Deep sedation in mitral transcatheter edge-to-edge repair – outcome and predictors for sedation failure

Tobias Schmidt (Lübeck)1, M. Mathern (Lübeck)1, F. Foth (Lübeck)1, R. Saraei (Lübeck)1, F. Genske (Lübeck)1, E. Rawish (Lübeck)1, D. Jurczyk (Lübeck)1, T. Stiermaier (Lübeck)1, C. Marquetand (Lübeck)1, T. Graf (Lübeck)1, I. Eitel (Lübeck)1, C. Frerker (Lübeck)1

1Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland


: 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. 

Figure 2: Survival rate of sedation only group and patients in the need for an emergency conversion to general anesthesia after 30-days (A) and after 12 months (B). 

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