Cardiovascular Rounds

How Hartford Hospital adopted conscious sedation for TAVR

By Megan Tooley and Marissa Schwartz Schaffer

Since its inception, TAVR has been one of the most exciting innovations in cardiovascular services. In recent years, TAVR has seen significant clinical advancements, leading both to better quality outcomes, and to opportunities for structural heart programs to become more efficient and cost-effective.

Indeed, with TAVR's burgeoning growth and positive forecasts for future volumes, achieving these dual aims of enhanced efficiency and high-quality outcomes will be imperative for structural heart programs to succeed.

One of the areas many have turned to is anesthesia modality. Rather than using general anesthesia (GA) during all TAVR procedures, programs are increasingly using conscious sedation (CS) for many cases, particularly those performed through transfemoral (TF) access. CS has the potential to reduce the complication risks associated with GA, enhance efficiency through a typically shorter procedure time and less intensive recovery setting, decrease length of stay (LOS), and improve patient satisfaction.

In fact, a recent, large analysis of patients in the STS/ACC TVT Registry found shorter LOS and lower rates of in-hospital and 30-day mortality for TAVR patients who received CS vs. GA, though the observational nature of this study precluded definitive determinations of superiority. At the same time, proponents of GA argue that it allows for superior imaging through transesophageal echocardiography (TEE) and expedites the rare conversion to surgery.

Given these considerations, it is important for programs to carefully approach the adoption of CS to ensure it is the optimal choice for their program and their patients.

How Hartford Hospital adopted CS for TAVR procedures

To learn more about the process of adopting CS for TAVR procedures, we spoke with Dr. Raymond McKay, the Director of Interventional Cardiology Research and the Cardiovascular Data Management Center at Hartford Hospital, an 867-bed hospital in Connecticut.

Hartford's structural heart program began their transition to CS in 2015, and they've seen remarkable results. As of 2017, 86% of all TAVR cases—and 93% of all TF TAVR cases—are performed under conscious sedation. As a result of these changes, Hartford found significant improvements in composite outcome measures (mortality, stroke, major vascular complication, renal compromise and new onset atrial fibrillation), and saw that patients were more satisfied with CS than with GA.

Moreover, the adoption of a more streamlined approach to TAVR has had significant financial benefits. In fact, in 2016, the contribution margin for cases performed under CS was $5,000 higher than for those performed under GA.

Dr. McKay shared Hartford's experience with us, and offered advice for other programs looking to adopt CS for TAVR. Here are a few of the lessons he shared.

Adopting CS doesn't happen overnight. Hartford began performing TAVR in 2012, giving them three years of experience before beginning CS. Once they started considering a transition to CS, Hartford found that guidance from device vendors, combined with the previous experience of their physicians with changes to anesthesia policies, helped smooth the adoption process. Currently, Hartford still performs all TAVRs in the hybrid OR, where the procedural team includes the interventionalist and cardiac surgeon operators, an anesthesiologist, an echocardiologist, and OR and cath lab staff.

Anesthesiology engagement is critical to a successful transition; to get anesthesiologists on board, have them meet with people who have already made the change. Despite the move to CS, Dr. McKay pointed out, anesthesiology participation is still crucial—and it's important to ensure buy-in from this team. Before initiating the transition to CS, Hartford brought in an anesthesiologist from a progressive program who had extensive experience using CS for TAVR. The guest anesthesiologist met with Hartford's anesthesiology team over a dinner meeting to share his experience, answer their questions, and assuage any concerns. By fostering honest, peer-to-peer discussion, and explaining how CS could be a good practice even for higher-risk patients, these interactions helped ensure that the anesthesiology team at Hartford was comfortable with CS.

Emphasize clinical benefits to engage the entire TAVR team. At Hartford's weekly multidisciplinary TAVR conference, Dr. McKay introduced anesthesia protocol changes and opened up discussion on them. Clinical representatives from Hartford's device vendors are also present at these meetings to help communicate the messages and offer input. Additionally, the guest anesthesiologist met with the broader TAVR team during his visit to answer questions from the group. Emphasizing the potential clinical benefit to the patient of transitioning to CS was particularly essential to securing buy-in from the entire team.

CS isn't just for the healthiest patients. At their weekly multidisciplinary TAVR case conference, Hartford's heart team discusses which patients would be eligible for CS. When considering adopting CS, the natural first assumption is that GA would still be necessary for all but the lowest-risk patients. However, as Dr. McKay and other leaders in the field have pointed out, the patients who stand to benefit the most from CS are actually not the healthiest ones. It's the patients who are at risk for an extended, difficult recovery—due to other risk factors—that could particularly benefit from CS and its streamlined recovery process.

Of course, this doesn't mean that programs should begin by testing out CS on the highest-risk cases. Dr. McKay recommends beginning with a smaller, stable group of patients. For example, before Hartford began using CS, the team thought that patients with COPD, where extubation can often be difficult, could particularly benefit from CS. However, anesthesiologists preferred to begin with a lower-risk group of patients to ensure protocols went smoothly. Soon after seeing the early successes of CS, they were able to expand protocols to include patients with COPD.

Ultimately, Hartford now uses CS for 93% of TF TAVR patients. The only TAVR patients for whom CS is not the default are those with alternative (non-TF) access, those who need a cutdown on the femoral artery, and those who experience a complication needing surgical intervention. Additionally, a small number of patients have been converted from CS to GA during their procedure, when TEE imaging is deemed essential.

Reevaluate anesthesia choice before the procedure. Discussions regarding alternative access begin at the multidisciplinary case conference. At this stage, the group makes an initial determination regarding the use of CS. However, the anesthesia choice is confirmed with the anesthesiologist on the morning of each procedure. If the team or anesthesiologist disagrees that CS is the appropriate choice, they reassess the appropriate plan of action.

Improving TAVR efficiency involves more than just anesthesia choice. In addition to anesthesia modality, Hartford has focused on streamlining TAVR efficiency in other ways—for both CS and GA patients. For instance, they are minimizing the use of Foley catheters, decreasing ICU time, protocolizing early ambulation, and judiciously determining the need for temporary pacing. As time goes on, a significant number of patients are now bypassing the ICU altogether, heading instead to a stepdown floor.

CS is driving both clinical and financial improvements at Hartford. In 2016, Dr. McKay and his team conducted a propensity-matched analysis of 100 TF TAVR patients performed under CS and 100 TF TAVR patients performed under GA. They found a nearly $5,000 differential in contribution margin between the CS and GA groups, accounting for both direct and indirect costs. This difference was driven in part by changes that affect important clinical outcomes as well—shorter average LOS (4 days for CS vs. 6.2 days for GA), fewer ICU days (1.2 vs. 2 days), shorter procedure time (86 vs. 100 minutes) and shorter fluoroscopy time.

That said, after running a repeat analysis in 2017, Hartford found that the difference in contribution margin was still favorable for CS, but had lost statistical significance. That's not because they weren't seeing savings with CS, but rather because they were seeing savings with GA, due to the efficiencies described above (e.g., lower LOS across the board). Similarly, CS is no longer leading to statistically superior outcomes—because outcomes for GA are improving as well. Of course, the lack of significant differences doesn't mean that transitioning to CS isn't a worthy discussion; it simply suggests that there are other, critical ways of improving efficiency alongside anesthesia.

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