Conscious Sedation in TAVR Cuts Costs by 25%, Boosts Patient Satisfaction

TAVR without general anesthesia should become the norm for transfemoral TAVR, a single-center study suggests. “Buy-in” from the heart team is key.

Conscious Sedation in TAVR Cuts Costs by 25%, Boosts Patient Satisfaction

Conscious sedation in patients undergoing transcatheter aortic valve replacement is safe and, not surprisingly, leads to shorter ICU and overall hospital stays, a new study suggests. Importantly, these gains were also associated with significant savings across all cost categories when compared with propensity-matched patients who received general anesthesia.

“Our main goal was actually to get these patients out of the hospital more quickly, to improve their overall satisfaction and recovery,” senior author on the study, Peyman Benharash, MD (University of California, Los Angeles), told TCTMD. “We thought, if we can get a cost savings of 10%, that’s pretty good, and we were surprised that we did quite a bit better than that.” In addition, operators also achieved their goal of improved patient satisfaction and equivalent clinical outcomes.

Benharash, with co-senior investigator and fellow UCLA surgeon Richard Shemin, MD, as well as first author William Toppen, MD, published their study April 5, 2017, in PLOS One.

Closing the Cost Gap

According to Benharash, the conscious sedation TAVR program at UCLA was modelled in part on the “minimalist” approach piloted at Emory University. That program led to high rates of same- or next-day hospital discharge and total savings in the range of $10,000. This goes some distance to closing the price gap between surgical and transcatheter valves—the former typically cost in the range of $6,000 to $8,000 while the average TAVR device costs $30,000, he explained.

To evaluate differences in outcomes between patients treated with conscious sedation versus general anesthesia at UCLA, records for all patients who had undergone TAVR between August 2012 and June 2016 were matched based on their STS predicted mortality risk, leaving 196 matched patients. All were treated with Sapien devices (Edwards Lifesciences).

Overall, in-hospital mortality was 1.5%, with three deaths occurring in the general anesthesia group and none in the conscious sedation group, a nonsignificant difference. Indeed, the only clinical endpoints that were significantly different between groups were need for new dialysis, non-GI/GU bleeding, and unplanned surgery, all of which were more common in the general anesthesia group. Hours spent in ICU were also three times higher in this group, and length of stay was twice as long. Finally, quality of life at 30 days, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), suggested that patients treated under conscious sedation had higher satisfaction postprocedure.

TAVR Outcomes by Sedation Type

Endpoint

General Anesthesia

Conscious Sedation

P

In-Hospital Death (n)

3

0

0.08

New Dialysis (n)

7

0

0.008

Unplanned Surgery (n)

5

0

0.024

ICU Time (hours)

96

30

< 0.001

Length of Stay (days)

10.4

4.9

< 0.001

KCCQ Score at 1 Month

78

90

< 0.001


Significant savings were seen in costs of ICU stay, anesthesia, operating room recovery, pharmacy, and hospital room, leading to total direct cost savings of 28%. In an analysis that looked only at newer-generation Sapien devices and excluded nonfemoral patients, costs were cut by 25%.

“As transcatheter valves become more and more utilized in less riskier patients, it becomes a social issue: is our resource utilization going to go through the roof?” Benharash said. And at least on the basis of their retrospective review, he believes institutions can realize significant cost savings by moving to conscious sedation as the default procedure. At UCLA, conscious sedation is now used in “basically everybody,” who is a candidate for transfemoral TAVR, he said.  “Our goal was to get this data out there to show that this really is possible outside of a clinical trial setting. . . . You can actually realize better patient outcomes and reduce costs.”

While this analysis was retrospective in nature, Benharash says the differences are palpable even in interactions with patients immediately after their procedures who are grateful to be spending less time in hospital than anticipated.

The key appears to be having a multidisciplinary program with “buy-in” from the anesthesiologists, surgeons, and interventionalists on the team. At UCLA, anesthesiologists are on hand so that patients can be swiftly put to sleep if complications arise, and femoral lines are in place in the case of bleeding. “But really, we’ve found with the newer-generation delivery devices and valves that the risks of something adverse happening [warranting surgical bailout] is really very small.”

The biggest hurdle is actually convincing the team to commit to conscious sedation, Benharash said. “You have to go out of your way a bit and compromise your own comfort for better patient outcomes. Everyone would prefer that the patient is fully sedated . . . but once you get over that hump, you realize the operation is not any more difficult and that patients do so much better.”

Sources
  • Toppen W, Johansen D, Sareh S, et al. Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up? PLoS One. 2017;12:e0173777.

Disclosures
  • Benharash reports no relevant conflicts of interest.

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Comments

2

sarvesh natani

2 months ago
Its intresting that patient needing unplanned surgery and all in hospital deaths were under GA. Or they needed GA as things were going bad and need other unplanned surgery and resusitation. .Also about 6% conversion rate from sedation to GA is low.( it actually is higher) Putting these high risk patient to sleep in between the procedure increases further risk. Lot of registers have shown that complications like paravalvular leaks are less under anaesthesia.

Gary Cims

7 months ago
I frequently and running across the term conscious sedation being used in place of what is truly monitored anesthesia care. CS is a term is reserved for sedation administered and directed by non-anesthesia providers in critical care areas. I have been put in situations a few times by my interventionist to gather protocols that eliminate anesthesia providers from the team. The drive for this is generally financial and for efficiency but the risks to the patients if complications arise are numerous. In my opinion, it would be more accurate to report these procedures as MAC, not CS, so as the programs trickle out to community hospitals and outpatient centers, corners are not cut placing patients at risk.