Purpose of Review The purpose of this chapter is to provide a brief review on current anesthesia techniques for transfemoral transcatheter aortic valve implantation (TF-TAVI). Recent Findings TF-TAVI has become a standard treatment option for high risk patients with severe aortic stenosis. Increasing experience with prosthetic durability and equivalent or superior outcomes of transcatheter over surgical aortic valve replacement will boost the caseload of high- and intermediate-risk patients. For TF-TAVI, general anesthesia (GA) had initially been widely preferred over local anesthesia with monitored anesthesia care (LA-MAC), but with large national practice variation. Institutional routines are changing now since evidence from large registries accrues that LA-MAC represents a feasible, safe, and economically sound alternative to GA, if no contraindications apply. Although prospective randomized TAVI anesthesia trials are lacking, observational data show that GA is associated with higher patient risk, longer procedural time, more vasopressor and transfusion requirement, and more resource use and costs, whereas periprocedural mortality is comparable or non-significantly better with LA-MAC. In summary, GA remains a robust solution for specific situations and teams. In many experienced centers, however, LA-MAC has become first choice whenever possible. Whether LA-MAC is an option should be decided upon by the anesthesiologist and the heart team in consultation with the patient, following prospectively defined decision pathways. With increasing caseload and decreasing invasiveness of TAVI technology, anesthesia providers must meet the challenge to reduce resource use and costs without compromising patient safety and satisfaction.
Transfemoral TAVI General anesthesia Sedation Vasopressor Transfusion Outcome
This is a preview of subscription content, log in to check access.
Compliance with Ethical Standards
Conflict of Interest
Jan-Oliver Friess declares that he has no conflict of interest.
Kalgini Durrer Ariyakuddy declares that she has no conflict of interest.
Balthasar Eberle has received speaker’s honoraria from Medtronic.
Gabor Erdoes declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
Leon MB, Smith CR, Mack M. et al; PARTNER trial investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.CrossRefPubMedGoogle Scholar
Authors/Task Force Members, Vahanian A, Alfieri O, et al. Guidelines on the management of valvular heart disease (version 2012): the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012;33:2451–96. doi:10.1093/eurheartj/ehs109.CrossRefGoogle Scholar
Osnabrugge RLJ, Mylotte D, Head SJ, Van Mieghem NM, Nkomo VT, LeReun CM, et al. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J Am Coll Cardiol. 2013;62:1002–12. doi:10.1016/j.jacc.2013.05.015.CrossRefPubMedGoogle Scholar
Mayr NP, Hapfelmeier A, Martin K, Kurz A, van der Starre P, Babik B, et al. Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome. Br J Anaesth. 2016;116(1):90–9. doi:10.1093/bja/aev294.CrossRefPubMedGoogle Scholar
Goren O, Finkelstein A, Gluch A, Sheinberg N, Dery E, Matot I. Sedation or general anesthesia for patients undergoing transcatheter aortic valve implantation—does it affect outcome? An observational single-center study. J Clin Anesth. 2015;27:385–90. doi:10.1016/j.jclinane.2015.03.025.CrossRefPubMedGoogle Scholar
Petronio AS, Giannini C, De Carlo M, et al. Anaesthetic management of transcatheter aortic valve implantation: results from the Italian CoreValve registry. EuroIntervention. 2016;12:381–8. doi:10.4244/EIJY15M03_05.CrossRefPubMedGoogle Scholar
• Toppen W, Johansen D, Sareh S, et al. Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: time to wake up? PLoS One. 2017;12:e0173777. doi:10.1371/journal.pone.0173777. Cost analysis of a single center with retrospective evidence for cost effectiveness of LA-MACCrossRefPubMedPubMedCentralGoogle Scholar
• Kiramijyan S, Ben-Dor I, Koifman E, et al. Comparison of clinical outcomes with the utilization of monitored anesthesia care vs. general anesthesia in patients undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med. 2016;17:384–90. doi:10.1016/j.carrev.2016.02.003. Single center experience with retrospective analysis of indications for intraprocedural conversion from LA-MAC to GACrossRefPubMedGoogle Scholar
• Brecker SJD, Bleiziffer S, Bosmans J, Gerckens U, Tamburino C, Wenaweser P, et al. ADVANCE study investigators. Impact of anesthesia type on outcomes of transcatheter aortic valve implantation (from the multicenter ADVANCE study). Am J Cardiol. 2016;117:1332–8. doi:10.1016/j.amjcard.2016.01.027. A multicenter, secondary analysis showing that there are large national differences in utilization of LA-MAC vs. GA.CrossRefPubMedGoogle Scholar
Kappetein AP, Head SJ, Généreux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the valve academic research consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg. 2012;42:S45–60. doi:10.1093/ejcts/ezs533.CrossRefPubMedGoogle Scholar
GALA Trial Collaborative Group, Lewis SC, Warlow CP, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372:2132–42. doi:10.1016/S0140-6736(08)61699-2.CrossRefGoogle Scholar
Bruder EA, Ball IM, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015;1:CD010225. doi:10.1002/14651858.CD010225.pub2.PubMedGoogle Scholar
Wutzler A, Huemer M, Boldt L-H, Parwani AS, Attanasio P, Tscholl V, et al. Effects of deep sedation on cardiac electrophysiology in patients undergoing radiofrequency ablation of supraventricular tachycardia: impact of propofol and ketamine. Europace. 2013;15:1019–24. doi:10.1093/europace/eut025.CrossRefPubMedGoogle Scholar
Weerink MAS, Struys MMRF, Hannivoort LN, Barends CRM, Absalom AR, Colin P. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;77:1125–1. doi:10.1093/europace/eut025.Google Scholar