General Anesthesia or Monitored Anesthesia Care for Transfemoral Transcatheter Aortic Valve Implantation: Current Trends and Future Directions

Abstract

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.