For patients who are unable to tolerate surgical correction of mitral regurgitation, percutaneous edge to edge mitral valve repair (PMVR) has been established as a safe and efficacious alternative. This procedure is currently performed mostly under general anesthesia, whereas other percutaneous interventions such as transcatheter aortic valve replacement (TAVR) are sometimes performed under conscious or deep sedation. General anesthesia has the benefit of providing controlled ventilation, immobility, and airway protection; however, its disadvantages include greater hemodynamic variability, increased duration of anesthesia, and higher incidence of perioperative hypotension.
To investigate the safety of performing PMVR under deep sedation, two European institutions published separate prospective studies last year of over 200 patients in each study, spanning for two to five years. Neither study was a randomized controlled trial. Patzelt et al stratified patients based on suitability determined by the cardiologist and anesthesiologist, e.g. more anatomically challenging patients received general anesthesia to access breath holds. Unsurprisingly, the general group had more severe disease and comorbidities, but the patients were younger; the sedation group had comparatively more patients with pulmonary hypertension. Horn et al assigned patients using a scheduling algorithm that did not take into account of patient characteristics, so there was no significant difference in baseline patient factors, but had twice the number of deep sedation patients than general anesthesia patients. Both studies used midazolam and propofol as their primary sedatives for the deep sedation group.
Both studies found no difference between the general and sedation groups in terms of procedure success, surgical complications, major cardiac and cerebrovascular events, and mortality or postoperative pneumonia. In addition, the deep sedation group in the Horn study had shorter preparation times in the cath lab and shorter ICU stay durations; in the Patzelt study, the deep sedation group required fewer admissions to the ICU and had shorter procedure time and fluoroscopy time. However, these results may be confounded by the patients in this group being generally healthier with more anatomically straightforward mitral valve pathology, given the stratification methods used.
These two studies both concluded that deep sedation for percutaneous mitral valve repair was a safe alternative to general anesthesia. Granted, these are single institution trials with a moderate sample size of patients, but the data shown are promising and warrant further investigation. In patients felt to be suitable with this procedure by both the interventional cardiologist and anesthesiologist, it may be worth discussing the pros and cons of undergoing PMVR under deep sedation.
Horn P, Hellhammer K, Minier M, Stenzel MA, Veulemans V, Rassaf T, Luedike P, Pohl J, Balzer J, Zeus T, Kelm M, Westenfeld R. Deep sedation Vs. general anesthesia in 232 patients undergoing percutaneous mitral valve repair using the MitraClip® system. Catheter Cardiovasc Interv. 2017 Dec 1;90(7):1212-1219.
Patzelt J1, Ulrich M, Magunia H, Sauter R, Droppa M, Jorbenadze R, Becker AS, Walker T, von Bardeleben RS, Grasshoff C, Rosenberger P, Gawaz M, Seizer P, Langer HF. Comparison of Deep Sedation With General Anesthesia in Patients Undergoing Percutaneous Mitral Valve Repair. J Am Heart Assoc. 2017 Dec 2;6(12).