Introduction
Transcatheter Aortic Valve Implantation (TAVI) has emerged over the last decade and has become a viable treatment option for those with severe symptomatic aortic stenosis (AS). The numbers of TAVI that are being performed in centres across the world is rising rapidly, and revolutionising treatment for AS and steering away from the need for open heart surgery. TAVI has been targeted for those who are deemed high risk to undergo open heart surgery such as the elderly, frail, or those with multiple co-morbidities. General anaesthesia (GA) has been used to facilitate TAVI especially when the procedure was in its infancy. The use of GA comes with its own set of risks such as haemodynamic compromise, risk for aspiration, longer procedure time and post-operative nausea and vomiting. These side effects and or complications may not be tolerated well in those who are elderly or have numerous co-morbidities.
Choice of GA, Sedation and/or LA for patients planned for TAVI should be discussed in a multidisciplinary team meeting including cardiologists, cardiac surgeons, anaesthetists, radiologists, and clinical nurse specialists. Factors such as age, co-morbidities, vascular access and anaesthetic fitness and risk are all vital in assessing whether a patient can undergo a GA. Patients with advanced age, frailty, significant lung disease or severe co-morbidities may be challenging to anaesthetise. Cardiopulmonary exercise testing, up to date lung function tests, and pre assessment clinics can aid to filter these patients. Vascular access such as poor femoral artery access can affect the operators experience and may affect how the anaesthetic is performed such as in cases of transcarotid TAVI. Sedation and LA should be tolerated well in most patients even those who may be restless or anxious. Centre and operator experience can guide decision making and the presence of local cardiac surgery support is paramount. LogEuroSCORE can be used to assess the operative mortality in those undergoing cardiac surgery and may be used for TAVI procedure, with higher values associated with increased GA risk. [1]
Table 1 shows a breakdown of the LogEuroSCORE.