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TRANSCATHETER AORTIC VALVE IMPLANTATION UNDER LOCAL ANALGESIA EXCLUSIVELY
3
Transcatheter Aortic Valve Implantation (TAVI) was started in most centres using general
anaesthesia (GA) and the same monitoring standard as for patients scheduled for open
surgical aortic valve replacement. After gaining experience, few centres switched to local
anaesthesia (LA) - with or without sedation.
1
Currently both, GA and LA (with or without
sedation) are options for the anaesthetic management of TAVI patients. Whether LA is
superior to GA has not been addressed in randomised trials before and no consensus upon
the preferable method has been reached yet.
2,3
We report on safety and feasibility of TAVI
under LA and present our own experiences in the largest cohort so far reported.
2
At our institution, transfemoral TAVI procedures started in 2007 under GA (n=55). In an
effort to minimise invasiveness in this fragile patient population, LA became the standard
method for transfemoral TAVI`s beginning October 2010. We included consecutive patients
who were planned for TAVI under LA between October 2010 and May 2013. All patients
were rejected for surgical treatment due to anticipated high surgical risk by our heart team.
Patients signed written informed consent for the procedure, data collection and utilisation
according the ethical guidelines of our institute. All patients received pre-procedural
consultation by both, the operator as well as the anaesthesiologist.
Premedication and use of conscious sedation were left at the discretion of the cardio-
anaesthesiologist.
A total of 40 cc lidocaine 1% mixed with bupivacaine 0.5% (T
1/2
=2.7h) was injected in the
percutaneous femoral access site for local wound analgesia. Appropriate valve positioning
was achieved by fluoroscopy and aortography without the use of transoesophageal
echocardiography (TOE). Results and complications were assessed based on direct patient
contact, haemodynamics, angiography, and transthoracic echocardiography (TTE). A
cardiovascular anaesthesiologist was constantly present to monitor the patient, stabilise
haemodynamics, or perform GA if necessary. All patients treated under LA were post-
procedurally observed on the Cardiac Care Unit (CCU) instead of being transported to the
Intensive Care Unit (ICU) as is it standard after GA. For the clinical endpoint de nitions the
criteria of the Valve Academic Research Consortium
4
were used.
A comparison was made between the group of patients treated under LA and conscious
sedation and the group under LA without conscious sedation. Differences of continuous
variables between two groups were analysed with a two-tailed student’s t-test or Mann–
Whitney U test where appropriate.
Of the 178 patients included, 4 patients (2.2%) needed a conversion to GA (1 conversion
to surgery due to prosthesis embolism, 2 complicated peripheral vasculature puncture/