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Candela et al. Vessel Plus 2018;2:28 I http://dx.doi.org/10.20517/2574-1209.2018.31 Page 3 of 9

Table 1. Comparison of general anesthesia (GA) and local anesthesia with a mild sedation (LAS) in TAVR
GA LAS
Advantage Disadvantages Advantages Disadvantages
Safety in starting TAVR Myocardial depression due to Hemodynamic stability Patient discomfort
program anesthetic drugs
Safety in predicted difficult Weaning from mechanical Reduced in-hospital stay Not safe in predicted difficult airway
airway ventilation
Safety in expected technical Increased in-hospital stay and Reduced ICU stay Not safe in starting TAVR program
complications ICU stay
Patient immobility More invasive (catheterization, Reduced delirium Not safe in expected technical
CVC, mechanical ventilation) complications
Easy use of TEE Less invasive (catheterization, CVC,
mechanical ventilation)
TAVR: transcatheter aortic valve replacement; TEE: tranesophageal ecocardiography; ICU: intensive care unit; CVC central venous
catheter

ease extubation at the end of the procedure. Airway control is performed by endotracheal intubation. Any
supraglottic device is not advised because of the use of transesophageal echocardiography.

The reason why most centers initially perform TAVR under GA is the safety of anesthesiologic management
and the easier management of procedural complications. TAVR has already been demonstrated to be an
effective and safe procedure, but it may have important and very dangerous complications leading to true
catastrophic events that are often life threatening such as coronary artery occlusion, annular rupture,
prosthesis embolization, major vascular injuries, cardiac tamponade, aortic dissection, and/or ventricular
perforation [27,28] .

Although conversion to GA because of emergency complications is not common, ranging from 2%-5% [29-32] , most
of these events cause serious hemodynamic instability and any delay of ventilation can worsen significantly
patient outcome.

Similar considerations are needed for major vascular injuries such as vascular dissection, vascular
perforation, and hematoma often requiring blood transfusions. Even in these circumstances conversion to
GA may be necessary.

Further advantages of performing TAVR under GA include patient immobility during valve positioning,
reduction of breathing artifacts, patient tolerability for the length of the procedure, but above all,
facilitating the use of tranesophageal ecocardiography (TEE). TEE is an useful instrument during the
procedure to assist optimal valve placement and prompt recognition of complication such as tamponade
or interference with mitral valve. TEE guides the advancement of guidewires and the delivery system
and allows to evaluate the effects of the balloon aortic valvuloplasty and the position of the prosthesis at
deployment, also it allows to perform a post-implant valve assessment to identify residual regurgitation
or paravalvular leaks. Also, 3D TEE may give additional information about structures, catheters and
device [33,34] .

Whereas many institutions still perform TAVR under GA, many clinicians in recent years have
proposed local anesthesia with or without mild sedation. Several drugs and compounds have been used
as monotherapy or in combination for sedating patients during TAVR, including dexmedetomidine,
remifentanil, midazolam, ketamine and propofol [15,31,35-39] .

Local anesthesia combined with conscious sedation provides multiple advantages compared with
GA [Table 1]. These benefits are especially noticeable in an old age and a high level of frailty patient