Paravertebral analgesia in transapical transcatheter aortic valve replacement

INTRODUCTION Transapical transcatheter aortic valve replacement is an option for patients who are not candidates for traditional aortic valve surgery but have severe aortic stenosis and unfavorable ileo-femoral anatomy. Epidural analgesia in these cases has been associated with improved morbidity and mortality. The following manuscript presents the findings of an initial clinical experience employing paravertebral analgesia for patients undergoing transapical transcatheter aortic valve replacement. METHODS A retrospective review was performed of 61 transapical transcatheter aortic valve replacement cases over a two-year period from November 2012 through July 2014. Paravertebral analgesia was provided as left sided single injections covering 1-3 dermatome levels using 0.2% ropivicaine with supplemental clonidine to 48 patients. The following outcome metrics were collected: 1) peri-operative opiate administration, 2) rate of extubation in the operating room, 3) new atrial fibrillation, 4) duration of intensive care stay, 5) 30-day mortality. RESULTS The mean opiate administration was less in patients with paravertebral analgesia (128.65mcg vs. 163.46mcg fentanyl, p value 0.05) and these patients were more frequently extubated in the operating room (83.3% vs. 46.2%, p-value 0.0107). Incidence of atrial fibrillation was less in patients who received paravertebral analgesia (18.8% vs. 75.0%, p-value 0.0048). There was a non-significant trend towards decreased intensive care stay in patients who received paravertebral analgesia (58.3 hrs vs 75.8 hrs, p value 0.35). There was no difference in 30-day mortality. No complications resulted from paravertebral analgesia. CONCLUSIONS This is the first reported case series of paravertebral blockade in transapical transcatheter aortic valve replacement  patients. The findings suggest that paravertebral single shot blocks are both safe and practical for use in this patient population. A formal prospective investigation of paravertebral analgesia in these patients is warranted.