Sohail Sareh

Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

Background Transcatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR. Methods Records for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institutions data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost. Results Of the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses. Conclusion Conscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.

Financial and clinical outcomes of extracorporeal mechanical support

Over the past decade, extracorporeal mechanical support (ECMO) has been increasingly utilized in respiratory failure and cardiogenic shock. There is a need for assessing clinical and financial outcomes of ECMO use. This study presents our institutions experience with veno‐arterial ECMO (VA‐ECMO) over a 9‐year period.

Addition of Statins to Treatment With β-Blockers to Improve Outcomes for Cardiac Surgery Patients: Beyond the Surgical Care Improvement Project.

Addition of Statins to Treatment With β-Blockers to Improve Outcomes for Cardiac Surgery Patients: Beyond the Surgical Care Improvement Project For nearly 2 decades, β-blockers have been thought to reduce the risk of major adverse cardiovascular events during the perioperative period. Beginning with the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography trial1 in 1999, a series of studies have provided compelling evidence that patients undergoing high-risk operations should receive β-blockers before surgery.2 Given these findings, the Surgical Care Improvement Project required that all patients previously receiving β-blockers should receive their medication in the 24 hours before surgery. More recently, however, several large-scale studies have failed to reproduce these beneficial effects,3,4 and the Perioperative Ischemic Evaluation trial4 found increased mortality with the use of β-blockers before surgery. A similar controversy exists with regard to the perioperative administration of statins, agents that may reduce