Results
From January 2014 to December 2019, 356 elective percutaneous transfemoral TAVR procedures were performed at the NF/SG VAMC. Seven of these met exclusion criteria, leaving 349 patients included in the study. Of these, 244 cases were classified as MAC, and 105 as GA. Starting in 2015, there was a steep decline in the use of GA, and a rapid increase in the use of MAC (Figure 2 ). Baseline characteristics of the entire cohort are summarized in Table 1 . With unmatched data, the MAC group had higher mean BMI (30.4 vs. 28.7 kg/m2, P = .010), higher average preoperative hemoglobin (12.7 vs. 12.2 g/dL, P = .031), and were less likely to have a history of prior cardiac surgery (27.9% vs. 41.0%, P= .018). Patients who underwent TAVR with MAC had lower VASQIP estimated mortality (2.18% vs. 6.11%, P < .001). All other patient characteristics were similar between the two groups. Outcomes between unmatched groups are summarized in Table 2 . Despite patients in the MAC group having lower estimated VASQIP estimated mortality preoperatively, there was no difference in postoperative renal failure (0%), postoperative MI (0.4% vs. 1.9%, P = .216), postoperative cerebrovascular accident (0% vs. 1%, P = .301), postoperative atrial fibrillation (1.6% vs 3.8%, P = .248), postoperative cardiac arrest (0.4% vs. 0%, P = 1), and percentage of patients discharged to home (97.1% vs. 96.3%, P = .628). Intraoperative cardiac arrest (2.9% vs. 0.4%, P = .083) and 30-day mortality (2.9% vs. 0.4%, P = .083), were not different between groups. The GA TAVR cohort had a significantly higher 180-day mortality (12.4% vs. 3.3%, P = .002). TAVR cases performed with MAC had shorter OR times (146 vs. 198 minutes, P< .001), shorter lengths of stay in the ICU (1.4 vs. 1.8 days,P < .001) and shorter total hospital length of stay (3.4 vs. 5.4 days, P < .001). The use of MAC was also associated with lower hospital cost ($48,800 vs. $52,600, P< .001) and lower overall cost after valve cost was included ($81,300 vs. $85,400, P < .001). Average ICU cost was $8,513 for MAC and $11,161 for GA (P = .019). Mean OR costs were $35,994 for MAC and $32,943 for GA (P = .024). The average costs of valves were $32,514 for MAC and $32,843 for GA (P = .178).
Propensity matching resulted in 83 MAC patients matched to 83 GA patients (Figure 1 ). Demographics and patient characteristics of the 83 matched pairs were compared (Table 3 ). Between matched pairs, there were no significant differences between patients who underwent MAC to those that received GA in age (77.6 years vs. 77 years, P = .831), sex (97.6% male, P = 1), BMI (29.4 vs. 29.3 kg/m2, P = .581), preoperative creatinine (1.4 vs. 1.2 mg/dL, P = .791), preoperative hemoglobin (12.3g/dL,P = .791), or VASQIP estimated mortality (2.7% vs. 3.1%,P = .200). There were no differences between propensity-matched groups in the incidence of postoperative MI (0% vs. 2%, P = .480), renal failure requiring renal replacement therapy (0%), intraoperative cardiac arrest (1.2% vs. 1.2%, P = 1), postoperative atrial fibrillation (1.2% vs. 3.6%, P = .335), postoperative CVA (1% vs. 1.2%, P = 1), or frequency of discharge home (96.4% vs. 97.4%, P = .780). The MAC TAVR cohort did have significant reductions in OR times (147 vs. 196 minutes,P < .001), ICU LOS (1.2 vs. 1.7 days, P = .006), total LOS (3.5 vs. 5.1 days, P = .001), and 180-day mortality (2.4% vs. 12%, P = .030) when compared to the propensity-matched GA TAVR group (Table 4 ). There were no significant differences between matched groups in hospital costs ($49,700 vs. $50,400, P = .709) or overall cost ($82,100 vs. $83,100, P = .936).
OR time for all 2016 TAVR cases were compared by anesthesia modality to eliminate bias secondary to physician and institutional experience. There was a significant reduction in OR time when MAC was used for TAVR (150 vs. 201 minutes, P < .001).