Intuitively one would expect patients undergoing TAVI under LA to have a shorter recovery period post-procedure, to mobilise earlier and have a shorter length of stay as compared with those patients undergoing the procedure under GA. Published data comparing TAVI under GA and LA are few and far between, perhaps because TAVI is a relatively new procedure, but it may also be that many centres regard the superiority of LA as self-evident. However, before there is a general shift over to LA, it is important that we are sure the proposed advantages of LA are not offset by higher incidence of aortic regurgitation, prolonged screening times, higher contrast loads and procedural complications relating to patient movement.
This paper reviews the currently available literature. Key data are documented in Table 1. For the sake of brevity, procedures not performed under a GA are referred to as LA procedures. In general, however, as well as local anaesthetic agents being used at access sites, a combination of opiates (often remifentanil) and benzodiazepines are used for the purposes of sedation. Additionally, regional anaesthesia (e.g. epidural) is used in some cases.
A single meta-analysis3 including seven studies4–10 has recently been published by Fröhlich et al. They found that procedures performed under LA were significantly shorter than those performed under GA, and that length of stay was shorter. No other differences in procedures or outcomes were demonstrated, perhaps reflecting the absence of randomised studies as well as the marked heterogeneity of the included studies.
Other than this meta-analysis, published data about TAVI under LA are limited to single-centre experiences. Publications can loosely be divided into two categories. Firstly, there are registries of cases performed under LA where outcome data are compared with those from other published studies in which GA is used in all or the majority of cases. These studies are not included in the meta-analysis. Secondly, there are papers where cases performed in the single centre under both LA and GA are compared directly.
In the former group, Greif et al have published their experience of a large cohort (n=461) of patients from a single centre using both Sapien and CoreValve prostheses where LA is the default for transfemoral procedures. They have provided detailed procedural information including X-ray duration, procedure duration, volume of contrast used, inotrope requirement and rates of conversion to GA, as well as standard outcomes such as degree of aortic regurgitation, vascular complications, length of stay and mortality. They have gone on to compare their outcomes with those from other studies including Placement of aortic transcatheter valves (PARTNER) A&B,1,2 the German Aortic Valve Registry (GARY)12 and the French Aortic National CoreValve and Edwards (France 2) Registry,13 and have demonstrated similar rates of death, stroke and vascular complications. Durand et al.14 published their single-centre experience of 151 Sapien and Sapien XT cases in 2012, again documenting detailed procedural information as well as standard outcomes that are compared with those from other studies including PARTNER,1,2 the SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry15 and Vancouver TF.16 This latter paper by Durand et al. confirms that both surgical cut down to the femoral artery and the use of percutaneous closure devices are compatible with the use of LA; all cases using the Sapien prosthesis involved surgical cut down whereas a Prostar closure device was used in 97 % of cases involving the Sapien XT prosthesis.
These two papers provide indirect evidence of the efficacy and safety of TAVI procedures performed under LA in a total of over 600 patients. They also document the important procedural data points that are required to make useful comparisons between the two types of anaesthesia.