Conclusion
The use of sedation with or without local anaesthesia appears to be a safe and effective method to facilitate TAVI. The use of sedation over general anaesthesia has been shown to reduce length of stay in the ICU and in hospital, reduce polypharmacy and cause much less haemodynamic compromise. In those who are high risk; frail, elderly or have severe co-morbidities the risk of GA may be too great and can outweigh the benefits intended from TAVI. Experienced centres will have clinicians trained in how to anaesthetise and deal with these group of patients; a multidisciplinary team discussion is vital to ensure the appropriate anaesthetic is chosen for each patient. As TAVI continues to revolutionise the treatment for symptomatic aortic stenosis, the rise in cases in inevitable and the use of sedation and local anaesthesia allows clinicians with a viable option to treat a challenging group of patients.
References:
1) Imnadze G, Hofmann S, Billion M, et al. Clinical value of the 20% logistic EuroSCORE cut-off for selecting TAVI candidates: a single-centre cohort study analysis. Open Heart . 2020;7(1):e001194. Published 2020 Feb 19. doi:10.1136/openhrt-2019-001194
2) Afshar AH, Pourafkari L, Nader ND. Periprocedural considerations of transcatheter aortic valve implantation for anesthesiologists. J Cardiovasc Thorac Res . 2016;8(2):49-55. doi:10.15171/jcvtr.2016.10
3) Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JD. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012 Mar 27;59(13):1200-54. doi: 10.1016/j.jacc.2012.01.001. Epub 2012 Jan 31. PMID: 22300974.
4) Debry N, Delhaye C, Azmoun A, Ramadan R, Fradi S, Brenot P, Sudre A, Moussa MD, Tchetche D, Ghostine S, Mylotte D, Modine T. Transcarotid Transcatheter Aortic Valve Replacement: General or Local Anesthesia. JACC Cardiovasc Interv. 2016 Oct 24;9(20):2113-2120. doi: 10.1016/j.jcin.2016.08.013. PMID: 27765304
5) Gauthier C, Astarci P, Baele P, et al. Mid-term survival after transcatheter aortic valve implantation: Results with respect to the anesthetic management and to the access route (transfemoral versus transapical). Ann Card Anaesth . 2015;18(3):343-351. doi:10.4103/0971-9784.159804
6) Renner J, Tesdorpf A, Freitag-Wolf S, et al. A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience. Health Sci Rep . 2018;2(1):e95. Published 2018 Nov 1. doi:10.1002/hsr2.95
7) Husser O, Fujita B, Hengstenberg C, Frerker C, Beckmann A, Möllmann H, Walther T, Bekeredjian R, Böhm M, Pellegrini C, Bleiziffer S, Lange R, Mohr F, Hamm CW, Bauer T, Ensminger S; GARY Executive Board. Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: The German Aortic Valve Registry. JACC Cardiovasc Interv. 2018 Mar 26;11(6):567-578. doi: 10.1016/j.jcin.2017.12.019. PMID: 29566803.
8) Miles LF, Joshi KR, Ogilvie EH, Densem CG, Klein AA, O’Sullivan M, Martinez G, Sudarshan CD, Abu-Omar Y, Irons JF. General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before-and-after study. Anaesthesia. 2016 Aug;71(8):892-900. doi: 10.1111/anae.13522. Epub 2016 Jun 29. PMID: 27353456.
9) 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 Aug;27(5):385-90. doi: 10.1016/j.jclinane.2015.03.025. Epub 2015 Apr 24. PMID: 25912486.
10) Thiele H, Kurz T, Feistritzer HJ, Stachel G, Hartung P, Lurz P, Eitel I, Marquetand C, Nef H, Doerr O, Vigelius-Rauch U, Lauten A, Landmesser U, Treskatsch S, Abdel-Wahab M, Sandri M, Holzhey D, Borger M, Ender J, Ince H, Öner A, Meyer-Saraei R, Hambrecht R, Fach A, Augenstein T, Frey N, König IR, Vonthein R, Rückert Y, Funkat AK, Desch S, Berggreen AE, Heringlake M, de Waha-Thiele S; SOLVE-TAVI Investigators. General Versus Local Anesthesia With Conscious Sedation in Transcatheter Aortic Valve Implantation: The Randomized SOLVE-TAVI Trial. Circulation. 2020 Oct 13;142(15):1437-1447. doi: 10.1161/CIRCULATIONAHA.120.046451. Epub 2020 Aug 21. PMID: 32819145.
11) Romano SM, Ristalli F, Giglioli C, et al. Deep sedation vs femoral block anesthesia: beat-by-beat hemodynamic impact on TAVI procedure. Am J Cardiovasc Dis . 2020;10(4):340-349. Published 2020 Oct 15.
12) Durand E, Borz B, Godin M, Tron C, Litzler PY, Bessou JP, Bejar K, Fraccaro C, Sanchez-Giron C, Dacher JN, Bauer F, Cribier A, Eltchaninoff H. Transfemoral aortic valve replacement with the Edwards SAPIEN and Edwards SAPIEN XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: feasibility and 30-day outcomes. JACC Cardiovasc Interv. 2012 May;5(5):461-467. doi: 10.1016/j.jcin.2012.01.018. Epub 2012 May 9. PMID: 22560979.
