Susanne Eberl

TRANSFEMORAL AORTIC VALVE REPLACEMENT: DOES ANAESTHESIA MAKE THE DIFFERENCE?

Transcatheter aortic valve implantation (TAVI) have been introduced and further developed

as a last therapeutic option in patients with severe aortic stenosis, who are – because of

severe comorbidity - not suitable for open-heart operations. Different approaches for

aortic valve implantation are nowadays routinely performed: transapical, transaortic, and

transfemoral placement of the aortic valve.

Transapical and transaortic (via direct aortotomie or via the arteria subclavia/axillaris) TAVI is

routinely performed under general anaesthesia, transfemoral (TF-) TAVI can be done under

either general (GA) or local anaesthesia (LA).

1–5

The latter is most often combined with

additional sedation.

While there is still debate on bene cial long-term effects of TAVI compared with classical

aortic valve replacement,

an additional question arises whether the type of anaesthesia

provided for these procedures makes a difference for patient outcome.

The latter question canbe further divided into twoparts: rst, does the individual anaesthetist

make a difference to patient outcome, and second, does the type of anaesthesia play a role?

A recent publication

reports an increased mortality by nearly 50% in patients undergoing

coronary artery bypass graft surgery served by “low-performance anaesthetists”. One might

look for shortcomings of this publication, and we might feel uncomfortable with the

mentioned statement, but several published comments also point out, what we all know:

the individual anaesthetist makes a difference,

8,9

and this will most likely also be the case in

TF-TAVI procedures!

But does the type of anaesthesia also make a difference in patients undergoing TF-TAVI?

There are supporters and opponents for GA or LA, as are advantages and disadvantages

for either of the two options.

Looking at the available evidence-based data, we have

to agree that we cannot answer the question at this moment. There are no randomised

controlled trials but only retrospective analyses or prospective observational registries.

While some of these publications state that there is lower incidence of complications

and better outcome when performing TF-TAVI under local anaesthesia,

one has to take

into account that retrospective and prospective observational studies have a signi cant

reporting bias. In most of these registries, GA was used while the innovative technique of

TF-TAVI was implemented; in contrast, use of LA increased over time during later years after

gaining more experience with the technique.

If this holds true, how can we then compare

these two options on an evidence-based level with the respective data, and is it justi ed to

perform a meta-analysis over the available results?

In the current issue of the British Journal of Anaesthesia, Mayr and colleagues

present

results of the rst randomised study comparing sedation vs. GA for TF-TAVI. They analysed 62

patients randomised to either GA or sedation with propofol and remifentanil. Noteworthy,

there was already experience with more than 600 TAVI procedures performed before

in the respective investigational centre, most likely omitting the effects of the learning