Development of the Minimalist Approach for Transcatheter Aortic Valve Replacement at a Veterans Affairs Medical Center

OBJECTIVES: While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding developing this approach at Veterans Affairs (VA) medical centers (VAMCs). We implemented TAVR with minimalist approach (MA) using conscious sedation (CS) with transthoracic echocardiography (TTE) and compared safety and outcomes with general anesthesia (GA) with transesophageal echocardiography (TEE) at a university-affiliated VAMC. METHODS: A total of 258 patients underwent transfemoral TAVR at a VAMC between November 2013 and October 2019. Ninety-three patients underwent GA/TEE and 165 patients underwent CS/TTE with dexmedetomidine and remifentanil. Propensity-score matching with nearest-neighbor matching was used to account for baseline differences, yielding 227 participants (81 GA, 146 CS). RESULTS: MA-TAVR had no effect on 30-day mortality or paravalvular leakage. No differences were found in permanent pacemaker implantation, major vascular complications, or postoperative hemodynamics. In this population, MA-TAVR did not reduce procedural time, hospital length of stay, or intensive care unit length of stay. CONCLUSIONS: Unlike civilian hospitals, MA with CS/TTE did not reduce overall length of stay in the veteran population; however, it was safe and effective for transfemoral TAVR without impacting clinical outcomes of mortality, major vascular complications, and paravalvular leakage.