13) Oguri A, Yamamoto M, Mouillet G, Gilard M, Laskar M, Eltchaninoff H, Fajadet J, Iung B, Donzeau-Gouge P, Leprince P, Leguerrier A, Prat A, Lievre M, Chevreul K, Dubois-Rande JL, Chopard R, Van Belle E, Otsuka T, Teiger E; FRANCE 2 Registry Investigators. Clinical outcomes and safety of transfemoral aortic valve implantation under general versus local anesthesia: subanalysis of the French Aortic National CoreValve and Edwards 2 registry. Circ Cardiovasc Interv. 2014 Aug;7(4):602-10. doi: 10.1161/CIRCINTERVENTIONS.113.000403. Epub 2014 Jul 8. PMID: 25006175
14) Jain R, O’Hair DP, Bajwa TK, et al. Transthoracic echocardiography is adequate for intraprocedural guidance of transcatheter aortic valve implantation. Echo Res Pract . 2017;4(4):63-72. doi:10.1530/ERP-17-0050
15) Zaouter C, Smaili S, Leroux L, Bonnet G, Leuillet S, Ouattara A. Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone. Ann Card Anaesth . 2018;21(3):277-284. doi:10.4103/aca.ACA_204_17
16) Sherifi I, Omar AMS, Varghese M, et al. Comparison of transesophageal and transthoracic echocardiography under moderate sedation for guiding transcatheter aortic valve replacement. Echo Res Pract . 2018;5(2):79-87. doi:10.1530/ERP-17-0080
17) He W, Huang RR, Shi QY, Liu XB, Wang JA, Yan M. Bispectral index-guided sedation in transfemoral transcatheter aortic valve implantation: a retrospective control study. J Zhejiang Univ Sci B . 2017;18(4):353-359. doi:10.1631/jzus.B1600522
18) 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(4):e0173777. Published 2017 Apr 5. doi:10.1371/journal.pone.0173777
19) Ahmad M, Patel JN, Vipparthy SC, et al. Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: A Cost and Outcome Analysis. Cureus . 2019;11(6):e4812. Published 2019 Jun 3. doi:10.7759/cureus.4812
20) Mosleh W, Mather JF, Amer MR, Hiendlmayr B, Kiernan FJ, McKay RG. Propensity Matched Analysis Comparing Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Implantation. Am J Cardiol. 2019 Jul 1;124(1):70-77. doi: 10.1016/j.amjcard.2019.03.042. Epub 2019 Apr 10. PMID: 31064667.
21) Melidi E, Latsios G, Toutouzas K, Vavouranakis M, Tolios I, Gouliami M, Gerckens U, Tousoulis D. Cardio-anesthesiology considerations for the trans-catheter aortic valve implantation (TAVI) procedure. Hellenic J Cardiol. 2016 Nov-Dec;57(6):401-406. doi: 10.1016/j.hjc.2016.10.001. Epub 2016 Oct 6. PMID: 28375080.
22) Mayr NP, Wiesner G, Husser O, Joner M, Michel J, Knorr J, Pellegrini C, Bleiziffer S, Schunkert H, Lange R, Tassani-Prell P. Critical adverse events during transfemoral TAVR in conscious sedation. Is an anesthesiologic support mandatory? Cardiovasc Revasc Med. 2018 Sep;19(6S):41-46. doi: 10.1016/j.carrev.2018.06.014. Epub 2018 Jun 21. PMID: 30327095.
23) Goldfuss S, Wittmann S, Würschinger F, et al. Anaesthesia-related complications and side-effects in TAVI: a retrospective study in Germany. BMJ Open . 2019;9(4):e025825. Published 2019 May 1. doi:10.1136/bmjopen-2018-025825
24) Mayr NP, Hapfelmeier A, Martin K, Kurz A, van der Starre P, Babik B, Mazzitelli D, Lange R, Wiesner G, Tassani-Prell P. Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome†. Br J Anaesth. 2016 Jan;116(1):90-9. doi: 10.1093/bja/aev294. Epub 2015 Sep 29. PMID: 26424178.
25) van der Wulp K, van Wely M, van Heijningen L, et al. Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival. J Am Geriatr Soc . 2019;67(11):2325-2330. doi:10.1111/jgs.16087
26) Goudzwaard JA, de Ronde-Tillmans MJAG, de Jager TAJ, et al. Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation. Age Ageing . 2020;49(3):389-394. doi:10.1093/ageing/afaa001
27) Yamamoto M, Meguro K, Mouillet G, Bergoend E, Monin JL, Lim P, Dubois-Rande JL, Teiger E. Effect of local anesthetic management with conscious sedation in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2013 Jan 1;111(1):94-9. doi: 10.1016/j.amjcard.2012.08.053. Epub 2012 Oct 12. PMID: 23068861.
28) Hyman MC, Vemulapalli S, Szeto WY, Stebbins A, Patel PA, Matsouaka RA, Herrmann HC, Anwaruddin S, Kobayashi T, Desai ND, Vallabhajosyula P, McCarthy FH, Li R, Bavaria JE, Giri J. Conscious Sedation Versus General Anesthesia for Transcatheter Aortic Valve Replacement: Insights from the National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circulation. 2017 Nov 28;136(22):2132-2140. doi: 10.1161/CIRCULATIONAHA.116.026656. Epub 2017 Sep 1. PMID: 28864443.
29) Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care–a feasibility study. Anaesthesia. 2011 Nov;66(11):977-82. doi: 10.1111/j.1365-2044.2011.06788.x. Epub 2011 Sep 20. PMID: 21933156.