with increased rates of postoperative heart-failure, hemodynamic instability, respiratory failure and delayed extubation. PAH has been described as a common comorbidity in patients undergoing transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI). Two different anesthetic methods, general anesthesia (TAVI-GA) and conscious sedation (TAVI-S) have become established. Both must be measured by their influence on pulmonary vascular resistance, as all factors worsening PAH have to be avoided. To date, there are no practice guidelines advising the the optimal anesthetic approach for patients with PAH.

Methods
We included all consecutive tf-TAVI patients between 2014 and 2019 in our prospective TAVI registry. A combined endpoint covering the aspects of hemodynamic stability, ventilation and awareness was chosen as primary endpoint. 1. Freedom from catecholaminergic support, 2. Spontaneous breathing and 3. Alertness, defined as GCS &gt;12 points were prerequisite for achieving. PAH was diagnosed by echocardiography immediately before the procedure. The choice for TAVI-GA or TAVI was made by the anesthesiologist.

Results
A total of 1390 patients were included in this analysis. PAH was diagnosed in 74% (n=1031) of the patients. As shown in Tab.1, patients with and without PAH were comparable in terms of pre-procedural comorbidities, blood gas analysis before and after their procedure and procedural data. Postprocedural, a longer stay on ICU was observed in patients with PAH. This was also seen after propensity-score marching. In terms of the primary endpoint, no difference was found between the groups. In addition, the single points catecholaminergic support, spontaneous ventilation and awareness at the time of transfers revealed no difference. Same holds true for secondary endpoints like 30-day mortality, heart failure and adverse procedural events. An analysis based on the choice of anesthesia showed a clear difference in the successful achievement of the primary endpoint. Independent of the presence of PAH, patients undergoing the procedure in TAVI-GA the primary endpoint was less often successfully documented. TAVI-GA patients were more often in need of catecholaminergic support at the end of the procedure and a reduced alertness was more often found.
In patients with PAH and TAVI-GA, a longer length of ICU-stay and a higher incidence of congestive heart failure (CHF) within 30days was found.

Conclusion
Independent of PAH, patients undergoing tf-TAVI in TAVI-GA, were more often in need of catecholaminergic support and less often awake at the end of the procedure. General anesthesia was also more often associated with CHF but not death at 30 days. The achievement of the primary endpoint was independent of the presence of PAH. tf-TAVI can be done under sedation safely in patients with PAH.

Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Deutsches Herzzentrum München, Technische Universität München Table 1. Analysis with regard to PAHTable 2. Analysis with regard to Anesth