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Original articles
Valvular heart disease
Effect of thoracic epidural analgesia on clinical outcomes following transapical transcatheter aortic valve implantation
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  1. Ignacio J Amat-Santos1,
  2. Eric Dumont1,
  3. Jacques Villeneuve1,
  4. Daniel Doyle1,
  5. Michel Rheault1,
  6. Dominique Lavigne1,
  7. Jerôme Lemieux1,
  8. André St-Pierre1,
  9. Michael Mok1,
  10. Marina Urena1,
  11. Luis Nombela-Franco1,
  12. Steve Blackburn1,
  13. Mathieu Simon1,
  14. Christine Bourgault1,
  15. José Luis Carrasco1,
  16. Philippe Pibarot1,
  17. Melanie Côté1,
  18. Robert DeLarochellière1,
  19. David J Cohen2,
  20. Josep Rodés-Cabau1
  1. 1Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
  2. 2Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
  1. Correspondence to Dr Josep Rodés-Cabau, Quebec Heart Lung Institute, Laval University, 2725 chemin Ste-Foy, G1V 4G5 Quebec city, QC G1V 4G5, Canada; josep.rodes{at}criucpq.ulaval.ca

Abstract

Objective To determine the impact of perioperative thoracic epidural analgesia (TEA) on acute and late outcomes following transapical transcatheter aortic valve implantation (TA-TAVI).

Patients and intervention A total of 135 consecutive patients who underwent TA-TAVI were included. All patients received catheter-based pain control, either via TEA (TEA group, n=74) or intercostal local analgesia with a catheter placed at the surgical incision site (non-TEA group, n=61), depending on the preference of the anaesthesiologist responsible for the case.

Main outcome measures Pain level during early postoperative period (verbal rating scale from 1 to 10), 30-day/in-hospital complications and mortality, and 1-year mortality.

Results There were no differences in baseline or procedural characteristics between groups except for a lower left ventricular ejection fraction in the TEA group. The maximal pain score related to thoracotomy in the postoperative period was higher in the non-TEA group as compared with the TEA group (4 (IQR: 3–5)) vs 2 (IQR: 1–3), p<0.001). Non-TEA was associated with a higher rate of pulmonary complications (p<0.05 for nosocomial pneumonia, reintubation and tracheostomy). The 30-day/in-hospital mortality rate was higher in the non-TEA group (22.9% vs 2.7% in the TEA group, p<0.001). At 1-year follow-up, overall mortality remained higher in the non-TEA group (31.1%) compared with the TEA group (10.8%), p=0.005. Similar periprocedural and late results were obtained in a propensity score-matched analysis that included 100 matched patients. In the multivariable analysis, STS score (p=0.027) and absence of TEA (p=0.039) were independent predictors of increased cumulative late mortality.

Conclusions TEA provided superior analgesia following TA-TAVI, and was associated with a dramatic reduction in periprocedural respiratory complications, and both, short- and long-term mortality. These results highlight the importance of obtaining optimal analgesia following TA-TAVI to improve the results associated with this procedure.

  • Aortic valve disease
  • transcatheter aortic valve implantation
  • transapical
  • anaesthetics
  • interventional cardiology
  • non-coronary intervention
  • percutaneous valve therapy
  • myocardial ischaemia and infarction
  • cardiac function
  • coronary artery disease
  • coronary physiology
  • allied specialities
  • coronary collateral circulation
  • chronic total occlusion
  • EBM
  • aortic stenosis
  • valve disease
  • prosthetic heart valves
  • coronary stenting
  • statistics
  • mitral stenosis

https://doi.org/10.1136/heartjnl-2012-302185

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    Footnotes

    • Funding Dr IJA-S received support from the Institute of Heart Sciences (ICICOR, Clinical Hospital of Valladolid, Spain).

    • Competing interests Dr ED is consultant for Edwards Lifesciences; Dr DJC has received research grant support from Edwards Lifesciences and Medtronic Inc. Dr JR-C is consultant for Edwards Lifesciences and St Jude Medical.

    • Ethics approval The study protocol was performed in accordance with the institutional ethics committee.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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