Remimazolam versus dexmedetomidine-based sedation for transcatheter aortic valve implantation: hemodynamic stability and early clinical outcomes

Background Monitored anesthesia care (MAC) is increasingly used as part of minimalist transcatheter aortic valve implantation (TAVI) pathways, but evidence directly comparing remimazolam- and dexmedetomidine-based MAC with respect to intraprocedural hemodynamic stability and early clinical outcomes remains limited. Methods In this retrospective, single-center, propensity score-matched cohort study, 433 patients who underwent TAVI under MAC between January 2021 and May 2026 were identified. After 1:1 propensity score matching, 264 patients were included, with 132 patients in each group. The primary outcome was intraoperative hemodynamic instability, defined as bradycardia requiring anticholinergic treatment or hypotension requiring vasoactive treatment. Other outcomes included rescue midazolam use, respiratory adverse events, and early postoperative clinical outcomes. Results Remimazolam-based MAC was associated with less intraprocedural hemodynamic instability than dexmedetomidine-based MAC (53.8% vs. 69.7%; adjusted OR, 0.50; 95% CI, 0.31–0.82; P = 0.006), primarily reflecting less frequent vasoactive treatment for hypotension (50.8% vs. 67.4%; adjusted OR, 0.49; 95% CI, 0.30–0.81; P = 0.005). Bradycardia requiring anticholinergic treatment was numerically lower but not statistically significant. Rescue midazolam use was markedly lower with remimazolam (1.5% vs. 43.2%; P < 0.001). Respiratory adverse events, conversion to general anesthesia, postoperative delirium, length of stay, and 30-day clinical outcomes did not differ significantly between groups. Conclusions In patients undergoing TAVI under MAC, remimazolam-based sedation was associated with a lower incidence of intraprocedural hemodynamic instability and less frequent rescue midazolam administration than dexmedetomidine sedation, without significant differences in early postoperative clinical outcomes.