1Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland
Background: Mitral transcatheter-edge-to-edge-repair (M-TEER) has become an established treatment option for high-risk patients with symptomatic severe mitral regurgitation (MR). Until today, most of the procedures are done with using general anesthesia (GA). Limited data are existing for a deep sedation approach with avoiding of an intubation and mechanical ventilation.
Objective: Comparing outcome of successful used deep sedation without intubation in patients undergoing M-TEER to patients who were in the need of a conversion to GA.
Methods: Between 01/2016 and 06/2022, all patients with severe MR undergoing M-TEER using a deep sedation approach were analyzed. Patients with successful use of deep sedation were compared to patients who were in the need of a conversion to GA. In addition, a multivariate analysis for conversion to general anesthesia were done.
Results: 464 patients were enrolled (n=433 successful sedation and n=31 conversion to GA). The conversion rate in this cohort was 6.7%. Mean age was 80 years (79.7 vs. 78.0 years; p=0.176) and 56% were female (57% vs. 45%; p=0.217). Risk scores like log. EuroSCORE (30.3% vs. 32.2%; p=0.539), EuroSCORE II (7.2% vs. 7.8%; p=0.648) and STS-score (5.3% vs. 7.0%; p=0.172) did not show any significant difference between the two groups. Multivariate analysis for conversion to GA showed higher Body-Mass-Index (p=0.023), pre-existing renal insufficiency (p<0.001), obstructive sleep apnoe syndrome (p=0.031), systolic pulmonary pressure value (p=0.013) and concomitant tricuspid regurgitation (p=0.049) as risk factors. Patients within the sedation group had a higher procedural success rate (96.1% vs. 80.1%; p<0.001), a lower number of implanted devices (1.4 vs. 1.8; p=0.002) and a shorter duration of the procedure (103 minutes vs. 134 minutes; p<0.001). Severity of baseline MR did not show a significance difference (p=0.674). After the procedure patients within the sedation group had a higher reduction in severity of MR (p=0.02) (Figure 1). Bleeding complications (2.5% vs. 25.8%; p<0.001), pneumonia (2.1% vs. 38.7%; p<0.001), cardiac decompensation (1.6% vs. 9.6%; p=0.003), time on the intensive care unit (3.9 hours vs. 126 hours; p=0.023) after the procedure were less frequent for patients with sedation only. Patients who were in the need for a conversion to GA had a lower 30-days and 1-year survival rate (Figure 2).
Conclusions: Using a deep sedation only approach in M-TEER is feasible and safe with a low conversion rate to GA. However, in case of a conversion the M-TEER procedure is less successful regarding reduction of MR and more complications occurred with a lower survival rate up to 12 months. Different predictors for the need of a conversion to GA could be identified. Further studies are necessary to show if limited patients at risk for a conversion might benefit from using of a GA approach at baseline.
Figure 1: Severity of mitral regurgitation (MR) before and after transcatheter-edge-to-edge (TEER) for the sedation only group and patients in the need for an emergency intubation.