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Page 4 of 9 Candela et al. Vessel Plus 2018;2:28 I http://dx.doi.org/10.20517/2574-1209.2018.31

population. Indeed, anesthetic drugs may have depressant effects on myocardial tissue and vasodilatory
activity resulting in hemodynamic instability, hypotension and bradycardia which may reduce vital organ
perfusion pressure, leading to several postoperative complications such as neurological deficits, myocardial
ischemia or renal disfunction [40,41] . The use of LAS as an anesthetic choice for TAVR permits to avoid
collateral effects of general anesthetics, minimizing hemodynamic instability.

It is furthermore not surprising that using LAS decreases pulmonary complications such as respiratory
[28]
failure and pneumonia by avoiding mechanical ventilation .

Also, has been showed a significant reduction in postprocedural delirium, which has been showed to
prolong in-hospital stay and impair long-term survival. Delirium after TAVR occurs early in the post-
operative period, with a percentage around 13%. Patients who developed postprocedural delirium more
[42]
frequently underwent non-TF procedures under GA .

REGISTRY DATA ANALYSIS
Since LAS has emerged as an alternative to GA, many groups have conducted systematic reviews and met-
analysis in order to determine if the change in anesthetic management has modified the outcome.

In the French Aortic National CoreValve and Edwards 2 (FRANCE 2) registry, data from 2326 patients who
[43]
underwent TF-TAVR were analyzed, comparing patients receiving GA vs. LAS . This analysis highlighted
similar clinical outcomes for GA and LAS about procedure success, 30-day and 1-year survival rates,
incidence of complications such as myocardial infarction, stroke, and vascular and bleeding complications.
The only significant difference in outcomes was that there is a higher incidence of postprocedural aortic
regurgitation in the LAS group. This result is probably due to the less frequent use of TEE support during
TAVR under LAS.

However, the new model of Edwards valve minimizes postoperative aortic regurgitation, indeed further
studies demonstrated that residual postprocedural aortic regurgitation is completely absent or insignificant
in patients implanted with this third-generation valve under LAS [44,45] .

Data from the Italian CoreValve registry also analyzed a cohort of 1316 patients to assess the safety and
non-inferiority of LAS vs. GA. The authors demonstrated that, in experienced centers which have gone over
their initial learning period with TAVR, LAS can be performed safely with good clinical outcomes, with no
significant difference in myocardial infarction, stroke or mortality than GA group .
[27]
In a recent review the authors screened publications (randomized controlled trials and observational
studies) published between 1 January 2006 and 26 June 2016 that compared LAS to GA in an adult study
population undergoing TAVR, to identify the potential favorable effects of LAS compared with GA. They
analyzed differences between LAS and GA in terms of 30-day mortality, in-hospital mortality and other
[46]
endpoints that address safety and complications rates . The authors showed no significant difference
in the 30-day mortality rate among the two groups. Similarly, the in-hospital mortality rate did not
demonstrate any significant difference between the study groups. Instead, the authors revealed a significant
decrease in both intraprocedural and postprocedural catecholamine need in the LAS group. During TAVR,
31% of the LAS group received catecholamines, in contrast, the rate was 65.0% in the GA group.

As explained previously, this result in LAS group is probably due to the absence of hemodynamic
effects of general anesthetics, such as vasodilation and myocardial depression. Regarding catecholamine
administration, inotropes are more used than vasopressors, since patients suitable for TAVR often have a