The main advantages of transcatheter aortic valve implantation (TAVI) over conventional aortic valve replacement (cAVR) surgery are the avoidance of sternotomy, heart lung bypass and prolonged procedure times. These advantages facilitate early mobilisation and discharge – important both clinically and in terms of resource utilisation. Balanced against this, TAVI is less predictable than cAVR – evidenced by valve embolisation, the requirement for implantation of more than one prosthesis and conversion to cAVR – and there is a higher rate of significant aortic regurgitation post-procedure.1,2
While technical advances in valve and delivery system design are reducing unpredictability and residual aortic regurgitation, TAVI operators are increasingly trying to reduce the invasiveness to further reduce procedural mortality and morbidity, and length of stay. Key elements in this are the move from surgical cut down to the use of percutaneous closure devices for vascular access and from general anaesthetic (GA) to local anaesthetic (LA) with sedation.
Most centres when starting TAVI programmes perform procedures under GA. The primary advantage of GA is the ability to have a transoesophageal echocardiogram (TOE) probe in place throughout the procedure. The TOE probe is useful for allowing early recognition of complications, for positioning the prosthesis and for the assessment of residual aortic regurgitation. In addition, a GA eliminates patient discomfort, anxiety and movement during the procedure. However, a GA involves intrinsic risk in the form of haemodynamic instability and the need for intubation and ventilation.