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.