Local versus general anesthesia for transfemoral aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) represents a novel option for elderly with severe aortic valve stenosis who are denied surgical aortic valve replacement due to high perioperative risk. While transfemoral TAVI generally is being performed in general anesthesia (GA), TAVI under local anesthesia plus mild sedation (LAPS) might be an effective and safe alternative. METHODS: In a single-centre analysis, we assessed clinical data, preoperative risk scores (STS-Score), echocardiography, periprocedural data and labor costs in 74 patients undergoing transfemoral TAVI under GA (n = 33) and LAPS (n = 41). RESULTS: Patients who underwent TAVI in LAPS presented significantly more often with pulmonary hypertension and impaired renal function, and tended to have a higher STS score and more severe symptoms (higher NYHA class) versus the GA group. There were no significant differences in procedure-related 30-day mortality or complications between groups. The peak systolic and mean central aortic pressure were significantly higher in the LAPS group, while at the same time these patients required significantly less often periprocedural adrenergic support. Intervention time was shorter in the LAPS group due to avoidance of surgical cut-down of the access site. Moreover, total procedure time was significantly shorter and labor costs were lower in the LAPS group. Patients who underwent TAVI in LAPS could be mobilized significantly earlier. CONCLUSION: Our study indicates that TAVI under LAPS is as effective and safe as TAVI under GA. Furthermore, total procedure time, intervention time and labor costs could be reduced by LAPS. Mobilization of patients could be achieved earlier. We therefore consider LAPS to be favorable in patients undergoing transfemoral TAVI.

NT-pro-BNP for differential diagnosis in patients with syncope.

BACKGROUND: Syncope is a frequent diagnosis and establishing the etiology is often elaborate. Aim of this study was to evaluate the diagnostic value of NT-pro-BNP in patients with syncope. METHODS: NT-pro-BNP was assessed in 61 patients admitted for syncope to our cardiological department of the University hospital Cologne, Germany. RESULTS: 16 patients (26.2%) had neurally-mediated syncope, 9 (14.8%) had orthostatic syncope, 12 (19.7%) had cardiac arrhythmias, 8 (13.1%) had structural cardiac/cardiopulmonary disease, 2 patients (3.3%) had cerebrovascular disease, 3 (4.9%) had non-syncopal attack and in 11 (18%) patients the cause remained unknown. Patients with cardiac syncope had significantly higher NT-pro-BNP values (514 IQR 286-1154 pg/ml) than patients with non-cardiac cause (182 IQR 70-378 pg/ml, p=0.001). NT-pro-BNP at a cut-off of 164 pg/ml identified patients with cardiac syncope and patients requiring interventional cardiological therapy with a sensitivity of 90% and 93.8%, a specificity of 48.8% and 46.7% and a negative predictive value of 91% and 95.5%. NT-pro-BNP pre-testing could save 45% of the Holter ECGs, 83% of the telemetry monitoring, 47% of stress tests, 49% of echocardiographies, 67% of coronary angiographies and 43% of electrophysiological examinations. CONCLUSIONS: NT-pro-BNP assessment was helpful in differentiating cardiac from non-cardiac syncope. Further studies are needed to define the role of NT-pro-BNP in the diagnostic algorithm of syncope.