Comment on “Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study”

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Korean J Anesthesiol. 2025;78(1):86-87
Publication date (electronic) : 2024 November 11
doi : https://doi.org/10.4097/kja.24716
1Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
2Department of Mechanical Engineering, Yuan Ze University, Taoyuan, Taiwan
Corresponding author: Hui-Zen Hee, M.D. Department of Anesthesiology, Far Eastern Memorial Hospital, 21, Section 2, Nan-Ya South Road, Pan-Chiao, Taipei County 220, Taiwan Tel: +886-2-89667000, ext. 2373 Fax: +886-2-23680782 Email: femh98940@femh.org.tw
*Hui-Zen Hee and Cheng-Wei Lu have contributed equally to this work.
Received 2024 October 10; Accepted 2024 October 24.

Dear Editor,

The study conducted by Kim et al. [1] titled “Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study” offers significant insights into the use of remimazolam in transcatheter aortic valve replacement (TAVR) procedures. It emphasizes the non-inferiority of remimazolam to dexmedetomidine in terms of early recovery and a reduced need for vasopressors, inotropes, and temporary pacemakers (TPMs). We would like to discuss several aspects of this study further.

The significantly low requirement for remifentanil in the remimazolam group is particularly noteworthy. The authors attributed this to the greater sedative efficacy of remimazolam compared to dexmedetomidine; however, the methodology used for adjusting remifentanil dosing is not clear. We would like clarification on whether the doses were adjusted based on specific monitoring devices, such as processed electroencephalography, analgesia nociception index, or fluctuations in blood pressure and heart rate. Additionally, we would appreciate clarification on whether, in cases of inadequate anesthesia depth assessed by the Modified Observer’s Assessment of Alertness and Sedation score, the team’s initial approach was to adjust the infusion rate of the sedative agents (dexmedetomidine or remimazolam) or modify the remifentanil dosage. In a similar study in which the bispectral index (BIS) was employed to measure anesthesia depth, the remifentanil dose was adjusted when the BIS values exceeded the 40–70 range [2]. Although the overall doses of remimazolam and dexmedetomidine were higher in that study, the remifentanil requirements were comparable between the two groups. Therefore, we would like to request additional details regarding the dosage modifications applied in this study as it would allow readers to have a deeper understanding before applying the findings to clinical practice.

Furthermore, we would like clarification on whether it is standard practice at the authors’ hospital to use local infiltration or peripheral nerve blocks before transfemoral puncture. Based on our clinical experience, patients tend to be highly agitated during this procedure. Kinoshita et al. [3] observed a substantial reduction in the remifentanil dosage when a fascia iliaca block was incorporated into the conscious sedation protocol for TAVR procedures. We would like to understand whether any regional anesthesia techniques were utilized in this study to enhance the quality of monitored anesthesia care.

Additionally, as acknowledged by the authors, the categorization of patients into the dexmedetomidine or remimazolam group before and after July 2021 could potentially introduce a chronological bias. However, this is contrary to our intuition that the procedure duration was longer in the remimazolam group given the increased experience of the interventional team. We would greatly appreciate clarification on whether other factors, such as increased patient movement or procedural difficulties associated with remimazolam use, contributed to this discrepancy.

Finally, we would like to inquire whether the authors conducted a cost analysis comparing the two protocols. Hassan et al. [4] demonstrated that remimazolam and dexmedetomidine have comparable costs, with remimazolam being slightly less expensive. However, that study did not include the cost of flumazenil, which was routinely used as a reversal agent for remimazolam. Considering the reduced use of vasopressors and TPMs, remimazolam may be a more cost-effective choice. If this is the case, it would have significant implications, and we would be grateful if the authors could provide a brief report on this matter.

In conclusion, the research presented by Kim et al. [1] is highly valuable and we are eager to implement it into our clinical practice. We wish to emphasize our appreciation of the authors’ contributions to this field and our inquiries regarding the aforementioned points are not intended to question the study’s findings. In contrast, we hope that by gaining a deeper understanding of these specific aspects, we can optimize anesthetic management in TAVR procedures.

Notes

Funding: None.

Conflicts of Interest: No potential conflict of interest relevant to this article was reported.

Author Contributions: Jo-Hsin Wu (Conceptualization; Writing – original draft); Hui-Zen Hee (Conceptualization; Writing – review & editing); Cheng-Wei Lu (Conceptualization; Supervision; Writing – review & editing)

References

1. Kim JH, Nam JS, Seo WW, Joung KW, Chin JH, Kim WJ, et al. Effects of remimazolam versus dexmedetomidine on recovery after transcatheter aortic valve replacement under monitored anesthesia care: a propensity score-matched, non-inferiority study. Korean J Anesthesiol 2024;77:537–45. 10.4097/kja.24138. 39039823.
2. Kitaura A, Tsukimoto S, Sakamoto H, Hamasaki S, Nakao S, Nakajima Y. A retrospective comparative study of anesthesia with remimazolam and remifentanil versus dexmedetomidine and remifentanil for transcatheter aortic valve replacement. Sci Rep 2023;13:17074. 10.1038/s41598-023-43895-0. 37816802.
3. Kinoshita H, Yamamoto M, Adachi Y, Yamaguchi R, Takemura A. Fascia iliaca block reduces remifentanil requirement in conscious sedation for transcatheter aortic valve implantation- a randomized clinical trial. Circ J 2024;88:475–82. 10.1253/circj.cj-22-0580. 36403975.
4. Hassan H, Shado R, Novo Pereira I, Mistry M, Craig D. Efficacy and cost analysis of intravenous conscious sedation for long oral surgery procedures. Br J Oral Maxillofac Surg 2024;62:523–38. 10.1016/j.bjoms.2024.04.006. 38797651.

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