Efficiency, Safety, and Quality of Life After Transcatheter Aortic Valve Implantation Performed With Moderate Sedation Versus General Anesthesia.

There is growing interest in "minimalist" transcatheter aortic valve implantation (M-TAVI), performed with conscious sedation instead of general anesthesia (GA-TAVI). We assessed the impact of M-TAVI on procedural efficiency, long-term safety, and quality of life (QoL) in 477 patients with severe aortic stenosis (82 years, women 50%, STS 5.0), who underwent M-TAVI (n = 278) or GA-TAVI (n = 199). M-TAVI patients were less likely to have NYHA Class ≥3, valve-in-valve TAVI, and receive self-expanding valves. M-TAVI was completed without conversion to GA in 269 (97%) patients. M-TAVI was more efficient that GA-TAVI including shorter lengths of stay (2 vs 3 days, p <0.0001), higher likelihood of being discharged home (87% vs 72%, p <0.0001), less use of blood transfusions (10% vs 22%, p = 0.0008), inotropes (13% vs 32%, p <0.0001), contrast volume (50 vs 90 ml, p <0.0001), fluoroscopy time (20 vs 24 minute, p <0.0001), and need for >1 valves (0.4 vs 5.5%, p = 0.0004). At 1-month, death/stroke (M-TAVI vs GA-TAVI 4.0 vs 6.5%) and a "safety composite" end point (death, stroke, transient ischemic attack, myocardial infarction, new dialysis, major vascular complication, major or life-threatening bleeding, and new pacemaker: 17.6% vs 21.1%) were similar (p = NS for both). At a median follow-up of 365 days, survival curves showed similar incidence of death/stroke as well as the safety composite end point between the groups. QoL scores were similar at baseline and 1-month after TAVI. In multivariable analyses, M-TAVI showed significant improvements in all parameters of procedural efficiency. In conclusion, M-TAVI is more efficient than GA-TAVI, with similar safety at 1-month and long-term, and similar QoL scores at 1 month.

The prediction of difficult intubation in obese patients using mirror indirect laryngoscopy: A prospective pilot study.

BACKGROUND: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. MATERIALS AND METHODS: 60 patients with a body mass index (BMI) greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. RESULTS: Sixty patients met the inclusion criteria; however, 8 (13.3%) patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. CONCLUSIONS: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.

Perioperative pulmonary embolism: diagnosis and anesthetic management.

All perioperative patients, but especially trauma victims and those undergoing prostate or orthopedic surgery, are at increased risk of venous thromboembolism. Patients at highest risk include those with malignancy, immobility, and obesity; those who smoke; and those taking oral contraceptives, hormone replacement therapy, or antipsychotic medications. Dyspnea, anxiety, and tachypnea are the most common presenting symptoms in awake patients, and hypotension, tachycardia, hypoxemia, and decreased end-tidal CO(2) are the most common findings in patients receiving general anesthesia. The presence of shock and right ventricular failure are associated with adverse outcomes. Helical computed tomographic scanning is the preferred definitive diagnostic study, but transesophageal echocardiography may be valuable in making a presumptive diagnosis in the operating room. Early diagnosis allows supportive therapy and possible anticoagulation (in some cases, to be started before the conclusion of surgery).