Background
Surgical valve replacement is the gold standard for treatment of severe aortic stenosis. In recent years, transcatheter aortic valve implantation (TAVI) proved to be a comparable method for a large group of patients. The majority of TAVI procedures is now done under procedural sedation with propofol. Recently, the use of dexmedetomidine for procedural sedation has been increasing. Prospective studies have shown an association between the use of dexmedetomidine and a lower incidence of postoperative cognitive decline and postoperative delirium. In accordance with the trend towards minimally invasive treatment approaches in the elderly, who are the majority of candidates for TAVI, our research aimed to determine whether dexmedetomidine is a better choice of sedative agent than propofol for patients undergoing TAVI.
Methods
In this randomized, double-blind, prospective study, 78 patients who underwent TAVI under procedural sedation between January 2019 and June 2021 were included. Patients were previously randomized into two groups; 39 patients to the propofol sedation group (propofol group) and 39 patients to the dexmedetomidine sedation group (dexmedetomidine group). We observed the incidence of postoperative cognitive decline (by performing the Mini Mental State Examination (MMSE) before and 48 hours after TAVI) and the occurrence of postoperative delirium (using the Confusion Assessment Method for the Intensive Care Unit, CAM-ICU). During the procedure, hemodynamic and respiratory parameters, the need for additional boluses of analgosedation and vasoactive agents were recorded with standard monitoring. The need for vasoactive agents and the occurrence of atrial fibrillation in the first 24 hours after the procedure was recorded. We observed the duration of treatment in high dependancy unit (HDU), the complete duration of hospital stay and 30-day mortality. Differences between groups were tested using Student's t-test, Mann-Whitney U test, Chi-square test and likelihood ratio test. The relationship between the used sedative agent and postoperative cognitive outcome, final heart rate and mean arterial pressure were evaluated using the multiple linear regression method.
Results
Of the 78 patients included in the study, 71 were eligible for the final data analysis. The median postoperative MMSE score was 2 points lower in the propofol group compared to baseline, while it remained the same in the dexmedetomidine group. The difference between the groups was statistically significant. Early postoperative cognitive decline incidence was statistically significantly higher in the propofol group compared to the dexmedetomidine group. There was no statistically significant difference between the groups in the occurrence of postoperative delirium. In the propofol group, there was a statistically significant higher incidence of desaturation during sedation, and a higher need for additional analgosedation. Patients in the dexmedetomidine group had higher final mean arterial pressure than patients in the propofol group. We did not detect a difference in the occurrence of postoperative atrial fibrillation. We did not detect statistically significant differences in the duration of treatment in HDU, the duration of hospitalization and 30-day mortality.
Conclusion
The results of our study show that dexmedetomidine is a better choice of sedative for controlled sedation during TAVI than propofol in several points. A major advantage of dexmedetomidine is its association with a lower incidence of early postoperative cognitive decline in the TAVI patient population. In addition, it also provides more stable sedation with less respiratory depression and simultaneous analgesic effects.
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