Minimalist TAVI: What it means and why it works

Taking a minimalist approach to transcatheter aortic valve implantation (TAVI), which involves using conscious sedation in lieu of general anesthesia, could result in greater procedural efficiency and a comparable quality of life for patients, according to research published Jan. 8 in the American Journal of Cardiology

TAVI has evolved to become the standard of care for heart patients with severe symptomatic aortic stenosis (AS), study lead Kishore J. Harjai, MD, and co-authors wrote in the journal, and researchers have become increasingly interested in the idea of minimalist TAVI (M-TAVI). M-TAVI favors moderate sedation, percutaneous vascular access and post-implant transthoracic echo (TTE) over the general anesthesia (GA), transesophageal echocardiography (TEE) and femoral artery surgical cut-down of GA-TAVI. Early reports have been encouraging, suggesting M-TAVI is safe and effective in the short-term.

“Despite the trend toward increasing use of M-TAVI, significant gaps in knowledge remain,” Harjai, of Pearsall Heart Hospital in Wilkes-Barre, Pa., and colleagues wrote. “Data on M-TAVI has largely been obtained from large centers or in carefully selected patients. Concerns remain that minimalist TAVI may pose risks due to inadvertent over-sedation with an unprotected airway, that lack of TEE imaging may lead to significant residual aortic regurgitation, and that inadequate hemostasis may cause more bleeding.”

Other studies have also failed to report on quality of life after M-TAVI, the authors said. The team assessed the impact of the more minimal approach in 477 patients with severe AS, including 278 patients who underwent M-TAVI and 199 patients who opted for GA-TAVI. Patients were on average 82 years old with a Society of Thoracic Surgeons score of 5.0.

The authors said M-TAVI patients were less likely than their peers to have valve-in-valve TAVI or receive self-expanding valves, and they were also less likely to fall into a New York Heart Association class of 3 or higher. The procedure was successfully completed without conversion to GA-TAVI in 97% of patients.

According to the team’s results, M-TAVI was more efficient than GA-TAVI, resulting in:

  • Shorter lengths of stay (2 vs. 3 days in GA-TAVI patients)
  • Higher likelihood of being discharged home (87% vs. 72%)
  • Less use of blood transfusions (10% vs. 22%)
  • Minimized use of inotropes (13% vs. 32%)
  • Lower contrast volume (50 ml vs. 90 ml)
  • Shorter fluoroscopy time (20 min. vs. 24 min.)
  • Less need for more than one valve (0.4% vs. 5.5%)

At one month, rates of death and stroke were similar between groups—4% in the M-TAVI cohort and 6.5% in the GA-TAVI cohort—as were rates of a safety composite endpoint that included death, stroke, transient ischemic attack, MI, new dialysis, major vascular complications, major or life-threatening bleeding or a new pacemaker (17.6% in M-TAVI patients vs. 21.1% in GA-TAVI patients). Quality of life scores were similar at baseline and one month after TAVI.

The authors said M-TAVI demonstrated significant improvements in “all parameters of procedural efficiency,” suggesting the minimalistic approach could be a feasible option for patients with severe symptomatic AS. They said the true feasibility of M-TAVI hinges on a host of factors, though, including the ability of an anesthesia team to provide adequate monitored anesthesia and the ability of an imaging team to provide adequate post-TAVI TTEs. 

“In the absence of operators experienced in percutaneous access and hemostasis techniques, we urge that minimalist TAVI be adopted cautiously with ongoing training and immediately available surgical backup for vascular complications in the operating room or catheterization lab,” Harjai et al. wrote. “...We recommend that TAVI programs strive toward greater adoption of minimalist TAVI.”

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