Local and general anaesthesia do not influence outcome of transfemoral aortic valve implantation.

BACKGROUND: There is great variability for the type of anaesthesia used during TAVI, with no clear consensus coming from comparative studies or guidelines. We sought to detect regional differences in the anaesthetic management of patients undergoing transcatheter aortic valve implantation (TAVI) in Europe and to evaluate the relationship between type of anaesthesia and in-hospital and 1 year outcome. METHODS: Between January 2011 and May 2012 the Sentinel European TAVI Pilot Registry enrolled 2807 patients treated via a transfemoral approach using either local (LA-group, 1095 patients, 39%) or general anaesthesia (GA-group, 1712 patients, 61%). RESULTS: A wide variation in LA use was evident amongst the 10 participating countries. The use of LA has increased over time (from a mean of 37.5% of procedures in the first year, to 57% in last 6 months, p<0.01). MI, major stroke as well as in-hospital death rate (7.0% LA vs 5.3% GA, p=0.053) had a similar incidence between groups, confirmed in multivariate regression analysis after adjusting for confounders. Dividing our population in tertiles according to the Log-EuroSCORE we found similar mortality under LA, whilst mortality was higher in the highest risk tertile under GA. Survival at 1 year, compared by Kaplan-Meier analysis, was similar between groups (log-rank: p=0.1505). CONCLUSIONS: Selection of anaesthesia appears to be more influenced by national practice and operator preference than patient characteristics. In the absence of an observed difference in outcomes for either approach, there is no compelling argument to suggest that operators and centres should change their anaesthetic practice.

Targeting the autonomic nervous system: measuring autonomic function and novel devices for heart failure management.

Neurohumoral activation, in which enhanced activity of the autonomic nervous system (ANS) is a key component, plays a pivotal role in heart failure. The neurohumoral system affects several organs and currently our knowledge of the molecular and systemic pathways involved in the neurohumoral activation is incomplete. All the methods of assessing the degree of activation of the autonomic system have limitations and they are not interchangeable. The methods considered include noradrenaline spillover, microneurography, radiotracer imaging and analysis of heart rate and blood pressure (heart rate variability, baroreceptor sensitivity, heart rate turbulence). Despite the difficulties, medications that affect the ANS have been shown to improve mortality in heart failure and the mechanism is related to attenuation of the sympathetic nervous system (SNS) and stimulation of the parasympathetic nervous system. However, limitations of compliance with medication, side effects and inadequate SNS attenuation are issues of concern with the pharmacological approach. The newer device based therapies for sympathetic modulation are showing encouraging results. As they directly influence the autonomic nervous system, more mechanistic information can be gleaned if appropriate investigations are performed at the time of the outcome trials. However, clinicians should be reminded that the ANS is an evolutionary survival mechanism and therefore there is a need to proceed with caution when trying to completely attenuate its effects. So our enthusiasm for the application of these devices in heart failure should be controlled, especially as none of the devices have trial data powered to assess effects on mortality or cardiovascular events.

Implementation of primary angioplasty in Europe: stent for life initiative progress report.

AIMS: Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, a 2007 study reported that only 40-45% of European STEMI patients were treated with PPCI, with large variations in treatment availability between countries. In 2008, the Stent for Life (SFL) initiative was launched by the European Association of Percutaneous Cardiovascular Interventions and EuroPCR in partnership with the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care and country-specific national cardiac societies. The aim is to promote the prioritisation of percutaneous coronary intervention treatment towards those who will benefit most, namely STEMI patients. The following countries are currently participating: Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey. METHODS AND RESULTS: Since SFL was launched, several activities have been initiated in the participating countries. Preliminary reports suggest that major increases have been seen in the numbers of PPCI performed, with some countries reporting very significant increases in PPCI use from 2008-2010. Improvements in STEMI mortality rates have also been observed. CONCLUSIONS: This report summarises the progress of the SFL initiative in the 10 target countries.

Comparison of primary angioplasty in rural and metropolitan areas within an integrated network.

AIMS: To compare reperfusion times and in-hospital outcome of patients with STEMI treated with primary percutaneous coronary intervention (PCI) in a teaching hospital (TH) with or without inter-hospital transfer and in community hospitals. METHODS AND RESULTS: We performed a retrospective analysis of 536 patients with STEMI treated between January 2005 and December 2006 with primary PCI. Three groups were identified. A: 207 patients presented to the TH. B: 121 patients transferred to TH from metropolitan area hospitals (MAH). C: 208 patients presented in two rural area hospitals (RAH) with primary PCI capability. Baseline characteristics were similar. Door-to-balloon (DtB) times were significantly (p<0.001) higher in group B (median 120, range 90-180 min) both compared to group A (median 60, range 45-90 min) and C (median 73, range 55-99 min). In group B 79,5% of patients present a DtB > 90 min. In-hospital mortality was 4.9%, 3.3% and 4.3% respectively in group A, B and C without significant differences. CONCLUSIONS: The expansion of primary PCI to RAH achieves reperfusion delays similar to that of patients admitted to TH. Transferred patients present very higher DtB when compared to patients treated on-site. In-hospital outcome are similar but further studies are warranted.